Snus as a Substitution for Smoking: The Swedish Experience

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Oral presentation by Lars Ramström

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  • My presentation today will deal with specifically SWEDISH conditions related to the use in Sweden of ”snus”, the Swedish kind of oral smokefree tobacco. Most of my data come from a current study: NEXT
  • The study population constitutes a nationwide representative sample of 6,700 people age 16-79. Combining data from this study with data from a 1996 study of ours, we find the following key prevalence data for tobacco use in Sweden. NEXT
  • These figures suggest that, among males, but not among females, snus has been a substitution for smoking to a certain extent during the period from 1996 till now. But, in order to draw more definite conclusions about the interaction between smoking and use of snus, there is a need for further, more in-depth studies. Let us first have a look at the patterns of combinations of smoking and use of snus. NEXT
  • First: Daily smoking in relation to concurrent use of snus: Daily use of both kinds is a quite rare practice. Most daily smokers do not use snus at all. Then: Daily snus use in relation to concurrent smoking: Most daily users of snus do not smoke at all. Let’s now look at the patterns of initiation of tobacco use NEXT
  • When defining categories of onset patterns, a major distinction has to be done between those who have taken snus as their primary daily use of tobacco, and those who have not. NEXT
  • The category ”Primary Daily Snus Users”, is defined as those who have started daily snus use without previous daily smoking and have either never started daily smoking or done so AFTER the start of daily snus use. The primary snus users constitute a minority, 15 %, of all males and a negligable fraction of females. Among the primary snus users one out of five has later started daily smoking. Among those without primary snus use, a much larger proportion has started daily smoking NEXT
  • An overview of onset patterns shows, that among males at large, 40 % have started daily smoking Among primary snus users, the onset rate of daily smoking is half as large. This suggests that primary use of snus would keep down onset of smoking rather than serve as a gateway to smoking. Next comes the question: Which is the further development of smoking practices after onset, and how is this development influenced by various conditions? By looking at the current smoking status of different categories of ever daily smokers, we can trace some of those influences. NEXT
  • Looking at the influence of onset patterns, it seems that those who have started smoking after primary snus use, maintain their smoking to a lesser degree than other smokers. But, the small size of this category makes it difficult to draw firm conclusions. Then comes the question about the influence of snus use that starts AFTER the onset of smoking. To get on overview picture, let’s look at the development of smoking up till now in categories of tobacco users with, respectively without, a history of ever having been a daily snus user. NEXT
  • These figures suggest that use of snus does reduce maintenance of daily smoking and increase smoking cessation. To further elucidate the mechanisms behind this picture it will be interesting to find out what cessation practices that are used by Swedish smokers, and the success rate of various such practices. In the current study we have asked all ever daily smokers who have made a quit attempt, if they did use a particular cessation aid or not. NEXT
  • Both among males and females, more than half of the ”triers” have NOT used a particular cessation aid at their latest quit attempt. These have been more successful than those who have used a cessation aid. This finding implies that smokers who have used particular cessation aids, are those who have greatest difficulties to quit. Let’s now look closer at those who have used a particular cessation aid. NEXT
  • Which are the most commonly used cessation aids? Among males, snus is most common, among females nicotine gum is most common. None of the other options, (nicotine tablet, nicotine nasal spray, nicotine inhalator, zyban, psychological treatment) was indicated by more than 7 % of the respondents. The sum of percentages in this table exceeds 100 since a number of respondents have indicated use of more than one aid. When trying to assess the effectiveness of the different aids we have therefore restricted the analysis to those who have used one kind of aid only. Further, the less common aids have had to be excluded because of small numbers. NEXT
  • These figures refer to males. Detailed interpretation is difficult because of the small numbers for Gum and Patch. But, the figures for snus are the only ones to show success above average. This suggests that snus is an effective cessation aid. NEXT
  • These are the figures for females. Here the number of snus users is very small, But, the snus figures are the only ones that show substantially better success than average. In summary: NEXT
  • Snus as a Substitution for Smoking: The Swedish Experience

