“Nicotine pouches save lives”: Just more data manipulation from the nicotine industry
The nicotine and tobacco industries are adapting manipulative tactics that they used for cigarettes to market their nicotine pouch products. They are using industry-funded studies, questionable experts, hidden financing, and crooked reports to manipulate the “harm reduction” debate and to force open the EU market to nicotine pouches. In this article we propose to show how the argument of harm reduction is used in a context that can only serve tobacco industry interests and that goes against public health.
from Luciano Ruggia
A new “study”? Who pays the expert?
A press release from Snusmarkt.ch, which was picked up by the Swiss news agency Keystone SDA on 18 October 2022, argued that opening the market up to nicotine pouches could save as many as 210,000 lives in the EU and as many as 3,400 in Switzerland. This press release originates from a new ”study“ from Sundén (2022) on “Fighting smoking with alternative nicotine products. Exemplified by the public health effects of Swedish snus,” published in September 2022.[i]
The study mentions that its aim was “to assess the potential of snus as an instrument to reduce the harm from smoking. More specifically the report tries to estimate the potential of snus in reducing the number of smoking-attributable deaths and the incidence of smoking-attributable cancer cases.” As a caveat, the authors immediately add that the “results should not be interpreted as a case for allowing snus sales in the EU. Rather, the results should be seen as an estimate of the possible long run public health effects of the new and less harmful nicotine products, such as nicotine pouches and e-cigarettes.” However, the real objective is clear: to exploit the “harm reduction” argument to open the EU market to nicotine pouches.
Snus and nicotine pouches in Switzerland
The sale of snus was banned in the EU in 1992, with the single exception of Sweden, because the product was already historically consumed in this country.[ii] Switzerland followed the EU in banning snus in 1995, but, following a decision of the Federal Tribunal in 2019, snus became readily available on the market again. Snus remains banned in the EU today, however nicotine pouches are available for purchase. In Switzerland, the popular nicotine pouches massively outperform snus sales. The pouches appear to be a popular choice especially among young people, as they allow for stealth consumption, making their use nearly undetectable in public.[iii] Although we lack clear surveillance data, the marketing is clear: the sale of nicotine pouches is directed towards young people, particularly those who are active in sports. Moreover, the expansion of online shops, with ineffective age-control barriers, has further spurred sales.
Snus and nicotine pouches are often a gateway to the use of other nicotine or tobacco products, or they are used in combination with other products (Brief AT: Snus). Currently, in Switzerland, no evidence shows that the arrival of snus or nicotine pouches has promoted a switch away from cigarettes. The Swiss market experience demonstrates that the unrestricted sale of snus and nicotine pouches in a context different from the Swedish one does not seem to bring any public health advantage and in fact appears to simply increase dual and multiple consumption.
The study from Sundén (2022) is based on a very simple and mathematical projection. The study promotes the idea that if other countries would have opened their market to snus, with similar policies and pricing structures, then they would have an identical smoking prevalence rate and identical death rates caused by smoking to those of Sweden. This assumption, which might seem charming in its simplicity, lacks consideration of the very different situations in other EU countries, in tobacco control policies as well as cultural attitudes toward tobacco consumption.
