512045 2013
SJP42310.1177/1403494813512045Z. Ben TalebSnus usage
Scandinavian Journal of Public Health, 2014; 42: 225–226
Letter
Snus usage: Harm induction or harm reduction?
Ziyad Ben Taleb Florida International University, USA
To the editor, With a great interest I read an article in your journal titled “The low prevalence of smoking in the Northern Sweden MONICA study, 2009” [1]. The authors presented a study where they used a secondary data to describe tobacco usage. The results of this study consistently shows that there is a decrease in tobacco prevalence from 2004 to 2009 in both genders, and it’s combined with a decrease in snus use. The decrease in smoking can be logically attributed to the strict regulations in a country that has a successful record in tobacco control; surprisingly, the authors interpret that as a result of snus usage and eagerly link it to harm reduction. One of the major unstated shortcomings is that the selected age group targeted in this analysis was 25–64, its clear that the authors have missed a very important age group which is the adolescent. It’s a well-known fact that smoking and smokeless tobacco use are initiated and established mostly during adolescence, and the youth continue to be targeted by the tobacco industry [2], thus missing such a vital age sector highly decrease the external validity of the study. Moreover, the results are not illustrated clearly, and there is no confidence intervals reported when the results were compared with the data from the previous survey. The authors mentioned that there is a 69% participation rate, such a low response rate can cause considerable difficulty in interpretation of the results as it can be easily argued that non-responders are atypical when compared with responders with respect to their tobacco usage habits, therefore, estimates of prevalence necessarily obtained from responders only will be inherently biased. The authors failed efforts in the discussion part to highlight any risk in using snus on health is
particularly worrisome. In fact, there is a plethora of evidence available that shows the negative health impact of using snus. Many studies with sounds methodological approaches have suggested an association of snus use with not only oral cancer, but with other cancers as well, including pancreatic cancer [3]. Moreover, results from two independent cohorts indicate that use of snus may be associated with a higher risk of heart failure [4]. Furthermore, a 10-year cohort study found that high consumption of snus, similar to smoking, can predict the risk of developing Type 2 diabetes [5]. Research has proven not only that using snus is a harm induction rather than harm reduction, but also that promoting smokeless tobacco as a safer substitute to cigarettes smoking is unlikely to produce any significant health benefits at the population level [6]. The role of snus in decreasing cigarette smoking is unclear; in fact, it is likely that snus use may reduce the success rate of quitting cigarette smoking [7]. The usage of snus in Sweden is merely a cultural and historical heritage that was only revived by the tobacco industry, and eventually is going to diminish as science continue to show the negative health impact of smokeless tobacco. The authors insist to link the decreased prevalence of tobacco use in their study to the usage of snus, ignoring the fact that the descriptive nature of their cross sectional study limit its ability to draw any causality between snus use and the decreased prevalence of smoking. Effective harm reduction programs like needle exchange or methadone therapy, do not introduce any new harm; in contrast, snus use has been linked to many health issues. We need to stop accommodating the tobacco epidemic. Switching cigarettes with snus is like changing a flat tire for another flat tire.
Correspondence: Ziyad Ben Taleb, Department of Epidemiology, Florida International University, 11200 SW 8th St, Miami, FL 33174, USA. E-mail: [email protected] © 2013 the Nordic Societies of Public Health DOI: 10.1177/1403494813512045
Downloaded from sjp.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 11, 2015
226 Z. B. Taleb Conflict of interest None declared. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References [1] Rodu B, Jansson J-H and Eliasson M. The low prevalence of smoking in the Northern Sweden MONICA study, 2009. Scand J Publ Health 2013;41:808–11. [2] Peeters S and Gilmore AB. Transnational tobacco company interests in smokeless tobacco in europe: analysis of internal industry documents and contemporary industry materials. PLoS Med 2013;10:e1001506.
[3] Luo J, Ye W, Zendehdel K, et al. 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 2007;369:2015–20. [4] Arefalk G, Hergens M-P, Ingelsson E, et al. Smokeless tobacco (snus) and risk of heart failure: results from two Swedish cohorts. Eur J Prev Cardiol 2012;19:1120–7. [5] Östenson C-G, Hilding A, Grill V, et al. High consumption of smokeless tobacco (“snus”) predicts increased risk of type 2 diabetes in a 10-year prospective study of middle-aged Swedish men. Scand J Publ Health 2012;40:730–7. [6] Mejia AB, Ling PM and Glantz SA. Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA. Tob Control 2010;19:297–305. [7] Hamari AK, Toljamo TI, Kinnula VL, et al. Dual use of cigarettes and Swedish snuff (snus) among young adults in Northern Finland. Eur J Publ Health 2013;23:768–71.
