"Give up" has been the medical advice to smokers since the early 1960s. But to help the millions of nicotine addicts in the UK who just can't quit tobacco even if it means a winter spent shivering outside both pub and office, health professionals may soon be offering a compromise: try snusing.
Hailing from Sweden, snus (it rhymes with "loose") is a moist tobacco that comes in small brown pouches that are tucked under the top lip to deliver a hit of nicotine orally. Its name is a Swedish translation of "snuff", and it is developed from the powdered tobacco of the same name that found its way up the nostrils of all self-respecting courtiers back in the 18th century.
It is currently banned in the UK and every EU member state apart from Sweden – which has the lowest cancer rates and fewest smokers in Europe. But its prohibition may soon be over: public health experts here are saying it may be a less dangerous alternative for the heaviest smokers. Last week, in a report by the Royal College of Physicians on how oral forms of nicotine might help to wean the most addicted smokers off cigarettes, snus was singled out as a potentially useful cessation aid.
"There's no question that snus is much safer than smoking," says Professor John Britton, a lung specialist at the University of Nottingham and the chair of the RCP's Tobacco Advisory group, which produced the report. "If you are a smoker already, you're much better off switching to a product like that than carrying on smoking cigarettes."
If patches, hypnotism and Allen Carr have all failed, and an inch of ash is dangling over this page as you read, the most pressing question you'll want answered is: what is it like to snus? Unlike medicinal nicotine replacement therapies (NRT) such as gum, snus has a taste similar to cigarettes. More importantly, the shaky-fingered, cold-sweating and sleepless would-be quitter is assured that 20-40 minutes of snus-sucking provides a fix of nicotine comparable to lungfuls of cigarette smoke. And at least it's an addiction that won't get you kicked out of a restaurant.
The Swedes first got hooked on tucking tobacco under their top lips in the 18th century. It is so much part of the national culture that the Swedish government negotiated an exemption from the prohibition of snus when it joined the EU. The country's stringent public smoking ban, introduced in June 2005, only drove sales of smokeless tobacco higher. Today, there are an estimated 800,000 male and 200,000 female users in Sweden – out of a population of nine million. The biggest manufacturers of snus, Swedish Match, claims that, after the smoking ban, half a million smokers switched from cigarettes to sucking on these miniature teabags of tobacco.
The pouches are sold in €2 (£1.40) tins that resemble cans of tuna. They have manly brand names such as General, Offroad and Catch. Associated in Swedish culture with male, blue-collar workers, snus is less popular with women for the strange manner in which it makes the top lip bulge. In pursuit of that market, manufacturers such as Swedish Match have begun to introduce smaller tins and tobacco flavoured with rose or cranberry.
Although Sweden has many tobacco-control measures in place, Dr Britton and other experts believe that the country's low number of smokers – particularly male – can be attributed to snus consumption. "The numbers of male smokers are the lowest in Europe, and I don't think there's any argument that the availability of snus has contributed to that," Dr Britton says.
He cautions, however, that smokeless products differ enormously in what he terms their "risk profile". The term "smokeless" covers more than 30 types of tobacco product, which can be either chewed, sucked or inhaled. Each has different levels of cancer-causing chemicals. The most dangerous contain a group of chemicals called tobacco-specific nitrosamines (TSNAs) – and some smokeless tobacco products contain far higher levels of these toxic substances than cigarettes. Advocates of snus counter that it is manufactured using a process that lowers the levels of TSNAs in the finished product.
Many Swedes are not aware that snusing is less dangerous than smoking. "There's a vast differential in health risk between snus and cigarettes, but the public doesn't known about it," says Dr Lars E Rutqvist, the vice president for scientific affairs at Swedish Match. The drive in snus sales in Sweden, he says, has been in response to the smoking ban rather than any perceived advantage to users' health. Even Cancer Research says that Swedish snus is less harmful both than smoking and other types of chewed tobacco. "It's possible that it could be used to help smokers quit," says Jean King, director of tobacco control at Cancer Research UK. "But it's important to remember that, as with all tobacco products, snus is not completely risk-free."
