Patterns of Smoking and Snus Use in Sweden: Implications for Public Health.

There has been concern that the availability of alternative less harmful forms of nicotine might inhibit smoking cessation and/or encourage those who would not otherwise have smoked to do so. The plausibility of such effects can be best assessed by looking at population trends in use of smoking in relation to alternatives. This paper looks at the relationships between snus use and smoking in Sweden. Analyses are based on a data set for the period January 2003 to February 2011 from a long-term study covering nationally representative samples of the Swedish population aged 18-79, with a total study population of 60,675 individuals. Questionnaires made it possible to identify detailed tobacco use categories and use trajectories. The results showed that uptake of snus use is much more common in males than females. Those who began daily tobacco use using snus were much less likely to subsequently take up smoking than those who had not, both among males (17.6% vs. 45.9%), and females (8.2% vs. 40.2%). Further, among those who started using snus after starting as smokers, 76.3% of men and 71.6% of women had stopped smoking completely, including 31.5% of the men and 28.6% of the women who had quit all forms of tobacco. Indeed, those who were primary snus users were also more likely to have quit altogether than those who only ever smoked. Snus was also reported as the most common smoking cessation aid among men and yielded higher success rates than nicotine replacement therapy and other alternatives. As conclusions, snus has both contributed to decreasing initiation of smoking and, when used subsequent to smoking, appears to facilitate smoking cessation. All these effects suggest that the availability and use of snus has been a major factor behind Sweden's record-low prevalence of smoking and the lowest level of tobacco-related mortality among men in Europe.

Mortality attributable to tobacco among men in Sweden and other European countries: an analysis of data in a WHO report.

BACKGROUND: It is well known that Swedish men have lower tobacco-related mortality than men in other European countries, but there are questions that need further investigation to what extent this is related to the specific patterns of tobacco use in Sweden, where use of snus, the Swedish low-nitrosamine oral tobacco, dominates over smoking in men but not in women. The recent WHO Global Report: Mortality Attributable to Tobacco provides a unique set of estimates of the health burden of tobacco in all countries of the world in the year 2004, and these data can help elucidating the above-mentioned questions. METHODS: For Sweden and all other European Union Member States mortality data for a number of tobacco-related causes of death were extracted from the WHO Report. The size of the mortality advantage for selected causes of death in different age groups of Swedish men compared to men of the same age in Europe as a whole was calculated in terms of ratios of death rates attributable to tobacco. Differences between age groups with respect to tobacco-related mortality were analyzed with respect to differences in terms of development and status of smoking and snus use. The analyses also paid attention to differences between countries regarding tobacco control regulations. FINDINGS: Among men in the European Union Member States the lowest level of mortality attributable to tobacco was consistently found in Sweden, while Swedish women showed levels similar to European average. A strong co-variation was found between the mortality advantage and the degree of dominance of snus use in the different age groups of Swedish men. Among Swedish women there are no age groups with dominant use of snus, and similar observations were therefore not possible for women. CONCLUSION: The above findings support the assumption that the widespread use of snus instead of cigarettes among Swedish men may be a major part of the explanation behind their position with Europe's lowest mortality attributable to tobacco.

Effects of a Fact Sheet on beliefs about the harmfulness of alternative nicotine delivery systems compared with cigarettes.

BACKGROUND: This study explored the value of providing information in a Fact Sheet to correct misperceptions about the relative harmfulness of nicotine replacement products (NRT) and smokeless tobacco (ST), when compared to cigarette smoking. METHODS: Four convenience samples from different countries (Australia, UK, Sweden and USA) were surveyed concerning their beliefs about the relative harmfulness of smokeless tobacco and NRT. Study participants were given the Fact Sheet that explained that nicotine, as used by consumers, is not particularly harmful and explained why. They were resurveyed one week later regarding their beliefs about the relative harmfulness of smokeless tobacco and NRT and future intentions to use the products. RESULTS: In all four samples knowledge increased by similar amounts and beliefs regarding the lower harmfulness of smokeless tobacco increased. However, misconceptions remained common and responses to belief measures were not always consistent. Likelihood of use of ST increased in all four samples after exposure to the Fact Sheet, but interest in NRT use only increased in the US sample. CONCLUSIONS: A Fact Sheet such as this one can help address misconceptions about NRT and smokeless tobacco, at least in the short term. However, as is true of most educational interventions, exposure to a single educational session is not sufficient to overcome misperceptions that smokers have about the relative harmfulness of oral versus combustible forms of nicotine delivery.

Harm perception among Swedish daily smokers regarding nicotine, NRT-products and Swedish Snus.

BACKGROUND: In Sweden NRT-products and Snus, are easily available and used as smoking cessation aids. However, most quit attempts are made without any cessation aids. The limited use of these products as cessation aids may be influenced by the way smokers perceive the harmfulness of NRT-products and Snus compared to smoking. The present study examines these perceptions and their association with perceptions of the harmfulness of nicotine itself. METHODS: The study is based on the Swedish part of a two-nation web-based survey of daily smokers in Sweden (n = 1016) and Norway (n = 1000). Questionnaire items addressed perceptions of NRT-products' and Snus' harmfulness and nicotine's part of the health risks of smoking. Data analyses included cross-tabulations and logistic regressions. RESULTS: A majority, 59% of the answers to the question about harmfulness of NRT-products, and 75% of the answers about harmfulness of Snus, were inconsistent with the scientific evidence by demonstrating exaggerated perceptions of harmfulness. The strongest predictor of consistent answers was the perception of the harmfulness of nicotine. There were also significant associations with own experience of successful use of the products in question. Overall the perceptions of the harmfulness of nicotine were considerably exaggerated. This pattern was more pronounced among women than men. Prevailing misperceptions may be related to the way that different tobacco and nicotine products are presented in the media and other publicly available information sources. CONCLUSIONS: Public information about smoking and health should be expanded to include objective and unambiguous information regarding nicotine's part in the harmfulness of smoking and the harmfulness of different nicotine-containing products compared to smoking.This is essential in order to preclude that misperceptions regarding these matters could discourage smokers from adopting effective cessation practices with use of nicotine-containing aids.