In the mid 1980s, I assisted in South Australia becoming the first Australian state to ban the sale of smokeless tobacco products.1 In 1991, the ban went national, effectively restricting access to small quantities imported for personal use. New Zealand and the European Union imposed similar bans, although in almost all other nations smokeless tobacco products are sold openly, with many also allowing advertising.

The bans sought to prevent the tobacco industry from building demand for an uncommon form of tobacco use known to increase the risk of oral cancers.2 Since that time, growing understanding of differences in the risk profiles of different smokeless tobacco products has generated often volatile debate on whether such bans had the unintended consequence of preventing genuinely less harmful products being available to smokers who might be interested in switching from cigarettes. The emergence of low nitrosamine smokeless tobacco (LNST) products such as Swedish snus, which pose far less risk than smoking,3 and the emerging, compelling epidemiological evidence of an association between rising LNST use in Swedish men and their low rates of tobacco-caused disease,4 has led to widespread debate on whether this form of tobacco should be made more accessible.

Gartner and Hall have articulated a strong case for the affirmative (→ Should Australia lift its ban on low nitrosamine smokeless tobacco products?).5 They and others6 have correctly excoriated those who continue to mislead the public by obfuscating the reduced risks associated with LNST use, and have raised important ethical concerns of denying reasonable access to less harmful forms for adults who wish to continue to use tobacco products. Nonetheless, several broad concerns demand that any liberalisation should be subject to strict access controls and that the tobacco industry be prevented from using the issue as a wedge to subvert advertising bans and undermine the important benefits of reduced smoking caused by smoking restrictions.

Much is made of the example of Sweden. However, in nations where no bans exist, demand for smokeless products has not mirrored the Swedish experience, with use remaining marginal. In 2002 in the United States, where there is a long tradition of use and the products are aggressively advertised, only 1.5% of men and 0.16% of women used smokeless tobacco.7 In Canada, use is similarly marginal.8 There has been little reflection on why, outside Sweden, LNST use remains apparently unacceptable to most consumers despite the best efforts of transnational tobacco companies. Sweden has a 200-year history of smokeless tobacco use, which may explain a great deal about why an intuitively strange form of tobacco use, typically involving holding the product in the mouth for up to 15 hours a day, holds little attraction for today’s consumers elsewhere. Advocates for the liberalisation of access in nations that ban sale of LNST products are thus almost certainly over-hyping their potential for widespread adoption.

The core of Gartner and Hall’s argument is the objective of assisting “inveterate” smokers to access smokeless tobacco products. The term is shorthand for smokers who either do not wish to stop smoking, or whose repeated failed attempts at quitting have resigned them to be reluctant, continuing smokers. The size, characteristics and stability of this group merit close consideration. In recent years, daily smoking prevalence in Australia has been falling faster than at any time (Box). In 2006, daily smoking prevalence in New South Wales fell to 13.9%,10 following unprecedented but still relatively modest campaign expenditure by the Cancer Institute NSW. If national effort could match this commitment and, conservatively, we halved the most recent relative annual rate of decline experienced in NSW (ie, − 10.06% to − 5.03%) and applied it nationally, we would see smoking prevalence fall below 10% by 2013.

Some claim that today’s remaining smokers are “hardening” and that those still smoking are mostly inveterate, with poor prospects of ever stopping. A US review of the evidence for hardening found “little evidence that the population of smokers as a whole” was hardening.11 Twenty-nine per cent of Australian smokers now describe themselves as only occasional smokers,12 and daily consumption is reducing — facts incompatible with hardening. Moreover, around 70% of smokers are planning to quit and making attempts to do so,13 meaning that only about 4.2% of adults say they want to continue using tobacco. Nonetheless, many of these will subsequently quit without previously planning to do so.14 So, it is an unknown but plausibly small fraction of this “smoking committed” group that harm-reduction advocates believe might be interested in using LNST.

