What is snuff?

What is snuff?

What is snuff?

Snuff: a compelling harm reduction alternative to cigarettes!

Snuff is an oral smokeless tobacco product which is usually placed behind the upper lip, either in a loose form or in portioned sachets, and is primarily used in Sweden and Norway. Snuff is a moistened fine-grained tobacco added with water and salts. Snuff usually has a clear, distinct tobacco taste. it´s often flavored by spices, sometimes with sweet flavors such as mint, wintergreen, cola, vanilla etc.

Snus, Snuff, Swedish Snuff, Dip tobacco, Chewing tobacco!

The purpose of this review is to examine the reported effects of snus use in relation to specified health effects, namely lung cancer, cardiovascular disease, pancreatic cancer, diabetes, oral cancer and non-neoplastic oral disease. The review also examines the harm reduction potential of snus as an alternative to cigarettes by comparing the prevalence of snus use and cigarette smoking, and the reported incidence of tobacco-related diseases across European Union countries. The scientific literature generally indicates that the use of snus is not a significant risk factor for developing lung cancer, cardiovascular disease, pancreatic cancer or oral cancer. St

Snuff, Snus, Dip tobacco health effects and studies!

udies investigating snus use and diabetes have reported that high consumption of snus (estimated as being four or more cans per week) may be associated with a higher risk of developing diabetes or components of metabolic syndrome; however, overall results are not conclusive. Snus use is associated with the presence of non-neoplastic oral mucosal lesions which are reported to heal rapidly once use has stopped. The most recent Eurobarometer data from 2017 reported that Sweden had the lowest prevalence of daily cigarette use in the European Union at 5% whilst daily “oral tobacco” use was reported to be 20%. European data published by the World Health Organisation in 2018 indicated that Sweden had the lowest rate of tobacco-related mortality and the lowest incidence of male lung cancer. Overall, prevalence statistics and epidemiological data indicate that the use of snus confers a significant harm reduction benefit which is reflected in the comparatively low levels of tobacco-related disease in Sweden when compared with the rest of Europe. The available scientific data, including long-term population studies conducted by independent bodies, demonstrate that the health risks associated with snus are considerably lower than those associated with cigarette smoking.

Snuff, snus – Smokeless tobacco! Sweden use Snuff and has the lowest rate of lung cancer in the World!

Sweden has the longest history of snus use in Europe. Snus was reportedly introduced into Sweden in 1637 and became popular among aristocratic men and women. Snus use reached record levels in 1919 but started to decline with the introduction of cigarettes. From the 1970s to 2005, the prevalence of smoking declined in Sweden whilst snus use increased in popularity.

Snus has now been used widely by consumers in Sweden over the past four to five decades, which is sufficient time for epidemiological studies to assess potential effects of its use on health. In 2016, The UK Royal College of Physicians stated that the trends in smoking and snus use indicated that snus had become a substitute for smoking particularly among men. This is corroborated by data from 1986 to 2009 showing that the prevalence of snus use has increased over time, above and beyond that of cigarettes, especially in men.

Swedish national statistics indicate that snus has been more popular than smoking among men since around 1996 [1]. Among women, daily snus use is much lower. However, in recent years, this has increased from 1% in 1996 to 4% in 2015. Recently, the growth of daily snus use among men has slowed; rates were 19% in both 1996 and 2015, and the most recent Eurobarometer data from 2017 reported daily oral tobacco use at 20%. The Swedish pattern of increasing snus use and declining cigarette smoking has also been observed in Norway.

According to Statistics Norway, smoking rates in Norway have declined over the past decade whilst snus use has increased over the same time period.

In 2017, 11% of the Norwegian population aged 16 to 74 were daily cigarette smokers, whilst 12% used snus daily. 2017 was reported as being the first year in which there were more daily snus users than cigarette smokers. Statistics Norway reported that the prevalence of daily snus use is highest among young men below 35 years of age.

Since the early 1950s, thousands of epidemiological, clinical and scientific publications have reported the adverse health consequences of smoking. Based on these findings, numerous public health bodies, including the UK Royal College of Physicians, the US Surgeon General and the International Agency for Research on Cancer have concluded that smoking is causally associated with numerous diseases.

According to the European Parliament, tobacco consumption is reportedly responsible for nearly 700,000 deaths in the EU every year, with half of smokers dying an average of 14 years earlier than a never-smoker. The World Health Organization (WHO) European Region reports the highest proportion of deaths attributable to smoking compared to the rest of the world. The WHO has estimated that smoking is currently responsible for 16% of all deaths in adults over 30 years of age in Europe, which is above the global average of 12%. Lung cancer has been found to be the most common cancer-related cause of death in Europe, and smoking has been associated with an increased risk of squamous cell carcinoma, adenocarcinoma, large cell carcinoma and small cell carcinoma of the lung. Swedish males reportedly have the lowest rate of lung cancer and lowest rate of tobacco-related mortality in Europe.

Harm reduction potential of Snus and Snuff

Cardiovascular disease – no or low risk when you use Snuff and Snus!

