18A.4.1 The ‘Swedish experience’
Sweden has a similar prevalence of tobacco use to its neighbours, but one of the world’s lowest tobacco-attributable mortality rates. Some observers have suggested this phenomenon, known as ‘the Swedish experience’ is explained by the increasing use of smokeless tobacco, a trend that has corresponded with a decline in smoking prevalence, particularly among Swedish men who are the greatest users of smokeless tobacco.1-3 However, this interpretation has been debated.4
The most common form of smokeless tobacco used in Sweden is a moist oral snuff called snus, which is available either as loose tobacco or pre-packaged portions that resemble teabags. Unlike other smokeless tobacco products marketed in the US and other countries, snus is pasteurised rather than fermented and stored under refrigeration to minimise bacterial growth. These processes greatly reduce the formation of nitrosamines, the main carcinogens in tobacco. This, and the absence of the combustion products associated with smoking (e.g. carbon monoxide, small particulate matter) reduces the risks of cardiovascular disease, chronic obstructive pulmonary disease and cancer compared to smoking. Unlike cigarettes, snus does not produce secondhand smoke or carry a risk of causing accidental fires.
Long-term prospective cohort studies have observed a lower risk of many tobacco-related diseases and overall lower mortality in snus users compared to smokers.3, 5-9 A recent study measured changes in biomarkers, representing toxicants commonly associated with tobacco-related morbidity and mortality, in cigarette smokers who switched to smokeless tobacco products (Camel Snus, Sticks, Strips or Orbs). After 5 days, substantial reductions of most biomarkers, including nicotine, were observed, and toxicant exposures were similar to being tobacco abstinent.10
Compared to no tobacco use, use of snus does appear to carry some residual risks, albeit lower than for smoking, of pancreatic cancer,6, 11, 12 and cardiovascular disease.13, 14 Snus use is also associated with dental disease and gum lesions, called leukoplakia, but these appear to disappear on discontinuation of use.15 Past studies suggested an association between snus use and diabetes,16, 17 however a recent study in Sweden found no such increased risk among users.18
In Sweden, among people who have ever smoked regularly, those who use snus are more likely to have quit smoking than those who do not.2, 19, 20 A similar relationship is also seen in Norway among currently daily and former snus users.21 In the past few decades, the market share for snus has increased by over 20% and cigarette consumption has decreased at a comparable level, with snus the most commonly cited cessation aid.22 When Finland joined the EU in 1995, it was subject to a ban on oral tobacco products and smoking rates subsequently increased, leading researchers to conclude that the availability of snus was associated with lower rates of smoking prevalence.23 The Swedish experience has prompted some researchers to suggest that smokers who are unable to quit should use low nitrosamine smokeless tobacco products such as snus to reduce tobacco-related harm.24 This proposal is contentious.25-27
Some health professionals do not feel that the existing epidemiological studies showing a lower risk of tobacco-related disease in snus users are sufficient to support snus use as a harm reduction strategy. Others are concerned that the difference in potential harm between snus and smoking has not have been fully described in existing studies. Some believe that any health risk from snus, no matter how small, is too great for its use to be encouraged. However, the difference in healthy life expectancy and overall mortality risk between smokers who quit all tobacco and smokers who switch to low nitrosamine smokeless forms appears to be small.28, 29 Sweden has also achieved substantial reductions in tobacco-attributable mortality despite a high prevalence of use of snus among men.