Downloaded from sjp.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 11, 2015
SJP42310.1177/1403494813512045Z. Ben TalebSnus usage
Scandinavian Journal of Public Health, 2014; 42: 225–226
Letter
Snus usage: Harm induction or harm reduction?
Ziyad Ben Taleb Florida International University, USA
To the editor, With a great interest I read an article in your journal titled “The low prevalence of smoking in the Northern Sweden MONICA study, 2009” [1]. The authors presented a study where they used a secondary data to describe tobacco usage. The results of this study consistently shows that there is a decrease in tobacco prevalence from 2004 to 2009 in both genders, and it’s combined with a decrease in snus use. The decrease in smoking can be logically attributed to the strict regulations in a country that has a successful record in tobacco control; surprisingly, the authors interpret that as a result of snus usage and eagerly link it to harm reduction. One of the major unstated shortcomings is that the selected age group targeted in this analysis was 25–64, its clear that the authors have missed a very important age group which is the adolescent. It’s a well-known fact that smoking and smokeless tobacco use are initiated and established mostly during adolescence, and the youth continue to be targeted by the tobacco industry [2], thus missing such a vital age sector highly decrease the external validity of the study. Moreover, the results are not illustrated clearly, and there is no confidence intervals reported when the results were compared with the data from the previous survey. The authors mentioned that there is a 69% participation rate, such a low response rate can cause considerable difficulty in interpretation of the results as it can be easily argued that non-responders are atypical when compared with responders with respect to their tobacco usage habits, therefore, estimates of prevalence necessarily obtained from responders only will be inherently biased. The authors failed efforts in the discussion part to highlight any risk in using snus on health is
particularly worrisome. In fact, there is a plethora of evidence available that shows the negative health impact of using snus. Many studies with sounds methodological approaches have suggested an association of snus use with not only oral cancer, but with other cancers as well, including pancreatic cancer [3]. Moreover, results from two independent cohorts indicate that use of snus may be associated with a higher risk of heart failure [4]. Furthermore, a 10-year cohort study found that high consumption of snus, similar to smoking, can predict the risk of developing Type 2 diabetes [5]. Research has proven not only that using snus is a harm induction rather than harm reduction, but also that promoting smokeless tobacco as a safer substitute to cigarettes smoking is unlikely to produce any significant health benefits at the population level [6]. The role of snus in decreasing cigarette smoking is unclear; in fact, it is likely that snus use may reduce the success rate of quitting cigarette smoking [7]. The usage of snus in Sweden is merely a cultural and historical heritage that was only revived by the tobacco industry, and eventually is going to diminish as science continue to show the negative health impact of smokeless tobacco. The authors insist to link the decreased prevalence of tobacco use in their study to the usage of snus, ignoring the fact that the descriptive nature of their cross sectional study limit its ability to draw any causality between snus use and the decreased prevalence of smoking. Effective harm reduction programs like needle exchange or methadone therapy, do not introduce any new harm; in contrast, snus use has been linked to many health issues. We need to stop accommodating the tobacco epidemic. Switching cigarettes with snus is like changing a flat tire for another flat tire.
Correspondence: Ziyad Ben Taleb, Department of Epidemiology, Florida International University, 11200 SW 8th St, Miami, FL 33174, USA. E-mail: [email protected] © 2013 the Nordic Societies of Public Health DOI: 10.1177/1403494813512045
Downloaded from sjp.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 11, 2015
226 Z. B. Taleb Conflict of interest None declared. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References [1] Rodu B, Jansson J-H and Eliasson M. The low prevalence of smoking in the Northern Sweden MONICA study, 2009. Scand J Publ Health 2013;41:808–11. [2] Peeters S and Gilmore AB. Transnational tobacco company interests in smokeless tobacco in europe: analysis of internal industry documents and contemporary industry materials. PLoS Med 2013;10:e1001506.
[3] Luo J, Ye W, Zendehdel K, et al. 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 2007;369:2015–20. [4] Arefalk G, Hergens M-P, Ingelsson E, et al. Smokeless tobacco (snus) and risk of heart failure: results from two Swedish cohorts. Eur J Prev Cardiol 2012;19:1120–7. [5] Östenson C-G, Hilding A, Grill V, et al. High consumption of smokeless tobacco (“snus”) predicts increased risk of type 2 diabetes in a 10-year prospective study of middle-aged Swedish men. Scand J Publ Health 2012;40:730–7. [6] Mejia AB, Ling PM and Glantz SA. Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA. Tob Control 2010;19:297–305. [7] Hamari AK, Toljamo TI, Kinnula VL, et al. Dual use of cigarettes and Swedish snuff (snus) among young adults in Northern Finland. Eur J Publ Health 2013;23:768–71.
Downloaded from sjp.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 11, 2015
