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ENVIRON International Corporation Arlington, Virginia Review of the Scientific Literature on Snus (Swedish Moist Snuff) Prepared for: Swedish Match, Stockholm, Sweden and Swedish Match North America, Richmond, Virginia Prepared by: ENVIRON International Corporation Arlington, Virginia Date: March 31, 2010 Review of Scientific Literature on Snus Contents Page 1 Introduction 6 1.1 Background 6 1.2 Risk Assessment Process 8 1.2.1 Risk Assessment 8 1.2.2 Hazard Identification 8 1.2.3 Dose-Response Assessment 9 1.2.4 Exposure Assessment 9 1.2.5 Risk Characterization 9 1.2.6 Uncertainty 10 1.3 Identification of Published Literature on Snus 10 2 Chemical Properties of Snus 11 2.1 Manufacture of Snus 11 2.2 Chemical Analysis of Snus 15 2.2.1 Composition of Snus 15 2.2.2 Sodium Salts 16 2.2.3 Alkaloids 17 2.2.4 Nicotine, Free Nicotine, pH and Moisture 18 2.2.5 Nitrate and Nitrite 20 2.2.6 Other Components 20 2.2.7 Trace-Level Components 20 2.2.8 Potentially Protective Compounds 30 2.3 Summary and Discussion of Chemical Properties 30 3 Biomarkers of Exposure to and Effect from Snus and Tobacco Components 32 3.1 Overview of Biomarkers for Components in Tobacco 32 3.1.1 Introduction 32 3.1.2 Biomarkers of Exposure for Components in Tobacco 33 3.1.3 Biomarkers of Effect for Components in Tobacco 36 3.2 Biomarkers of Exposure for Tobacco-Specific Nitrosamines 37 3.3 Biomarkers of Exposure for Nicotine 39 3.4 Biomarkers of Exposure Studies with Snus 41 3.5 Biomarkers of Effect Studies with Snus 45 3.6 Summary of Biomarkers 45 4 Toxicological Studies with Snus Ingredients and Snus 47 4.1 Introduction 47 4.2 In Vitro Studies with Swedish Snus 47 4.2.1 Mutagenicity and Genotoxicity of Snus 47 4.2.2 Effects of Snus on Immunological Parameters 49 4.2.3 Effects of Snus on Cellular Proliferation and Epithelial Changes 50 4.3 In Vivo Toxicological Studies 51 4.3.1 Studies with Tobacco-Specific Nitrosamines 51 4.3.2 Toxicological Studies with Swedish Snus 54 4.4 Summary of Toxicological Studies 56 5 Human Health Effects of Snus 58 Contents i Review of Scientific Literature on Snus 5.1 Introduction 58 5.1.1 Exposure Assessment 59 5.1.2 Consideration of Other Risk Factors 61 5.1.3 Appropriateness of the Data Analysis and Other Potential Sources of Error and Uncertainty 61 5.1.4 Determination of Etiology 61 5.2 Non-Carcinogenic Oral Effects 62 5.2.1 Overview 62 5.3 Dental Effects and Periodontal Disease 64 5.3.1 Dental Effects 64 5.3.2 Periodontal Disease 65 5.3.3 Oral Mucosal Lesions 67 5.3.4 Severity of Oral Mucosal Lesions 67 5.3.5 Histologic Changes Accompanying Oral Mucosal Lesions 69 5.3.6 Leukoplakia 69 5.3.7 Dysplasia 71 5.3.8 Reversibility of Oral Mucosal Lesions 71 5.3.9 Miscellaneous Oral Changes 72 5.4 Summary of Non-Carcinogenic and Pre-Carcinogenic Oral Conditions 72 5.5 Cancer 72 5.5.1 Head and Neck Cancer 73 5.5.2 Pancreatic Cancer 78 5.5.3 Stomach Cancer 81 5.5.4 Kidney and Bladder Cancer 82 5.5.5 Lung Cancer 83 5.5.6 Other Cancers 84 5.5.7 Summary of Carcinogenicity Studies 85 5.6 Cardiovascular Effects 86 5.6.1 Overview of Cardiovascular Effects 86 5.6.2 Acute Cardiovascular Effects 89 5.6.3 Hypertension 90 5.6.4 Other Indicators of Cardiovascular