Snus and Health

Some facts about
Swedish Snus and health

From a perspective of public health, there is much to say about Swedish snus and its positive influence, foremost as a more healthy alternative to smoking.

An increasing amount of scientific studies, regarding the positive health aspects of the unique Swedish snus, has lately been highlighted in the media and through various interest organisations.

At the same time, the international interest concerning Swedish snus is growing steadily, specifically as a more healthy alternative to smoking and the significant damages to public health that it entails.

Swedish snus is the most common smoking cessation in both Sweden and Norway today.

Swedish snus contains nicotine to various degrees. The pharmacological effects of nicotine to the central nervous system has long been well documented and in studies it has been made clear that nicotine, as well as its metabolites, does not cause cancer within man (A). All use of nicotine is however additive, even substitutes such as nicotine gums and patches.

Today, Swedish snus is the most common smoking cessation aid in both Sweden and Norway. Due to that fact there are medical researchers whom states that Swedish snus has a considerable positive effect in regards to public health. This is evidently noticeable in Scandinavian countries such as Sweden and Norway, where there are more snus users than smokers.

An example of this, often worth mentioning in this context, is that Sweden has the lowest amount of lung cancer incidence and mortality within Europe, according to the WHO’s International Agency for Research on Cancer (IARC) and World Health Ranking statistics, despite the fact that the total amount of tobacco users are in parity with other countries.

This is primarily due to the fact that Swedish snus, which is produced through a process very similar to pasteurization, contains very low amounts of TSNA (Tobacco Specific Nitros Amines), which are the main group of cancerogenic substances in tobacco, as well as the fact that the delivery of nicotine does not occur through harmful smoke being transported via the windpipe down to the lungs.

New scientific studies, as well as reviewed analysis of earlier scientific investigations, has shown a lack of evidence in order to connect Swedish snus specifically to such medical states of disease that are usually considered to be caused by other kinds of tobacco use, primarily smoking, such as lung cancer, cardiovascular disease, stroke and various diseases and infections to the respiratory organs (WHO 2014).

Furthermore, the use of Swedish snus does not cause any secondary or peripheral injuries to the close environment, as passive tobacco smoking have been known to do for a long time. In 2014 the U.S. Department of Health determined that passive smoking increases the risk for lung cancer and cardiovascular disease for adults as well as for children. It is also established that tobacco smoke in relation to pregnancy increases the risk for inhibited fetal growth, low birth weight and premature birth. Pregnant women are however recommended to refrain from all sorts of nicotine use.

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For further reading on Swedish snus and Health, please see the following reports in PDF-format:

Swedish Snus Report October (121 kB – English only)
Environ – Review of the Scientific Literature on Snus (1,5 MB – English only)

Some myths and the facts

”NO CONNECTION TO HEAD AND NECK CANCER.”

Interview statement, May 2020:

”A large proportion, perhaps as much as 20 %, of the Swedish population use Swedish snus, regularly. And there is yet to see any head and neck cancer patients where we can see a direct connection with the use of Swedish snus and cancer. I also know of several scientific studies… where they have tried to establish connections to head and neck cancer and Swedish snus and the conclusion have always been that they can not find such a connection.”

Dr. Thomas Westin, associate professor, Sahlgrenska University Hospital, Sweden, former clinical director at the Head and neck cancer unit, Royal Hallamsire Hospital, UK.

”RISK HYPOTHESIS LACKS CREDIBILITY.”

Dagens Medicin Magazine, published 26 May 2012:

”From a molecular biological perspective, the hypothesis that Swedish snus constitutes a significant risk for cancer, lacks credibility. A recently conducted gathering analysis of every epidemiological study of the subject supports this conclusion.”

Professor Robert Nilsson, The Institute for genetics, microbiology and toxicology, Stockholm University, Sweden.

”SMOKING IS THE VILLAIN.”

Dagens Medicin Magazine, published 24 March 2016. Debate article:

”We can establish that nicotine in itself probably does not constitute any major health hazard. It is smoking that is the villain when it comes to chronic obstructive lung disease and lung cancer.”

Dr. Stefan Willers, chief physician, associate professor Lung- and allergy unit, Lund University, Sweden.

