Is Snus a Model for Harm Reduction: The Scientific Evidence from Sweden Lars Ramström

Is Snus a Model for Harm Reduction: The Scientific Evidence from Sweden

Lars RamströmInstitute for Tobacco Studies

Stockholm, Sweden

Presentation atThe 13th World Conference on Tobacco OR Health

Session: Swedish Snus: Panacea or Pandora's Box?Saturday, 15 July 2006: 10:30 AM-12:00 PM

June 2006 (Volume 15, Number 3). Research paper:

Role of snus in initiation and

cessation of tobacco smoking in Sweden

L M Ramström and J Foulds

Adding the 113 individuals with missing initiation data does not make much difference to the above proportions. (Data for the total male study population .are shown below.)

Daily dual use 1.9% Daily smoking 13.0% Daily snus use 19.6% No daily tobacco use 65.4%

Figure 1 (From: Ramström & Foulds. Tobacco Control 2006)

PATHWAYS OF MALE TOBACCO USE (Percentages in boxes based on “All men” ages 16-79)

Patterns of initiation processes Patterns of current tobacco use

All men (with known

initiation pattern) n=3125 100.0%

5. NTOB Never started

any daily tobacco use

n=1397 44.7%

PSNU “Primary Snus Users”

(Started daily tobacco use as snus users) n=502 16.0%

PSMO “Primary smokers”

(Started daily tobacco use as

smokers) n=1226 39.2%

1. PSNU who never started daily smoking n=402 12.9%

4. PSMO who started

secondary daily snus use n=338 10.8%

3. PSMO who never started daily snus use n=888 28.4%

2. PSNU who started

secondary daily smoking n=100 3.2%

Daily dual use n=16 0.5%

Daily smoking n=10 0.3%

Daily snus use n=56 1.8%

No daily tob use n=18 0.6%














NPSNU “Non Primary Snus Users” n=2623 84.0%

16%

10%

56%

18%

77% 23%

9%

3% 61%

27%

44%

56%

20%

80%

28%

73%

47%

53%

16%

84%

7-12 13-17 18-22 23-27 28-32 33-37 38-420

25

50

AGE (years)

%

Onset of daily tobacco use in Swedish males, age 42-61

Prevalence at different ages

Data from 2001/2002 ITS/FSI study (Ramström & Foulds 2006)

Ever Daily Smoking

Ever Daily Snus Use



Initiation of daily snus use PATHWAYS OF MALE TOBACCO USE (Percentages in boxes based on “All men” ages 16-79)


All men (with known




n=1397 44.7%

PSNU “Primary Snus Users” (Started daily tobacco

use as snus users) n=502 16.0%



smokers) n=1226 39.2%


4. PSMO who started

secondary daily snus

use n=338 10.8%


2. PSNU who started




















16%

10%

56%

18%

77% 23%

9%

3% 61%

27%

44%

56%

20%

80%

28%

73%

47%

53%

16%

84%

Does primary snus use make young people more likely to start smoking???



Initiation of daily smoking PATHWAYS OF MALE TOBACCO USE (Percentages in boxes based on “All men” ages 16-79)


All men (with known






n=1397 44.7%


(Started daily tobacco use as smokers)

n=1226 39.2%


4. PSMO who started

secondary daily snus use n=338 10.8%


2. PSNU who started



















16%

10%

56%

18%

77% 23%

9%

3% 61%

27%

44%

56%

20%

80%

28%

73%

47%

53%

16%

84%


7-12 13-17 18-22 7-12 13-17 18-220

25

50

Cohort with current age 42-61

AGE (years)

Cohort with current age 22-41%

Juvenile onset of daily tobacco use in two birth cohorts of Swedish MALES



Ever Daily Smoking

Ever Daily SmokingEver Daily Snus Use

Ever Daily Snus Use


Does snus use favour smoking cessation???



