Should we keep quiet about this?

I write my column Should we keep quiet about this? in TCS Daily on 17 October 2003.

Understanding the nature of harm reduction

Recently the 12th World Conference on Tobacco or Health, entitled "Global action for a tobacco free future," was held in Helsinki. Scientists, activists, researchers and organizations from all over the world came to discuss tobacco and public health issues, and strategies for tobacco prevention.

It is perhaps surprising that at a conference with such an ominous name the question of harm reduction would be raised. Harm reduction has become an alternative to the "quit or die" policy. Swedish "snus" is a type of smokeless tobacco that has been found less dangerous than cigarettes by many scientific researchers. Even if the use of "snus" cannot be seen as harmless, the lack of combustion near the oral cavity, associated with smoking, eliminates the risk for lung cancer and other pulmonary diseases, which are the main causes of tobacco-related death. Some researchers have pointed out the availability of "snus," used as an alternative to cigarettes, as the factor behind the low figures for smoking in Sweden, especially for men, and as an easy step towards smoking cessation for many Swedes.

The increased risks for cardio-vascular diseases that have been reported earlier have not been reproduced in several broad Swedish studies, including one by Kjell Asplund (professor of medicine at the Umeå university and now director of medical questions at the National Board of Health and Welfare).

In Helsinki the question of snus was controversial. Since the anti-smoking movement has taken on so many moralistic and paternalistic overtones the "harm reduction" viewpoint, even with scientific support, was seen as a complete capitulation to the big tobacco companies that would lead to increased tobacco-related harms. This critique seems to imply that snus would be proposed as a harmless alternative, not a harm-reducing alternative.

In a way this is understandable. Since smoking and other tobacco consumption has gone from being the responsibility of the smoker to a public concern the harm-reduction policy seems to have taken a backseat to the strategy of achieving complete cessation in the whole population.

But if you want to achieve the goal of reducing smoking in the population, this is not the way to do it. It has been calculated that in affluent countries smoking decreases by nearly 1.4 percent per year, while it is increasing at a rate of 1.7 percent per year in developing countries. Harsh regulation and taxation of cigarettes has not resulted in any improvements.

Personally, I dislike these rather authoritarian calculations. I think snus should be left as an option for the individual smoker to decide upon, since we are talking about consenting adults who know that smokeless tobacco products could induce harm. "Public health" is a very vague concept that implies that there is a total health level for society and leads to an unproductive stigmatization of tobacco users -- and we are on very dangerous ground if we start relieving people of the ultimate responsibility to make decisions about their bodies.

Sometimes I get the suspicion that many of the anti-tobacco activists have been so emotionally involved in their struggle that the plights of individual smokers have been subsumed into broad statistics. Thus it becomes easier to view a harm-reduction strategy as merely a capitulation by formerly esteemed colleagues and researchers to the big tobacco companies. But then the fight against big tobacco companies has become more important than actually saving lives.

The sale of snus is banned in all EU member states except Sweden, which was granted an exception when it joined the Union in 1995. This derogation from EU law was a quite simple decision before the Nordic countries joined. No one in the existing member states had used snus. The product was sold only in Sweden and Norway, and to a much lesser extent in Finland. Legislators could appear to be responsible while not aggravating anyone. The less harmful vector of nicotine was banned while sale of the more harmful cigarettes was still fully allowed (and tobacco production is even subsidized by the EU in some member countries). It was like banning Diet Coke while still allowing the sale of regular Coca-Cola, because of health reasons. One could at least demand some consistency. It should also be noted that the sale of smokeless tobacco products that are more harmful than snus is still allowed in the EU.

The Swedish government very quietly decided this past March that it would recommend a lifting of the ban of the sale of snus in the EU. In Sweden, the previously compulsory cancer warning has been removed from the boxes snus is sold in -- even as huge warnings have appeared on cigarette packs all across the EU.

Finland did not negotiate this exception when it joined in 1995 and the sale of snus was banned everywhere in that country except for the islands of Åland. Åland has been a self-governing region of Finland since 1921, when an accord was mediated by the League of Nations between Sweden and the newly independent Republic of Finland. Thus Åland was in an uncertain position regarding many of Finland's treaties with the EU, and snus was still sold there. But at the time of the conference in Helsinki, the supreme court of Finland ruled that Åland would not receive an exception for the ban of snus sales. Certainly not a step in the right direction, and it could lead to increased pressure on Sweden to renegotiate its exception, too.

Often when researchers have advanced the idea of harm-reduction or the results of their scientific enquiries about snus they have been asked (rather harshly) to not make them known to the general public, or at least to be very subdued about their results.

I think Asplund's reply in a recent interview for the Swedish newspaper Svenska Dagbladet said it best: Remember that all of us scientists started to study snus to prove its dangers. It was self-evident to us. But the results were different from this. We saw that smokers that switched to snus made a gain in health. Should we keep quiet about this?

Certainly not. All would stand to gain from discussing snus as a serious alternative without the blinders that have characterized the debate so far.