Oral Tobacco: Snuffer, Beware

12. December 2017

Snuff is considered a healthy alternative to cigarettes. According to The Global Forum For Nicotine, it is "up to 95 % safer than cigarettes". Critics warn that the risks are being underestimated, as it contains 28 cancer promoting substances. Its consumption can lead to miscarriage in pregnant women.

They look like tiny tea bags, however the tiny sachets contain no tea, but rather a mixture of fine ground tobacco, water, salt and aromas. Snus is pushed under the upper or lower lip and remains there for up to an hour, sometimes even longer. Saliva dissolves the nicotine, which eventually finds its way into the circulatory system through the oral mucosa. The salt contained enhances the uptake of the nicotine. The effect is similar to that of a cigarette: snus raises the pulse, relaxes and awakens the user.

Snus has a long tradition in Sweden and Norway. The oldest sort was first manufactured by Jacob Fredrik Ljunglöf in the year 1822. This aromatic product is particularly loved by Swedish and Norwegian youth. In the rest of Europe, in contrast, the trade of snus is forbidden. Regulation is governed by “directives to achieve conformity between member states regarding legal and administrative aspects for distribution and sale of tobacco products (2001/37/EC)”. The goal of the guidelines is to protect health. Looking at Germany, it states expressly in § 11 of the tobacco product laws: “The sale and distribution of oral tobacco is forbidden”.

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Snuff is held under the upper lip for up to an hour/ Christian Jensen, flickr

In contrast the consumption of snus is permitted in Germany if the consumer is at least 18 years of age. Germans spending their holiday time in Sweden are permitted to return home with a 1 kg amount of snus for private consumption. Assuming dosage sizes of 34 grams, this is equivalent to 29 snuff-doses. Delivering and further selling to friends and acquaintances are however forbidden.

Prohibition under fire

The British consumer group New Nicotine Alliance (NNA) views snus as a healthy alternative to the cigarette. They have for this reason filed a legal action against this prohibition, which will now be examined in the European Court of Justice. Gerry Stimson, chairperson of the NNA, says: “A ban allows smokers fewer options for healthy alternatives and has a negative impact on the health of the population”.

Participants of the Global Forum On Nicotine, an international conference dealing with the subject of nicotine products, also view snus as a healthy alternative to cigarettes. Yet what is the so-titled Global Forum On Nicotine quite about? “This conference according to my assessment pursues the goal of promoting harm reduction, which furthermore is also a goal of the tobacco industry”, Katrin Schaller of the German Cancer Research Institute in Heidelberg (Germany) says. “The key theme of the conference is the e-cigarette, aside from that the main subject of discussion is snus. With respect to e-cigarettes in particular, what stands out is that many experts appeared as speakers who are strongly in favour of e-cigarettes; among them some also have conflicts of interest. E-cigarette interest associations were specified to be sponsors of the event in 2017. In 2015, 2016 and 2017 representatives of the tobacco industry spoke as part of the conference program, as did in recent years the inventor of the modern e-cigarette”.

According to Peter Lee, epidemiologist and medical statistician, in terms of cancer risk snus is 95 % safer than cigarettes. Swedish researcher Lars Ramstäm is convinced that – if snus were obtainable in Europe and similar consumption figures were to be assumed – every year up to 320,000 premature death cases could be prevented. The reason for this is that the consumption of snus would not raise the risk of lung disease, stroke or heart disease, he says.

Snus contains 28 cancer promoting substances

Yet the aromatic tobacco sachets are not quite as problem free as one might assume from this statement. This is because even if manufacturers were able to reduce cancer promoting substances through changing production processes, there still are in snus 28 cancer promoting substances, among them the poison n-nitrosamine.

