Snus

Not to be confused with the dry tobacco product, Snuff (tobacco).
Snus, made of tobacco, salt, and sodium carbonate
"White portion" snus of the Swedish label General

Snus (/ˈsnuːs/; Swedish pronunciation: [snʉːs]) is a moist powder tobacco product originating from a variant of dry snuff in early 18th-century Sweden. It is placed under the upper lip for extended periods. Snus is not fermented and contains no added sugar. Although used similarly to American dipping tobacco, snus does not typically result in the need for spitting and, unlike naswar, snus is steam-pasteurized.

The sale of snus is illegal in the European Union (except for Sweden, where it is legal),[1][2] Belarus,[3] and Russia.[3] Local varieties of snus, growing in popularity in the United States, have been seen as an alternative to smoking, chewing, and dipping tobacco. However, as US-manufactured snus does not have the same production standards or ingredients as Swedish snus (the use of significant amounts of sugar in US products being one major difference), some believe that it should not be called "snus."[4]

History

Catchlid found on many snus tins, which snaps in and out of place. The small compartment is typically used for the temporary storage of used snus portions.

In the 16th century, snuff (pulverized tobacco), the precursor of snus (moist snuff), was introduced to France by French diplomat Jean Nicot, who worked at the court of King Henry II of France. He recommended snuff to Catherine de' Medici as a migraine remedy. When she became a regular user of snuff, it became a fashion among the court and upper class citizens of France, especially among females, as it was deemed more socially acceptable than other forms of tobacco.

This trend of using snuff in the nose also spread to Sweden at the beginning of the 17th century. In the 19th century, Swedish producers began to manufacture moist snuff, which was placed under the upper lip and did not require spitting. It became known as snus. Ettan (meaning "number one"), registered since 1822, is the oldest brand of snus still sold.

It is a popular myth that snus or any other forms of smokeless tobacco contains fiberglass as an aid to the absorption of nicotine by the user's blood. This is not true.[5] Mucous membranes readily absorb free nicotine. The burning sensation is caused by the nicotine itself (similar to the tingle of nicotine gum) and some food additives such as sodium carbonate (E500). Sodium carbonate is a food additive used to increase the pH of the tobacco (reduce the acidity). This increases the bioavailability of the nicotine, meaning more is available for absorption. Some flavorings (mints in particular) are astringent and may increase the tingling or burning sensation.

Confusion of snus and snuff

A tin of American snus (Camel Snus brand)

Confusingly, the English word "snuff" is translated to snus in Swedish, and the word "snuff" is often used in English to refer to both the nasal form and both the placed-under-the-lip forms of snus and dipping tobacco.

However, snuff used in the nose is referred to as torrsnus (dry snuff) or, more correctly, as luktsnus ("smelling snuff") in Swedish. The moist form of snuff placed under the upper lip is called simply snus in Swedish.

The word "snuff" can also refer to dipping tobacco (also known as moist snuff), which is applied to the lower lip and the gums, rather than used nasally or placed under the upper lip. However snus, dry snuff, and dipping tobacco are distinct products.

Differences between snus and similar tobacco products

Some forms of tobacco consumed in the mouth may be categorized as:

Types

Cylindrical (fingertips) pris of Swedish brand Skruf
Left is an original (or "regular") portion. Right is a "white portion". White portions can be any color, as the name refers to the style, not the color.

Many types of snus are available:

Portioned snus is available in three different sizes: mini, normal/large (most common) and maxi. The weights may vary, but the labelling on most packages of snus disclose their net weight. Mini portions typically weigh close to 0.5 g, normal (large) portions weigh around 1 g, and maxi portions weigh up to 1.7 g, depending on brand. Some brands also offer the choice of "regular" and "long" versions of the normal size sachet, which are similar in content weight. These long portions differ from traditional sachets in that they are slimmer but longer, in order to fit against the gums more comfortably.

The nicotine content of snus varies among brands, with the most common strength being 8 mg of nicotine per gram of tobacco. In recent years, snus manufacturers have released stark (strong or sterk) and extra stark (extra strong or extra sterk) varieties with greater nicotine content. Stark varieties contain, on average, 11 mg of nicotine per gram of tobacco, while extra stark varieties may contain up to 22 mg of nicotine per gram of tobacco. Recently, the Siberia brand released its "Extremely Strong" snus which boasts 42 mg of nicotine per gram of tobacco and is currently the highest nicotine-per-gram snus available.