18A.4.2 Cultural adaptability
Snus has been used extensively for many decades in Sweden, where it was known as ‘the poor man’s luxury’. Whether the Swedish experience would transfer to Australia, which has never had a significant smokeless tobacco tradition, is uncertain. A growing smokeless tobacco market in Australia during the 1980s was halted by the introduction of a commercial sales ban in 1991, but it is unknown whether these products would have become widespread without the ban.30 A survey of Australian smokers in 2008 found that about half were interested in purchasing low-nitrosamine varieties of smokeless tobacco.31 However, the survey participants were only provided with pictures and written descriptions of the products rather than samples to try, and most had no previous experience of using smokeless tobacco. In contrast only 13% of smokers in a Californian survey stated they would probably or definitely switch to smokeless tobacco if they thought it was less harmful than smoking.32
There are also behavioural aspects of smoking that may not be adequately replaced by snus use. For example, smoking offers something to do with the hands and is easy to do while engaging in other social activities such as drinking and talking. Snus is simply placed under the top lip and left there until it is removed. Talking and drinking while using snus requires more skill than smoking to keep the tobacco portion in place. The small bulge visible in the upper lip during snus use may also lack the supposed glamour of smoking.
18A.4.3 Ethical issues
Low nitrosamine smokeless tobacco products are not harmless and can be as addictive as smoking.33 Many health professionals feel it is unethical to promote the use of a substance that offers no direct benefit to the user (the indirect benefit is the absence of smoking), is addictive, and still carries risks. Proponents of tobacco harm reduction with smokeless tobacco counter that it is unethical to deny smokers access to products with substantially lower risks than smoking and to deny them accurate information about the benefits of switching to them, particularly as cigarettes, the most harmful tobacco product, are readily available.34
Opponents argue that quitting all tobacco use is the only health advice that doesn’t carry any risk. Proponents argue that many smokers fail to follow this advice and that ‘quit’ or ‘keep smoking’, sometimes described as ‘quit or die’, should not be the only options available.35 While it is debatable whether health professionals should recommend low nitrosamine smokeless tobacco products to smokers, it is arguably unethical to provide inaccurate information about the relative harms of these products and cigarettes due to the mistrust such misinformation can create.36, 37 This may be further confounded by a lack of understanding of relative harms; a survey of GPs in Sweden and the US found that they erroneously ranked nicotine above smoke and tobacco in terms of health risks.38
The lower harmfulness of low nitrosamine smokeless tobacco compared to cigarettes is likely to be an important motivator for smokers to switch products. For example, in a survey of Australian smokeless tobacco users, just over half stated they used smokeless tobacco because it was less harmful than smoking30 and users of non-cigarette tobacco products are more likely to believe they are less harmful than cigarettes than non-users.39-41 Surveys of smokers in Australia, Canada, the UK and the US suggest that few smokers believe that smokeless tobacco is less harmful than cigarettes.39, 42 Misperceptions about the relative harmfulness of smokeless tobacco products compared to cigarettes could be an important barrier to smokers switching to these less-harmful products. The challenge is avoiding messages that products such as snus are ‘less harmful’ being misinterpreted as meaning that they are ‘harmless’.
18A.4.3 Individual and population level harm
Using low nitrosamine smokeless tobacco products may reduce tobacco-related disease in individual smokers who make the switch, but widespread use could still result in population level harm in a number of ways. Firstly, if these products proved more popular among non-smokers than smokers, then overall harm could increase. Secondly, their promotion could keep current smokers smoking (instead of quitting) or lead some non-smokers to commence smoking. This is the most likely way in which smokeless tobacco promotion could produce population harm because the large difference in health risk between smoking and use of low nitrosamine smokeless tobacco means that a very large number of non-smokers need to use these products to offset the health gain achieved from a smoker switching to them.25, 43 In Sweden, snus use very rarely leads to smoking in non-smokers,2 although dual use is relatively common among adolescents who smoke in Sweden44 and Finland.45 It is unknown whether similar patterns of use would occur in Australia.
Tobacco manufacturers have argued that they should be able to market and promote reduced harm smokeless tobacco products in order to inform smokers of the benefits of switching. This is an important issue because if these products are to have a population-level benefit, a sufficient number of smokers need to make the switch. However, promotion of smokeless tobacco via tobacco industry advertising may increase overall tobacco use, possibly including smoking among current non-smokers. Some cigarette manufacturers have also produced ‘snus versions’ of their most popular brands of cigarettes.46 Allowing these products to be promoted for tobacco harm reduction would simultaneously facilitate the promotion of the corresponding cigarette brand.
