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© 2003 Society for the Study of Addiction to Alcohol and Other Drugs

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, 1197–1207

SMOKELESS TOBACCO: FRIEND OR FOE?

Cigarette smoking is highly addictive and highly toxic.Most smokers start to smoke in their teens, when a major-

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ity of young people—in the UK, about 70% by the age of15 [1]—experiment with cigarettes. A substantial pro-portion of these progress to regular use, and in due courseto addiction [2]. Once established as regular smokers,most wish they had never started smoking [3], want toquit, and have tried and failed to do so. More than half stillexpect to give up smoking within 2 years, but are in factmore likely to continue smoking for 20 years or more [3].Half of all regular smokers die as a consequence of theirsmoking, currently accounting for about 120 000 deathsin the UK each year [4] and 3 000 000 worldwide [5].This is a substantial public health problem, and any strat-egy that might reduce it deserves serious consideration.Two papers in this issue of

Addiction

draw further atten-tion to the potential role of oral moist snuff, or

snus

[6,7]

.

Nicotine addiction is the underlying force that drivescontinued smoking, and the traditional medicalapproach to helping smokers to quit has been to usemedicinal nicotine to ‘replace’ that obtained from ciga-rettes. Medicinal nicotine is generally safe, especiallywhen compared with continued smoking, and increasesthe chance of success in any quit attempt by around 70%[8]. At their best, interventions combining medicinal nic-otine with intensive behavioural support can achieve12 month sustained cessation rates of up to 20% [9,10],but the balance of this statistic is that 80% of smokerswho make a serious quit attempt with the best medicalsupport available relapse into regular smoking. Otheranti-smoking therapies such as bupropion provide analternative to nicotine replacement, but are no moreeffective [11]. Although many smokers will make furtherquit attempts and some will succeed, the fact is that untiland unless the efficacy of medical interventions improvessubstantially, the great majority of current smokers willcontinue to smoke. These individuals need an acceptable,safer alternative to cigarettes.

An ideal pharmaceutical solution would be a medici-nal device that delivers nicotine to the brain at a dose andrate similar to cigarettes, something that none of the cur-rently available products achieves. To be a viable alterna-tive, the product would also need to be as readily availableas cigarettes, competitively priced, socially acceptable andapproved for regular long-term social use rather than ashort-term cessation aid. It would also probably be highlyaddictive. In the present regulatory climate in the UK andEuropean Union, such a product is unlikely to be licensed.

An alternative approach, which has already provedacceptable to smokers and to be commercially viable, issmokeless tobacco. Smokeless tobacco is used in manyforms: in the USA predominantly as chewing tobacco, indeveloping countries in a mixture with other substancessuch as betel nut or leaf, and in Sweden as

snus

. Some ofthese products have important adverse health effects,particularly oral cancer [12,13], but as a recent review

has demonstrated, the extent of these risks varies sub-stantially between products [14]. Studies of

snus

in par-ticular have demonstrated relatively modest effects onoral cancer and cardiovascular disease, few of which arestatistically significant [14]. Whilst a lack of statisticalsignificance clearly does not rule out important effects, itis also evident that the risks of

snus

are substantially lessthan those of smoked tobacco [15].

Snus

is available inSweden by special exemption from European Union laws,which prohibit the sale of smokeless tobacco in othermember states. Sweden also currently has the lowestsmoking rate in the European Union, which may be due,in no small part, to the availability and acceptability of

snus

as an alternative product for smokers [16].In this issue of

Addiction

, Fagerström & Schildt alsoreview the health evidence on

snus

and explore the Swed-ish data in relation to the hypothesis that

snus

might havethe further adverse health effect of acting as a ‘gateway’to smoking in young people. They conclude that

snus

,although not risk-free, carries substantially lower risksthan smoking tobacco, and in relation to the gatewaytheory that far more smokers appear to use

snus

in theprocess of quitting smoking than progress into smokingfrom

snus

use [7]. Gilljam & Galanti present data from anational survey of

snus

use among current and ex-smokers, demonstrating that smokers who use

snus

smoke fewer cigarettes per day than non-users and thatever users of

snus

are less likely to be current smokersthan never users [6]. Therefore, these findings also sug-gest that, on balance,

snus

is more of a gateway from thanto smoking.

The crucial point arising from these papers is whetherthe current ban on the use of

snus

in the European Unionshould be lifted, and Fagerström & Schildt argue thatdoing so would probably be beneficial to public health [7].However, many involved in tobacco control find this pol-icy difficult to support, not least because it grants newmarket freedoms to the traditional enemy—the tobaccoindustry—and because of fears that the industry mightabuse this privilege by marketing smokeless tobacco as astarter product and utilizing it to maintain tobacco use insmokers who would otherwise quit completely. On theother hand, there are those who argue that smokers havea right to access safer tobacco products and that, at thepopulation level, the health gains in smokers who switchto

snus

will more than offset any adverse effect from wideruse of smokeless tobacco [17].