The methodology used by Sundén (2022) takes into consideration three sets of criteria: 1) economic instruments (taxation of cigarettes); 2) administrative instruments (i.e. unit packets, which we consider as being totally irrelevant; the ban of Swedish snus in the EU since 1992; and smoking bans in public areas, which in the Swiss context have had no impact on smoking prevalence); and 3) information-based instruments, such as health warnings on cigarette packages. The author seems to choose his analytic criteria in an arbitrary way and his choice results in focusing all the attention on a single relevant difference: snus is on sale in Sweden and not in the EU. The use of such an analytical framework promotes the idea that a snus or nicotine pouch liberalisation would have a positive impact on public health in the EU. The study does not discuss why this framework was chosen, instead of, for instance, the one established by the European Tobacco Control Scale.[iv]
Other methodological elements of the Sundén (2022) study remain unclear. Often some sources are inadequately referenced, such as just “Lakeville”, further highlighting the questionable scientific qualities of the study. The author is careful to openly state some limitations, like the fact that his calculation applies only to men. The author is very quick to discount any consideration on women’s health simply arguing that a lack of data for women makes it more difficult to draw any conclusion. In Norway, among women who used snus throughout pregnancy, a study found an increased risk of stillbirth, premature delivery, small-for-gestational age foetus, low birth weight, increased rate of Caesarean section, neonatal arrhythmia, oral cleft malformations. and neonatal apnoea.[v] Disregarding the possible impact of snus on women’s health, simply because it is less consumed by women and the data are less developed, is unacceptable. But for the author, this, among other elements, can only lead to an underestimation of the new nicotine products’ effect on public health. The overall impression however is of a very partial and biased analysis which would never stand in an independent peer-review examination.
"The assumption of Sundén’s (2022) study, to copy-paste Swedish policy and assume it would be effective in other contexts, fails to consider any historical or cultural differences in relation to smoking habits."
The conclusion of the study is clear: “An EU policy allowing the sales of snus, and indirectly new nicotine products, can be estimated to reduce the number of male smoking-attributable deaths with about 210,000 per year. The number of smoking-attributable lung cancer deaths is estimated to be reduced with about 75,000 and the number of smoking-attributable new cancer cases with 175,000 per year. This calculation presumes an uptake of, and substitution to, snus among European men to the same degree as in Sweden.” Even if the study is draped with cautions and declared limitations, its conclusion is definitive: the Swedish snus policy works in its context because a large proportion of Swedish men consume snus.
Some countries like Ireland have very advanced tobacco control policies that include higher taxes on cigarettes, but no legal saleof snus or nicotine pouches. Ireland was able to massively reduce its smoking prevalence to 18% in 2021 among the adult population, with even better results among teenagers (the smoking rate in Switzerland remains at least 27%). This is still far from the Swedish 6% adult prevalence, which is historically low. The assumption of Sundén’s (2022) study, to copy-paste Swedish policy and assume it would be effective in other contexts, fails to consider any historical or cultural difference in relation to smoking habits.
The absence of evidence
Once examining what evidence was left out of the study from Sundén (2022), upon which snusmarket.ch based their press release, one may begin to question the motives behind these exclusions.
The study fails to mention recent and strong evidence on the dangers of snus consumption. Snus use among men is positively associated with increased all-cause mortality, cardiovascular mortality, with death from other causes, and possibly with increased cancer mortality.[vi]
Other studies also raised doubts on the benefit of snus use for harm reduction, as the combined dual use with smoking resulted in higher smoking rates among young adults.[vii] Dual, and even multiple use among teenagers in Nordic countries seems to be on the increase, but this risk is not considered in the study.[viii] In Switzerland, a longitudinal study showed that snus consumption significantly increased the likelihood of smoking initiation and continuation.[ix]
New nicotine pouches seem to contain alarming amounts of dangerous components. A recent study concluded that, although nicotine pouches may potentially be a less risky alternative for cigarette smokers or users of some other oral tobacco products, the nicotine content of some pouches was alarmingly high. In particular, the presence of carcinogenic tobacco-specific nitrosamines (TSNAs) in the nicotine pouches is of serious concern.[x] In Germany too, a recent analysis of nicotine pouches’ health risks cast a clear doubt on the use of those product for smoking cessation.[xi]
Another extensive research study not mentioned by the Sundén (2022) report is the 2019 “Health risks from snus use” report from the Norwegian Institute of Public Health, which explains how the use of Swedish snus, increasing in Norway, also carries significant increased health risks, such as[xii] a significant impact on mental health.[xiii]
Nicotine pouches use a wide variety of flavours and associated marketing techniques. To market these products as ‘flavour-ban approved’ may give consumers the false perception that some regulatory agency deemed these products as unflavoured and approved them as not subject to the same policies as flavoured products. One could also say that the producers are trying to indicate that their specific flavour is safe and approved by some authority, as opposed to others’ unsafe flavours. Policies restricting the sale of products with a variety of flavours, including menthol, in other tobacco products are under consideration in the USA, Canada, and the European Union. Careful attention should be given to marketing techniques that may be used as a precedent for introducing similar new oral nicotine products, e-cigarettes, or combustible tobacco products, and which may put the health of young people at risk.[xiv]
This short review does not claim to be any kind of systematic analysis of the snus and nicotine pouch risks. However, the studies mentioned here however are recent, the oldest from 2019, and all of them are easily accessible online and independently produced with no conflict of interest with the snus or nicotine industry. So, it begs the question as to why none of them were mentioned by the Sundén (2022) study. The study appears to follow the classic old playbook of using studies financed by the tobacco industry, by taking in consideration only the evidence that supports their view and their lobby strategies.