In April 2015, an FDA advisory panel voted against the smokeless tobacco manufacturer Swedish Match’s application to change the warning labels on snus. Swedish Match sought to remove the warnings stating that snus causes mouth cancer, gum disease and tooth loss, arguing that there isn’t sufficient scientific evidence to support them. It also wanted the new warning to read: ‘No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes.’ Although the panel was split on certain issues, it ultimately disagreed with Swedish Match’s claims, voting that the proposed label fails to adequately communicate the potential health risks from using snus.47
In countries where tobacco advertising is allowed, cigarette manufacturers have promoted dual use of smokeless and smoked tobacco products as a way to get around public smoking bans.48 Such ‘dual use’ could reduce or even negate any health benefit from snus use by deterring quitting. Public smoking bans not only protect non-smokers from environmental tobacco smoke, but have the added benefit of encouraging smokers to quit due to the inconvenience these bans produce. Some of these quitters may therefore be encouraged to keep smoking as they can get through the inconvenient times with a short-term alternative.49
In Norway, while current daily or former snus use is associated with quitting smoking, current occasional snus use is not.21 This may be evidence of a specific pattern of dual use that deters quitting smoking. Alternatively, these dual users may be in a process of gradually moving from one product to another or of quitting all tobacco use. In the US and Sweden, dual use of smoked and smokeless tobacco is uncommon and does not appear to be a stable pattern of tobacco use.50, 51 Some harm reduction advocates have suggested that dual use is not necessarily a negative if it encourages smokers to try smokeless tobacco and leads to some switching completely. Indeed, epidemiological evidence (albeit with some limitations) has suggested that dual use of snus and cigarettes might increase smoking quit rates.52, 53 Clearly, addressing the need to inform inveterate smokers of the benefits of switching to low nitrosamine smokeless tobacco without deterring would-be quitters or encouraging smoking in non-smokers requires careful regulation of information to avoid these potential negative consequences.
18A.4.4 An unnecessary distraction?
Some tobacco control professionals view tobacco harm reduction with smokeless tobacco as a distraction from the main task of encouraging smokers to quit tobacco use and discouraging uptake.25 Tobacco smoking, they point out, has declined in Australia without these products. Supporters of harm reduction argue that it offers an additional strategy that may hasten the decline in smoking and may reach those smokers who have been resistant to traditional tobacco control strategies or have been unable to quit tobacco use despite repeated efforts.31, 54
18A.4.5 How does smokeless tobacco compare to nicotine replacement therapy?
Long-term use of nicotine replacement therapy (NRT) products, such as gum, lozenges or inhalers, has also been suggested as an alternative to smoking. Because these present lower risk than smokeless tobacco, it has been argued that there is no need for smokeless tobacco products as a harm reduction alternative.
This argument ignores the possibility that smokeless tobacco may be more attractive to smokers than NRT. Smokeless tobacco is a purely recreational tobacco product that can deliver nicotine in similar amounts to the user as smoking. It may, therefore, be a better substitute for cigarettes for smokers who want to continue using tobacco recreationally. NRT is also primarily marketed as a medicine for short-term assistance during cessation. Currently available NRT products are low dose, which prevents them from providing a sufficient ‘buzz’ for smokers who want to use nicotine recreationally. Higher dose, recreational, ‘clean’ nicotine products face substantial regulatory barriers because of their addictiveness. Australia’s drugs and poisons regulatory system also does not provide for nicotine to be sold for recreational use, unless it is contained within tobacco intended for smoking.55 Pharmaceutical companies, who manufacture NRT, are unlikely to see the marketing of a recreational, addictive product as their core business. Pharmaceutical companies may also be concerned that long-term use of high-dose nicotine products may carry a higher health risk than short-term use of low-dose NRT, which has been established as safe.