Major problems often demand radical solutions, andthere is no problem in public health so great as smoking.The current danger is that medical and political conser-vatism—arising variously from a fear of doing harm, ofalienating smokers, a failure to recognize smoking as achronic addictive disease and many other factors—willcontinue to perpetuate the current market freedoms

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enjoyed by cigarette manufacturers and result in millionsmore avoidable deaths. The Royal College of Physicians inLondon has recently argued that the regulatory system inthe UK, which currently grants the greatest commercialfreedom to the most dangerous nicotine product, needs tobe overhauled to apply controls on medicinal nicotineand smokeless and smoked tobacco in proportion to theharm they cause [18]. A similar proposal has been madefrom Action on Smoking and Health in the UK to theEuropean Union [19]. If adopted, these proposals wouldallow medicinal nicotine,

snus

and potential new smoke-less products to become commercially available in a suit-able environment of control, monitoring and review. TheSwedish experience suggests strongly that this wouldreduce the current burden of disease caused by smoking.To date, the UK Government has responded by saying that‘the time is not right’. One wonders if it will ever be oth-erwise.

JOHN BRITTON

Division of Epidemiology and Public HealthUniversity of NottinghamClinical Sciences BuildingCity HospitalNottingham NG5 1PBUKE-mail: j.britton@virgin.net

References

1. Higgins, V. (2000)

Young Teenagers and Smoking in 1998. AReport of the Key Findings from the Teenage Smoking AttitudesSurvey Carried Out in England in 1998.

London: Office forNational Statistics.

2. Di Franza, J. R., Rigotti, N. A., McNeill, A. D., Ockene, J. K.,Savageau, J. A., St Cyr, D. & Coleman, M. (2000) Initialsymptoms of nicotine dependence in adolescents.

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, 313–319.3. Jarvis, M. J., McIntyre, D. & Bates, C. (2002) Effectiveness of

smoking cessation initiatives—efforts must take intoaccount smokers’ disillusionment with smoking and theirdelusions about stopping.

British Medical Journal

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, 608.4. Royal College of Physicians (2000)

Nicotine Addiction inBritain. A Report of the Tobacco Advisory Group of the RoyalCollege of Physicians.

London: Royal College of Physicians ofLondon.

5. Peto, R., Lopez, A. D., Boreham, J., Thun, M., Heath, C. &Doll, R. (1996) Mortality from smoking worldwide.

BritishMedical Bulletin

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, 12–21.6. Gilljam, H. & Galanti, M. R. (2003) Role of

snus

(oral moistsnuff) in smoking cessation and smoking reduction in Swe-den.

Addiction

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, 1183–1189.7. Fagerström, K. O. & Schildt, E.-B. (2003) Should the Euro-

pean Union lift the ban on

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? Evidence from the Swedishexperience.

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, 1191–1195.8. Silagy, C., Mant, D., Fowler, G. & Lancaster, T. (2000) Nic-

otine replacement therapy for smoking cessation (CochraneReview). In:

The Cochrane Library

(CD000146). Oxford:Update Software.

9. Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Fox,B. J., Goldstein, M. G., Gritz, E., Hasselblad, V., Heyman, R.B., Jaen, C. R., Jorenby, D., Kottke, T. E., Lando, H. A., Meck-lenburg, R. E., Mullen, P. D., Nett, L., Piper, M., Robinson,L., Stitzer, M., Tommasello, A., Welsch, S., Villejo, L., Wew-ers, M. E. & Baker, T. B. (2000) A clinical practice guidelinefor treating tobacco use and dependence.

Journal of theAmerican Medical Association

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, 3244–3254.10. West, R., McNeill, A. & Raw, M. (2000) Smoking cessation

guidelines for health professionals: an update.

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11. Hughes, J. R., Stead, L. F. & Lancaster, T. (2002) Antide-pressants for smoking cessation (Cochrane Review). In:

TheCochrane Library

(CD000031). Oxford: Update Software.12. International Agency for Research on Cancer (IARC)

(1985)

IARC Monographs on the Evaluation of the Carcino-genic Risk of Chemicals to Humans. Tobacco Habits Other thanSmoking: Betel Quid and Areca Nut Chewing; and Some RelatedNitrosamines.

Lyon: IARC.13. US Department of Health and Human Services (1986)

TheHealth Consequences of Using Smokeless Tobacco. Report of theAdvisory Committee to the Surgeon General.

Bethesda, MD: USDepartment of Health and Human Services, Public HealthService.

14. Critchley, J. A. & Unal, B. (2003) Health effects associatedwith smokeless tobacco: a systematic review.

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15. Doll, R., Peto, R., Wheatley, K., Gray, R. & Sutherland, I.(1994) Mortality in relation to smoking: 40 years’ observa-tions on male British doctors.

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16. Henningfield, J. E. & Fagerström, K. O. (2001) SwedishMatch Company, Swedish

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17. Kozlowski, L. T. (2002) Harm reduction, public health andhuman rights: smokers have a right to be informed of sig-nificant harm reduction options.

Nicotine and TobaccoResearch

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(Suppl. 2), 55–60.18. Tobacco Advisory Group of the Royal College of Physicians.

(2002)

Protecting Smokers, Saving Lives. The Case for aTobacco and Nicotine Regulatory Authority.

London: RoyalCollege of Physicians.

19. Bates, C., Fagerström, K. O., Jarvis, M., Munze, M., McNeill,A. & Ramstrom, L. (2003)

European Union policy on smoke-less tobacco. A statement in favour of evidence-based regulation

[WWW document]. URL http://www.ash.org.uk/html/regulation/pdfs/eusmokeless.pdf.