Pluses and Minuses to Snus, Sweden's Cigarette Alternative

By Peggy Peck, Managing Editor, MedPage Today

Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
May 10, 2007

STOCKHOLM, May 10 -- Moist snuff known as snus, Sweden's most popular tobacco product, is associated with a greater risk of pancreatic cancer, researchers here reported.

But that risk is less than the pancreatic cancer risk associated with cigarette smoking, according to two studies published online by The Lancet.

The relative risk of pancreatic cancer among snus users was 2.0 (95% CI 1.2-3.3) compare with the risk in those who never used tobacco, wrote Olaf Nyrén, M.D., of the department of medical epidemiology and biostatistics at the Karolinska Institute and colleagues.

But current and former smokers were almost three times more likely to develop pancreatic cancer (RR 2.8 at the 95% CI) than Swedish men who had never used tobacco products.

Snus is placed under the upper lip and kept there for up to several hours, depending on user preference. It's typically stored in the refrigerator to minimize formation of nitrosamines.

Dr. Nyrén and colleagues analyzed data collected from 279,897 Swedish construction workers from 1978 through 1992, along with follow-up health registry data through 2004. Thirty-one percent of the men used or had previously used snus and 55% were smokers or former smokers.

In the second paper Corel E. Gartner, Ph.D., of the University of Queensland, Herston, Australia, estimated the potential public health benefit of switching from smoking to snuff using life expectancy data. When analyzed at the population level, they argued, switching could produce a net health benefit.

They found the relative risk of tobacco-attributable mortality in snus users compared with current smokers among those ages 50 and up was 0.10 (0.075-0.125) for cardiovascular disease; 0.30 (0.225-0.375) for upper digestive, pancreatic, bladder, and renal cancer; and 0.034 (0.0255-0.0425) for lung cancer and 0.0 for COPD.

Although the researchers found little difference in health-adjusted life expectancy between smokers who quit and those who switch to snus, (0.1-0.3 years for men and 0.1-0.4 years for women) they noted that for net harm to occur, 14 to 25 ex-smokers or 14 to 25 never smokers would have to start using snus to offset the health gain from every smoker who switched to snus instead of smoking.

"The findings suggest that snus may be a safer form of nicotine that should be sold as a competitor to cigarettes, which is the "most harmful and addictive form" of nicotine, said Jonathan Foulds, Ph.D., M.App.Sci. M.A., and Lynn Kozlowski, Ph.D., of the public health tobacco dependence program at the University of Medicine and Dentistry of New Jersey School of Public Health in New Brunswick, N.J.

In a commentary that accompanied the snus studies Dr. Foulds and Dr. Kozlowski concluded that "we should not delay in allowing snus to compete with cigarettes for market share and we should be prepared to accurately inform smokers about the relative risks of cigarettes, snus, and approved smoking-cessation medications. In light of all available evidence, the banning or exaggerated opposition to snus in cigarette-rife environments is not sound public health policy."

The sale of snus is banned in Australia and in all European Union countries except Sweden.

Swedish Match, a maker of snus, has been marketing its product in the United States since 2001, but Drs. Foulds and Kozlowski said that "most of the big multinational tobacco companies are test-marketing low-nitrosamine snus products."

Dr. Nyrén declared no conflicts; her study was partly funded by a grant from the Swedish Cancer Society. Dr. Gartner also declared no conflicts; the Australian study was funded by the National Health and Medical Research Council. Dr. Foulds is funded by the New Jersey Department of Health and Senior Services, the Cancer Institute of New Jersey, the Robert Wood Johnson Foundation, the National Institutes of Health, and has testified as an expert witness for plaintiffs in suits against tobacco companies. Dr. Kozlowski receives funding from the National Cancer Institute, the Robert Wood Johnson Foundation and has received honoraria from drug companies involved in the development of tobacco-dependence treatments.

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Primary source: The Lancet
Source reference:
Juhua L et al "Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective study" Lancet published online May 10, 2007
Gartner CE et al "Assessment of Swedish snus for tobacco harm reduction: an epidemiological modeling study" Lancet published online May 10, 2007

Foulds J and Kozlowski L "Snus -- what should the public health response be?" Lancet published online May 10, 2007

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