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Epidemiology of tobacco use in Sweden, the country with Europe’s lowest level of tobacco-related disease
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Epidemiology of tobacco use in Sweden, the country with Europe’s lowest level of tobacco-related disease


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Oral presentation by Lars Ramström at the the 47th International ICAA Conference on Dependencies, Venice, Italy November, 2004

Oral presentation by Lars Ramström at the the 47th International ICAA Conference on Dependencies, Venice, Italy November, 2004

Published in: Health & Medicine

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  • This is the current picture of tobacco use in Sweden. Among men cigarette smoking is less common than use of the Swedish kind of oral tobacco, ”snus”. When using snus, a portion is kept (not chewed) between the gum and the upper lip.
  • An overview of the long term development shows that total tobacco consumption has been quite stable, while the cigarette/snus proportions have gone up and down.
  • Male smoking prevalence (blue regression line), has had a higher rate of decline, than female smoking (red regression line), the difference being of the same order as the male rise in snus use (green regression line). Although not being a proof of causality, this observation is well compatible with the idea that the increase of snus use has favoured the decrease of smoking in males.
  • Low TSNA content due to choice of raw tobacco, curing method and the special manufacturing process.
  • Swedish men have the lowest level of tobacco-related mortality in Europe .
  • The record high snus consumption among Swedish males has NOT prevented them from occupying a bottom position with regard to oral cancer.
  • This is a key question!
  • The ”gateway hypothesis” postulates that the onset rate of smoking is higher in those with, than in those without snus as a primary tobacco use.
  • This means that primary use of snus is associated with lower rate of onset of smoking, that is - the direct opposite of the gateway hypotheseis. Consequently, primary use of snus seems to prevent smoking rather than serve as a gateway to smoking.
  • Both males and females with a history of snus use (left column), have less maintenance of daily smoking (top line in the table) and more cessation of smoking (partial and/or complete) than those without snus use. That is, there is an overall connection between snus use and smoking cessation.
  • Among men, snus is the most commonly used cessation aid. This observation strengthens the connection between snus use and smoking cessation .
  • Among males snus is not only the most commonly used but also the most efficient ones of the cessation aids. This finding further supports the idea that snus use has contributed to the increase of smoking cessation among men. Of those men who have quit smoking completely after having used snus as a cessation aid, 75% are currently daily snus users and 35% have quit snus use as well.
  • Those who continue daily smoking do not often use snus also. The prevalence of combining daily smoking and daily snus use is very low, just 2 %. Most daily smokers do not use snus at all.
  • You sometimes hear statements that snus use would entail an up to 5-fold burden of nicotine. This is entirely false. The average 24 hour systemic intacke is rather equal for smokers and snus users, and the ”nicotine burden” of snus users is rather less because of the absence of the ”arterial boli” hitting the smoker at each puff. One important implication of the above is that, while snus use does produce nicotine dependence, the dependence in snus users is not stronger, rather weaker than in smokers, since there is a lower ”delivery speed” of the nicotine from snus than from smoking, both in general terms and with respect to the absence of ”arterial boli” for snus users.
  • Transcript