Contents

Swedish snus is made from air-dried tobacco from various parts of the world. In earlier times, tobacco for making snus was laid out for drying in Scania and Mälardalen, Sweden. Later, Kentucky tobaccos were used. The ground tobacco is mixed with water, salt, an alkylizing agent (today this is sodium carbonate), and aroma, and is prepared through heating. After the heating process, food grade aromas are typically added. In Sweden, snus is regulated as a food product and, for this reason, all ingredients are listed on the label of each individual package (can) of snus. Moist snus contains more than 50% water, and the average use of snus in Sweden is approximately 800 grams (16 units) per person each year. About 12% (1.1 million people) of the population in Sweden use snus . Unlike dipping tobacco and chew, most snus today does not undergo the fermentation process, but is instead steam-pasteurized. Although steam-pasteurization is remarkably complex, it has the advantages of inhibiting the growth of bacteria that facilitate the formation of tobacco-specific nitrosamines, while preserving the desired texture and mouthfeel of the snus. A voluntary quality standard for snus products has been introduced (Gothiatek®) which sets maximum levels for certain controversial constituents including nitrosamines, heavy metals, and polyaromatic hydrocarbons. Most manufacturers of Scandinavian type snus adhere to this standard.

Snus is sold primarily in Sweden, Denmark, Faroe Islands and Norway, and has more recently been introduced to South Africa and the US. It can be found in places frequented by Scandinavian tourists, such as Murmansk in Russia or Chania in Greece (with the notable exception of countries in the European Union—see below). It is sold in small tins which, in the earlier years, were made of porcelain, wood, silver, or gold. Portioned snus usually comes in plastic tins of 24 portions, containing about a gram of snus each, while loose snus is mostly sold in cardboard containers with plastic lids, at 45 g (50 g before 2008). Mini-portion and medium-portion snus are increasingly popular formats. Most of these products come in tins containing 20 portions, of either 0.65 or 0.5 grams each for a total of just under 13 or 10 grams, particularly with those for whom concealing their use of smokeless tobacco in places is of utmost importance.

Industry

Although Swedish snus was previously only available by mail order in the US, an increasing number of tobacco retailers have now begun to stock it. R. J. Reynolds Tobacco Company, Philip Morris USA, and U.S. Smokeless Tobacco Company now produce similar products called Camel Snus, Marlboro snus, and Skoal snus, respectively. While American snus is packaged in much the same way (moist tobacco in a small pouch), production methods vary considerably from traditional Scandinavian methods. Additionally, differences in the way American snus is formulated may diminish some of its possible health benefits over other tobacco products.[7] Swedish Match, the leading manufacturer of Swedish snus, is currently test-marketing snus in Canada, Russia, and several regions throughout the US.

In October 2012, the European Union's commissioner for health and consumer policy, John Dalli, resigned,[8] following an investigation by the European Anti-fraud Office (OLAF), into a complaint made by tobacco producer Swedish Match. OLAF found that an unnamed Maltese entrepreneur approached Swedish Match using his contacts with Mr. Dalli, seeking payments in exchange for influence over possible snus legislation. The new EU's Tobacco Products Directive was expected to be appointed during autumn 2012.

Swedish Match has commented that they expect, given the proven scientific facts regarding snus, that it should be considered in a fair legal process for the proposal of a new Tobacco Products Directive.[9]

Health consequences

Warning label on a container of Swedish snus. The text reads: "This tobacco product may damage your health and is addictive". Note the "best before" date and list of ingredients, which is required by Swedish law.

A study of almost 10,000 Swedish men published in the International Journal of Cancer in 2008 found a statistically significant increase in the incidence of the combined category of oral and pharyngeal cancer among daily users of snus.[10] Other studies and opinion pieces in renowned journals, such as the British Medical Journal and The Lancet,[11][12] do not confirm any correlation between snus usage and oral cancer, but one study suggests a probable increased risk of pancreatic cancer as a result of snus use.[13]

Many cardiologists believe oral nicotine products contribute to the potentiation of sympathetic nerve tone, and may aggravate hypertension due to the effects of nicotine on cholinergic and dopaminergic neurotransmission. At higher doses, tachycardia, reflex bradycardia, arrhythmia or even cardiac arrest can occur in some individuals. Further studies are needed in this regard.[14]

The European Union banned the sale of snus in 1992, after a 1985 World Health Organization (WHO) study concluded that "oral use of snuffs of the types used in North America and western Europe is carcinogenic to humans",[15] but a WHO committee on tobacco has also acknowledged the evidence is inconclusive regarding health consequences for snus consumers.[4] Only Sweden and European Free Trade Association (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 sale ban of snus a condition of the membership treaty.

