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• W1986126220 abstract "Cigarette smoking is highly addictive and highly toxic. Most smokers start to smoke in their teens, when a majority of young people—in the UK, about 70% by the age of 15 [1]—experiment with cigarettes. A substantial proportion of these progress to regular use, and in due course to addiction [2]. Once established as regular smokers, most wish they had never started smoking [3], want to quit, and have tried and failed to do so. More than half still expect to give up smoking within 2 years, but are in fact more likely to continue smoking for 20 years or more [3]. Half of all regular smokers die as a consequence of their smoking, currently accounting for about 120 000 deaths in the UK each year [4] and 3 000 000 worldwide [5]. This is a substantial public health problem, and any strategy that might reduce it deserves serious consideration. Two papers in this issue of Addiction draw further attention to the potential role of oral moist snuff, or snus[6,7]. Nicotine addiction is the underlying force that drives continued smoking, and the traditional medical approach to helping smokers to quit has been to use medicinal nicotine to ‘replace’ that obtained from cigarettes. Medicinal nicotine is generally safe, especially when compared with continued smoking, and increases the chance of success in any quit attempt by around 70%[8]. At their best, interventions combining medicinal nicotine with intensive behavioural support can achieve 12 month sustained cessation rates of up to 20%[9,10], but the balance of this statistic is that 80% of smokers who make a serious quit attempt with the best medical support available relapse into regular smoking. Other anti-smoking therapies such as bupropion provide an alternative to nicotine replacement, but are no more effective [11]. Although many smokers will make further quit attempts and some will succeed, the fact is that until and unless the efficacy of medical interventions improves substantially, the great majority of current smokers will continue to smoke. These individuals need an acceptable, safer alternative to cigarettes. An ideal pharmaceutical solution would be a medicinal device that delivers nicotine to the brain at a dose and rate similar to cigarettes, something that none of the currently available products achieves. To be a viable alternative, the product would also need to be as readily available as cigarettes, competitively priced, socially acceptable and approved for regular long-term social use rather than a short-term cessation aid. It would also probably be highly addictive. In the present regulatory climate in the UK and European Union, such a product is unlikely to be licensed. An alternative approach, which has already proved acceptable to smokers and to be commercially viable, is smokeless tobacco. Smokeless tobacco is used in many forms: in the USA predominantly as chewing tobacco, in developing countries in a mixture with other substances such as betel nut or leaf, and in Sweden as snus. Some of these products have important adverse health effects, particularly oral cancer [12,13], but as a recent review has demonstrated, the extent of these risks varies substantially between products [14]. Studies of snus in particular have demonstrated relatively modest effects on oral cancer and cardiovascular disease, few of which are statistically significant [14]. Whilst a lack of statistical significance clearly does not rule out important effects, it is also evident that the risks of snus are substantially less than those of smoked tobacco [15]. Snus is available in Sweden by special exemption from European Union laws, which prohibit the sale of smokeless tobacco in other member states. Sweden also currently has the lowest smoking rate in the European Union, which may be due, in no small part, to the availability and acceptability of snus as an alternative product for smokers [16]. In this issue of Addiction, Fagerström & Schildt also review the health evidence on snus and explore the Swedish data in relation to the hypothesis that snus might have the further adverse health effect of acting as a ‘gateway’ to smoking in young people. They conclude that snus, although not risk-free, carries substantially lower risks than smoking tobacco, and in relation to the gateway theory that far more smokers appear to use snus in the process of quitting smoking than progress into smoking from snus use [7]. Gilljam & Galanti present data from a national survey of snus use among current and ex-smokers, demonstrating that smokers who use snus smoke fewer cigarettes per day than non-users and that ever users of snus are less likely to be current smokers than never users [6]. Therefore, these findings also suggest that, on balance, snus is more of a gateway from than to smoking. The crucial point arising from these papers is whether the current ban on the use of snus in the European Union should be lifted, and Fagerström & Schildt argue that doing so would probably be beneficial to public health [7]. However, many involved in tobacco control find this policy difficult to support, not least because it grants new market freedoms to the traditional enemy—the tobacco industry—and because of fears that the industry might abuse this privilege by marketing smokeless tobacco as a starter product and utilizing it to maintain tobacco use in smokers who would otherwise quit completely. On the other hand, there are those who argue that smokers have a right to access safer tobacco products and that, at the population level, the health gains in smokers who switch to snus will more than offset any adverse effect from wider use of smokeless tobacco [17]. Major problems often demand radical solutions, and there is no problem in public health so great as smoking. The current danger is that medical and political conservatism—arising variously from a fear of doing harm, of alienating smokers, a failure to recognize smoking as a chronic addictive disease and many other factors—will continue to perpetuate the current market freedoms enjoyed by cigarette manufacturers and result in millions more avoidable deaths. The Royal College of Physicians in London has recently argued that the regulatory system in the UK, which currently grants the greatest commercial freedom to the most dangerous nicotine product, needs to be overhauled to apply controls on medicinal nicotine and smokeless and smoked tobacco in proportion to the harm they cause [18]. A similar proposal has been made from Action on Smoking and Health in the UK to the European Union [19]. If adopted, these proposals would allow medicinal nicotine, snus and potential new smokeless products to become commercially available in a suitable environment of control, monitoring and review. The Swedish experience suggests strongly that this would reduce the current burden of disease caused by smoking. To date, the UK Government has responded by saying that ‘the time is not right’. One wonders if it will ever be otherwise." @default.
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• W1986126220 date "2003-08-27" @default.
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• W1986126220 title "Smokeless tobacco: friend or foe?" @default.
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