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

tobacco-related disease

Lars M. RamströmInstitute for tobacco studies

Stockholm, Sweden

ICAA Venice 2004

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 %

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

%%

0

5

10

15

20

25

30

35

40

45

50

1976 1980 1985 1988 1996 2000 2002

0

5

10

15

20

25

30

35

40

45

50

Daily snus use, womenDaily snus use, men

Daily smoking, womenDaily smoking, men

1976-1988 NTS-surveys, 1996-2002 ITS/FSI-surveys

Ramström 2003

Prevalence of daily moking and daily snus useMen and women (age 18-70) in Sweden 1976-2002

Observations (bars) and least square regression lines

Swedish snusFine 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)

Netherlands Denmark Spain Sweden0

10

20

30

4

32

15

25

0

23

4

11

FemalesMales

Deaths attributed to tobacco (% of total) in 1990 Selected WHO/EUR "Very low mortality" countriesBy gender

Source: Peto et al, 1994

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

Has the use of snus

had an influence on

the smoking habits

in Sweden?

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?

ONSET RATE OF DAILY SMOKINGBy 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)

Pathway after start of daily smokingBy 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 occ.nl smo. 12 % 4 % 14 % 6 %Quit smo. compl. 71 % 54 % 71 % 51 %

(Source: ITS/FSI study 2001/2002)

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)

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 occ.nl smo. 11 % 2 % 15 %

Quit smo. compl. 46 % 32 % 65 %

(Source: ITS/FSI study 2001/2002)

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)

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

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

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 dailysnus users who have …● continued to use snus daily 74% 65%• cut down to occasional snus use 3% 5%• quit completely 23% 30%

SCORES FOR WISH TO QUIT (Scale from 1 to 3)

SMOKERS SNUS USERSMenObserved score for wish to quit 2.16 1.64

WomenObserved score for wish to quit 2.25 1.79

Reproduced from: Lunell E.: SRNT Europe 2003

SUMMARY/CONCLUSIONS (1)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.

SUMMARY/CONCLUSIONS (2)

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..