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[16] and to others.

Since snus is not inhaled it does not affect the lungs as cigarettes do. Because it is steam-pasteurized 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 million for Ettan brand, compared to as high as 127.9 parts per million in some American brands.[17] WHO acknowledges 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, stating that the effects of snus still remain unclear. Around 2005, several reports, partially funded by the snus industry, indicated that no carcinogenic effects could be attributed to Nordic snus, and this resulted in the removal of the warning label that claimed snus could cause cancer. It was replaced with the more vague label "May affect your health negatively". Research is continuing, but no conclusive reports have been made regarding major adverse health effects of snus.

A 2014 report commissioned by Public Health England on electronic cigarettes said snus "has a risk profile that includes possible increases in risk of oesophageal and pancreatic cancer, and of fatal (but not non-fatal) myocardial infarction, but not COPD or lung cancer."[18]

Based on the mounting research demonstrating the limited harm of snus, snus manufacturer Swedish Match filed a Modified Risk Tobacco Product application with the U.S. Food and Drug Administration Center for Tobacco Products to modify the warning label requirements by:[19]

  1. removing the current warnings, "This product can cause mouth cancer" and "This product can cause gum disease and tooth loss."
  2. replacing the current warning, "This product is not a safe alternative to cigarettes,” with “No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes."
  3. retaining the current warning, "Smokeless tobacco is addictive."

The FDA's Tobacco Products Scientific Advisory Committee voted against the request in April 2015 but Swedish Match is continuing their efforts for this change.[20]

Scandinavian snus is regularly available, refrigerated, in the United States at smokeshops, especially in major cities. The considerably different, sweetened American snus is more commonly found at convenience stores, in multiple brands produced by US-based cigarette companies. Neither product category has made much of an inroad into the market-share held by the dipping tobacco products more common in that country.

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. Some (primarily in the European Union and Canada) believe in "tobacco harm reduction", with the general belief 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 is more pragmatic than the desire to reduce overall nicotine addiction. In other words, people using more harmful forms of tobacco (e.g., cigarettes) should be encouraged to switch to less harmful products (e.g., snus). The other school of thought is that no tobacco product should be promoted, and that attention should be placed instead on getting users to switch to nicotine replacement therapy or quit altogether.

One proponent of using snus for harm reduction is Karl Fagerström, a PhD in psychology regarded as a leading researcher in smoking cessation in Sweden. Some research available today shows snus use reduces or eliminates the risk of cancers associated with the use of other tobacco products, such as chewing tobacco (the type primarily used in the US and Canada, created in a process similar to cigarette tobacco) and cigarettes.[21] The widespread use of snus by Swedish men (estimated at 30% of Swedish male ex-smokers), displacing tobacco smoking and other varieties of snuff, is thought to be responsible for the incidence of tobacco-related mortality in men being significantly lower in Sweden than any other European country. In contrast, since women traditionally are less likely to use snus, their rate of tobacco-related deaths in Sweden can be compared to that of other European countries.

Snus may be less harmful than other tobacco products (see above). 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."[22]

A 2014 report commissioned by Public Health England on another avenue for tobacco harm reduction, electronic cigarettes, examined the case of snus as "a unique natural experiment in the impact of a socially accepted, non-medical, affordable and easily accessible reduced harm product on the prevalence of tobacco smoking". They concluded that "Although controversial, the Swedish natural experiment demonstrates that despite dual use and primary uptake of the reduced-harm product by young people, availability of reduced-harm alternatives for tobacco smokers can have a beneficial effect. While snus is not likely to become a legal or indeed politically viable option in the UK, this data proves the concept that harm reduction strategies can contribute to significant reductions in smoking prevalence."[23]

Ongoing discussion and debates among primary scientific researchers of the effects of snus use on life expectancy appear to indicate a significant increase in life expectancy among persons who previously smoked tobacco and switch to snus, depending on the age of the persons who switch, even when it is assumed that 100% of the risk of cardiovascular diseases among smokers transfers to snus users. This study determined that "for net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus."[24] It is also noted, in the correspondence seen in the previous citation,[25][26] that concerns about the effect of marketing by the tobacco industry, as influenced by the results of these scientific studies, is of primary concern to many researchers in the field, including the risk of emboldening the industry to attempt to increase snus sales among young people and promote dual-use of snus and smoked tobacco, and the use of medical nicotine, rather than snus, can better target at-risk populations, given better access and pricing.