”NO CONNECTION TO MOUTH AND THROAT CANCER.”

The Lancet, 16 September 2017:

In September 2017 the renowned medical journal The Lancet published an extensive metastudy (B). The study titled ”The Global Burden of Disease Study” (GBD) is a systematic analysis and includes research published during the years 1990–2016. In relation to Swedish snus the study’s summary of the scientific conclusions read as follows: ” There is sufficient evidence that chewing tobacco and products with similar toxidity causes excessive risks for mouth- and throat cancer, while existing evidence does not support any liability for snus or similar smoke free tobacco products.”

Click here to read the study online. (English only)

“SWEDISH SNUS BENEFITS PUBLIC HEALTH.”

Aftonbladet newspaper, Sweden, 29 September 2013:

The scientific community agrees that Swedish Snus is less harmful than other tobacco products. In an article published in the international magazine Drugs and Alcohol Today, Dr. Karl Erik Lund, chief researcher at ‘Statens Institutt for Rusmiddelforskning’ (SIRUS) in Norway, presents new observations.

– We have been studying the impact of Swedish snus in regards to public health during many years. At this point we can establish the fact that Swedish snus contributes explicit gains to the health status of the population. This also applies to Sweden, Dr. Karl Erik Lund says to Aftonbladet.

According to the scientific report, the use of Swedish snus have not resulted in double addiction, where people both smokes and uses snus. The consequences of the Anti-Snus lobby activities may prove lethal, according to Dr. Karl Erik Lund.

– The focus on a tobacco free society may stand in the way of using Swedish snus as a harm reducing means. We might not be able to state how many lives has been won thanks to Swedish snus, but in all it indicates that Swedish snus have a positive effect on public health, says Dr. Karl Erik Lund.

The Swedish Experience

Within the boundaries of international research concerning tobacco consumption there is an expressed established paradox, known within the scientific community as “The Swedish Experience”.

According to multinational Swedish snus manufacturer Swedish Match, everything centres around the statistic fact that asserts that ”the risk of dying in a tobacco related disease is less in Sweden than in any other European country, despite that the tobacco consumption is on a comparable level with other countries in Europe, measured in kilograms.

”The Swedish Experience” can, according to Swedish Match, probably be explained by the circumstance that the unique Swedish snus constitutes a large part of Swedish men’s tobacco consumption, even though the total tobacco consumption is about the same as in other comparable countries.

The major difference thus comes from the fact that Swedish men doesn’t smoke to the same extent, but uses Swedish snus instead. Statistics brought forward by Swedish Match also shows that the proportion of Swedish men that uses snus amounts to 18%, while the share of daily smokers amounts to 10%, which moreover is the lowest number in Europe.

As previously established, this results in a very low rate of tobacco related diseases and thus also a very low mortality rate related to smoking amongst Swedish men. ”This unique relationship is documented in a large number of epidemiological studies that, among other things, shows that people in Sweden has the lowest risks of contracting lung cancer among the industrialized countries.” According to Swedish Match, the use of Swedish snus may perhaps not entirely be disclaimed from any negative health effects, but scientific results has shown that the health risks of using Swedish snus are considerably less than from smoking.

They exemplify these results with the following facts concerning the use of Swedish snus:

In 2011, 10% of all adult Swedish men smoked on a daily basis. The corresponding number in Norway was 19%, Denmark 22% and the average for Europe was 32%, according to a survey of 2010 (1).
In 2011, 18% of all adult Swedish men used Swedish snus on a daily basis, in Norway the corresponding number was 12% and in Denmark 1,5% used some sort of smoke free tobacco product regularly (1).
In 2011, 12% of all adult Swedish women smoked on a daily basis. The corresponding number in Norway was 19%, Denmark 22% and the average for Europe was 21%, according to a survey of 2010 (1).
In 2011, 3% of all adult Swedish women used Swedish snus on a daily basis, in Norway the corresponding number was under 2% and in Denmark 0,2% used some sort of smoke free tobacco product regularly (1).
In 1997, Sweden was the first country in the world to reach WHO’s goal for the years 2000, where the proportion of adult smokers would be below 20% (3). The second country in Europe to achieve this goal was Iceland in 2005, which as a Scandinavian country also have long tradition of using smokeless tobacco.
In the year 2000, 10% of the mortality rate amongst Swedish men were smoking related, which was the lowest rate in Europe. The average rate within the EU 25 was 23% (4).
Women in Sweden had the same mortality rate as the average rate within the EU 25 by the year 2000; 7% of the mortality rate was smoking related (4).
In the year 2000, the risk for a 35 year old male to die from a smoking related disease before the age of 70 was 3% in Sweden, comparable to 5% in Norway, 8% in Denmark and 9% in average for the EU 25 (4).
The incidence for lung cancer amongst Swedish men has been reduced during the last 20 years. Swedish women, however, showed an increasing trend within lung cancer statistics (5).
In two epidemiological studies conducted in Sweden, no connection could be shown between the use of Swedish snus and cancer to the mouth (6,7).
In two epidemiological studies concerning stomach cancer and throat cancer, no connection between Swedish snus and any of these two types of cancer could be shown (8,9).
The mortality rate of cancer is not elevated among Swedish snus users (10).
The risk of suffering cardiac arrest is not elevated among Swedish snus users (11).
In a study comprehending Swedish snus users the scientists did not find any significant increase to diastolic blood pressure, concentration of hemoglobin, white blood cell counts, serum cholesterol or triglyceride levels. These results contrasts the results from corresponding studies of cigarette smokers (12).

References:

A. Adlkofer, F.X. 1995. Involvement of nicotine and its metabolites in the pathology of smoking-related diseases: Facts and hypothesis. In: P.B.S. Clarke, M. Quik, F. Adlkofer. & K. Thurau (Eds.), Advances in Pharmacological Sciences, Effects of Nicotine on Biological Systems II. (pp. 17-25). Basel, Boston, Berlin: Birkhäuser Verlag.

B. ”Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016”.

1. Sverige: Statens Folkhälsoinstitut. Norge: Sosial- og helsedirektoratet. Danmark: Sundhedsstyrelsen. Europa (EU 25+ Island, Norge och Schweiz): The European Tobacco Control Report 2007. WHO Regional Office for Europe.

2. Folkhälsa. Lägesrapport 2005, sid 24-25. Socialstyrelsen

3. Tobacco Statistics 1970-1999. Statistical Report 2000-09-18, VECA HB Statistical Bureau, p. 12.

4. Peto, R.; Lopez, AD.; Boreham, J.; Thun, M.; Heath, C. Mortality from smoking in developed countries 1950-2000 (2nd edition). Oxford, Oxford University Press; 2003. Updated in June 2006.

5. Swedish Cancer Registry, 1998.

6. Lewin, F., Norell, S.E., Johansson, H., Gustavsson, P., Wennerberg, J., Björklund, A., Rutqvist, L.E. Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck. Cancer, 82, 1367-75 (1998).

7. Schildt, E.-B., Eriksson, M., Hardell, L., Magnusson, A. Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. Int. J. Cancer, 77, 341-6 (1998).

8. Ye, W., Ekström, A.M., Hansson, L.-E., Bergström, R., Nyrén, O. Tobacco, alcohol and the risk of gastric cancer by sub-site and histologic type. Int. J. Cancer, 83, 223-9 (1999).

9. Lagergren, J., Bergström, R., Lindgren, A., Nyrén, O. The role of tobacco, snuff and alcohol use in the aetiology of cancer of the oesophagus and gastric cardia. Int. J. Cancer, 85, 340-6 (2000).

10. Bolinder, G., Alfredsson, L., Englund, A., de Faire, U. Smokeless tobacco and increased cardiovascular mortality among Swedish construction workers. Am. J. Public Health, 84, 399-404 (1994).

11. Huhtasaari, F., Lundberg, V., Eliasson, M., Janlert, U., Asplund, K. Smokeless tobacco as a possible risk factor for myocardial infarction: A population-based study in middle-aged men. J. Am. Coll. Cardiol., 34, 1784-90 (1999).

12. Eliasson, M., Lundblad, D., Hägg, E. Cardiovascular risk factors in young snuff-users and cigarette smokers. J. Int. Med., 230, 17-22 (1991).