Sweden is the only country in the world with a long-lasting experience of large-scale use of snus or similar smokeless tobacco. Therefore the Swedish experience is the main source of EVIDENCE regarding public health aspects of the use of such products.
To get an overview background, let us look at some European data for tobacco-related cancer. Swedish MEN have incidence rates far below the EU average -- but Swedish WOMEN are not equally different from the rest of Europe. This raises the question about the corresponding patterns of tobacco use.
In the period 1976 – 2010 smoking in MEN was going down dramatically and snus use was going up significantly and is now almost double as common as smoking. Smoking in WOMEN has also gone down, but not as much as in men. Snus use has gone up in women as well, but quite modestly only.
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Large surveys in Sweden have shown that among ” Boys who did not….(as above) among ….. … .. A frequently asked question is
These findings do NOT support assumptions that snus would be a ”gateway” to smoking. They rather suggest that initiation of snus use could protect against initiation of smoking. In the public health perspective an other question arises: Does snus use come as an addition to smoking and thereby increase total tobacco use, or, does it come INSTEAD of smoking? To answer that question we have to look at the development over time. In summary:
The green segments of the bars represent the fraction of young men and women who initiated snus use - around 1960 - around 1970 etc. The red segments represent the fraction initiating smoking, and the blue segments represent the fraction with no initiation of tobacco use. From 1960 to 2000 there was a striking increase of male initiation of snus use, while smoking initiation was decreasing – even more than snus use was increasing. Consequently, total initiation of tobacco use was decreasing, and the fraction without initiation of tobacco use, the blue segments, was increasing. This development demonstrates that snus use did not come as an addition to smoking, but as an alternative. It further demonstrate that increasing initiation of snus use is well compatible with decreasing total recruitment to tobacco use, and suggest that the increasing number of primary snus users are mainly drawn from presumptive smokers . Female patterns of initiation have similar shape, but the changes are smaller. In summary: (next slide) This graph shows
(just read the slide, and then…) Snus use is not only initiated by young non-tobacco-users, but also by many established smokers.
What happens after smokers have taken up snus use? Some of them switch to snus-use-only, blue bars , and almost as many do eventually quit snus-use as well and become free from tobacco use, green bars . A small fraction yellow bars , will become dual users. They have lower cigarette consumption than remaining pure smokers and should therefore have decreased rather than increased their health risk. Another very small fraction has abandoned snus and gone back to smoking as before.
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The bar to the left represents smokers not using snus, the bar to the right represents snus users who have switched from smoking. In each category, the red and yellow segments of the bars show the size of the fraction with the highest levels of nicotine dependence, 64% in smokers, 45% in snus users. Read
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Successfulness of smoking cessation is reflected by the Quit rate, the proportion of ”ever daily smokers” having quit smoking completely. Both in men and women quit rates are distinctively higher among former and current snus users than among never snus users. There is no difference between men and women with equal history of snus use. The difference between ”All men” and ” All women” is a consequence of the lower prevalence of snus use in women. Gender itself does not influence smoking cessation, but snus use does favour smoking cessation. Read
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In our surveys 2003 - 2006 all ”ever daily smokers” who had made a Self-help quit-attempt were asked about what aid, if any, they had used. As indicated by the height of the bars in this chart, snus was by far the most widely used aid among men , while nicotine gum was most used among women. In each bar the proportion between the green segment – success -- and the red segment – failure -- illustrates the quit rate achieved with that aid. The quit rate is also indicated numerically in each green field . Read
(just read the slide)
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The Swedish experience the role of snus in the decrease of smoking
Lars M. Ramström PhD Director, Institute for Tobacco Studies Stockholm, Sweden Email: firstname.lastname@example.org The Swedish experience the role of snus in the decrease of smoking Presentation at ROUND TABLE MEETING THE EMBASSY OF SWEDEN MOSCOW, 2011-12-08
Changes of smoking prevalence are due to the combined effect of - changes of initiation practices, and - changes of cessation practices. Both these practices are influenced by snus use.
<ul><li>Category </li></ul><ul><li>Boys who did not use snus </li></ul><ul><li>(n = 23281) </li></ul><ul><li>Boys who used snus </li></ul><ul><li>(n = 5021) </li></ul><ul><li>Girls who did not use snus </li></ul><ul><li>(n = 31846) </li></ul><ul><li>Girls who used snus </li></ul><ul><li>(n = 527) </li></ul><ul><li>46% started smoking </li></ul><ul><li>18% started smoking </li></ul><ul><li>40% started smoking </li></ul><ul><li>8% started smoking </li></ul>HOW DOES SNUS USE INFLUENCE INITIATION OF SMOKING? Source: FSI / ITS surveys 2003 - 2011
Snus use is associated with a substantially reduced probability of starting to smoke.
HOW DOES INCREASING INITIATION OF SNUS USE INFLUENCE TOTAL INITIATION OF TOBACCO USE?
<ul><li>During the later half of the last century an increasing initiation of snus use was accompanied by </li></ul><ul><li>increasing proportion of those not initiating any tobacco use </li></ul><ul><li>decreasing initiation of smoking (suggesting that most snus users would have started smoking if there had been no snus) </li></ul>
WHAT HAPPENS AFTER SMOKERS HAVE TAKEN UP SNUS USE?
<ul><li>Among smokers who take up snus use </li></ul><ul><li>87% become smoke-free (48% snus only, 39% no tobacco at all) </li></ul><ul><li>very few, 6 – 8 %, become dual users </li></ul>
HOW DOES SWITCHING FROM SMOKING TO SNUS INFLUENCE NICOTINE DEPENDENCE? Smokers not using snus Snus users having switched from smoking Sources: VAKT-smoke, Vakt-snus surveys
Among those who have switched from smoking to snus the proportion with high dependence levels is smaller than among smokers not using snus. This suggests that smokers who switch to snus do rather weaken than strengthen their dependence . This is also consistent with the finding that many switchers eventually quit all tobacco/nicotine use. A lower level of dependence in snus users may be due to the slower delivery of nicotine from snus compared to cigarettes.
WHAT IS THE OVERALL ASSOCIATION BETWEEN SNUS USE AND SMOKING CESSATION?
Both in men and women quit rates are distinctively higher among former and current snus users than among never snus users . The difference between ”All men” and ” All women” is a consequence of the lower prevalence of snus use in women. Gender itself does not influence smoking cessation, but snus use does favour smoking cessation.
WHAT ARE THE BENEFITS OF USING SNUS AS A SMOKING CESSATION AID?
<ul><li>Use of snus as a smoking cessation aid provides double benefits over nicotine gum and patch: </li></ul><ul><li>among men, snus is the most widely used aid (51% of all quit attempts) </li></ul><ul><li>both among men and women snus yields the highest quit rates (indicated numerically in the lower part of each bar). Consequently, snus appears to be a more effective cessation aid than nicotine gum or patch. </li></ul>
DOES SWEDISH SNUS HAVE A POTENTIAL TO YIELD AN OVERALL PUBLIC HEALTH BENEFIT? Sweden has developed record-low levels of smoking and record-low levels of all tobacco-induced diseases. Increasing snus use has been accompanied by – decreased initiation of smoking, and – increased cessation of smoking. By helping to reduce smoking, snus has been an important contributory factor for the favorable development of public health in Sweden. Similar development should be possible in other countries, but only if prevailing knowledge gaps are filled and common misperceptions are corrected by appropriate public information .