Comparison Between Different Pathways of Tobacco Use in Sweden – Implications for the Prevention of Tobacco Induced Diseases

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Oral presentation by Lars Ramström at the 6th Annual Conference of ISPTID, Little Rock, Arkansas, 2-4 November, 2007

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  • Patterns of tobacco use in Sweden differ to a large extent from those in other European countries.
  • Swedish men have a uniquely low prevalence of daily smoking, lowest in all Europe, just 13%, and mortality in lung cancer and other smoking-related diseases is correspondingly record low. Another Swedish feature is…
  • … SNUS, the Sweden-specific kind of moist oral snuff that is widely used instead of cigarettes by Swedish men. While just 13% smoke daily, the prevalence of daily snus use is 22%. This record high use of oral tobacco raises the question: Is there a correspondingly high level of oral ill-health, for example oral cancer?
  • No. Swedish men have lower oral cancer mortality rate than men in any other country in Northern or Western Europe or North America. This is just one of the illustrations that the adverse health effects of Swedish snus are far below those of cigarettes and quite modestly above those of no tobacco use.
  • The pathways of tobacco use start by initiation. Primary initiation can be either by snus use or by smoking. In each case there may, or may not, be a secondary initiation…. -secondary smoking among primary snus users, or -secondary snus use among primary smokers, So, there are four categories of initiation.
  • From each one of the initiation categories, there are different further pathways in terms of continuing or quitting previous kinds of tobacco use. The sizes of the various categories are here indicated by figures, but an overview can more easily be seen in a graphical representation.
  • Here we see the four categories of initiation, the height of each box representing the size. Those who take up secondary smoking after primary snus use (the box at the top), is a very small category. Virtually all initation of smoking takes place among those without previous daily snus use. This suggests that primary snus use is NOT a gateway to smoking, but rather a prevention of smoking. Some primary smokers take up secondary snus use, some do not. How does that influence subsequent cessation achievements?
  • The primary smokers WITH secondary snus use are the most successful quitters. They end up with a very small fraction continuing smoking (13%). The primary smokers WITHOUT secondary snus use end up with a much higher fraction continuing smoking (43%). Next question: Have all these general patterns of tobacco use been static, or has there been a development with large changes over time?
  • The primary smokers WITH secondary snus use are the most successful quitters. They end up with a very small fraction continuing smoking (13%). The primary smokers WITHOUT secondary snus use end up with a much higher fraction continuing smoking (43%). Next question: Have all these general patterns of tobacco use been static, or has there been a development with large changes over time?
  • In terms of prevalence there have been large changes, particularly among men. But, for several reasons, prevalence data alone are not enough for a deeper analysis of the development,….. … for example…
  • (Read the slide)
  • In this diagram on primary initiation each bar represents a 10 year birth cohort of Swedish men. Over time there has been an increasing initiation of primary snus use (sectors at the top), associated with decreasing initiation of primary smoking (sectors in the middle). Total initiation of tobacco use has been decreasing across all cohorts from the next oldest one.
  • Among women the general pattern of change is similar. The changes come later than among men and primary initiation of snus use is still quite small. So, what about secondary initiation of snus use ?
  • Across all cohorts there has been a continuous increase in initation of secondary snus use among primary smokers , both in men and women. We have already seen that secondary snus users have an overall higher quit rate than those without secondary snus use. How have quit rates developed over time?
  • This diagram compares, within each cohort, quit rates among the male primary smokers WITHOUT, and those WITH secondary snus use. Those WITH secondary snus use have significantly higher quit rates in all cohorts, and the difference has been increasing over time.
  • The same pattern applies to women as well. This brings us further to the question regarding use of cessation aids.
  • Among those who have made attempts to quit smoking, there is a majority having used no particular aid at all. Among aid users, snus is the most commonly used aid among men. Among women nicotine chewing gum is the most commonly used aid. These overall figures have also been changing over time.
  • This diagram shows, within each birth cohort, a comparison between the frequency of use of the three most common aids, nicotine gum, nicotine patch and snus. Use of snus as cessation aid has been continuously increasing among men…
  • … as well as among women. In the youngest cohort snus has taken the lead also among women. These three leading aids should also be compared in terms of effectiveness.
  • The outcome of latest quit attempt shows similar patterns for men and women. Use of snus as cessation aid yields the highest proportion of ”quitting completely” and the lowest proportion of ”continuing daily smoking”. The Swedish experiences of reducing smoking and related diseases have raised a lot of international interest. A recent example is the October 2007 report by the Royal College of Physicians.
  • Here it is stated that: (read the slide) My own conclusions are briefly summarized like this:
  • (Read the slide)
  • Comparison Between Different Pathways of Tobacco Use in Sweden – Implications for the Prevention of Tobacco Induced Diseases

    1. 1. Comparison Between Different Pathways of Tobacco Use in Sweden – Implications for the Prevention of Tobacco Induced Diseases Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden 6th Annual Conference of ISPTID, Little Rock, Arkansas, 2-4 November, 2007
    2. 3. SNUS (moist oral snuff) in portion packages or loose
    3. 11. The changes of prevalence depend both on – changes of initiation patterns and on – changes of cessation patterns <ul><li>For an in depth study of the development over time it would have been desirable that the two above parameters had been continuously monitored in the past. However, we can now emulate such a monitoring by retrospective analysis of consecutive birth cohorts from a 50 year period. </li></ul>
    4. 17. Ever-Daily-Smokers who have tried to quit smoking. Percentage having used different cessation aids at latest quit attempt. Source: FSI/ITS surveys 2003-2006 61% 57% No particular aid 2% 2% Other combination 4% 2% Gum and patch 2% 1% Bupropion only 4% 3% Other single aid 1% 1% Snus and gum 5% 21% Snus only 8% 5% Nicotine patch only 12% 7% Nicotine gum only WOMEN (n=5388) MEN (n=4528) Category of aid
    5. 21. <ul><li>p.161 </li></ul><ul><li>“ The epidemiology of tobacco use in Sweden suggests that if the public is offered a substantially less harmful smokeless tobacco product along with access to accurate information on relative risks, a substantial proportion can switch to the less harmful product. This has clear implications for public health.” </li></ul>
    6. 22. Conclusions <ul><li>Prevention of Tobacco Induced Diseases is first of all a matter of reducing cigarette smoking </li></ul><ul><li>Comparisons between different pathways of tobacco use in Sweden suggest that the use of snus has contributed to lower smoking rates by – reducing initiation of smoking – helping smokers to quit smoking (switching to snus or quitting all tobacco) </li></ul><ul><li>This suggests that the use of snus has had implications for public health in a way that has contributed to the Prevention of Tobacco Induced Diseases in Sweden </li></ul>

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