When enough is enough

    The continued call for more evidence about the relative risks of “tobacco” products presents a risk in its own right.

    By Marina Murphy

    Anyone who reads this magazine and takes an interest in the vapor industry will be familiar with phrases like “more research needed” and “not enough evidence.” But when is enough evidence, enough evidence? I ask this because there is another product that has suffered from the “more research needed” mantra: snus. Despite extensive evidence that snus is harm reducing, it remains banned in the European Union.  And as we listen to continued calls for more research on e-cigarettes and other alternative tobacco and nicotine products, these categories risk becoming another “snus.”

    In the last issue, I discussed snus and the legal challenge being brought against the EU ban (see “No entry,” Vapor Voice, Issue 3, 2017). But I think it is worth revisiting this issue because—guess what—there is new evidence of the advantages of snus!  In June, new data was released and suggested that around 320,000 men would not die prematurely from smoking-related diseases every year in the EU if snus were available and use levels mirrored those in Sweden.

    Now, it is highly unlikely that use levels in other European countries would mirror those of Sweden anytime soon, if ever, but if snus were available, it would add to an ever-increasing arsenal of potentially safer nicotine and tobacco products in the EU. This could only be a good thing for smokers looking for an alternative to conventional cigarettes. Because after all, we’re all different, and one size does not fit all. A wider range of alternative tobacco and nicotine products gives more choice to the consumer. And if these alternatives have the potential to present reduced risks in comparison with smoking, why shouldn’t they be available to those who want to use them?

    Snus, Sweden and Scandinavia

    At some stage, somebody somewhere decided that snus should be banned in the EU, which it duly was in 1992. Now this ban may have been barely noticed in EU countries without an oral tobacco tradition, but in Sweden, snus had been popular for around 200 years. Snus has also been long used in neighboring Norway and Finland.

    When Sweden and Finland joined the EU in 1995, Sweden applied for and received a waiver on the EU’s existing snus prohibition. This meant that Swedes could continue producing and selling snus in their country. In contrast, Finland accepted the ban, leaving Finnish consumers without a legal source of snus in their own country. Norway never joined the EU, so snus remained available, and it remains available and popular today.

    So, what happened to smoking rates in these countries after 1995? A study by Jennifer Maki from the Center for Healthcare Economics and Policy compared the smoking rates in these countries and found that in both Sweden and Finland there had been a steady decline in smoking until the mid-1990s. After 1995, the decline in smoking leveled off in Finland but continued in Sweden, even though smoking rates in Sweden had been far lower in the first place. “In the post-ban period, smoking increased in Finland by 3.47 percentage points relative to Sweden. … This estimate can be interpreted as an increase in the smoking rate relative to what it would have been in the absence of the ban,” says Maki (see Figure 1).

    Figure 1

    When Finland is compared with Norway over the same period (see Figure 2), the decline in smoking rates in the two countries is similar prior to 1995. However, after 1995, the rates diverge, with the decline in smoking rates in Norway similar to that observed in Sweden, albeit less significant.

    Figure 2

    Snus today

    In June, Lars Ramstrom, of the Institute for Tobacco Studies in Sweden, presented new data at the Global Forum on Nicotine conference in Warsaw, Poland, suggesting that around 320,000 men over the age of 30 would not die prematurely every year from smoking-related diseases in the EU if snus were available and used like it is in Sweden.

    “This new analysis reveals the true human cost of the European snus ban,” says Gerry Stimson, who is on the board of directors of the New Nicotine Alliance, one of the groups challenging the EU ban. “Snus is at least 95 percent safer than smoking. … This ban on the sale of snus contravenes a fundamental principle that EU law should be based on a high level of health protection.” Overall tobacco use in Sweden (including smoking, snus and other tobacco products) is higher than in many other countries in the EU. What makes Sweden different is that most tobacco use, at least for men, is in the form of snus. Sweden has the lowest smoking rates in Europe. According to the 2017 Eurobarometer survey, only 5 percent of men in Sweden are daily smokers compared with a European average of 24 percent. Swedish men have Europe’s lowest level of tobacco-related mortality: 152 per 100,000 compared with the European average of 373 per 100,000 (see Figure 3).

    If you look at tobacco-related mortality in the EU 28 plus Norway (Figure 3), Sweden is at the very bottom, where it has been for many years. The death rate in Sweden is less than a fourth of the top rate and less than half of the EU average. And who is keeping Sweden company in the lowest positions? Norway and Finland.

    In Norway, there is also lots of snus use because Norway is not in the EU and snus was never banned there. According to Ramstrom, snus use in Norway has become prevalent enough to have a significant impact on smoking rates; so perhaps it’s not surprising that Norway is close to the bottom of the chart. But what about Finland? Although snus was traditionally used in Finland, it is now banned. But there are indications that snus use is still prevalent, with reports of a black market worth in the range of €50 million a year. The 2017 Eurobarometer survey results also suggest high levels of smokeless tobacco use in Austria, which also features at the bottom of the chart.

    Not so surprising

    While the data might be new, the knowledge is not; we already knew that snus presents considerable opportunity for harm reduction. There are decades of data in respect of snus use from Sweden. And those in the know have come to call the phenomenon of higher snus use and lower smoking rates, along with lower incidences of some cancers and associated death rates, the “Swedish experience.” A parallel “Norwegian experience” is increasingly being recognized as well.

    Marina Murphy is head of scientific media relations at British American Tobacco.

    Despite all this evidence, snus researchers are in the position of having to prove their point over and over again. When is enough evidence, enough evidence?

    As long as local regulators, the European Commission and many in the public health community fail to acknowledge such an encouraging example of success, it’s hard to see how newer products are going to make significant inroads.

    We hear the phrase “more research needed” a lot in the vaping world, too. But there is a risk that this phrase is being relied on far too much and that it is becoming an empty cliche or cop-out for those who just don’t want to believe what the science is already telling them.