Doubtful experts and hidden financing
This study was produced by the Swedish consulting company Lakeville.[xv] This consultancy seems to conduct its “research” according to the well-known playbook of similar institutions, like other better known and murky ultra-economically liberal think tanks financed by, among others, the tobacco industries: a well-known example of which is the Institute of Economic Affairs (IEA).[xvi] The cigarette industry financed the IEA and other so-called research institutes in order to produce reports and research to oppose tobacco control measures.[xvii] In the study by Sundén (2022) we find well-paid consultants producing a partial and incomplete analysis in order to provide evidence with the aim to support lobby activities. Then this report is circulated to the media and ends up in political and regulatory debates, without the transparency that it was fully paid by the industry. These kinds of reports are often used as a subtle violation of art. 5.3 FCTC, which requires that “in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”.[xviii] The EU is itself a full member of the FCTC. In November 2018, the European Union’s top court confirmed the ban of snus in the EU,[xix] but there is currently a renewed legal battle to overturn the ban.
Source: The SnusMarkt.ch web page: cheap prices and discounts (23.10.2022)
The study mentioned that the “Haypp Group AB has commissioned Lakeville to assess the potential of snus as an instrument to reduce the public health harm from tobacco smoking in the EU”, yet this mention is not easily spotted. The Haypp Group is a large Swedish e-marketing group focused on promoting and selling snus and nicotine pouches.[xx] Haypp claims to have 131 employees, a presence in seven countries (Sweden, Norway, and the US are mentioned on its website, but not Switzerland) and, according to their web page, “we served more than 680,000 active customers” with the brands of e-shops for snus and nicotine pouches. In the Swiss press release, the presence of this group is formulated a bit differently, claiming to be present in 30 countries with eight e-commerce brands having 500,000 customers. In Switzerland, Haypp Group is present through Snusmarkt.ch, one of the major Swiss web portals to buy those products online.[xxi] According to Snusmarkt.ch, the sale of nicotine pouches increased in 2021 by 37% compared to 2020, while snus decreased by 15%, showing the transition to nicotine pouches from classical snus.
"But who is really behind the Haypp Group? All major nicotine pouches are produced by the classic giant tobacco companies: Epok, Lyft, and Velo belong to BAT; Skruf and ZoneX to Imperial Tobacco; LD and Nordic Spirit to Japan Tobacco; and General and Zyn to Swedish Match, which belongs mostly to PMI."
But who is really behind the Haypp Group? All major nicotine pouches are produced by the classic giant tobacco companies: Epok, Lyft, and Velo belong to BAT; Skruf and ZoneX to Imperial Tobacco; LD and Nordic Spirit to Japan Tobacco; and General and Zyn to Swedish Match, which belongs mostly to PMI.[xxii]
Classifying this study as biased would be a gross understatement. This study is a classic example of scientific manipulation financed by the tobacco industry in order to influence public health policies.