Cardiovascular disease is a broad term referring to a range of conditions that affect the heart and the blood vessels including ischaemic heart disease (also known as coronary heart disease) which can lead to myocardial infarction and stroke. Cardiovascular diseases are complex, chronic conditions and there are many different risk factors associated with their development such as being overweight (as indicated by an increased body mass index (BMI)), high blood pressure, high cholesterol, diabetes, being physically inactive, tobacco smoking, excessive alcohol consumption, family history of cardiovascular disease, ethnicity, gender and age. The potential association between snus use and cardiovascular disease is based on the presence of nicotine, which is a mild stimulant.

Stroke – no or low risk when you use Snuff and Snus!

There are six Swedish epidemiological studies and one meta-analysis published to date which have specifically investigated the potential adverse effect of snus use on the incidence of stroke. The earliest study was based on data from the male Swedish construction workers cohort (n = 135,036) and reported a statistically insignificant age-adjusted RR of 1.9 (95% CI 0.6–5.7) for snus users (aged 35 to 54 years at entry into the study) compared to non-tobacco users. Data were reportedly adjusted for BMI, blood pressure and unspecified “history of heart symptoms”. However, the analysis was based on only four cases of stroke among the smokeless tobacco users in the cohort. The study did not adjust for smoking history or alcohol consumption.

Four other studies all reported insignificant RRs for current snus use and stroke. One study (n = 118,465) which investigated morbidity and mortality from stroke and its subtypes (ischaemic, haemorrhagic and unspecified stroke) reported no overall association with snus use. However, an increased RR was reported specifically for fatal ischaemic stroke and current snus use (1.72, 95% CI 1.06–2.78).

The most recent publication to date investigated the incidence of, and survival after stroke, both overall and according to subtypes. The study conducted a pooled analysis of eight Swedish prospective cohort studies (n = 130,485). No associations were observed between the use of snus and the overall risk of stroke (HR 1.04, 95% CI 0.92–1.17) or for any specific stroke subtype. However, the authors of this study reported an OR of 1.42 (95% CI 0.99–2.01) for “28-day case fatality” among users of snus who had experienced a stroke, and the HR of death during the follow-up period was reported to be 1.32 (95% CI 1.08–1.61). However, the authors acknowledge they could not differentiate whether the reported associations were due to snus use or social disadvantage.

A number of the above studies either reported on or referred to an increased risk of stroke associated with smoking. On the basis of the results reported for snus, several authors suggested that nicotine is unlikely to contribute significantly to the pathophysiology of stroke.

Lung cancer – use Snuff and Snus and avoid the risk of lung cancer!

Respiratory diseases, predominantly lung cancer, chronic obstructive pulmonary disease (COPD) and pneumonia, are reported to account for 46% of all deaths due to smoking. With snus use, there is negligible risk of lung cancer since there is no combustion and exposure to nicotine and tobacco constituents does not occur via inhalation through the respiratory tract.

Lung cancer is the leading cause of cancer death among men in all European countries except Sweden. One study estimated that if the Swedish male lung cancer mortality rate was extrapolated to the rest of the EU, there would be a 54% reduction in male mortality from lung cancer.

Use Snus and Snuff and avoid lung cancer!

Lung cancer is the leading cause of cancer death among men in all European countries except Sweden. One study estimated that if the Swedish male lung cancer mortality rate was extrapolated to the rest of the EU, there would be a 54% reduction in male mortality from lung cancer.

Oral cancer – Snuff and Snus doesn´t increase the risk for oral cancer!

Mouth cancer, also known as oral cancer, is classified as such when a tumour develops in the lining of the mouth. It may occur on the surface of the tongue, the insides of the cheeks, the roof of the mouth (palate) or the lips or gums.

Of eight publications, five large, well-controlled studies, that adjusted for smoking and alcohol consumption reported insignificant RR values for the association of oral cancer with snus use. One Danish study  (n = 644) reported tobacco use as a significant risk factor for developing oral cancer; however, the study did not stratify results by the type of tobacco used (i.e. smoked cigarettes, chewing tobacco and snus (described by the authors as snuff)). The authors reported that none of the participants were current snus users and that very few individuals within their sample had previously used snus.

The seventh study, conducted by Roosaar et al., analysed a subset of data from the Swedish construction worker study (n = 9,976). The authors reported a statistically significant RR of 3.1 (95% CI 1.5–6.6) for combined oral and pharyngeal cancer among ever-daily users of snus compared to never-daily users. It should be noted that the reported RR was based on 11 cases of oropharyngeal cancer. When the analysis was further restricted to those who had never smoked, the authors reported a RR of 2.3 (95% CI 0.7–8.3). The refined RR was based on only five cases of oropharyngeal cancer and was not statistically significant for combined oral and pharyngeal cancer among daily users of smokeless tobacco compared to never-daily users. The authors reportedly adjusted the results for alcohol consumption and smoking. An observational study by Hirsch et al. [81] reported 16 cases of patients who developed oral cancer at the exact anatomical site where snus was placed daily. The authors concluded a potential link between the use of snus and oral cancer; however, several patients had a history of smoking, and alcohol consumption was not recorded. The authors did not collect any control data regarding the location of oral cancer in other snus users; therefore, it is difficult to contextualise the findings.