Disease 92 5.6.5 Chronic Cardiovascular Disease 92 5.6.6 Reviews, Meta-Analyses and Population Attributable Risk of Death from Cardiovascular Disease Due to Use of Snus 94 5.6.7 Summary of Cardiovascular Effects 95 5.7 Stroke 96 5.7.1 Overview 96 5.7.2 Literature Reviews and Meta-analyses of Effects on Stroke 98 5.7.3 Summary of Effects on Stroke 98 5.8 Gastrointestinal Effects 100 5.8.1 Heartburn and Peptic Ulcer 100 5.8.2 Crohn’s Disease or Ulcerative Colitis 100 5.8.3 Summary of Gastrointestinal Effects 101 5.9 Insulin Resistance and Type 2 Diabetes 101 5.9.1 Studies of Insulin as a Risk Factor for Heart Disease 101 Contents ii Review of Scientific Literature on Snus 5.9.2 Studies on Diabetes 101 5.9.3 Summary of Effects on Insulin Resistance and Diabetes 103 5.10 Metabolic Syndrome 104 5.10.1 Summary of Studies on Metabolic Syndrome 104 5.11 Effects on Body Weight 105 5.11.1 Overview 105 5.11.2 Summary of Studies on Effects on Body Weight 107 5.12 Pregnancy Outcomes and Reproductive Effects 107 5.12.1 Overview 107 5.12.2 Effects on Infants 108 5.12.3 Effects on Male Fertility 108 5.12.4 Summary of Pregnancy Outcomes and Reproductive Effects 108 5.13 Other Health Effects 109 5.13.1 Amyotrophic Lateral Sclerosis (ALS) 109 5.13.2 Complications after Hernia Surgery 109 5.13.3 Delayed Bone Healing 109 5.13.4 Circulating Selenium 110 5.13.5 Chronic Pain Intensity 110 5.13.6 Multiple Sclerosis 110 5.13.7 Disability Related to Neck and Back Pain 111 5.13.8 Summary of Studies of Other Health Effects 111 6 Conclusion 112 7 References 115 List of Tables Table 2-1: Composition of Snus 15 Table 2-2: Sodium Chloride Extraction from Used Snus Samples 17 Table 2-3: GothiaTek® Standard Limits 21 Table 5-1: Mean Daily Snus Use in Sweden (Standard Deviation) 60 Table 5-2: Studies of Cardiovascular Disease Risk Factors and Events among Swedish Snus Users 87 Table 5-3: Studies of Stroke Among Swedish Snus Users 99 List of Figures Figure 2-1. Distinction Between Snus and Other Oral Smokeless Tobacco Products 11 Figure 2-2. Manufacturing Process of Snus 14 Contents iii Review of Scientific Literature on Snus List of Appendices Appendix I: Description of Literature Search Appendix II: Appendix to Chapter 2 Chemical Properties of Snus Appendix III: Summary Tables of Epidemiology and Toxicology Studies of Snus Appendix A1: Descriptive Studies of Dental Effects and Periodontal Disease Appendix A2: Case-Control Studies of Periodontal Disease Appendix B: Descriptive Studies of Oral Mucosal Lesions Appendix C1: Descriptive Studies of Head and Neck Cancer Appendix C2: Case-Control Studies of Head and Neck Cancer Appendix C3: Cohort Studies of Head and Neck Cancer Appendix D: Cohort Studies of Pancreatic Cancer Appendix E1: Case-Control Studies of Stomach Cancer Appendix E2: Cohort Studies of Stomach Cancer Appendix F: Cohort Studies of Kidney and Bladder Cancers Appendix G: Cohort Studies of Lung Cancer Appendix H: Other Cancers Appendix I: Animal Studies of Carcinogenicity Appendix J1: Descriptive Studies of Cardiovascular Effects Appendix J2: Case-Control Studies of Cardiovascular Diseases Appendix J3: Cohort Studies of Cardiovascular Diseases Appendix J4: Experimental Studies of Cardiovascular Effects Appendix K1: Case-Control Studies of Stroke Appendix K2: Cohort Studies of Stroke Appendix L1: Descriptive Studies of Gastrointestinal Effects Appendix L2: Case-Control Studies of Gastrointestinal Effects Appendix M1: Descriptive Studies of Insulin Resistance and Diabetes Appendix M2: Cohort Studies of Insulin Resistance and Diabetes Appendix M3: Experimental Studies of Insulin Resistance and Diabetes Appendix M4: Case-Control Studies of Insulin Resistance and Diabetes Appendix N1: Cohort Studies of Metabolic Syndrome Appendix N2: Descriptive Studies of Metabolic Syndrome Appendix O1: Descriptive Studies of Body Weight Appendix O2: Cohort Studies of Body Weight Appendix O3: Case-Control Studies of Body Weight Appendix P1: Cohort Studies of Pregnancy Outcomes and Reproductive Effects Appendix P2: Descriptive Studies of Pregnancy Outcomes and Reproductive Effects Appendix Q1: Cohort Studies of Other Health Effects Appendix Q2: Descriptive Studies of Other Health Effects Appendix Q3: Case-Control Studies of Other Health Effects Appendix R: In-Vitro Investigations Appendix IV: Studies of Cardiovascular Disease Risk Factors and Events among Snus Users that Present Effect Estimates Appendix V: Smokeless Tobacco Reviews and Meta-analyses: Objectives and Author Conclusions Contents iv Review of Scientific Literature on Snus List of Acronyms 1-HOP 1-hydroxypyrene (urinary biomarker of exposure) ACS American Cancer Society AHA American Heart Association ALS amyotrophic lateral sclerosis AUC areas under the curve B[b]F benzo[b]fluoranthene B[k]F benzo[k]fluoranthene BMI body mass index Bq becquerel (SI derived unit of radioactivity) B-Se selenium in whole blood CD Crohn’s disease CHD coronary heart disease CI confidence interval CMM cutaneous malignant melanoma CO carbon monoxide concanavalin A (a mitogenic substance that is used to induce T-cell Con A proliferation) CSCC cutaneous squamous cell carcinoma CVD cardiovascular disease DNA Deoxyribonucleic acid ESTOC The European Smokeless Tobacco Council EU European Union g Gram Hb Hemoglobin HD Hodgkin's disease HDL high-density lipoprotein HIV human immunodeficiency virus Hp Helicobacter pylori (an infection which increases risk of gastric cancer) HPB 4-hydroxy-1-(3-pyridyl)-1-butanone (a type of DNA-adduct) HPRT hypoxanthine-guanine phosphoribosyl transferase HPV human papillomavirus HR hazard ratio HSV herpes simplex virus HSV-1 herpes simplex virus-1 IARC International Agency for Research on Cancer IBD inflammatory bowel disease Contents i Review of Scientific Literature on Snus ICD International Classification of Diseases IHD ischemic heart disease IMM intraocular malignant melanoma INS-GAS a strain of mice genetically predisposed to developing gastric cancer IOM Institute of Medicine IRR incidence rate ratio LCMR lung cancer mortality rate LDL low-density lipoprotein LSRO Life Sciences Research Office, Inc. MDPH Massachusetts Department for Public Health MetSy metabolic syndrome MI myocardial infarction MIS melanoma in situ MM multiple myeloma MNBA 4-(methylnitrosamino) butyric acid (an N-nitrosamino acid) MNPA 3-(methylnitrosamino) propionic acid (an N-nitrosamino acid) MS multiple sclerosis NAB N-nitrosoanabasine (a
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