Lars Ramström, Institute for Tobacco Studies, Ingemarsgatan 4 B Stockholm 11354, Sweden. E-mail: lars.ramstrom@tobaccostudies.com

At the up-coming Fourth session of the Conference of the Parties to the WHO Framework Convention on Tobacco Control, COP4, 15–20 November 2010, there is an agenda item dealing with smokeless tobacco products. This is a very pertinent area in the current discussions of tobacco control policies, since some of these products are almost as harmful as cigarettes, while others may have a potential role in harm reduction strategies [1–5]. Both these aspects represent strong reasons for evidence-based product regulations. An excellent scientific basis for the discussions under this agenda item has been provided by the WHO Study Group on Tobacco Product Regulation [6,7]. However, it appears uncertain if the COP4 delegates will have these reports presented to them. Instead, the FCTC Secretariat has prepared a separate background report [8]. Surprisingly, this report is incompatible with the WHO scientific reports.

The WHO scientific reports do very distinctively emphasize the broad variation among different smokeless tobacco products. It is pointed out that:

‘Among the smokeless tobacco products on the market, products with low levels of nitrosamines, such as Swedish snus, are considerably less hazardous than cigarettes, while the risks associated with some products used in Africa and Asia approach those of smoking.’

When discussing implications for WHO programmes it is noted that:

‘The wide range of smokeless tobacco products and use characteristics means that WHO should support individual and population-based research on specific products. Better knowledge about the effects and mechanisms of action of smokeless tobacco products and about what modifications can be made to alter the effects is needed so that governments can implement the WHO Framework Convention on Tobacco Control.’

The Study Group also provides very practical recommendations for action contained in these three summary points:

  • • Smokeless tobacco products should be regulated by controlling the contents of the products.
  • • The combined concentration of NNN plus NNK in smokeless tobacco should be limited to 2 µg/g dry weight of tobacco.
  • • The concentration of benzo[a]pyrene in smokeless tobacco should be limited to 5 ng/g dry weight of tobacco.

Virtually all of this scientific basis is, however, absent in the background report. Instead the language of this report consistently gives an impression of speaking of smokeless tobacco as ONE kind of products with uniform properties. A typical example is the following statement in section 3:

‘Until recently it was erroneously believed that smokeless tobacco was a less harmful alternative to smoking tobacco as it did not contain PAH. This assumption was proved to be wrong by recent research that has established that moist snuff becomes contaminated with PAH during the curing of tobacco leaves required for its preparation.’

There is indeed no justification for a categorical claim that (understood: all) ‘moist snuff becomes contaminated with PAH during the curing of tobacco leaves’, and the reference given to this claim correctly pointed out that the PAH contamination in question is related to fire curing, a procedure used in manufacturing of American moist snuff. This is then not applicable to Swedish snus that is made from air cured tobacco leaves. These distinctions are concealed in the background report resulting in an inaccurate and misleading statement.

Another weakness of the background report is the total absence of mentioning the discussions on the potential of some smokeless tobacco products as means of self-help for smokers to quit, a subject area that has also been recognized by the WHO Study Group. Research published since that report was finalised strengthens the evidence base for smokeless tobacco playing a role in smoking cessation. As a matter of fact, studies from Sweden, and also from Norway, some as late as September 2010, have found that among men in these countries Swedish snus is the most commonly used cessation aid and that its use as a cessation aid results in more ex-smokers (both in absolute and proportional terms) than medicinal nicotine [9–12]. This whole subject area cannot be neglected in a comprehensive review of the topic.

The WHO Study Group on Tobacco Product Regulation also emphasizes the diverse nature of smokeless tobacco products by saying:

‘The differences in risks associated with use of different smokeless tobacco products mean that it would be scientifically inappropriate to consider smokeless tobacco as a single product for the purposes of estimating risk or setting policies.’

Unfortunately the background report does consider smokeless tobacco as a single product as deemed scientifically inappropriate by the WHO Study Group.

These issues are important because it is vital that the regulation of different smokeless tobacco products, and indeed electronic cigarettes, takes into account the relative harmfulness of these different products in comparison with combustible tobacco.

It would be unfortunate if the credibility of the FCTC is questioned because of weaknesses in the material provided as a basis for discussions and decisions of the Conference of the Parties. We, authors and co-signatories, as active researchers studying smokeless tobacco matters, hope that the current background report will be replaced by a comprehensive summary of the reports of the scientific Study Group.

Declarations of interest

KF has consulted for (and accepted honoraria) most companies with an interest in smoking cessation treatments, among them Swedish Match (no honoraria accepted) for which he helped develop a protocol for using snus as a stopping smoking treatment. One of the smoking cessation companies—Niconovum—has recently been acquired by Reynolds. JF has done consulting work for manufacturers of smoking cessation products (e.g. Pfizer, GSK, Novartis). All other authors have no interests to declare.

Co-signatories Tony Axéll, Halmstad Hospital Maxillofacial Unit, Sweden; John Britton, Nottingham University, UK; Coral Gartner, University of Queensland, Australia; John Hughes, University of Vermont, USA; Lynn Kozlowski, University at Buffalo, USA; Michael Kunze, University of Vienna, Austria; Karl Erik Lund, Norwegian institute for alcohol and drug research, Oslo, Norway; Birgitta Stegmayr, Umeå University, Sweden; David Sweanor, University of Ottawa, Canada; Kenneth Warner, University of Michigan, USA