In 2016, Swedish Match submitted a modified risk tobacco product (MRTP) application to the FDA, which sought permission to remove a number of product health warnings; one of which related to oral cancer. The FDA rejected the MRTP application, citing the results published by Roosaar et al. stating (regarding the literature relating to snus and oral cancer) that “although the few epidemiological studies conducted on snus products are inconsistent, the most recently published study found a three-fold increase in the risk of oral cancer associated with the use of snus products”.

A meta-analysis of the scientific studies investigating oropharyngeal and oesophageal cancer and snus use found no association between the two. The Institute of Medicine in their assessment of the scientific basis for tobacco harm reduction concluded that some smokeless tobacco products increase the risk of oral cavity cancer and that a dose-response relationship exists. However, the overall risk is lower than for cigarette smoking, and some products, such as snus, may have no increased risk at all.

Smoking Cessation – use Snuff and Snus!

Seven studies investigating the effect of snus on smoking cessation were identified in the scientific literature; four were conducted in Scandinavia [and three in non-Scandinavian countries.

One Scandinavian study  investigated twelve variables and their interactions as correlates of smoking cessation among regular smokers in the population-based Swedish Twin Registry (n = 14,715) and concluded that snus use was the strongest independent correlate of smoking cessation. Other correlates included nicotine dependence score, education and socioeconomic status. A study that retrospectively examined the association between snus, and smoking behaviour in males split into two age groups found six smoking quitters per smoking starter was attributable to snus in the younger age group. In the older cohort, there were slightly more than two quitters per starter. This study suggested that snus contributed to the reduction of smoking among Swedish males in the 1990s. A large Norwegian study (n = 10,441) examined seven cross-sectional data sets collected between 2003 and 2008. The authors of this study reported that the quit ratio (quitters: ever-smokers) for smokers who used snus was significantly higher than for those with no experience of using snus in six of seven data sets. Pooled data suggested the primary reason for snus use among daily users was to quit smoking. The findings were consistent with Swedish data, supporting that snus may play a role in smoking cessation.

Rutgvist et al. conducted a survey (n = 6,008) to evaluate the methods used by Swedish smokers to quit. The results confirmed and extended previous studies that found most smokers quit unassisted. In addition, snus has been the most frequently reported cessation aid among male smokers, whereas usage of pharmaceutical nicotine was more prevalent among females. Use of snus in the latest quit attempt appeared to be associated with a significantly higher success rate among males.

With respect to countries outside of Scandinavia, a study conducted in the USA, which evaluated twelve methods used within a large cohort of males motivated to quit smoking (n > 4.3 million), reported that those who switched to snus had the highest rate of success (73%).

A 2-week study conducted in New Zealand investigated the acceptability of snus, “Zonnic” (a non-tobacco, oral nicotine delivery product) and nicotine gum as smoking cessation aids. Participants (n = 63) reported a preference for snus and Zonnic and both were reported effective in reducing smoking and dese to smoke. The authors concluded that long-term studies were warranted to test the efficacy for long-term quit rates.

A Swedish Match sponsored trial (n = 319) investigated the efficacy of snus as a smoking reduction and cessation aid in Serbia. At 24 weeks, a greater than 75% reduction in smoking was significant (p < 0.01) more likely to be reported in the snus group compared to the placebo group. The results in this study were biologically verified.

A review of smoking prevalence, snus use and associated effects on public health in Sweden suggested that the low rate of male smoking combined with a high rate of snus use indicated the displacement of smoking by snus. The authors concluded that snus use prevents rather than promoting smoking and has contributed a net public health benefit in Sweden. However, the 2008 SCENIHR report  and the 2016 Cochrane review concluded there was insufficient evidence to determine whether snus could aid long-term smoking cessation. The SCENIHR report was published prior to the seven studies cited above and was based on US research and the Cochrane review only included the Swedish Match sponsored trial when reviewing the effectiveness of different smoking interventions.

Snuff and Snus use – Conclusion of health effects

This review found that the health risks associated with snus use, where nicotine is decoupled from harmful tobacco smoke, are considerably lower than those associated with smoking cigarettes. Further, snus appears to be a viable alternative to smoking tobacco, is acceptable to consumers and does not act as a gateway product to smoking cigarettes. Snus should therefore be regarded as a reduced risk product relative to cigarettes. These findings are in keeping with those reached recently by the UK Royal College of Physicians. Snus as an alternative to cigarettes has the potential to deliver enormous harm reduction benefits as demonstrated in Sweden, particularly in reducing the incidence of lung cancer and cardiovascular disease of which smoking is a known cause, where the product can be marketed and sold to adult smokers widely. This review also shows that since the European Union implemented a ban on the sale and marketing of snus in 1992, a substantial and independent scientific evidence base has confirmed the harm reduction potential of snus. The EU ban on the marketing and sales of snus should be reviewed in line with this scientific evidence. If the ban on the sale of snus in the EU was lifted, snus could represent an opportunity to deliver extensive public health benefits across Europe as a strategy for harm reduction.

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