However, a growing consensus among researchers of smoking cessation have found nicotine replacement therapy (NRT) products to have limited effectiveness because tobacco users may be seeking the combination of MAO inhibitors (which are found in tobacco) and nicotine, or that NRT products do not delivery sufficient quantities of nicotine. MAO inhibitors in tobacco act to amplify the rewarding effects of nicotine, but may also act as a form of self-medication for people with depression. This could explain the association between mental illness and smoking, the minimal efficacy of NRT, and the findings of studies that smokers will choose a denicotinized cigarette over a dose of nicotine. These denicotinized cigarettes can also reduce subjective measures of craving in abstinent smokers. But a confounding variable is that chronic nicotine administration itself has been shown to desensitize nicotine receptors overtime and lead to antidepressant effects.[27] It should be noted that smoking cessation itself is strongly associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke.[28] It has been hypothesized that snus' success when compared with conventional NRT as a cigarette substitute could be attributed to its MAO inhibiting properties. However, studies seem to suggest that for MAO inhibition, tobacco has to be pyrolysized (i.e., ignited as in cigarettes, cigars, and pipes). The competing theory is that the success of snus as a smoking alternative is due to its ability to deliver nicotine similar to that acquired through cigarettes, and twice as high as that acquired through NRT.[29] Furthermore, the use of snus, similar to cigarettes, offers a choice of brand, aesthetic rituals of use, and tastes of tobacco and thus has sensory effects that NRT products perhaps lack. The use of daily snus for smoking cessation has had a 54% success rate for complete abstinence, and a 60% success rate for great reduction in cigarette consumption.[30]

Opponents of snus sales maintain, nevertheless, that 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.[31]

In addition, 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, as well as other NRTs, 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 side effects of nicotine on blood pressure, hypertension, and possible risk of pancreatic cancer due to tobacco-specific nitrosamines (TSNAs). TSNAs are the only component of tobacco shown to induce pancreatic cancer in laboratory animals.[32] 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.[33][34] Notably, the probability of developing pancreatic cancer from cigarettes is higher than the suggested chance of developing pancreatic cancer from snus.[35][36]

The effects of Swedish snus on blood pressure has been studied at Umeå University in a randomly selected population sample of 4,305 Swedish men between the ages of 25 and 74. In the study, published in November 2008, the researchers found no elevation of blood pressure in snus users who had never been smokers compared to tobacco nonusers. In fact, snus users had lower systolic blood pressure than tobacco nonusers in the unadjusted data.[37]

Tobacco-free snus

A tub of Kick-Up tobacco-free snus. This brand one uses coconut husk

One variation of snus is tobacco-free snus. This snus-like product, instead of using tobacco, uses a mixture of coconut husk and oat husk or tea leaves, with salts and flavourings. Like snus, it is available either loose or, more commonly, in bags, which are sometimes known as pods. Even though it is not made from tobacco, most retailers in Sweden would not sell it to persons under the age of 18.

Tobacco-free snus was introduced by Swedish Match with the Onico brand in 2006.[38] At first, it was made with corn starch but, in 2008, the formula was changed when it began causing teeth issues.