In 2010, former smokers in Sweden were significantly more likely to use smokeless tobacco than never smokers.56 In Sweden and Norway, snus is a more popular smoking cessation aid than NRT gum or patches and smokers who use snus are more likely to quit than smokers who use NRT.2, 20, 57-59 Among the possible reasons for this greater popularity and higher success rate are the social acceptance of snus use in Sweden, its lower cost (before 2007, snus was taxed at a lower rate than cigarettes), the higher nicotine delivery from snus compared to NRT, and possibly longer use of snus after quitting compared to NRT. Using NRT to quit smoking may also be stigmatised by some smokers who see the use of a medication to quit as a sign of drug addiction. Snus, which is not a medication, may be seen as a ‘smarter choice’ rather than a sign of weakness. As uptake of NRT in Australia remains relatively low,60 a product that may be more attractive to smokers and more effective, even if marginally riskier, could increase the number of quitters and therefore produce a greater population level benefit.
Smokeless tobacco products appear to be less effective at reducing withdrawal symptoms than cigarettes.61, 62 However, some small-scale trials suggest that smokers may prefer moist oral snuff over NRT and that snuff reduces cigarette cravings more than NRT.63, 64 There is also some evidence from population surveys that switching to smokeless tobacco may be more effective than using NRT.2, 58, 65 A small clinical trial found that smokers who were given smokeless tobacco products reduced their cigarette intake and increased their interest in quitting smoking compared to those who were not given these products.66
When presented with a range of hypothetical policy options, a sample of Australian smokers stated they would be more likely to quit if smokeless tobacco were made less expensive than cigarettes and if there were a substantial price increase on cigarettes, than if there were a cigarette price increase alone.31 The option of switching to smokeless tobacco appeared most attractive to those who were resistant to quitting rather than those who indicated they would quit with just a price increase. These results suggest that a lower tax on smokeless tobacco compared to smoked tobacco could produce a greater reduction in the number of smokers than simply increasing cigarette taxes. Similarly, a Californian survey found that smokers with greater intentions of quitting were less likely to be interested in switching to smokeless tobacco, but smokers who were trying to cut down their cigarette intake and smokers who had made unsuccessful quit attempts were more likely to be interested in switching to smokeless tobacco.32 However, a recent study comparing snus and NRT found that US-marketed snus performed similarly to nicotine gum in cigarette smokers who were interested in completely switching to these products, but was associated with greater toxicant exposure and less satisfaction than nicotine gum. The authors suggest that the harm reduction effects observed in Sweden may have limited generalisability to other countries.67
Another clinical trial in the US compared abstinence outcomes among smokers who were randomised to receive free samples of snus versus not. Overall, wide-scale provision of snus to smokers not ready to quit resulted in minimal uptake, and appeared to undermine quit attempts. There were no differences between groups on abstinence. However, the small number of participants who became regular users of snus were more likely to try and succeed in quitting.68 RJ Reynolds Tobacco reportedly carried out a randomised control trial in 2009–14 comparing Camel Snus to Nicorette NRT for cessation, but the results appear to not have been published. Researchers have called for release of the findings.69
Overall, more research is needed to determine whether the option of using smokeless tobacco translates to fewer smokers without detrimental effects on quitting.
18A.4.6 What should the public health response be?
The epidemiological evidence and the Swedish experience suggest that low nitrosamine smokeless tobacco may be an important tobacco harm reduction opportunity.70 With uncertainty about its potential effect on other tobacco control policies, most Australian commentators have been cautious about such proposals.71
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated March 2020)
1. Ramström LM. Snuff: An alternative nicotine delivery system, in Nicotine and Public Health. Ferrence R, et al., Editors. Washington, DC: American Public Health Association; 2000.
