Should doctors advocate snus and other nicotine replacements? Yes

Abstract

Use of snus is less harmful than smoking and John Britton thinks that doctors should suggest it to people who are unable to give up cigarettes. But Alexander Macara argues that it could result in increased use of tobacco

Smoking is the biggest avoidable cause of death and disability,¹ and of social inequalities in health,² in the United Kingdom. Smoking currently kills over 100 000 UK citizens each year,³ predominantly from lung cancer, heart disease, and chronic obstructive pulmonary disease. Half of all lifelong smokers die from smoking, typically losing 10 years of life.⁴ Non-smokers are victims too. Although smoking is prohibited in public and workplaces throughout the UK, smoking in the home remains an important cause of morbidity and mortality through passive exposure, especially in young children.⁵ Stopping smoking reverses or prevents progression of these problems.

Currently, 77% of UK smokers want to give up smoking, and 78% have tried and failed.⁶ Of the many reasons why they have not succeeded in quitting, the most important is addiction to nicotine. Cigarettes deliver nicotine to the brain rapidly, and in high doses, achieving arterial concentrations around five to six times those obtained, far more slowly, from conventional nicotine replacement therapy products.⁷ The repeated high dose hits of nicotine that cigarettes deliver not only reward the smoker directly but also confer rewarding properties on other stimuli arising from smoking and behaviours associated with it.⁸ The result is a powerful addiction, such that someone who is a regular smoker at 25 has a roughly even chance of still being a smoker at 60¹—assuming, of course, that they survive that long.

The tragedy is that nicotine addiction itself is not especially hazardous. Nicotine is not harmless,⁸ but in practice accounts for little if any of the morbidity and mortality caused by smoking. It is the hundreds of other toxins in tobacco smoke, not nicotine, that make smoking so deadly. So if smokers who are unable, unwilling, or simply unlikely to quit were to switch from cigarettes to other, less hazardous sources of nicotine, millions of lives could be saved.

Safer choices

By far the safest alternative is the current range of nicotine replacement products. All reduce the symptoms of withdrawal from smoking and therefore, although marketed and licensed primarily as cessation aids, are also logical long term substitutes for cigarettes. However, because of their low dose and delivery rate they are not highly effective; smokers find them helpful but not satisfying as a cigarette substitute. So it would help if medicinal nicotine products could be developed to mimic the cigarette more closely—delivering high doses, quickly, on demand.

Another, and more controversial, alternative source of nicotine is smokeless tobacco or snuff—tobacco for oral or nasal use. Smokeless tobacco products are all considerably more hazardous than nicotine replacement therapy and some especially so. The Swedish moist tobacco products (known as snus) are among the less hazardous and cause pancreatic cancer, probably cardiovascular disease, and various other health problems.^{8 9 10 11 12} However, because these risks are all lower for snus than for smoking, and because snus use does not cause lung cancer or chronic obstructive pulmonary disease, snus use is substantially less hazardous than smoking.

Recent data from Sweden, where snus has been available for years, indicate that habitual smokers and young people experimenting with tobacco products have substituted snus for cigarettes, resulting in low levels of smoking.^{13 14} This suggests that smokeless tobacco is an acceptable smoking substitute for some smokers and therefore snus may be effective in this role in other populations.

Although nicotine replacement therapy is not licensed for use as a long term substitute for smoking, in practice it is common sense for health professionals dealing with smokers who are unable to quit smoking to encourage use of medicinal nicotine products as a substitute for smoking, and prescribe them if necessary. They should strongly advise smokers that the best option would be to quit all nicotine use, and do all they can to support this by encouraging uptake of behavioural therapy supported by nicotine replacement therapy, bupropion, or varenicline in accordance with established clinical guidelines. However, for those who try repeatedly and fail, or for those who are not ready to stop using nicotine, switching to a medicinal nicotine product is the logical next best option. Doctors should encourage this.

Using smokeless tobacco is another matter. In the UK, the only legally available smokeless products are the more hazardous ones because the 1992 Tobacco for Oral Use (Safety) Regulations prohibit the supply of oral tobacco products that are not intended to be smoked or chewed. Snus is intended to be sucked, so it is illegal for a doctor or anyone else to supply it, although mail order purchase for personal use from a supplier in Sweden is within the law. In my view, as a measure of last resort in smokers who have tried all other cessation and substitution options, doctors would be justified in suggesting an individual trial of snus. Whether this approach will prove effective remains to be seen and desperately needs to be tested in clinical trials. However, while the alternative is equivalent to a form of Russian roulette in which every other chamber of the revolver holds a bullet, pursuing a less hazardous alternative—even this one—surely makes sense.