A communication operation
In Switzerland, Snusmarkt.ch promoted the report with a press release that was picked up only by Keystone, so it had little media impact. Snusmarkt suggested a biased mathematical interpretation of the report, asserting that if Swiss men used snus like the Swedes, we would have the same proportion of tobacco-related deaths, which would mean saving 3,400 lives (while we estimated the yearly direct tobacco-attributable deaths at 9,500).[xxiii] Snusmarkt fails to mention that since the arrival of snus and nicotine pouches, sold legally in Switzerland since 2018, we have not seen any decrease in smoking prevalence and actually the sale of cigarettes increased in 2020 by 4%, which is a very important increase.[xxiv]
Pretending that snus is a harm-reduction instrument for tobacco in Switzerland is a strategy used by the industry lobby to influence policy, in particular in the debate on taxation. We didn’t need to wait for long to see how “research” generated by the industry is used by politicians close to the tobacco lobby. A Swiss MP introduced a parliamentary question on September 29th, 2022, asking for a differentiated regulation of tobacco products according to their health risks.[xxv] Not only does this MP attack the Government because it will apply in an undifferentiated way the referendum, Kids Free from Tobacco, accepted by the Swiss population on February 13th, 2022, but argues that 66% of people ordering snus online could stop smoking thanks to snus, and that snus is 95% less carcinogenic than cigarettes, based on a “study” coming from Snusmarkt.ch itself. Snusmarkt suggests that their “data” should lead to a taxation of snus and nicotine pouches even lower than electronic cigarettes. Thus, Snusmarkt.ch produces a “study”, and based on this “study” they write a text that a “friendly” politician introduces to the Parliament in order to influence regulation and taxation policies that will mostly, and massively, benefit Smusmarkt.ch. It is not easy to find a better example of manipulation and lobbying aimed at promoting the financial interest of an industry over and above the health of the Swiss population.
Luciano Ruggia is the Director of the Swiss Association for Tobacco Control, the main national Swiss NGO active in tobacco control and prevention. Mr. Ruggia has degrees in political sciences, international relations and in public health. He worked for several years at the Swiss Federal Office of Public Health, then he moved to the Institute of Social and Preventive Medicine (ISPM) of the University of Bern, where he maintains a research position. He is also a fellow of the Swiss School of Public Health.
He was one of the first in Europe to raise the alarm about the disposable electronic cigarettes, which consumption is spreading among teenagers in Europe and several other countries.
[i] Sundén, David (2022): Fighting smoking with alternative nicotine products. Exemplified by the public health effects of Swedish snus. Lakeville Economic Consulting. Available online at https://hayppgroup.com/app/uploads/2022/08/Fighting-smoking-with-alternative-nicotine-products.pdf. and Haypp Group (9/23/2022): A ‘YES’ from the EU to oral nicotine would save 210,000 lives. Press release.
[iii] Ruggia, Luciano (2021): Les nouveaux produits du tabac: évolutions et conséquences. In Bull Med Suisses. DOI: 10.4414/bms.2021.20096.
[iv] Joossens, Luc; Feliu, Ariadna; Fernandez, Esteve (2020): The Tobacco Control Scale 2019 in Europe. Association of European Cancer Leagues. Brussels.
[v] Vist, Gunn Elisabeth; Grimsrud, Tom Kristian; Valen, Håkon; Becher, Rune; Brinchmann, Bendik Christian; Elvsaas, Ida-Kristin Ørjasæter; Alexander, Jan (2020): Er helserisikoen ved snus undervurdert? In Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke 140 (9). DOI: 10.4045/tidsskr.19.0746.
