Pinch Hit

Oral snuff as an alternative to cigarettes

How is a tin of Skoal Bandits like a sterile hypodermic needle? In public health lingo, both can be viewed as "harm reduction" devices that lower the risks of drug consumption. But while public health specialists have little trouble accepting the idea that clean needles can reduce disease among heroin users, they tend to rebel at the notion that oral snuff can reduce disease among tobacco users.

A paper by a British anti-smoking activist and five European health researchers, released at a London press conference today, challenges tobaccophobes to reconsider this reaction. Combining the collectivist logic of public health with libertarian-sounding rhetoric, their "statement in favor of evidence-based regulation" may surprise critics as well as supporters of the anti-smoking movement.

"The ultimate purpose of tobacco control campaigning and organizations should be clearly stated," write Clive Bates, director of the London-based Action on Smoking and Health, and his co-authors, Karl Fagerström of the Society for Research on Nicotine and Tobacco, Martin Jarvis of University College London, Michael Kunze of Vienna's Institute of Social Medicine, Ann McNeill of St. George's Hospital Medical School in London, and Lars Ramström of the Institute for Tobacco Studies in Stockholm. "In our view it is to reduce the burden of disease and death, mostly from cancer, cardio-vascular disease and lung disease, arising from tobacco use. The aim is not in itself to campaign against tobacco."

That point may seem obvious, but it is easily obscured by the all-or-nothing attitude toward tobacco that pervades the anti-smoking movement. "Many health advocates are uncomfortable with the concept that a certain class of tobacco products could play a role in a health strategy," Bates et al. note. In a surprisingly sharp rebuke, they observe that the debate about smokeless tobacco as an alternative to cigarettes pits "a smoker's right to options for harm reduction" against "the health professional's authoritarian insistence that the only valid choice for smokers is to quit or die."

As with heroin, the main health risks from nicotine use arise from the way in which it is consumed: in particular, the inhalation of tobacco combustion products, which exposes the body to myriad toxins and carcinogens. Unlike cigarettes, smokeless tobacco does not cause lung disease, and there is little evidence that it raises the risk of heart disease. The only well-established, potentially life-threatening risk from smokeless tobacco is oral cancer, and even that disease is about half as common among snuff users as it is among cigarette smokers.

Furthermore, oral cancer risk varies with the type of snuff used. According to a 2001 report from the National Academy of Sciences, the use of Swedish snuff (snus), which contains lower levels of carcinogens than other varieties, "has generally not been associated with oral cavity cancer." Bates et al. estimate that "Scandinavian and American smokeless tobaccos are at least 90 percent less hazardous than cigarette smoking."

University of Alabama oral pathologist Brad Rodu, a speaker at today's press conference, has been noting for years that smokers who are not prepared to give up tobacco entirely can greatly reduce their health risks by switching to oral snuff, which provides comparable doses of nicotine. In his 1995 book For Smokers Only: How Smokeless Tobacco Can Save Your Life, he estimated that if every cigarette smoker became a snuff user instead, annual tobacco-related deaths would be reduced by 98 percent.

The Bates paper is the latest sign that an increasing number of anti-smoking activists and scientists are coming around to Rodu's point of view. They are finding Sweden's experience with snus particularly persuasive. As Bates et al. note, "Sweden has the lowest levels of tobacco-related mortality in the developed world" and "the lowest male smoking prevalence in Europe." Yet overall tobacco consumption by men in Sweden is similar to that in Norway and Denmark, "suggesting the big difference is in the type of tobacco used." About half of Sweden's tobacco consumption is in the form of snus, and survey data indicate that Swedish smokers often switch to snus when they quit.

In the hope of duplicating the Swedish example, Bates et al. call upon the European Union to repeal its ban on oral snuff (from which Sweden is exempted). They argue that the ban, which bizarrely leaves out not only cigarettes and cigars but chewing tobacco, is "absurd" and counterproductive, eliminating a cigarette competitor that is far less hazardous. "It is…ethically wrong to actively deny users the option to reduce their risk in this way," they conclude. "The current ban violates the rights of smokers to control their own risks."