Snus

Snus (pronounced ) is a moist powder tobacco product that is consumed by placing it under the upper lip for extended periods of time. It was originally developed from powdered snuff that was inhaled through the nostrils. Snus is manufactured and consumed primarily in Sweden and Norway. A version has recently been introduced into the United States and is being test-marketed by two major American tobacco companies as well as one Swedish company. However, the health effects of these new versions of snus have not yet been studied.

Types
There are two main types of snus on the market:
 * originalsnus or lössnus is a loose, moist powder which can be portioned and rolled into a cylindrical or spherical shape with the fingertips or snus portion tool. The end result is often referred to as a pris (pinch) or prilla or prell (slang for pris).
 * portionssnus, is prepackaged powder in small bags made from the same material as teabags. It comes in smaller quantities than the loose powder but is considered easier to handle (and expectorate) than the loose powder.

Swedish snus is made from air dried tobacco from various parts of the world. In earlier times tobacco for making snus used to be laid out for drying in Scania and Mälardalen. Later Kentucky tobaccos were used. The ground tobacco is mixed with water, salt, sodium carbonate and aroma and is prepared through heating, generally via steam. Moist snus contain more than 50% water, and the average use of snus in Sweden is approximately 800 grams (16 units) per person each year. 12% (1,1 million people) of the population in Sweden uses snus Unlike American-sold oral tobacco, snus has not gone through a fermentation process.

Snus is sold mainly in Sweden and Norway and Denmark and is being trialed in South Africa, but can be found in outlets in various other countries frequented by Scandinavian tourists like Murmansk in Russia and other Russian Border Towns (Norwegian Border) (with the notable exception of countries in the EU; see below). It is sold in small tins, which in the earlier years were made of porcelain, wood, silver or gold. At the time of writing, portioned snus usually comes in plastic tins of 24g, while loose snus is mostly sold in compressed paper tins with plastic lids, at 50g.

Portioned snus is most commonly sold in three different variants, namely mini, normal and maxi/large. The weights may vary, but the most sold snus labels share their weight. Mini portions weigh 0.5g, with 20 pieces per tin. Normal - or standard - portions weigh 1g, with 24 portions per tin, and maxi portions weigh 1.7g, with 17 pieces per tin.

The price for the 50g product is approximately €3-€4 in Sweden and €7.50 in Norway as Norwegian taxes are higher.

The total production of Swedish snus, mainly for the Scandinavian market, has been reported to be in excess of 300 million units per year. After the Norwegian government in June 2004 implemented a strict indoor smoking ban in public places, sales of snus sky-rocketed and several new variants of the product were put on the Norwegian market. When the Swedish government did the same thing in June 2005, sales of snus also increased dramatically.

Usage and storage
The most usual way to consume snus is to place it beneath the upper lip, and keep it there for a time varying from a few minutes to several hours, which varies greatly from person to person. Snus should be stored refrigerated to minimize the formation of nitrosamines. Many users report that cold snus is subjectively better than warm snus, however, this is also from a person to another, since some perfer room tempered. But most snus cans say that snus should not be in anyplace warmer than 8°C.

Health consequences
Since snus is not intended nor recommended for inhalation, it does not affect the lungs as cigarettes do, although it does contain more nicotine than cigarettes. Because it is steam-cured, rather than fire-cured like smoking tobacco or other chewing tobacco, it contains lower concentrations of nitrosamines and other carcinogens that form from the partially anaerobic heating of proteins; 2.8 parts per mil for Ettan brand compared to as high as 127.9 parts per mil in American brands, according to a study by the Commonwealth of Massachusetts Department of Health. The World Health Organization (WHO) acknowledges that Swedish men have the lowest rate of lung cancer in Europe, partly due to the low tobacco smoking rate, but does not argue for substituting snus for smoking, citing that the effects of snus still remain unclear. Since the level of carcinogens in snus is not zero, however, it still poses some increased risk for oral cancer.

The European Union banned the sale of snus in 1992, after a 1985 WHO study concluded that "oral use of snuffs of the types used in North America and western Europe is carcinogenic to humans", but a WHO committee on tobacco has also acknowledged that evidence is inconclusive regarding health consequences for snus consumers. Only Sweden and EFTA-member Norway are exempt from this ban. A popular movement during the run-up to the 1994 referendum for Sweden's EU membership made exemption from the EU criminalization of snus a condition of the membership treaty. This may be due to taxation reasons.

Recent actions by many European governments to limit the use of cigarettes has led to calls to lift the ban on snus, as it is generally considered to be less harmful than cigarette smoke, both to the user and to others.