[vi] Byhamre, Marja Lisa; Araghi, Marzieh; Alfredsson, Lars; Bellocco, Rino; Engström, Gunnar; Eriksson, Marie et al. (2021): Swedish snus use is associated with mortality: a pooled analysis of eight prospective studies. In International journal of epidemiology 49 (6), pp. 2041–2050. DOI: 10.1093/ije/dyaa197. See also https://www.stop-tabac.ch/e-cigarette/autres-produits-du-tabac/snus-avec-ou-sans-tabac-snuff-tabac-a-priser-tabac-a-chiquer/snus-snuff-et-risques-pour-la-sante/
[vii] Grøtvedt, Liv; Forsén, Lisa; Ariansen, Inger; Graff-Iversen, Sidsel; Lingaas Holmen, Turid (2019): Impact of snus use in teenage boys on tobacco use in young adulthood; a cohort from the HUNT Study Norway. In BMC Public Health 19 (1), p. 1265. DOI: 10.1186/s12889-019-7584-5.
[viii] Raitasalo, Kirsimarja; Bye, Elin K.; Pisinger, Charlotta; Scheffels, Janne; Tokle, Rikke; Kinnunen, Jaana M. et al. (2022): Single, Dual, and Triple Use of Cigarettes, e-Cigarettes, and Snus among Adolescents in the Nordic Countries. In International journal of environmental research and public health 19 (2). DOI: 10.3390/ijerph19020683.
[ix] Gmel, Gerhard; Clair, Carole; Rougemont-Bücking, Ansgar; Grazioli, Véronique S.; Daeppen, Jean-Bernard; Mohler-Kuo, Meichun; Studer, Joseph (2018): Snus and Snuff Use in Switzerland Among Young Men: Are There Beneficial Effects on Smoking? In Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco 20 (11), pp. 1301–1309. DOI: 10.1093/ntr/ntx224.
[x] Nadja Mallock; Thomas Schulz; Sebastian Malke; Nadine Dreiack; Peter Laux; Andreas Luch (2022): Levels of nicotine and tobacco-specific nitrosamines in oral nicotine pouches. In Tobacco control. DOI: 10.1136/tc-2022-057280.
[xi] Bundesinstitut für Risikobewertung (2022): Health Risk Assessment of Nicotine Pouches: Updated BfR Opinion No. 023/2022 of 7 October 2022. With assistance of Bundesbehörden und Einrichtungen im Geschäftsbereich des Bundesministeriums für Ernährung und Landwirtschaft (BMEL).
[xii] Norwegian Institute of Public Health (2019): Health risks from snus use. Norwegian Institute of Public Health. Available online at https://www.fhi.no/en/publ/2019/health-risks-from-snus-use2/, updated on 4/4/2022, checked on 4/4/2022.
[xiii] Tjora, Tore; Skogen, Jens Christoffer; Sivertsen, Børge (2022): Establishing the association between snus use and mental health problems: A study of Norwegian college and university students. In Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. DOI: 10.1093/ntr/ntac208.
[xiv] Tackett, Alayna P.; Barrington-Trimis, Jessica L.; Leventhal, Adam M. (2022): 'Flavour ban approved': new marketing strategies from tobacco-free nicotine pouch maker Zyn. In Tob Control. DOI: 10.1136/tobaccocontrol-2021-057222.
[xvii] Horel, Stéphane (2018): Lobbytomie. Comment les lobbies empoisonnent nos vies et la démocratie. Paris: La Découverte (Cahiers libres).
[xix] WHO (2003): WHO Framework Convention on Tobacco Control. Geneva: World Health Organization. and World Health Organization: WHO Framework Convention on Tobacco Control. Guidelines for Implementation of Article 5.3 Articles 8 to 14. 2013th ed. Geneva (Documents for Sale).
[xxiii] «So ist zum Beispiel die Zahl der männlichen Raucher in der Schweiz rund fünfmal so hoch wie in Schweden (31% vs. 6%). Das Resultat anhand eines Beispiels: Würden in der Schweiz gleich viele Männer von Zigaretten auf weniger schädliche Snus und Nikotinbeutel wechseln wie in Schweden, wäre es gemäss der Studie möglich, rund 3'447 Leben zu retten.», Snusmarkt.ch (10/18/2022): Leben retten dank Snus und Nikotinbeutel: Szenarien für die EU und die Schweiz. Press release.