2. Ramström LM and Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control, 2006; 15(3):210–14. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/3/210
3. Foulds J, Ramström L, Burke M, and Fagerström K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 2003; 12(4):349–59. Available from: http://tc.bmjjournals.com/cgi/content/abstract/12/4/349
4. Tomar SL, Connolly GN, Wilkenfeld J, and Henningfield JE. Declining smoking in Sweden: Is Swedish match getting the credit for Swedish tobacco control's efforts? Tobacco Control, 2003; 12(4):368–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14660769
5. Critchley JA and Unal B. Is smokeless tobacco a risk factor for coronary heart disease? A systematic review of epidemiological studies. European Journal of Cardiovascular Prevention and Rehabilitation, 2004; 11(2):101–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15187813
6. Luo J, Ye W, Zendehdel K, Adami J, Adami H-O, et al. 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, 2007; 369(9578):2015–20. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140673607606783/abstract
7. Carlens C, Hergens M-P, Grunewald J, Ekbom A, Eklund A, et al. Smoking, use of moist snuff and risk of chronic inflammatory diseases. American Journal of Respiratory and Critical Care Medicine, 2010; 181(11):1217–22. Available from: http://ajrccm.atsjournals.org/cgi/reprint/200909-1338OCv1
8. Hansson J, Pedersen NL, Galanti MR, Andersson T, Ahlbom A, et al. Use of snus and risk for cardiovascular disease: Results from the Swedish twin registry. Journal of Internal Medicine, 2009; 265(6):717–24. Available from: http://www.ncbi.nlm.nih.gov/entrez/pubmed/19504754
9. Ramstrom L and Wikmans T. Mortality attributable to tobacco among men in Sweden and other European countries: An analysis of data in a who report. Tobacco Induced Diseases, 2014; 12(1):14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25191176
10. Krautter GR, Chen PX, and Borgerding MF. Consumption patterns and biomarkers of exposure in cigarette smokers switched to snus, various dissolvable tobacco products, dual use, or tobacco abstinence. Regulatory Toxicology and Pharmacology, 2015; 71(2):186–97. Available from: http://www.sciencedirect.com/science/article/pii/S0273230014003389
11. Boffetta P, Aagnes B, Weiderpass E, and Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. International Journal of Cancer, 2005; 114(6):992–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15645430
12. Boffetta P, Hecht S, Gray N, Gupta P, and Straif K. Smokeless tobacco and cancer. The Lancet Oncology, 2008; 9(7):667–75. Available from: http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2808%2970173-6/fulltext
13. Boffetta P and Straif K. Use of smokeless tobacco and risk of myocardial infarction and stroke: Systematic review with meta-analysis. British Medical Journal (Clinical Research ed), 2009; 339:b3060. Available from: http://www.ncbi.nlm.nih.gov/entrez/pubmed19690343
14. Bolinder G, Alfredsson L, Englund A, and de Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. American Journal of Public Health, 1994; 84(3):399–404. Available from: http://www.ajph.org/cgi/content/abstract/84/3/399
15. Larsson A, Axell T, and Andersson G. Reversibility of snuff dippers' lesion in Swedish moist snuff users: A clinical and histologic follow-up study. Journal of Oral Pathology and Medicine, 1991; 20(6):258–64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1890661
16. Persson P-G, Carlsson S, Svanstrom L, Ostenson C-G, Efendic S, et al. Cigarette smoking, oral moist snuff use and glucose intolerance. Journal of Internal Medicine, 2000; 248(2):103–10. Available from: www.ncbi.nlm.nih.gov/pubmed/10947888
17. Eliasson M, Asplund K, Nasic S, and Rodu B. Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: The Northern Sweden MONICA study. Journal of Internal Medicine, 2004; 256(2):101–10. Available from: www.ncbi.nlm.nih.gov/pubmed/15257722
18. Rasouli B, Andersson T, Carlsson PO, Grill V, Groop L, et al. Use of Swedish smokeless tobacco (snus) and the risk of type 2 diabetes and latent autoimmune diabetes of adulthood (lada). Diabetic Medicine, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27353226