References

  1. ↑ Gray, Nigel (2005). "Mixed feelings on snus". The Lancet 366 (9490): 966–7. doi:10.1016/S0140-6736(05)67352-7. PMID 16168760.
  2. ↑ Directive 2001/37/EC of the European Parliament and of the Council of 5 June 2001 on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco products & Commission statement
  3. 1 2 "Russian upper house approves bill banning snus". Russian Legal Information Agency (RAPSI). 25 December 2015.
  4. 1 2 Isabel Conway (21 April 2009). "Snuff is not to be sniffed at". Irish Times.
  5. ↑ Phillips, Carl V. "Smokeless tobacco and your health". Smokeless tobacco and your health. Retrieved 29 August 2013.
  6. ↑ "Snus – The Swedish Experience" (PDF). World Health Organization. Retrieved 20 October 2014.
  7. 1 2 Foulds, Jonathan; Furberg, Helena (2008). "Is low-nicotine Marlboro snus really snus?". Harm Reduction Journal 5: 9. doi:10.1186/1477-7517-5-9. PMC 2288606. PMID 18304348.
  8. ↑ http://europa.eu/rapid/press-release_MEMO-12-788_en.htm
  9. ↑ http://www.swedishmatch.com/en/Media/Pressreleases/Press-releases/2012/Comments-by-Swedish-Match-to-the-press-release-from-the-European-Commission/[]
  10. ↑ Roosaar, Ann; Johansson, Anna L.V.; Sandborgh-Englund, Gunilla; Axéll, Tony; Nyrén, Olof (2008). "Cancer and mortality among users and nonusers of snus". International Journal of Cancer 123 (1): 168–73. doi:10.1002/ijc.23469. PMID 18412245.
  11. ↑ MacAra, A. W (2008). "Should doctors advocate snus and other nicotine replacements? No". BMJ 336 (7640): 359. doi:10.1136/bmj.39479.491319.AD. PMC 2244771. PMID 18276711.
  12. ↑ Rodu, Brad (2007). "Snus and the risk of cancer of the mouth, lung, and pancreas". The Lancet 370 (9594): 1207–8; author reply 1208. doi:10.1016/S0140-6736(07)61533-5. PMID 17920914.
  13. ↑ Bertuccio, P; La Vecchia, C; Silverman, DT; Petersen, GM; Bracci, PM; Negri, E; Li, D; Risch, HA; Olson, SH; Gallinger, S; Miller, AB; Bueno-de-Mesquita, HB; Talamini, R; Polesel, J; Ghadirian, P; Baghurst, PA; Zatonski, W; Fontham, ET; Bamlet, WR; Holly, EA; Lucenteforte, E; Hassan, M; Yu, H; Kurtz, RC; Cotterchio, M; Su, J; Maisonneuve, P; Duell, EJ; Bosetti, C; Boffetta, P (June 2011). "Cigar and pipe smoking, smokeless tobacco use and pancreatic cancer: an analysis from the International Pancreatic Cancer Case-Control Consortium (PanC4).". Annals of Oncology 22 (6): 1420–6. PMID 21245160.
  14. ↑ Swislocki, A.L.M.; Tsuzuki, A.; Tait, M.; Khuu, D.; Fann, K. (1997). "Smokeless nicotine administration is associated with hypertension but not with a deterioration in glucose tolerance in rats". Metabolism 46 (9): 1008–12. doi:10.1016/S0026-0495(97)90270-5. PMID 9284888.
  15. ↑ "Tobacco habits other than smoking; betel-quid and areca-nut chewing; and some related nitrosamines. IARC Working Group. Lyon, 23-30 October 1984" (PDF). IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans 37: 1–268. 1985. PMID 3866741.
  16. ↑ Levy, David T.; Mumford, Elizabeth A.; Cummings, K. Michael; Gilpin, Elizabeth A.; Giovino, Gary; Hyland, Andrew; Sweanor, David; Warner, Kenneth E. (2004). "The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product Compared with Smoking Cigarettes: Estimates of a Panel of Experts". Cancer Epidemiology, Biomarkers & Prevention 13 (12): 2035–42. PMID 15598758.
  17. ↑ Gregory N. Connolly, and Howard Saxner (August 21, 2001). "Informational Update Research on Tobacco Specific Nitrosamines (TSNAs) in Oral Snuff and a Request to Tobacco Manufacturers to Voluntarily Set Tolerance Limits For TSNAs in Oral Snuff".
  18. ↑ Britton, John; Bogdanovica, Ilze (15 May 2014). "Electronic cigarettes – A report commissioned by Public Health England" (PDF). Public Health England. p. 11.
  19. ↑ "Swedish Match North America MRTP Applications". 27 August 2014. pp. 100,000+. Retrieved 24 October 2014.