    • 1.  
    • 2. Key prevalence data, Sweden (Source: ITS/FSI study 2001/2002)
      • MALES FEMALES (n=3205) (n=3507)
      • Daily Daily Daily Daily smoking snus use smoking snus use
      • 15 % 20 % 19 % 2 %
    • 3. Tobacco consumption per year in Sweden per person 15 years and older Cigarettes Snus (kg) (kg) Around 1920 0.2 1.4 Around 1970 1.1 0.4 Around 2000 0.6 0.9
    • 4.  
    • 5. Swedish snus Fine ground tobacco leaves predominantly from air-cured dark tobacco Manufactured by a pasteurizing-like heating process (without any fermentation so as used in most manufacturing procedures for American snuff) ∎ TSNA content: < 5 mg/kg ∎ BaP content: < 10  g/kg (TSNA content of American snuff: 16-130 mg/kg)
    • 6.  
    • 7. Oral cancer incidence rates per 100000 (age standardized to world population) Males in Northern and Western Europé Source: Cancer Incidence, Mortality and Prevalence Worldwide, Version 1.0. IARC CancerBase No. 5. Lyon, IARCPress, 2001.
      • Countries with highest rates
      • France 14.94
      • Germany 13.19
      • Belgium 10.78
      • Luxembourg 10.43
      • Austria 10.39
      • Countries with lowest rates
      • The Netherlands 5.79
      • Norway 5.77
      • Iceland 4.81
      • Sweden 4.52
      • United Kingdom 4.40
    • 8. Has the use of snus had an influence on the smoking habits in Sweden?
    • 9. Initiation of tobacco use: Snus, is it a gate leading to smoking, or a vaccination against smoking? Which is the onset rate of smoking in those who have, respectively have not, taken snus as a primary tobacco use?
    • 10. ONSET RATE OF DAILY SMOKING By presence or absence of primary use of snus
      • All males (n=2756) 40 %
      • With primary snus use (n=397) 20 % Without primary snus use (n=2359) 43 %
      • (Source: ITS/FSI study 2001/2002)
    • 11. Pathway after start of daily smoking By history of daily use of snus
      • Males Females
      • History of daily use of snus ?
      • Yes No Yes No (n=498) (n=775) (n=84) (n=1240)
      • Still smoking daily 17 % 42 % 14 % 43 %
      • Red. to smo. 12 % 4 % 14 % 6 %
      • Quit smo. compl. 71 % 54 % 71 % 51 %
      • (Source: ITS/FSI study 2001/2002)
    • 12. Cessation aid used at latest quit attempt
      • Kind of aid Males Females (n=447) (n=426)
      • Nicotine gum 36 % 55 %
      • Nicotine patch 20 % 42 %
      • Snus 55 % 15 %
      • All other (together) 13 % 24 %
      • (Source: ITS/FSI study 2001/2002)
    • 13. Outcome of latest quit attempt. ( Male ever daily smokers who have used an aid at latest quit attempt)
      • Gum Patch Snus only only only
      • (n=85) (n=41) (n=205)
      • Still smoking daily 44 % 66 % 20 %
      • Red. to smo. 11 % 2 % 15 %
      • Quit smo. compl. 46 % 32 % 65 %
      • (Source: ITS/FSI study 2001/2002)
    • 14. Prevalence of combinations of smoking and use of snus (males)
      • DAILY SMOKING Total (n=3205) 15 %
      • Daily smoking AND daily use of snus 2 % Daily smoking AND occasional use of snus 2 % Daily smoking, no use of snus 11 %
      • (Source: ITS/FSI study 2001/2002)
    • 15. MEAN SCORE OF NICOTINE DEPENDENCE (scale from 0 to 2)
      • Users of single aid
      • Gum Patch Snus No aid
      • MEN 0.68 0.80 0.70 0.54
      • WOMEN 0.74 0.84 0.72 0.42
    • 16. 24 hour systemic intake of nicotine Measured in: users of loose snus (≈ 2g pinches): around 25 mg (same as in smokers of 18-20 cigarettes per day) Source: Andersson et al 1994, Andersson et al 1997
    • 17. OVERVIEW OF CESSATION ACHIEVEMENTS Percentage of ever daily Men Women smokers who have …
      • ● continued to smoke daily 34% 45%
      • cut down to occasional smoking 7% 6%
      • quit completely 59% 49%
      • Percentage of ever daily
      • snus users who have …
      • ● continued to use snus daily 74% 65%
      • cut down to occasional snus use 3% 5%
      • quit completely 23% 30%
    • 18. SCORES FOR WISH TO QUIT (Scale from 1 to 3)
      • Men
      • Observed score for wish to quit 2.16 1.64
      • Women
      • Observed score for wish to quit 2.25 1.79
    • 19.  
    • 20. Reproduced from: Lunell E. : SRNT Europe 2003
    • 21.  
    • 22.  
      • In Sweden use of snus is more common than smoking among males but less common among females.
      • Use of snus seems to serve as a substitution for smoking thereby contributing to
      • — less initiation of smoking, — more cessation of smoking.
      • Snus seems to be an effective smoking cessation aid and it is commonly used as such by males.
      • Use of snus seems not to result in an ”overload” of nicotine.
      • Use of snus produces nicotine dependence but probably less strongly so than smoking.
      • Findings from current studies suggest that snus, although not a ”health product” by itself, can, by serving as a substitution for smoking, be one of the many factors that have contributed to the current situation in Sweden with low smoking rates and accordingly low rates of tobacco-related morbidity and mortality. .