19. Stenbeck M, Hagquist C, and Rosén M. The association of snus and smoking behavior: A cohort analysis of Swedish males in the 1990s. Addiction, 2009; 104(9):1579–85. Available from: www.ncbi.nlm.nih.gov/pubmed/19686528
20. Gilljam H and Galanti MR. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction, 2003; 98(9):1183–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12930201
21. Lund KE, Scheffels J, and McNeill A. The association between use of snus and quit rates for smoking: Results from seven Norwegian cross-sectional studies. Addiction, 2010; 106(1):162–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20883459
22. Lund I and Lund KE. How has the availability of snus influenced cigarette smoking in norway? International Journal of Environmental Research and Public Health, 2014; 11(11):11705–17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25402565
23. Maki J. The incentives created by a harm reduction approach to smoking cessation: Snus and smoking in Sweden and Finland. International Journal of Drug Policy, 2014; 26(6):569–74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25214359
24. Hall WD and Gartner CE. Supping with the devil? Promoting tobacco harm reduction using low nitrosamine smokeless tobacco products. Public Health, 2009; 123(3):287–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19223052
25. Gartner CE, Hall WD, Chapman S, and Freeman B. Should the health community promote smokeless tobacco (snus) as a harm reduction measure? PloS Medicine, 2007; 4(7):e185. Available from: www.ncbi.nlm.nih.gov/pubmed/17608560
26. Britton J. Should doctors advocate snus and other nicotine replacements? Yes. British Medical Journal, 2008; 336(7640):358. Available from: http://www.bmj.com/cgi/content/full/336/7640/358
27. Macara AW. Should doctors advocate snus and other nicotine replacements? No. British Medical Journal, 2008; 336(7640):359. Available from: http://www.bmj.com/cgi/content/full/336/7640/359
28. Gartner CE, Hall WD, Vos T, Bertram MY, Wallace AL, et al. Assessment of Swedish snus for tobacco harm reduction: An epidemiological modelling study. The Lancet, 2007; 369(9578):2010–14. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140673607606771/abstract
29. Henley SJ, Connell CJ, Richter P, Husten C, Pechacek T, et al. Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco. Tobacco Control, 2007; 16(1):22–8. Available from: http://tc.bmj.com/cgi/content/abstract/16/1/22
30. Gartner CE and Hall WD. Smokeless tobacco use in Australia. Drug and Alcohol Review, 2009; 28:284–91. Available from: www.ncbi.nlm.nih.gov/pubmed/21462413
31. Gartner CE, Jimenez-Soto EV, Borland R, O'Connor RJ, and Hall WD. Are Australian smokers interested in using low-nitrosamine smokeless tobacco for harm reduction? Tobacco Control, 2010; 19(6):451–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20671083
32. Timberlake DS. Are smokers receptive to using smokeless tobacco as a substitute? Preventive Medicine, 2009; 49:229–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19631684
33. Post A, Gilljam H, Rosendahl I, Bremberg S, and Galanti MR. Symptoms of nicotine dependence in a cohort of Swedish youths: A comparison between smokers, smokeless tobacco users and dual tobacco users. Addiction, 2010; 105(4):740–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20148785
34. Kozlowski LT. Harm reduction, public health, and human rights: Smokers have a right to be informed of significant harm reduction options. Nicotine & Tobacco Research, 2002; 4(suppl. 2):S55–S60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12580155
35. Fagerström K. Quit or die: Nothing in between? Respiration, 2002; 69(5):387–88. Available from: www.ncbi.nlm.nih.gov/pubmed/12232444
36. Kozlowski LT. First, tell the truth: A dialogue on human rights, deception, and the use of smokeless tobacco as a substitute for cigarettes. Tobacco Control, 2003; 12(1):34–6. Available from: http://tc.bmjjournals.com/cgi/content/abstract/12/1/34
37. Waterbor JW, Adams RM, Robinson JM, Crabtree FG, Accortt NA, et al. Disparities between public health educational materials and the scientific evidence that smokeless tobacco use causes cancer. Journal of Cancer Education, 2004; 19(1):17–28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15059752
