April 10, 2004

Exporting the Swedish Snus Model

I visited Brussels this week, to participate in a meeting about snus in the Hayek Series organized by Tech Central Station.

Snus?! What does moist oral snuff have to do with Hayek, or Brussels for that matter?

The basic problem with tobacco is that it is addictive and unhealthy. This is true for all forms, be they cigarettes, snuff or sweets. But smoking the stuff makes things worse, since it produces hundreds of carcinogenic and teratogenic chemicals which are directly breathed into the lungs - a recipe for lung cancer, and over 90% of all lung cancers are linked to smoking. Taking tobacco orally avoids the lung cancer issue (oral cancer is still a problem, but you get it from smoking too). This is very visible in the cancer statistics of Sweden, where snus is widely used among men: a significantly lower incidence of lung cancer than in the rest of Europe but only among men; for women the incidence is about equal. See the report on oral tobacco by the European Network for Smoking Prevention for a good review of the field.

So, if people took snus instead of smoked like in Sweden hundreds of thousands of lung cancer cases could be avoided every year in Europe. They would still have the addiction problem and other health problems, but it would at least be a better situation.

But snus is banned in all of EU except Sweden.

This has produced the current interesting situation. Many tobacco epidemologists have realized that harm reduction is a good thing: while the long-term goal is to get people stop using tobacco as much as possible, in the shorter term it would be healthier if they at least could switch to smokeless tobacco (there are also obvious benefits in terms of passive smoking and lowered fire risks). Thus they have become allied with parts of the tobacco industry (especially Swedish Match, the major snus producer) to have the ban repealed.

So who is fighting for it? The rest of the anti-tobacco movement, with the Swedish anti-tobacco establishment at the front. This has produced the bizarre situation that Sweden is generally viewed as a demonstration that harm reduction through snus is feasible, but most Swedish tobacco researchers are fiercely opposed to harm reduction. The typical Swedish approach to public health is very much to ban everything potentially unhealthy and not accept any compromises even if they would be helpful. Add to this that is is very easy to claim that anybody suggesting harm reduction has been bought by Big Tobacco or is secretly one of those satanic drug liberals who think the government shouldn't interfere in what people do with their body chemistry, and you have a recipe for stormy and polarized debates.

But the meeting in Brussels was surprisingly pleasant. Dr. Michael Kunze", professor of public health in and director of the Nicotine Institute in Vienna presented the case for harm reduction. Opposing him was Dr. Göran Boëthius from Doctors Against Tobacco, agreeing on the basic science but taking the typical Swedish line that it is better to try to reduce tobacco use than to get people to switch to something safer in the meantime. Mr. Paul Flynn, MP and Vice Chair of the UK House of Commons Drugs Misuse Group took the general pro-snus position. Nobody on the podium wanted more people to use tobacco, but it was clear that the debate has moved far beyond the Swedish internal debate. Even the report mentioned above from ENSP showed a depth that is rarely seen here. As Dr. Kunze remarked, it was refreshing not to be shouted off the stage as a heretic any more.

It remains to be seen if this thawing of the debate climate will have any effect on the EU ban. But it seems absurd to ban a form of tobacco that is slightly safer than other, legal, forms while still allowing the sale of dangerous things like chewing tobacco. Not to mention subsidizing tobacco farming at the same time (although that waste of money might be ending).

But the resistance to harm reduction exists. In Sweden much drug policy has been built on an implicit model of drug use as an epidemic: users "infect" others by acting as bad examples and the mere showing of drugs can entice people to try them - and then they are irrevocably stuck in use. Any lessening in the war on drugs would be risking having even more people exposed. That this model is not well supported by evidence doesn't change things, since it is promulgated not among scientists but rather among politicians and administrators. Even experiments with giving heroin addicts metadone have been fiercely resisted, and I doubt harm reduction will become even a thinkable thought in Swedish policy circles for many years. Hopefully they can be infected by seeing it implemented out there in Europe.

My own contribution to the discussion was merely to point out why learning theory predicts that people would be less likely to become addicted to snus than to cigarettes, but why it is fairly easy to move to snus from the poison sticks. The amount of nicotine that appears in the blood is roughly the same for both, but the rise time is much faster for smoking. This makes the "credit assignment problem" of learning systems easier - making the association between the action (smoking) and the reinforcement becomes much easier even with a small decrease in the time. The brain learns more from time differences than absolute values. The maintenance of the addiction is then caused by the total amount of nicotine (which causes the cholinergic systems to make more nicotinergic receptors). Nicotine is a learning enhancer, and this is usually the problem. It would be nice to have a less addictive learning enhancer with as well documented effect. Here is by the way the Hayek connection: addiction is simply mis-learning. We create spontaneous orders in our brains that are self-destructive.

Dr Kunze pointed out that most nicotine replacement therapies doesn't work unless they are heavily supervised. Maybe a nicotine vaccine could help, but the ethical issues involved are problematic (it can only be tested on addicts, but would likely work best on non-users - and be a terrible temptation to government busybodies seeking to limit unhealthy behavior). But it is clear that we need new approaches to get out of addiction. Personally I believe a better understanding of the neurochemistry of memory and conditioning will enable us to use medicines to treat addiction within a not too far future. There already exist some tentative experimental drugs that lessen the risk of relapses by acting on the amygdala pathways.

During the lunch afterwards I entertained happily shocked participants with explanations of how snus is actually used. It made me realize that I do indeed come from a northern barbaric country.

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