Debate among public health researchers
There is some debate among public health researchers over the use of "safer" tobacco or nicotine delivery systems, generally dividing along two lines of thought. Most researchers presently are of the "abstinence" belief, believing that no form of tobacco or nicotine use is acceptable or safe, and should be minimized among the population. A minority (primarily in the European Union and Canada) believes in "harm reduction," where the belief is generally that, while it should remain a goal to reduce addiction to nicotine in the population as a whole, the reduction of harm to the health of those who choose to use nicotine should override the need to reduce overall nicotine addiction. For example, some research available today shows that snus use reduces or eliminates the risk of cancers that afflict other users of tobacco products such as "chewing tobacco" (the type primarily used in the United States and Canada, created in a process similar to cigarette tobacco) and cigarettes. It is hypothesized that the widespread use of snus by Swedish men (estimated at 30% of Swedish male ex-smokers, possibly because it is much cheaper than cigarettes), displacing tobacco smoking and other varieties of snuff, is responsible for the incidence of tobacco-related mortality in men being significantly lower in Sweden than any other European country; in contrast, since women are much less likely to use snus, their rate of tobacco-related deaths in Sweden is similar to that in other European countries. There is an increase in the prevalence of hypertension in snus users, so the health effects are not all positive, however.

Snus may be less harmful than other tobacco products; according to Kenneth Warner, director of the University of Michigan Tobacco Research Network,
 * "The Swedish government has studied this stuff to death, and to date, there is no compelling evidence that it has any adverse health consequences. ... Whatever they eventually find out, it is dramatically less dangerous than smoking."

Opponents of snus sales maintain that, nevertheless, even the low nitrosamine levels in snus cannot be completely risk free, but snus proponents point out that inasmuch as snus is used as a substitute for smoking or a means to quit smoking, the net overall effect is positive, similar to the effect of nicotine patches, for instance.

In addition, rather obviously, this eliminates any exposure to second-hand smoke, further reducing possible harm to other non-tobacco users. This is seen by public health advocates who believe in "harm reduction" as a reason for recommending snus in addition to other nicotine replacement therapies rather than continued use of cancer-causing nicotine delivery systems.

This does not, however, eliminate any harm to health caused by the nicotine itself. Current research focuses on possible long-term effects on blood pressure, and possible risk of cancer of the pancreas due to tobacco-specific nitrosamines (TSNAs). TSNAs are the only component of tobacco shown to induce pancreatic cancer in laboratory animals (Rivenson et al. 1988). Nicotine may also exacerbate pancreatic illness, because nicotine stimulates the gastrointestinal tract's production of cholecystokinin, which stimulates pancreatic growth and may be implicated in pancreatic cancer. Thus far the evidence specifically implicating snus in pancreatic cancer is only suggestive. . It should also be noted that the probability of developing pancreatic cancer from cigarettes is higher than the suggested chance of developing pancreatic cancer from snus.

Published peer-reviewed studies

 * Effect of smokeless tobacco (snus) on smoking and public health in Sweden, October, 2003 (full text)
 * Broadstock M. Systematic review of the health effects of modified smokeless tobacco products, N Zealand Health Technol Assessment Rep, February 2007 (full text)

Cardiovascular diseases

 * Hergens MP, Ahlbom A, Andersson T, Pershagen G. Swedish moist snuff and myocardial infarction among men. Epidemiology. 2005 Jan;16(1):12-6. (full text)
 * Broadstock M. Systematic review of the health effects of modified smokeless tobacco products, N Zealand Health Technol Assessment Rep, February 2007, p37-56 (full text)

Diabetes

 * Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study, August 2004 (abstract - full text by subscription only)

Cancer

 * Juhua Luo MSc, Weimin Ye MD, Kazem Zendehdel MD, Johanna Adami MD, Prof Hans-Olov Adami MD, Prof Paolo Boffetta MD and Prof Olof Nyrén MD Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study The Lancet, Volume 369, Issue 9578, Pages 2015-2020 (abstract - full text by subscription only)

Tobacco control

 * Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden Hans Gilljam & M. Rosaria Galanti, September 2003 (abstract - full text by subscription only)
 * Tobacco harm reduction: an alternative cessation strategy for inveterate smokers, Brad Rodu & William T. Godshall, December 2006 Harm Reduction Journal

Medical community discussions and reports

 * Kjell Asplund. Snuffing, Smoking and the risk for heart disease and other vascular diseases. 3rd revised version. ASH Britain; 2002 (full text)
 * Discussion of Declining smoking in Sweden: is Swedish Match getting the credit for Swedish tobacco control’s efforts?; Tobacco control (BMJ). 2003.
 * Some practical points on harm reduction: what to tell your lawmaker and what to tell your brother about Swedish snus, Tobacco Control Online, December, 2003

General media articles

 * A Smokeless Alternative To Quitting (Unabridged Version), The New York Times, April 6, 2004
 * Should Snuff Be Used as a Tool To Quit Smoking?, The Wall Street Journal, September 16, 2006; Page A1.

Discussion

 * SnusOn.com - snus forum Popular snus users web community & discussion forum
 * The harm reduction Bulletin Board The Eudoxa think tank's Bulletin Board for discussing snus and harm reduction
 * Dr. Gunilla Bolinder talked about snus (video, in Swedish)

Articles

 * Snus article that compares a few online sellers
 * Hit and Run article on Snus
 * Editorial: Snus as a Smoking Replacement
 * Snus - a safer option for smokers Slate, July 10, 2007
 * Snus - a safer option for smokers Slate, July 10, 2007

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