Media exchange between myself and Swedish Public Health August 21st – Sept 3rd 2015

Dear Reader, finally a reply from Swedish Public Health on my snus Op-Ed article in Sweden’s largest daily. My response to their response is on top, the best known tobacco researcher in Sweden who was kind enough to reply is in the middle, and finally on the end is my initial article from august that really started the nationwide debate in Sweden. What do you think?

Atakan Befrits: Snus is not a cure, but one of the best cigarette alternatives available – Published: September 2, 2015

http://asikt.dn.se/asikt/debatt/snus-ar-inte-ett-allvarligt-folkhalsoproblem/snus-ar-inte-ett-botemedel-men-ett-av-de-basta-cigarettalternativen-som-finns/

If the Swedish Public Health Agency and the National Board of Public Health both advise the FDA not to allow removal of the cancer warning on Swedish snus, even though it was done in Sweden already 2001, that can hardly be considered to be proper, honest or objective, can it?

If India, referring to Sweden and WHO, creates several million new smokers by banning all types of snus, have they then really understood the situation in Sweden with regards to snus and harms from snus?

Professor Gilljam, thanks for the important and illuminating answers to my opinion article, the answer is very much appreciated and does you honor!

As I see it You do not refute one single critical point in my article, and only confirm what I wanted to highlight, that snus is not a serious public health problem in Sweden, and has never been one.

You mention snus in terms that in the current form, has been around for only 16-17 years and that this is not sufficient to rule out any risks associated with snus. This is not true!

Modern pouch snus with a tenfold higher levels of tobacco-specific nitrosamines, compared with current snus, made it’s entry in the Swedish offices around 1980. So we have quite enough ex-smokers (and exclusive snus users) who have used snus for far longer than 35 years, with no measurable severe damage, more than sufficient to rule out serious adverse health effects. The value in terms of public health and individual health benefits, for Sweden as a country for the individuals, cannot be distinguished from if they quit entirely or never began in the first place (always the best option, of course). Furthermore snus in general, as it is produced and used in Sweden, has not given rise to measurable severe adverse health effects in over 100 years. The Swedish Medical Journal magazine’s paper archives (1904-1995) for example, do not even have the world “snus” indexed, but of course it has hundreds of articles on the harmful effects of smoking.

You mention in your reply that Sweden cannot advocate a harmful product. I agree with you completely. Sweden should not advocate snus internationally in any other respect than that it has played an important role in the Swedish smoking, that is lower than any other EU country, without relevant measurable serious injury. So just completely objectively state established facts in a relevant context, basically just tell the truth, and then let the other countries / people make their own health calculations.

I hope that snus can play an important role in the world as a damage-minimizing tobacco product, but without giving rise to large groups snus users who would otherwise never have used tobacco. If it should prove unavoidable that there are young people internationally who start using snus anyway, one may assume that many of them would otherwise have started to smoke, so even then, snus is distinctly positive to public health. Not so good for Tobacco End Game of course, but infinitely better than if they were to start smoking, right?

You mention in your reply that because of aesthetic and cultural reasons snus has no place outside Sweden (what about Norway, USA, Canada?).

Are over 1 billion smokers practitioners of an aesthetics culture? Moreover also, without foreign influences?

300 million people worldwide are using extremely dangerous forms of smokeless formulations(very very dangerous snus, simply put), in their case it is definitely a question of a local cultural expression, compared with Sweden’s about 1 million snus users.

Therefore I simply cannot see any relevance in the comments about the aesthetics and culture. Women do not like to use snus because it is it’s ugly, true. Women might think it was worth it anyway, if they knew that snus is almost just as good as to stop completely with tobacco/nicotine? Accurate information in a relevant context certainly makes my decisions easier to make, do you agree?

Have we not reason to, even a responsibility to, be open with the information that the way we produce our snus in little Sweden, renders the product virtually harmless? That could hardly be considered advocating snus, or could it?

Finally: Well, Sweden does torpedo snus internationally, as much as we can, and all the time. Both actively and passively. Actively through international letters and studies that are taken completely out of the relevant context, and that definitely does not fit other nation’s contexts where hundreds of thousands die each year of smoking and poorly manufactured smokeless tobacco. Passively we torpedo snus internationally through not ever correcting completely erroneous and often malicious conclusions drawn from “Swedish quality research”. This erroneous conclusions, citing Swedish science, then start a new life as “scientific facts from Sweden”, since no one objects.

India has, with main reference to Sweden and WHO, totally banned smokeless tobacco affecting 200 million users! Instead of introducing quality standards equivalent to the Swedish ones, or for that matter the standards suggested by the WHO in it’s Technical Report 955, India blanket banned smokeless instead.