  20. ↑ [ http://www.cspnet.com/category-news/tobacco/articles/modified-risk-down-not-out Modified Risk: Down But Not Out An exclusive look inside Swedish Match’s MRTP application]
  21. ↑ http://www.tobaccoprogram.org/pdf/TC12349.pdf[]
  22. ↑ Rabinoff, Michael (2007). "Corporate Social Responsibility As A Tactic Used By Big Tobacco". Ending the Tobacco Holocaust. pp. 375–9. ISBN 978-1-60070-019-4.
  23. ↑ Britton, John; Bogdanovica, Ilze (15 May 2014). "Electronic cigarettes – A report commissioned by Public Health England" (PDF). Public Health England. p. 11=12.
  24. ↑ Gartner, Coral E; Hall, Wayne D; Vos, Theo; Bertram, Melanie Y; Wallace, Angela L; Lim, Stephen S (2007). "Assessment of Swedish snus for tobacco harm reduction: An epidemiological modelling study". The Lancet 369 (9578): 2010–4. doi:10.1016/S0140-6736(07)60677-1. PMID 17498798.
  25. ↑ McKee, Martin; Gilmore, Anna (2007). "Swedish snus for tobacco harm reduction". The Lancet 370 (9594): 1206; author reply 1206–7. doi:10.1016/S0140-6736(07)61530-X. PMID 17920913.
  26. ↑ Lambe, Mats (2007). "Swedish snus for tobacco harm reduction". The Lancet 370 (9594): 1206; author reply 1206–7. doi:10.1016/S0140-6736(07)61531-1. PMID 17920911.
  27. ↑ Mineur, Yann S.; Picciotto, Marina R. (2010). "Nicotine receptors and depression: Revisiting and revising the cholinergic hypothesis". Trends in Pharmacological Sciences 31 (12): 580–6. doi:10.1016/j.tips.2010.09.004. PMC 2991594. PMID 20965579.
  28. ↑ Taylor, G.; McNeill, A.; Girling, A.; Farley, A.; Lindson-Hawley, N.; Aveyard, P. (2014). "Change in mental health after smoking cessation: Systematic review and meta-analysis". BMJ 348: g1151. doi:10.1136/bmj.g1151. PMC 3923980. PMID 24524926.
  29. ↑ Foulds, J; Ramstrom, L; Burke, M; Fagerström, K (2003). "Effect of smokeless tobacco (snus) on smoking and public health in Sweden". Tobacco Control 12 (4): 349–59. doi:10.1136/tc.12.4.349. PMC 1747791. PMID 14660766.
  30. ↑ Lund, K. E.; McNeill, A.; Scheffels, J. (2010). "The use of snus for quitting smoking compared with medicinal products". Nicotine & Tobacco Research 12 (8): 817–822. doi:10.1093/ntr/ntq105.
  31. ↑ Furberg, H.; Lichtenstein, P.; Pedersen, N. L.; Bulik, C. M.; Lerman, C.; Sullivan, P. F. (2007). "Snus use and other correlates of smoking cessation in the Swedish Twin Registry". Psychological Medicine 38 (9): 1299–308. doi:10.1017/S0033291707002346. PMC 2914546. PMID 18680625.
  32. ↑ Rivenson, Abraham; Hoffmann, Dietrich; Prokopczyk, Bogdan; Amin, Shantu; Hecht, Stephen S. (1988-12-01). "Induction of Lung and Exocrine Pancreas Tumors in F344 Rats by Tobacco-specific and Areca-derived N-Nitrosamines". Cancer Research 48 (23): 6912–7. PMID 3180100.
  33. ↑ Fesinmeye, Megan Dann (July 14, 2006). Smokeless Tobacco, Swedish Snus, and Pancreatic Cancer. The 13th World Conference on Tobacco and Health Conference. Washington, DC.
  34. ↑ Luo, Juhua; Ye, Weimin; Zendehdel, Kazem; Adami, Johanna; Adami, Hans-Olov; Boffetta, Paolo; Nyrén, Olof (2007). "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 369 (9578): 2015–20. doi:10.1016/S0140-6736(07)60678-3. PMID 17498797.
  35. ↑ "Use Of Swedish 'Snus' Is Linked To A Doubled Risk Of Pancreatic Cancer". Science Daily. May 11, 2007.
  36. ↑ "Swedish Snus Much Safer Than Smoking But Linked To Pancreatic Cancer". Medical News Today. 10 May 2007.
  37. ↑ "Snus och blodtryck" [Snuff and blood pressure] (in Swedish). Läkartidningen. November 21, 2008.
  38. ↑ "Swedish Match checking tobacco-free snus complaints". Reuters. 6 May 2008.

Further reading

A number of peer-reviewed studies of snus use have been published:

Cardiovascular diseases

Diabetes

Cancer

Smoking cessation

Medical community discussions and reports

External links

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Articles

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