38. Klein A, Ramesh Patwardhan S, and Murphy MA. Survey of GPs' understanding of tobacco and nicotine products. Drugs and Alcohol Today, 2013; 13(2):119–50. Available from: http://www.ingentaconnect.com/content/mcb/dat/2013/00000013/00000002/art00007
39. O’Connor RJ, McNeill A, Borland R, Hammond D, King B, et al. Smokers’ beliefs about the relative safety of other tobacco products: Findings from the ITC collaboration. Nicotine & Tobacco Research, 2007; 9(10):1033–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17943619
40. Øverland S, Hetland J, and Aarø LE. Relative harm of snus and cigarettes: What do Norwegian adolescents say? Tobacco Control, 2008; 17(6):422–5. Available from: http://tobaccocontrol.bmj.com/cgi/rapidpdf/tc.2008.026997v2
41. Wikmans T and Ramström L. Harm perception among Swedish daily smokers regarding nicotine, NRT-products and Swedish snus. Tobacco Induced Diseases, 2010; 8(9). Available from: http://www.tobaccoinduceddiseases.com/content/8/1/9
42. O’Connor RJ, Hyland A, Giovino GA, Fong GT, and Cummings KM. Smoker awareness of and beliefs about supposedly less-harmful tobacco products. American Journal of Preventive Medicine, 2005; 29(2):85–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16005803
43. Tobacco Advisory Group of the Royal College of Physicians, Protecting smokers, saving lives: The case for a tobacco and nicotine regulatory authority. London: Royal College of Physicians of London; 2002.
44. Lund I and Scheffels J. Adolescent tobacco use practices and user profiles in a mature Swedish moist snuff (snus) market: Results from a school-based cross-sectional study. Scandinavian Journal of Public Health, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27340188
45. Tseveenjav B, Pesonen P, and Virtanen JI. Use of snus, its association with smoking and alcohol consumption, and related attitudes among adolescents: The Finnish national school health promotion study. Tobacco Induced Diseases, 2015; 13:34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26500472
46. McNeill A and Sweanor D. Beneficence or maleficence—big tobacco and smokeless products. Addiction, 2009; 104(2):167–8. Available from: www.ncbi.nlm.nih.gov/pubmed/19149806
47. Sifferlin A. FDA panel votes against smokeless tobacco safety claims. Time, 2015. Available from:http://time.com/3817902/fda-snus-smokeless-tobacco/
48. Carpenter CM, Connolly GN, Ayo-Yusuf OA, and Waynem GF. Developing smokeless tobacco products for smokers: An examination of tobacco industry documents. Tobacco Control, 2009; 18(1):54–9. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/1/54
49. Mejia AB and Ling PM. Tobacco industry consumer research on smokeless tobacco users and product development. American Journal of Public Health, 2010; 100:78–87. Available from: www.ncbi.nlm.nih.gov/pubmed/19910355
50. Frost-Pineda K, Appleton S, Fisher M, Fox K, and Gaworski CL. Does dual use jeopardize the potential role of smokeless tobacco in harm reduction? Nicotine & Tobacco Research, 2010; 12(11):1055–67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20847148
51. Tomar SL, Alpert HR, and Connolly GN. Patterns of dual use of cigarettes and smokeless tobacco among US males: Findings from national surveys. Tobacco Control, 2010; 19:104–9. Available from: http://tobaccocontrol.bmj.com/content/19/2/104.abstract
52. Lee PN. Health risks related to dual use of cigarettes and snus–a systematic review. Regulatory Toxicology and Pharmacology, 2014; 69(1):125–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24184647
53. Burris JL, Carpenter MJ, Wahlquist AE, Cummings KM, and Gray KM. Brief, instructional smokeless tobacco use among cigarette smokers who do not intend to quit: A pilot randomized clinical trial. Nicotine & Tobacco Research, 2014; 16(4):397–405. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24130144
54. Hall W and West R. Thinking about the unthinkable: A de facto prohibition on smoked tobacco products. Addiction, 2008; 103(6):873–4. Available from: http://www3.interscience.wiley.com/journal/119411997/abstract
55. Commonwealth of Australia. Poisons standard 2010, federal register of legislative instruments f2010l02386, 2010, Department of Health and Ageing. Available from: http://www.comlaw.gov.au/Details/F2010L02386.