    1. 1. Snus as a Substitution for Smoking: The Swedish Experience Lars M. Ramström Institute for tobacco studies Stockholm, Sweden
    2. 2. <ul><li>Current study: </li></ul><ul><li>” Tobacco use in Sweden 2001-2002 : Prevalence data, initiation and cessation practices” </li></ul>Study population: A nationwide representative sample of 6,700 people age 16-79
    3. 3. Key prevalence data, Sweden <ul><li> MALES FEMALES (2001/2002; n=3205) (2001/2002; n=3507) (1996; n=1481) (1996; n=1497) </li></ul><ul><li>Daily Daily Daily Daily smoking snus use smoking snus use </li></ul><ul><li>YEAR </li></ul><ul><li>2001/2002 15 % 20 % 19 % 2 % </li></ul><ul><li>1996 20 % 15 % 19 % 2 % </li></ul>
    4. 4. Prevalence of combinations of smoking and use of snus (males) <ul><li>DAILY SMOKING Total (n=3205) 15 % </li></ul><ul><li>Daily smoking AND daily use of snus 2 % Daily smoking AND occasional use of snus 2 % Daily smoking, no use of snus 11 % </li></ul><ul><li>DAILY USE OF SNUS Total (n=3205) 20 % </li></ul><ul><li>Daily use of snus AND daily smoking 2 % Daily use of snus AND occasional smoking 4 % Daily use of snus, no smoking 14 % </li></ul>
    5. 5. Initiation of tobacco use: Categories of onset patterns
    6. 6. ” P RIMARY D AILY SN US U SERS” (PDSNU) (Have started daily snus use without previous daily smoking and have either never started daily smoking or done so AFTER the start of daily snus use) <ul><li> ALL MALES (n=2756) PDSNU 15 % Started daily smoking 3 % Not started daily smoking 12 % </li></ul><ul><li>Non-PDSNU 85 % Started daily smoking 37 % Not started daily smoking 48 % </li></ul>
    7. 7. Proportion of males who have ever started daily smoking <ul><li>All males (n=2756) 40 % </li></ul><ul><li>PDSNU (n=397) 20 % Non-PDSNU (n=2359) 43 % </li></ul>
    8. 8. CURRENT SMOKING STATUS Male ever daily smokers <ul><li> Primary daily snus user? </li></ul><ul><li> Yes No (n=80) (n=1022) </li></ul><ul><li>Still smoking daily 26 % 33 % </li></ul><ul><li>Reduced to occ.nl smoking 14 % 6 % </li></ul><ul><li>Quit smoking completely 60 % 61 % </li></ul>
    9. 9. CURRENT SMOKING STATUS Male ever daily smokers <ul><li> Ever daily snus user? </li></ul><ul><li> Yes No (n=498) (n=775) </li></ul><ul><li>Still smoking daily 17 % 42 % </li></ul><ul><li>Reduced to occ.nl smoking 12 % 4 % </li></ul><ul><li>Quit smoking completely 71 % 54 % </li></ul>
    10. 10. CURRENT SMOKING STATUS Ever daily smokers who report having made an attempt to quit <ul><li>Males Females </li></ul><ul><li>Have used particular aid ? </li></ul><ul><li>Yes No Yes No (n=447) (n=583) (n=426) (n=743) </li></ul><ul><li>Still smoking daily 35 % 33 % 57 % 39 % </li></ul><ul><li>Red. to occ.nl smo. 11 % 6 % 8 % 6 % </li></ul><ul><li>Quit smo. compl. 54 % 61 % 35 % 55 % </li></ul>
    11. 11. Cessation aid used at latest quit attempt <ul><li> Males Females (n=447) (n=426) </li></ul><ul><li>Nicotine gum 36 % 55 % </li></ul><ul><li>Nicotine patch 20 % 42 % </li></ul><ul><li>Snus 55 % 15 % </li></ul><ul><li>All other (together) 13 % 24 % </li></ul>
    12. 12. CURRENT SMOKING STATUS Male ever daily smokers who have used an aid at latest quit attempt <ul><li> Gum Patch Snus All aid only only only users </li></ul><ul><li> (n=85) (n=41) (n=205) (n=447) </li></ul><ul><li>Still smoking daily 44 % 66 % 20 % 35 % </li></ul><ul><li>Red. to occ.nl smo. 11 % 2 % 15 % 11 % </li></ul><ul><li>Quit smo. compl. 46 % 32 % 65 % 54 % </li></ul>
    13. 13. CURRENT SMOKING STATUS Female ever daily smokers who have used an aid at latest quit attempt <ul><li> Gum Patch Snus All aid only only only users </li></ul><ul><li> (n=134) (n=88) (n=46) (n=426) </li></ul><ul><li>Still smoking daily 54 % 68 % 30 % 57 % </li></ul><ul><li>Red. to occ.nl smo. 8 % 2 % 17 % 8 % </li></ul><ul><li>Quit smo. compl. 37 % 30 % 52 % 35 % </li></ul>
    14. 14. SUMMARY <ul><li>In Sweden use of snus is more common than smoking among males but less common among females. </li></ul><ul><li>Snus seems to serve as a substitution for smoking thereby contributing to — less initiation of smoking. </li></ul><ul><li>more cessation of smoking. </li></ul><ul><li>Snus seems to be an effective smoking cessation aid that is commonly used by males. </li></ul>
    15. 15. CONCLUSION <ul><li>Findings from the current study suggest that snus, although not a ”health product” by itself, can, by serving as a substitution for smoking, have been one of the many factors contributing to the current situation in Sweden with low smoking rates and accordingly low rates of tobacco-related morbidity and mortality. . </li></ul>

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