Hit the snus button

I write my column Hit the Snus Button in TCS Daily 15 April 2004.

Exporting the Swedish harm reduction model

Earlier this month Tech Central Station-Europe held a Hayek Series seminar entitled Harm reduction: a way to make tobacco control work? in Brussels and I sent the Eudoxa think tank's science director Anders Sandberg to attend. Since he is a Ph.D. in computational neuroscience I was certain that he would find the seminar most interesting.

The sale of moist oral snuff, or snus, is banned in all of the EU except Sweden, but on June 8 this prohibition will be reviewed, and possibly even lifted.

The basic problem with tobacco is that it is addictive and poses a risk to health. This is true for all of its forms, be they cigarettes, snuff or sweets. But smoking tobacco increases the risks, since the combustion produces hundreds of carcinogenic and teratogenic chemicals which are directly breathed into the lungs. This seems to be a very important factor behind lung cancer, and over 90 percent of all lung cancer cases are estimated to be linked to smoking. Smokeless tobacco avoids the lung cancer issue (oral cancer is still a risk, as for smoking). This is very evident in cancer statistics in Sweden, where snus is widely used among men but there is a significantly lower incidence of lung cancer than in the rest of Europe but only among men. For women the incidence is about equal. (See the report on oral tobacco by the European Network for Smoking Prevention for a review of the field.)

The bottom line is this: if more tobacco addicts used snus, hundreds of thousands of lung cancer cases could be avoided every year in Europe. There would still be addiction and other health problems, but the situation would improve.

The ban on snus has produced an interesting situation at present. Many epidemiologists have realized that harm reduction is good. While the long-term goal is to get people to stop using tobacco as much as possible, in the shorter term it would be healthier if they at least could switch to smokeless tobacco (also taking into account the benefits in terms of passive smoking). Thus they have become allied with parts of the tobacco industry (especially Swedish Match, the major snus producer) to have the ban repealed.

So, who is fighting for the ban? The rest of the anti-tobacco movement, with the Swedish anti-tobacco establishment at the front. While Sweden is generally seen as proof that harm reduction through snus is feasible, most Swedish tobacco researchers are fiercely opposed to harm reduction. The typical Swedish approach to public health is very much to ban everything potentially unhealthy and not accept any compromises, even if they would be helpful. Add the fact that is easy to claim that anyone advocating harm reduction has been bought by Big Tobacco or is secretly a drug liberal, and you have a recipe for stormy and polarized debates.

But the meeting in Brussels was surprisingly civil. Dr. Michael Kunze, professor of public health and director of the Nicotine Institute in Vienna, presented the case for harm reduction. Opposing him was Dr. Göran Boëthius from Doctors Against Tobacco (he instituted a ban for the staff at the hospitals in the county of Jämtland to even use snus on the workplace). Boëthius agreed on the basic science, but took the typical Swedish line that it is better to try to reduce tobacco use than to get people to switch to something safer in the meantime. Paul Flynn, a Member of the UK Parliament and Vice Chair of the UK House of Commons Drugs Misuse Group, took the general pro-snus position. Nobody on the podium wanted more people to use tobacco, but it is clear that the debate has moved far beyond the argument in Sweden. Even the report mentioned above from ENSP showed a depth that is rarely seen here. As Dr. Kunze remarked, it was refreshing not to be shouted off the stage as a heretic any more.

Resistance to harm reduction is still strong. In Sweden much drug policy has been built on an implicit model of drug use as an epidemic. Users "infect" others by acting as bad examples and the mere existence of drugs can entice people to try them - and then they are irrevocably stuck. Any lessening of the war on drugs would be risking having even more people exposed. That this model is not well supported by evidence doesn't change things, since it isn't promulgated among scientists, but rather among politicians and administrators. Even experiments with giving methadone to heroin addicts have been fiercely resisted, and it is doubtful that harm reduction will become even thinkable in Swedish policy circles for many years.

Dr. Sandberg's contribution to the discussion was to point out why learning theory predicts that people would be less likely to become addicted to snus than to cigarettes, and why it is fairly easy to move to snus from cigarettes. The amount of nicotine that appears in the blood is roughly the same for both, but the rise time is much faster for smoking. This makes the "credit assignment problem" of learning systems easier - making the association between the action (smoking) and the reinforcement much easier even with a small decrease in time. The brain learns more from time differences than from absolute values. The maintenance of addiction is then caused by the total amount of nicotine (which causes the cholinergic systems to make more nicotinergic receptors). Nicotine is a learning enhancer, and this is usually the problem. It would be nice to have a less addictive learning enhancer with as well documented effect. Here Dr. Sandberg made a connection to F.A. Hayek's work: addiction is simply mis-learning. We create spontaneous orders in our brains that are self-destructive.

Dr. Kunze pointed out that most nicotine replacement therapies don't work unless they are heavily supervised. Maybe a nicotine vaccine could help, but the ethical issues involved are very problematic (it can only be tested on addicts, but would likely work best on non-users - and would provide a great temptation for government busybodies seeking to limit unhealthy behaviour). But it is clear that we need new approaches. A better understanding of the neurochemistry of memory and conditioning will enable us to use medicines to treat addiction within a not too far future. There already exist some tentative experimental drugs that lessen the risk of relapses by acting on the amygdale pathways.

It remains to be seen if this thawing of the debate climate will have any effect on the EU ban. But it seems absurd to ban a form of tobacco that is slightly safer than other forms, while still allowing the sale of more dangerous products like chewing tobacco - not to mention subsidizing tobacco farming at the same time (although that might be ending).