56. Leon ME, Lugo A, Boffetta P, Gilmore A, Ross H, et al. Smokeless tobacco use in Sweden and other 17 European countries. European Journal of Public Health, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27048433
57. Furberg H, Lichtenstein P, Pedersen NL, Bulik CM, Lerman C, et al. Snus use and other correlates of smoking cessation in the Swedish twin registry. Psychological Medicine, 2008; 38(9):1299–308. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914546/
58. Lund KE, McNeill A, and Scheffels J. The use of snus for quitting smoking compared with medicinal products. Nicotine & Tobacco Research, 2010; 12(8):817–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20622023
59. Lindström M. Nicotine replacement therapy, professional therapy, snuff use and tobacco smoking: A study of smoking cessation strategies in southern Sweden. Tobacco Control, 2007; 16(6):410–16. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/16/6/410
60. Doran CM, Valenti L, Robinson M, Britt H, and Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addictive Behaviors, 2006; 31(5):758–66. Available from: www.ncbi.nlm.nih.gov/pubmed/16137834
61. Cobb C, Weaver M, and Eissenberg T. Evaluating the acute effects of oral, non-combustible potential reduced exposure products marketed to smokers. Tobacco Control, 2010; 19(5):367–73. Available from: http://tobaccocontrol.bmj.com/content/19/5/367.full
62. Blank MD and Eissenberg T. Evaluating oral noncombustible potential-reduced exposure products for smokers. Nicotine & Tobacco Research, 2010; 12(10):336–43. Available from: http://ntr.oxfordjournals.org/cgi/content/full/ntq003v1
63. Caldwell B, Burgess C, and Crane J. Randomized crossover trial of the acceptability of snus, nicotine gum, and zonnic therapy for smoking reduction in heavy smokers. Nicotine & Tobacco Research, 2010; 12(2):179–83. Available from: http://ntr.oxfordjournals.org/cgi/content/full/12/2/179
64. Kotlyar M, Mendoza-Baumgart MI, Li Z-z, Pentel PR, Barnett BC, et al. Nicotine pharmacokinetics and subjective effects of three potential reduced exposure products, moist snuff and nicotine lozenge. Tobacco Control, 2007; 16(2):138–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17400953
65. Rodu B and Phillips CV. Switching to smokeless tobacco as a smoking cessation method: Evidence from the 2000 national health interview survey. Harm Reduction Journal, 2008; 5:18. Available from: http://www.harmreductionjournal.com/content/5/1/18
66. Carpenter MJ and Gray KM. A pilot randomized study of smokeless tobacco use among smokers not interested in quitting: Changes in smoking behavior and readiness to quit. Nicotine & Tobacco Research, 2010; 12(2):136–43. Available from: http://ntr.oxfordjournals.org/cgi/content/full/ntp186v1
67. Hatsukami DK, Severson H, Anderson A, Vogel RI, Jensen J, et al. Randomised clinical trial of snus versus medicinal nicotine among smokers interested in product switching. Tobacco Control, 2016; 25(3):267–74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25991608
68. Carpenter MJ, Wahlquist AE, Burris JL, Gray KM, Garrett-Mayer E, et al. Snus undermines quit attempts but not abstinence: A randomised clinical trial among US smokers. Tobacco Control, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27071730
69. Neeley EE and Glantz SA. RJ Reynolds has not published a negative randomised clinical trial of camel snus for smoking cessation. Tobacco Control, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27207852
70. Gartner CE and Hall WD. Should Australia lift its ban on low nitrosamine smokeless tobacco products? Medical Journal of Australia, 2008; 188(1):44–6. Available from:https://www.mja.com.au/journal/2008/188/1/should-australia-lift-its-ban-low-nitrosamine-smokeless-tobacco-products#21
71. Chapman S. Repealing Australia's ban on smokeless tobacco? Hasten slowly. Medical Journal of Australia, 2008; 188(1):47–9. Available from: https://mjainsight.com.au/system/files/issues/188_01_070108/cha11127_fm.pdf