Cigarette smoking - public health enemy number one
LARS ERIK RUTQVIST, whose previous work experience includes a period as a professor of oncology, has himself been involved in a number of major epidemiological studies relating to the health effects of Swedish snus.
"In this area, the current research situation is fairly unequivocal," he says. "It is well documented that as far as the substantial health risks associated with smoking are concerned, particularly different forms of cancer and cardiovascular diseases, there is no correspondingly elevated risk for users of Swedish snus." Despite these findings, it has been a tough uphill task to inculcate this knowledge among people working with public-health issues. The prevailing attitude is to lump all tobacco products together. This is the approach taken by the World Health Organization, for example, and within the EU the ban on the sale of snus in all the member countries except Sweden remains in effect.
Tax is off the target
Another example of this view occurred recently when the newly elected Swedish government proposed a 100-percent increase in the tax on snus in its budget bill, while the tax increase on cigarettes was 40 percent.
"It is deeply unfortunate from a public health standpoint to send the wrong signals to consumers, namely that all tobacco products are as harmful as cigarettes. This is not the case," says Lars-Erik Rutqvist.
Lars Erik Rutqvist believes that ideological and political objections are the main reason why it has been so difficult to gain a hearing for the harm-reduction philosophy - that is, substituting less harmful tobacco products for cigarettes - among public authorities and decision-makers. Once people have adopted an entrenched position, it is difficult for them to admit that perhaps they could be wrong.
Right focus in the debate
Nevertheless, Rutqvist believes he can discern an opinion shift. One example is the major conference on tobacco controls, the World Conference on Tobacco OR Health, which was held in Washington, DC, in June. The conference brought together representatives of public-health occupations and the research community from throughout the world. One of the main conference themes was publichealth issues in the developing world.
"It was an extremely interesting conference, with many speakers in a number of symposia displaying a highly positive attitude toward the idea of harm reduction. The organizers had invited both skeptical and supportive speakers, but overall it was a very good discussion that highlighted the current research situation, which does after all show that the risks from using snus are significantly lower than those from smoking," relates Lars Erik Rutqvist.
In response to the introductory question as to what was the overall objective for the participants in the symposium - to fight the tobacco companies, to combat all addictive substances, or to discuss health-related effects - the vast majority of participants stated that their most important objective was to find ways of reducing the negative health effects of smoking, which was very pleasing to hear."
Increasing attention is being paid to data showing that as more and more Swedes switch from cigarettes to snus, the incidence of serious smoking-related illnesses has declined. Today, Sweden has the lowest incidence of cancer of the oral cavity and pancreas in the whole of Europe, and Swedish men have the lowest frequency of lung cancer. This trend is often referred to internationally as "the Swedish experience."
Task is to spread knowledge
Today, the number of scientifically based objections to snus on health grounds is constantly decreasing. While Lars Erik Rutqvist does not rule out the possibility that future studies could reveal new, hitherto unknown risks, he still feels that in the overall publichealth perspective the message given by the studies conducted to date is clear: there are significant public-health gains to be realized by adopting an approach that includes harm reduction.
Based on his long experience as a physician and researcher, Lars Erik Rutqvist is convinced that a pragmatic rather than dogmatic approach to harm reduction would lead to significant gains for public health.
"We know after all that half of smokingrelated deaths occur in middle age. The victims lose perhaps as much as 20 years of their life expectancy," he says. "In the light of these statistics, it is both counterproductive and irresponsible to adopt a moralizing tone. Dogmatic public-health representatives keep both the public and many doctors believing that it is as dangerous to use snus as to smoke. If that is what people believe, how are you supposed to motivate smokers to quit?"
In view of this situation, he sees one of his own main tasks as being to help make the full picture regarding what we know today about snus and smoking better understood among decision-makers, researchers, physicians and the general public. People must be given a better opportunity to make a well-informed decision, based on facts rather than ideology. When asked what is his own most important health advice, he does not hesitate for a second:
"Give up smoking entirely!"