The potential for LNST to reduce health risks for this group needs balancing against any collateral negative effects of re-introducing smokeless tobacco. Few analysts of the tobacco industry doubt that its ambitions for LNST products lie well beyond servicing nascent demand from the small proportion of smokers likely to be interested in switching to these products. With youth smoking prevalence at an all-time low in Australia, the industry would be vitally interested in the potential of LNST to rekindle tobacco use in the group which is its future customer base. By naming smokeless products with cigarette brand names (Marlboro, Lucky Strike, etc) the industry hopes to heighten brand name prominence, with spin-off benefits in promoting cigarettes. Most obviously though, LNST provides would-be quitters with a reassuring product to use “for those times when you can’t light up”. Nowhere is there any evidence of companies seriously urging smokers to abandon smoking.

The investment advisors Citigroup are very clear on the potential for dual use: “The [retail] trade believes that snus will be consumed in addition to cigarettes. Given the increased bans on smoking, snus products seem like an obvious substitution.”15 These sentiments are echoed in the US retail trade newsletter Brandweek: “There’s money to be made from municipal smoking bans as another cigarette maker chases after smokers who get their nicotine fix between their cheek and gum during those many moments when they can’t light up.”16

Smoking bans have depressed daily consumption17 and stimulated cessation.18 If widespread dual smokeless/cigarette use were to occur to the delight of the industry, the net population effect of this would be to increase harm if the cessation effect was reduced and the numbers switching to snus marginal, as has occurred outside of Sweden. Some argue that the dual use concern is over-stated because in Sweden the phenomenon is typically a transitionary phase as smokers wean themselves on to snus. But, as argued, the Swedish experience has not been replicated elsewhere, so it is prudent to be cautious.

Overt tobacco advertising is banned in Australia, so some argue that tobacco companies will be unable to promote dual use. However, with the demise of overt advertising and promotion, the global industry is now harnessing “below-the-line” strategies like viral, buzz and stealth marketing,19-21 where covert efforts are made to spread interest in products. The Internet provides unparalleled opportunities here,22 with major sites heavily dominated by youth traffic already showing fingerprints of tobacco industry involvement.23 On 16 September 2007, for example, on the massively popular Facebook website, there were 242 “friendship” networks incorporating the word “snus” and 105 with “smokeless tobacco”. Many of these are overt promotional sites.

Although the rationale is compelling for allowing what is likely to be a small proportion of smokers to access LNST, precautionary health policy should tread warily. Optimists can point to Swedish-style outcomes of widespread smoking substitution, or at the very least to the small-scale uptake seen in the US, where choice is at least available to inveterate smokers wanting to switch. But other scenarios are plausible.

The tobacco industry has shown itself to be resourceful, rapacious and duplicitous in the service of sales maximisation, and any notion that they would be disinterested in the youth market, in providing nicotine substitutes for smoking “downtime”, and in preventing smokers from abandoning tobacco use altogether is naïve.

Thus, the challenge remains of how to provide choice to smokers without repeating the catastrophic legacy that the history of allowing cigarettes to be sold from every conceivable retail outlet, packed and advertised beguilingly, has brought. Tobacco retailers have repeatedly been shown to ignore the law prohibiting sales to minors, and so inspire little confidence in being trusted to confine distribution of smokeless products to adults, should the ban on smokeless tobacco sales be partly repealed. Trials of allowing LNST products to be scheduled S3 and made available under the counter from pharmacies offer a model of highly controlled access that could be investigated. These should investigate whether dual use with smoking is occurring so that the net public health benefit of permanently allowing such access could be assessed. LNST brand names using cigarette names, symbols or colours should be banned. Public awareness of the products’ reduced harm status could be generated via health authorities, with parallel investigation and prosecution of tobacco industry efforts to promote the products via below-the-line strategies. Pharmacists who might baulk at the thought of dispensing a tobacco product24 can reflect on the many precedents already embraced in medical practice, where lower risk agents and procedures are prescribed or implemented in the hope of achieving more important health benefits than the risks being posed by treatments and (for example) diagnostic radiation.

In the meantime, the recent tax increase on the importation of smokeless tobacco products should be reviewed, so that it discriminates between LNST and the very much more harmful varieties of smokeless products, such as those now openly sold illegally from most South Asian groceries.25