Eletter to Tobacco Control in response to an eletter published in the same journal about whether snus (Swedish moist oral snuff) was responsible for a decline in smoking prevalence among men in Sweden

Gartner, Coral E.

Hall, Wayne D.

University of Queensland eSpace

Does Snus use have a harm reduction effect in Sweden? 7 February 2007    
Prakash C 
Gupta,  
Research 
Scientist  
Healis - 
Sekhsaria 
Institute for 
Public Health, 
Navi Mumbai, 
India 
Send letter to 
journal:  
Re: Does Snus 
use have a 
harm 
reduction 
effect in 
Sweden? 
Email Prakash 
C Gupta 
Dear Editor  
Some tobacco control community members believe that advocating the use of snus, a form of Swedish smokeless 
tobacco said to be less harmful than cigarettes, would prove an effective harm reduction strategy against tobacco 
related diseases. One important basis for such a claim is the fact that snus is widely used in Sweden (23% men used 
snus daily in 2002), where the incidence of cancer caused by tobacco is relatively low, and the observation that the 
Swedish are switching from smoked tobacco to snus. One way of looking at this claim of harm reduction through the 
use of snus is to compare tobacco related cancer rates in Sweden to those in the state of Connecticut, where use of 
any kind of smokeless tobacco including snus has been consistently rare.  
The table below provides a comparison of age adjusted incidence rates for Sweden and Connecticut. As the data 
show, the incidence of tobacco related cancer is much lower in Sweden, about one half that of Connecticut. Trend 
data for Sweden seemingly provide further supportive evidence to the harm reduction hypothesis, as a dramatic 
increase in snus use in Sweden (0.4 kg/person in 1970 to 0.9kg/person in 2000) coincides with a decreasing 
cigarette consumption (1.1kg/person in 1970 to 0.6kg/person in 2000) resulting in a decrease of tobacco related 
cancer from 97.8 per 100,000 in 1966-1970 to 56.7 per 100,000 in 1993-1997.1,  
However, if snus has a harm reduction effect, the incidence of tobacco related cancers should not only decline in 
Sweden as snus use increases, but it should decrease more in Sweden than in Connecticut, where the consumption 
of smokeless tobacco has remained <1% over 1990s. However, the data below demonstrate that the ratio of the 
incidence of tobacco related cancer in Sweden and Connecticut has remained constant at about 0.5 since 1973, and 
the same ratio for lung cancer has been stable at about 0.4 since1960. Rather than snus causing the decrease in 
tobacco related cancer in Sweden, these data suggest that another factor was responsible in reducing cancer 
incidence in both Sweden and Connecticut. That factor is likely to be the decline in cigarette use, which fell in men 
from about 28% to 15% (Sweden) and 26.7% to 18.7% (Connecticut) from 1985-2003.1,3 During the period of 
1970s to 1990s, both populations were exposed to smoking reduction strategies such as increased awareness of 
health risks, increased prices, a change in social norms regarding tobacco use, etc but both places did not have an 
increase in snus use. Thus, the data do not seem to support the hypothesis that the decrease in tobacco related 
cancers in Sweden is due to increasing use of snus.  
 
References  
1. Foulds, J., Ramstrom, L., Burke, M., Fogerstrom K. Effect of Smokeless tobacco (snus) on smoking and public 
health in Sweden. Tobacco Control, 2003; 12:349–359.  
2. Cancer Incidence in Five Continents. Vol. I-VIII. Lyon: International Agency for Research on Cancer.  
3. CDC. State System: State Tobacco Activities tracking and evaluation system. Tobacco Use Supplement to the 
Current Population Survey. 2006. Available at http://apps.nccd.cdc.gov/statesystem/. Accessed January 17, 2007. 
RE: Does Snus use have a harm reduction effect in Sweden? 8 February 2007    
Coral E 
Gartner,  
Research 
Officer  
School of 
Population 
Health, 
University of 
Queensland,  
Wayne D Hall 
Dr Gupta’s comparison of trends in lung cancer mortality and smoking prevalence in Sweden and Connecticut 
purports to undermine the claim that increasing snus use in Sweden has contributed to declining lung cancer rates 
there.  
Dr Gupta argues that some factor other than snus must have been at work because the ratio of lung cancers 
between Sweden and Connecticut has remained constant despite the large difference in snus use between the two 
places. He identifies this “other factor” as a declining cigarette smoking prevalence that he attributes to tobacco 
control policies.  
Page 1 of 2Tobacco Control -- eLetters for Foulds et al., 12 (4) 349-359
6/03/2007http://tc.bmj.com/cgi/eletters/12/4/349
Send letter to 
journal:  
Re: RE: Does 
Snus use have 
a harm 
reduction 
effect in 
Sweden? 
Email Coral E 
Gartner, et al. 
We agree that a decline in cigarette smoking in both countries explains the lung cancer trends but we don’t see how 
this rules out a role for snus. This is exactly the mechanism by which proponents of snus would claim that snus use 
reduces smoking prevalence, namely, that population smoking prevalence declines because existing smokers switch 
to snus and new tobacco users use snus rather than cigarettes (Ramström and Foulds 2006).  
The fact that smoking prevalence declined in Connecticut as a result of more traditional tobacco control policies 
simply shows that there is more than one way to reduce smoking prevalence. The fact that the decline in cigarette 
smoking over the time period examined was greater in Sweden ( -13%) than in Connecticut (-8%) supports the 
hypothesis that the addition of snus to more conventional tobacco control policies has increased the decline in 
smoking prevalence.  
We concede that the comparison does not prove that snus was responsible for the decline in lung cancer rates in 
Sweden, but it is much more supportive of the claims for snus than Dr Gupta allows.  
Yours sincerely  
Coral Gartner and Wayne Hall  
References  
Ramström, L. M. and J. Foulds (2006). "Role of snus in initiation and cessation of tobacco smoking in Sweden." 
Tobacco Control 15(3): 210-214.  
Page 2 of 2Tobacco Control -- eLetters for Foulds et al., 12 (4) 349-359
6/03/2007http://tc.bmj.com/cgi/eletters/12/4/349


RE: Does Snus use have a harm reduction effect in Sweden?

http://espace.library.uq.edu.au/view/UQ:12884/Gartner_Hall_2007.pdf

RE: Does Snus use have a harm reduction effect in Sweden?

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