  • The first health damaging side effects can appear directly following consumption of a sachet: forms of poisoning such as nausea and breathing difficulties. With high doses breathing can even cease.
  • Pregnant women have a higher probability of miscarriage and premature birth.
  • Some seven in ten users of snus suffer oral leukoplakia, a predominantly white lesion of the oral mucosa.
  • In addition, lovers of oral tobacco have as much as a nine-fold higher risk of gum atrophy.

Until now no significant correlation has been able to be found between snus consumption and oesophageal carcinoma. One study, investigating the product naswar, shows that the situation is not the same for all tobacco products used orally. Naswar is a mixture of tobacco leaves, ash, slaked lime and diverse aromatic substances which is placed in the cheeks of the mouth. According to the study looking at people who have the disease and who use the green powder or paste, users suffer from oesophageal cancer some twenty times more often than non-consumers.

A case-control study confirmed the suspicion that the consumption of naswar elevates the risk of oesophageal cancer. The reason for this result, according to Hajo Zeeb, head of the section for Prevention and Assessment at Leibniz-Institute for Prevention Studies and Epidemiology, is that naswar carries a relatively high proportion of harmful tobacco-specific nitrosamine combined with a high nicotine content. “The presence of a lot of nicotine, which is addictive, induces consumers to reach for the harmful product more often”. What’s more, the slaked lime which is released increases pH levels, bringing them into the alkaline range, which also enhances the release and uptake of nicotine. The alkaline pH levels however also damage the oral mucosa, in this way creating lesions in tissue, which are always a risk factor for cancer. There is no lime contained in snus”. The ash in naswar in addition contains heavy metals, which further raise toxicity.

Snusing: anything other than healthy

Already 10 years ago scientists at the Karolinska-Institute [Paywall] found out that snus-consumers contract pancreatic tumours about twice as often as people who do not consume it. In addition snusers developed diabetes mellitus more frequently. Scientists [Paywall] at Umeå University in Umeå and at Karolinska Institute have therefore analysed five separate studies involving almost 55,000 participants. The outcome: for people with very high consumption habit of seven snus-boxes each containing 20 sachets per week, the risk of diabetes is elevated by 70 %. With consumption of five to six boxes per week (each containing 20 sachets) the likelihood of the illness rises by 40 %. The blame for this, according to the authors, lies with nicotine, which inhibits insulin sensitivity and promotes the release of cortisol, something which can lead to insulin resistance.

The use of snus is believed to even have negative effects on the lungs. According to a study from BMJ Open the snuser’s risk of getting asthma is as much as 50 % higher than for non-consumers. In order to obtain this result, scientists in Sweden and Iceland evaluated questionnaires from 16,000 people who had not smoked but had consumed snus. One weakness of the study: information on how many sachets they used per day was not specified. The scientists’ assumption is that the consumption of snus provokes an inflammation in the upper respiratory tract, which wanders on to the lower region – in a similar way to rhinitis or infection.

Snus as a form of breaking the smoking habit

Proponents at the Global Forum for Nicotine are convinced that snus can help people give up the smoking habit. The German Cancer Research Centre however emphasises: snus is banned in Germany and not approved as a tool for quitting tobacco smoking. As things stand today, no convincing evidence exists showing that smoke-free tobacco products could be helpful in quitting smoking. By employing oral tobacco in the process of quitting smoking, the person attempting to quit would falsely be given the impression that snus is of no concern in terms of health. Moreover, snuffing itself has the potential to become addictive, whereby quitting can be very difficult. Smoke-free tobacco products can therefore at best assist smokers in breaking their smoking habit but they cannot help a person to quit tobacco use.

In addition, the aromatic tobacco sachets act as a starting point of drug use by youth. Consumption in the USA and Sweden has most strongly increased among young men. According to Maja-Lisa Løchen, Professor of Preventive Medicine at the Institute for Public Health at Norway’s Arctic University (UiT) in Tromsø, “snusing” is done in Norway by 10 % of young women and 25 % of young men. Many firms have recognised snusing’s potential and have now initiated specific marketing strategies aimed at young people, especially young women.

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