A recent paper in The Lancet cast some doubt on the claims by snus manufacturers – who, clearly, are salivating at the potential for millions of new customers – that it poses aminimal cancer risk. The researchers followed more than 125,000 Swedish non-smoking, snus-using construction workers for 12 to 26 years. They found no increase in oral or lung cancers compared with non-smokers who did not use any form of tobacco. But the risk of pancreatic cancer was approximately doubled, resulting in more than 40 cases of the disease in the 125,000 snus users. "It's certainly more hazardous than using medicinal nicotine, but nothing like as hazardous as smoking," is how Dr Britton puts it, although he agrees that more research into its long-term health effects would be helpful.
Others are more cautious. "There is no scientific evidence whatsoever that smokers are able to switch to smokeless tobacco and remain switched," Thomas Glynn, the director of cancer science and trends at the American Cancer Society, told The New York Times last week. In the US, Philip Morris is among the tobacco giants that has begun test-marketing snus. And last week, British American Tobacco, which accounts for about 10 per cent of sales in the Swedish snus market, was pressing European regulators for its legalisation.
It seems unlikely that, given a free hand, tobacco companies could be trusted not to market smokeless products to non-smokers. The current prohibition dates back to 1992, following the high-profile findings that smokeless tobacco companies were marketing directly to children and adolescents.
There is a concern that, if tobacco companies were allowed to sell snus in the UK, they would not be satisfied with getting their existing customers to switch. "It's their job to sell as much tobacco as possible, so they will be targeting non-smokers rather than current ones – that's the worry," says Dr Britton. He wants a strict regulatory system to monitor the marketing of such products.
Even in the country of its origin, not all snus users enjoy their juicy habit. Since it allows users to get their nicotine fix on planes, in the cinema and while cuddling babies, snusing has the potential to be more addictive than smoking. "It's not healthy, it's really not," insists Carl Tesdorpf, 36, a Stockholm brand manager who quit snus three years ago after a 13-year habit. "I had never smoked cigarettes, and I started using snus when I was 20. I used it all day, from first thing in the morning. I have friends who sleep with it sitting in their mouths. When you're snusing you don't look nice, it gives you dirty fingers, and you can't taste food. But I gave up because of my health. There's so much nicotine in it, it's so hard to quit. I've got a lot of friends who use it, and not many of them have been able to give up. Why should a company earn money out of me treating my health badly?"
Stubbed out: smoking bans around the world
A California city this week rejected a bill that would have banned smoking in private apartments. In Calabasas smoking has already been banned in public places, and the question of extending the ban to apartments will be revisted in November. Over 50 per cent of Americans are now covered by some form of smoking ban.
From 1 October smoking was banned in all Beijing taxis, in preparation for the 2008 Olympic Games. Bans have already been introduced in hospitals, schools, restaurants, government offices and private organisations. The aim is to have the first "smoke-free Olympics", and there will be no tobacco on sale at any venue, training site or accommodation area.
In July, smoking was even banned from the counters of the Netherland's "coffee shops", which sell cannabis. Smokers will now have to use separate smoking rooms.
In February, 175,000 cigarette police were deployed in France to enforce smoking bans that have been place, but largely ignored, since 1991.
In total, more than 140 countries signed an international treaty on tobacco control in 2005, with some still in the process of introducing regulations. Smoking in schools is still allowed in Belgium – but only until September 2008.
By Mary Morgan
Chewing is one of the oldest and simplest ways of ingesting tobacco leaves, and was practised by Native Americans in both North and South America. Also called spitting tobacco, this variety remains popular in parts of the US and beyond, with an estimated 3 per cent of American citizens smokeless tobacco users. It is especially popular among athletes.
American snuff or dipping tobacco is applied to the gums rather than chewed. It is similar to snus and comes in two varieties, salty and sweet. Both chewing and dipping tobacco have been linked with oral cancer and gum disease.
European snuff is inhaled, not chewed. Snuff-taking became popular in Europe from the late 15th century, the arrival of tobacco on the continent attributed to Christopher Columbus. The habit soon became a mark of social status, and codes of etiquette evolved. European snuff tends to be dry and flavoured; varieties include cinnamon and rose.
Recently, the concept of nicotine replacement therapy has reintroduced smoke-free tobacco as a way of helping smokers shake off nicotine dependency. Nicotine gum came along in the 1970s, while the nicotine patch was invented in 1989 and went on sale in the UK in 1992.