Testimony of Dr. Diana Zuckerman at the Tobacco Products Scientific Advisory Committee Meeting on General Snus

June 26, 2024

I’m Dr. Diana Zuckerman, president of the National Center for Health Research. Our center is a nonprofit public health think tank that scrutinizes the safety and effectiveness of medical and consumer products, and we don’t accept funding from companies that make those products. Our largest program focuses on cancer prevention and treatment.

Thank you for the opportunity to share my views today. My expertise is based on my current work as well as my post-doc training in epidemiology and public health, and as a former faculty member and researcher at Yale and Harvard.  I’ve also previously served as professional staff in the US House of Representatives and US Senate, at the Dept of Health and Human Services, and the White House.  I’m a founding Board member of the nonprofit Alliance for a Stronger FDA, which educates Congress about the need to financially support the essential work of the FDA.

The question today is whether General snus should continue to be labeled as safer than other tobacco products.  I will focus on the scientific evidence, which I personally found challenging due to lack of some key information. So, I will raise the questions that weren’t a focus of the FDA review, and I respectfully encourage you to try to get the answers to these questions today. Several panel members and previous speakers have already asked some of these questions.

  1. We all know the risks of smoking, including cancer, lung disease, and cardiovascular diseases.
  2. Equally important: Most smokers start smoking as children or teenagers and most of these diseases are diagnosed decades later – usually in the patients 50’s or 60’s or even later. That’s more than 30 years later—often 40 or 50 years later, or even later.

In contrast, the data being discussed today found:

  1. A significant increase in several serious cardiovascular diseases, and these were diagnosed in studies that followed relatively young white men. For example the Araghi et al. study published in 2022 included 9 million person years of study, which sounds impressive, but averaged 22 years, including some men that were followed for only 5 years
    • Those results indicate some serious risks are evident apparently at a younger age than found with cigarettes.
  1. There was no increase found in oral cancers, despite previous evidence that smokeless tobacco can cause oral cancers. However, oral cancers usually develop in people in their 50’s or older, and many of the individuals in these studies were younger.  My question is whether the follow-up for these individuals in any of these studies is long enough to draw conclusions about oral cancer.  In addition, information provided in previous research indicate that snus in Sweden differs from snus sold in the U.S. and therefore the data provided on Swedish consumers may differ from the impact on U.S. consumers.  I hope you will ask that question.

Bottom line:

  1. How good is the evidence that using the General snus sold in the U.S. is safer than smoking cigarettes in either the shorter term (10 or 20 years) or longer term (30, 40, or 50 years)?
  2. How often do General snus users also use other tobacco products or switch to other tobacco products? Apparently the answer is often, so does the nicotine in General snus make it more difficult to quit tobacco use and instead result in continued use of snus and other tobacco products?
  3. Can the information available be understood by teenagers or adults who consider using snus if it has a modified risk claim – which will be perceived as a seal of approval by the FDA? If the lack of information makes it so difficult for me to make sense of the risks of snus, I have to assume they will too.

Thank you for the opportunity to share these views.  I encourage you to ask these questions and make sure the answers make sense.