Dr Steve Stotesbury is head of Regulatory Science at Imperial Tobacco.
"Some Europeans are aware of a significant development which has been unfolding right on Europe’s doorstep. First in Sweden, and more recently in Norway, smoking is becoming much less prevalent due to a growing preference for smokeless tobacco, especially in men.
The curious thing is that this important phenomenon does not seem to be more widely known – especially amongst those in Brussels who are tasked with regulating tobacco products and protecting public health in the European Union.
Smokeless tobacco includes a range of products containing tobacco that are designed for chewing, sucking and snuffing and have been in use for a long period of time. Moist snuff is more commonly known as snus in Sweden.
The reason this switch to smokeless products is so interesting is that some researchers and organisations, including the World Health Organization (WHO), believe it may have a positive impact on the incidence of smoking-related diseases.
In 2008, a WHO report (WHO Technical Report Series report 951, 2008) stated that:
- “There is little question that, in general, smokeless tobacco products are less harmful than combusted tobacco products such as cigarettes”.
- "Among the smokeless tobacco products on the market, products with low levels of nitrosamines, such as Swedish snus, are considerably less hazardous than cigarettes, while the risks associated with some products used in Africa and Asia approach those of smoking.”
So what has happened in Sweden and why is this so relevant to the further regulation of tobacco products as it is currently proposed by the EU Commission?
The overall prevalence of total tobacco use in the EU is approximately 25 to 30% of the adult population, but tobacco use patterns in the EU vary country-by-country – and a unique situation has developed in Sweden.
At present, the Swedes have the highest prevalence of snus use and the lowest prevalence of smoking in the EU, down to a mere 13% in men and 16% for women in 2008/2009. By contrast, the per-capita consumption of snus approximately doubled between 1970 and 2008 (Drug Trends Sweden, 2010), with 21% of male adults now using smokeless tobacco.
This constitutes a major change in tobacco consumption preferences, and when coupled with the view of the WHO quoted above, marks an important development that needs to be better understood and warrants closer examination.
We find that in both Sweden and Norway – where use of smokeless tobacco has increased while smoking prevalence has fallen - rates of many of the diseases traditionally associated with smoking are well below the European average. In fact, Sweden now has the lowest mortality rates from these diseases compared to anywhere else in Europe.
You might expect EU decision-makers to showcase this situation and proclaim it to be an outstanding success story – after all, where else have smoking incidence and, in parallel, rates of smoking-related diseases fallen in such a short period of time?
The reason they do not is because the special Swedish situation has been created by legislation from the EU – but only in a negative sense that does them no credit. Sweden is the ‘exception’ – the one in 27 member states – simply because the EU has banned the sale of snus everywhere else whereas Sweden was granted this exemption as part of their accession terms in 1995. Snus is thus rarely used in other EU countries because of this blanket ban.
And the only reason that Norway has a growing snus consumption is because it is not a member of the EU and therefore unaffected by the ban in the other 26 states.
This does not mean that the EU has not considered the phenomenon – indeed they have on a number of occasions. In 2008, the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) – a Commission group of independent experts – adopted its final opinion on the Health Effects of Smokeless Tobacco Products. In reference to tobacco for oral use, Swedish snus, SCENIHR said;
- “…These reports suggest that in northern Sweden, the availability of snus and the way in which it has been used may have been beneficial to public health since the harm to health caused by any use of snus as a gateway into smoking may have been more than outweighed numerically by the numbers quitting smoking for snus”
This was not the only conclusion that SCENIHR reached, as they also said that:
- “STP [smokeless tobacco products] are clearly less hazardous, and in relation to respiratory and cardiovascular disease substantially less hazardous, than cigarette smoking. The magnitude of the overall reduction in hazard is difficult to estimate, but as outlined above, for cardiovascular disease is at least 50%, for oral and GI cancer probably also at least 50%, and for respiratory disease close to 100%. A recent study using a modified Delphi approach to estimate the relative hazard of snus concluded that the product was likely to be approximately 90% less harmful than smoking…”
To the casual observer these figures, with the advice from the EU’s own expert group, would suggest that the Commission and its co-legislators, the EU Parliament and the Council of Ministers – should jump on any chance to overturn the ban and extend the Swedish ‘exception’ to the rest of the EU.
In fact, that opportunity could be at hand as the European Commission currently prepares its revision of the existing European Tobacco Products Directive (EUTPD) dating back to 2001. In the new Directive, given the evidence collected over the past decade, it could easily reverse the snus ban.
Surprisingly, in the draft of the new EUTPD published in various international media over the past few weeks, however, the EU Commission does the exact opposite – it seems that it intends to make the Swedish ‘exception’ even more exceptional by actually extending the ban on oral tobacco to all types of smokeless tobacco products throughout the whole European Union.
Why would the Commission take a decision that flies in the face of such a solid body of evidence?
In their efforts to engage with the Commission on this issue, tobacco manufacturers have been joined by members of the scientific community and the Swedish Government, who all want the Commission to lift the ban on Scandinavian smokeless tobacco products and make them available to all Europeans.
They jointly realise the data derived from the Swedish ‘exception’ may represent the most significant step forward in our understanding of the association between tobacco and health since the 1950s and this should be more than enough to get any responsible regulators’ attention and create a pause in their dash to extend the ban against all evidence.
Understanding the evidence, and yet maintaining a commitment to a dogma driven by prejudice against a choice they do not understand or agree with, is simply not good enough from an EU legislative perspective. One even suspects that their hatred of tobacco has itself become such a passion that it blinkers them and those activists driving the anti-tobacco agenda internationally from recognising the historic opportunity now sitting on Europe’s doorstep.
The window of opportunity to have an informed dialogue and consider the compelling evidence without prejudice is open. Let’s hope that the months to come see the Commission applying its principles of ‘Smart Regulation’ a little more rigorously to itself - otherwise don’t let them dare to maintain their claim that they are aiming to protect the public health of Europe’s citizens."