Quitting daily smoking PATHWAYS OF MALE TOBACCO USE (Percentages in boxes based on “All men” ages 16-79)


All men (with known


5. NTOB Never started any daily tobacco use n=1397 44.7%





smokers) n=1226 39.2%


4. PSMO who started

secondary daily snus use

n=338 10.8%

3. PSMO who never started

daily snus use n=888 28.4%

2. PSNU who started

secondary daily smoking

n=100 3.2%



















16%

10%

56%

77% 23%

9%

3% 61%

27%

44% 56%

20%

80%

28%

73%

47%

53%

16%

84%

18%

26% 74%

12% 88%

QUIT RATE (Proportion of ”Ever daily smokers” having quit completely)

• All men 59%All women 49%

• Men WITHOUT a history of daily snus use 51%Women WITHOUT a history of daily snus use 48%

• Men WITH a history of daily snus use 72%Women WITH a history of daily snus use 71%

• All WITHOUT a history of daily snus use 49%All WITH a history of daily snus use 72%

Gum onlyPatch onlySnus only

Gum onlyPatch onlySnus only

0 25 50 75 100

Quit smoking completelyQuit daily Continuing daily smoking

Outcome of latest attempt to quit smokingby type of cessation aid used

smoking, continuing to smoke occasionally

Men

Women

47%

32%

66%

37%

29%

55%

10%

2%

15%

8%

2%

16%

43%

66%

19%

55%

69%

29%


How hazardous is snus to health???

Cigarette smokers

Snus users

Never-smokers

0,0 0,5 1,0 1,5 2,0 2,5

Relative risk of death for male tobacco users (whole bar)

Green sector: Never-smokers' death risk (reference) Red sector: Excess risk (above Never-smokers)

Less than 9% of

Data derived from:Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarfettes per day. Tobacco Control 2005;14:315-320.Levy D T et.al. The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product Compared with Smoking Cigarettes: Estimats of a Panel of Experts. Cancer Epidemiol Biomarkers Prev 2004;13(12):2035-2041.

Male daily smoking – from initiation to current status

Initiation category

Prevalence ”Ever daily smokers”

Prevalence “Current daily

smokers”

Fraction continuing

daily smoking

All ever daily smoking

42.4 % 14.6 % 0.344

Daily smoking + daily snus use

14.0 % 2.1 % 0.150

Daily smoking, no daily snus

28.4 % 12.5 % 0.440

Possible scenario if there had been no snus use:

Among “All ever daily smoking” the fraction remaining as daily smokers might have been 0.440 instead of 0.344.

Without snus use the overall prevalence of current daily smoking would not have been (42.4 % 0.344) = 14.6 % (as now), but (42.4 % 0.440) = 18.7 % i.e. about 1.28 times as high as now.

Possible scenario without snus• According to Peto et al (2006)* there were 4678 deaths attributed to

smoking among men in Sweden in the year 2000. *http://www.ctsu.ox.ac.uk/~tobacco/index.htm

• Adopting the calculation that, in the absence of snus use, the prevalence of daily smoking would have been 1.28 times as high as now…

• and assuming that the number of smoking-attributed deaths would then also have been 1.28 times as high, i.e. 5988…

• it may be suggested that male snus use in Sweden has been preventing more than one thousand deaths annually around the year 2000.

Summaryof evidence from Sweden

• Primary snus users are less likely so start smoking. • Increasing primary snus use has been associated with even

larger decrease of onset of daily smoking.• Secondary snus use is associated with attempts to quit

smoking.• Both in men and women are quit-smoking-rates higher in

those with than in those without a history of daily snus use.• Snus is a commonly used smoking cessation aid in men.• Both in men and women is snus more efficient as smoking

cessation aid than nicotine gum or patch.• The use of snus appears to have decreased the number of

deaths attributed to tobacco use.

What is snus? A panacea? No.

A Pandora’s box? No.

A useful toolbox for Yes. In Sweden it has contributed Harm Reduction? to health beneifts in spite of wide- spread misbeliefs exaggerating

its toxicity. Further efforts are needed for regulation and

education to make sure that only the best possible products are

available, through responsible channels, to a well informed public.

Documents

Is Snus a Model for Harm Reduction: The Scientific Evidence from Sweden Lars Ramström