The total ban in India of course makes improvement, taxation and quality control totally impossible. What is infinitely worse, the tax losses from the now banned smokeless tobacco in India is replaced by increased sales of cigarettes, through tax cuts on combustible tobacco.

Professor Hans Gilljam: The cigarette is lethal – but snus is not the cure! – Published: September 1, 2015

The headline sums up my response to Atakan Befrits post “Snus is not a serious public health problem” in which he argues that the Swedish authorities back-stab snus without justification and that this puts obstacles in the way of snus’ deserved global sales opportunities.

Befrits is quite right regarding combustible tobacco, read “the cigarette”, the cigarette is the “Number 1” that has killed more people than all wars and epidemics combined the past 100 years, and the situation is only getting worse.

However, a full 50-year follow-up of chronic smokers was required to understand the extent of the catastrophe. Modern Swedish snus has only been around for 16-17 years, so it will be some time before we know everything about the harm from snus.

I share Befrits view that snus must be far less harmful than cigarettes, but suggesting that Swedish authorities should actively advocate snus internationally is going too far. New research shows that snus causes risks such as cardiovascular disease. Research also shows that traditional Swedish snus is culturally/aesthetically repugnant to many, and therefore snus is not a relevant product internationally.

I argue that the “Tobacco Endgame – Smoke free Sweden 2025” (www.tobaksfakta.se) is a better option to reduce tobacco-related mortality than to peddle snus internationally, a product that few outside Sweden even want.

Atakan Befrits: Snus is not a serious public health problem – Published: august 21, 2015

It is time for Karolinska Institute (KI), the Public Health Agency and the National Board of Health in Sweden to do the right thing and explain how stumblingly near zero the harm from snus actually is in Sweden. They should then refer and recommend that adult consumers make their own informed decisions.

Sweden has a unique responsibility to the world to rectify a 40-year old mistake and potentially save hundreds of millions of lives. It is not the tobacco itself, or the nicotine, that kills. It is the combustion gasses from tobacco smoking, or poor quality tobacco mixed with other dangerous carcinogens, which kill and destroy health.

According to the WHO, one billion people this century will die from smoking given the current developments. Broad international knowledge that a 99% less hazardous tobacco use is quite possible, inexpensive, and furthermore proven in Sweden since 100 years. Snus has every potential to save hundreds of millions of lives worldwide.

Is it then reasonable that Sweden, nationally and especially internationally, continues to push the line that snus is a serious public health problem, when it patently clearly is not?

Would it not be better to cooperate with our public health authorities to maximize the benefits we can realize from snus (e-cigarette) to smokers, while minimizing the use of snus (e-cigarette) among those who otherwise would never have initiated tobacco or nicotine use?

The Swedish government in June 2013 ordered an investigation to be done by the National Board of Health, the Public Health Agency and the Karolinska, to present to the government the total cost and harms to health of total tobacco consumption in Sweden. The report from the National Board could not show a single data point as evidence that snus is a serious public health problem, but clearly showed that about 12,000 die from smoking each year in Sweden. Can anyone draw any other conclusion from that, other than that the harms from snus are below relevant measurable levels in terms of public health?

  • Snus in Sweden used by 300,000 people for not smoking, it saves about 3,589 lives a year and causes up to 11 cases of cancer overall (Wickholm 2005)
  • Snus in Sweden used by 700,000 people who have never smoked, as a mild stimulant and addictive pleasure product, that results in no more than 24 cases of cancer per year, according to a Swedish study from 2005 (Wickholm)
  • The total maximum of 35 cases of cancer a year (if any at all), have for a hundred years not caught any attention from healthcare, and harm from snus is thus so low that it is not meaningful to measure (National Board of Health 2014)
  • If all of Sweden (ten million) took snus daily and nobody smoked, we would have about 12,000 fewer deaths from smoking in Sweden each year, while the snus use would cause a total maximum of 350 cases of cancer per year and no other measurable serious adverse health effects
  • Cancer warnings were removed from snus in Sweden in 2001, since not even the 35 (possible) cases of cancer per million user years mentioned above, could be verified with evidence-based science according to the European Union
  • The Public Health Agency of Sweden has actively (2015) sought to influence the FDA to not allow the removal of the cancer warning on Swedish snus sold there
  • Reduction in risk of continued tobacco use if one switches from cigarettes to snus use is 99.7% according to the figures above
  • A lifetime of snus use causes substantially lower risks than only 3 months of smoking or continued smoking does

So, snus is not harmless, but definitely not a serious “public health problem”.

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