Tobacco Harm Reduction and the right to health

14 Swedish snus is the dominant form of smokeless tobacco in the Nordic countries. It is illegal to sell snus in all European Union countries except Sweden. In Canada and several regions of the USA, it is sold alongside American-produced forms of snus, and in October 2019, the US Federal Drug Administration (FDA) granted the first ever modified risk orders to eight Swedish snus products, meaning they can be advertised with specific information about the lower risks of certain health effects compared to smoking cigarettes. 40 A European Commission review concluded that complete substitution of smokeless tobacco products for tobacco smoking would ultimately prevent nearly all deaths from respiratory disease currently caused by smoking, and reduce the cardiovascular mortality that currently arises from smoking by at least 50%. 41 There is no significant association between snus and premature deaths, diabetes, pancreatic and oral cancers, heart disease or strokes. substitution of smokeless tobacco products for tobacco smoking would prevent nearly all deaths from respiratory disease caused by smoking Substituting Swedish snus for high risk oral or chewed smokeless tobacco (SLT) products could be transformative to health in many LMIC. In India, for example, the use of high risk SLT products is common, especially among women, for whom it is less socially acceptable to smoke; around 70 million girls and women in India aged 15 or over are thought to use SLT on a regular basis. India has the highest global rate of oral cancer due to the high prevalence of SLT use, accounting for around 400,000 deaths annually. 42 Case study: Sweden and snus – low rates of smoking and the lowest level of tobacco-related mortality in Europe Sweden provides a unique case study of the impact of snus on smoking. It is the only country in the EU where snus may be sold legally. Snus dominated tobacco use in the country until the early 1900s, when the invention of the cigarette rolling machine popularised the cigarette. However, from the 1960s, the trend reversed and use of snus increased. In 1996, snus became more popular than cigarettes; the reduction in smoking was faster in men than women. According to the European Commission's Eurobarometer report in 2017, on average, just 5% of Swedish adults now smoke daily – a level that is less than one fifth of the EU average of 24%. 43 Sweden has, for men, the lowest tobacco-related mortality rate in Europe at 152 per 100,000. The rate is less than one third of the European average of 467 per 100,000. 44 The long-term epidemiological evidence provided by this natural experiment gives us information on the uptake and plausible impact of snus on smoking and tobacco-related disease. It also acts as proof of concept for the potential efficacy and effectiveness of tobacco harm reduction, as identified by the UK Royal College of Physicians: “The availability and use of […] snus in Sweden […] demonstrates […] that a substantial proportion of smokers will, given the availability of a socially acceptable and affordable consumer alternative offering a lower hazard to health, switch from smoked tobacco to the alternative product.” 45 As a non-EU member, snus is legal in Norway. Fewer Norwegians smoke (11%) than use snus (12%). Among young women aged 16 to 24, smoking has all but disappeared (1%) . 46 40 Federal Drug Administration (FDA) (2019). FDA authorizes modified risk tobacco products. https://www. fda.gov/tobacco-products/advertising-and-promotion/fda-authorizes-modified-risk-tobacco-products?utm_ source=CTPTwitter&utm_medium=social&utm_campaign=ctp-webfeature 41 European Commission (2008). Scientific Committee on Emerging and Newly Identified Health Risks. Health effects of smokeless tobacco products . Health and Consumer Protection Directorate. https://ec.europa.eu/health/ph_risk/ committees/04_scenihr/docs/scenihr_o_013.pdf 42 Gupta PC, Arora M, Sinha DN, Asma S, Parascandola M (eds.); Smokeless Tobacco and Public Health in India. Ministry of Health & Family Welfare, Government of India; New Delhi; 2016. https://www.mohfw.gov.in/sites/default/files/ Final%20Version%20of%20SLT%20Monograph.pdf 43 European Commission (2017) Special Eurobarometer 458: Attitudes of Europeans towards tobacco and electronic cigarettes https://data.europa.eu/euodp/en/data/dataset/S2146_87_1_458_ENG 44 WHO (2012) WHO Global Report: mortality attributable to tobacco https://apps.who.int/iris/bitstream/ handle/10665/44815/9789241564434_eng.pdf?sequence=1 45 Royal College of Physicians (RCP) (2016). Nicotine without smoke; tobacco harm reduction. A report by the Tobacco Advisory Group of the Royal College of Physicians . Retrieved from: https://www.rcplondon.ac.uk/projects/outputs/ nicotine-without-smoke-tobacco-harm-reduction 46 The Norwegian Directorate of Health (2017) Statistics Norway: 2017 data https://www.ssb.no/en/helse/artikler-og-publikasjoner/snus-more-used-than-cigarettes