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Epidemiology of tobacco use in Sweden,
the country with Europe’s lowest level of
tobacco-related disease
Lars M. Ramström
Institute 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
smoking snus use
Daily
Daily
smoking snus use
15 %
20 %
19 %
2%
Tobacco consumption per year in Sweden
per person 15 years and older
Around 1920
Around 1970
Around 2000
Cigarettes
(kg)
Snus
(kg)
0.2
1.1
0.6
1.4
0.4
0.9
Prevalence of daily moking and daily snus use
Men and women (age 18-70) in Sweden 1976-2002
Observations (bars) and least square regression lines
50
%
%
50
45
45
40
40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
1976
1980
1985
1988
Daily smoking, men
Daily smoking, women
1996
Daily snus use, men
Daily snus use, women
1976-1988 NTS-surveys, 1996-2002 ITS/FSI-surveys
Ramström 2003
2000
2002
Swedish snus
Fine 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)
Oral cancer incidence rates per 100000
(age standardized to world population)
Males in Northern and Western Europé
Countries with highest rates
Countries with lowest rates
France
Germany
Belgium
Luxembourg
Austria
The Netherlands
Norway
Iceland
Sweden
United Kingdom
14.94
13.19
10.78
10.43
10.39
Source: Cancer Incidence, Mortality and Prevalence Worldwide, Version 1.0.
IARC CancerBase No. 5. Lyon, IARCPress, 2001.
5.79
5.77
4.81
4.52
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 SMOKING
By presence or absence of primary use of snus
All males (n=2756)
40 %
With primary snus use (n=397)
Without primary snus use (n=2359)
20 %
43 %
(Source: ITS/FSI study 2001/2002)
Pathway after start of daily smoking
By 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
Red. to occ.nl smo.
Quit smo. compl.
17 % 42 %
12 % 4 %
71 % 54 %
(Source: ITS/FSI study 2001/2002)
14 %
14 %
71 %
43 %
6%
51 %
Cessation aid used at latest
quit attempt
Kind of aid
Nicotine gum
Nicotine patch
Snus
All other (together)
Males
(n=447)
Females
(n=426)
36 %
20 %
55 %
13 %
55 %
42 %
15 %
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)
Still smoking daily 44 % 66 %
Red. to occ.nl smo. 11 % 2 %
Quit smo. compl.
46 % 32 %
(Source: ITS/FSI study 2001/2002)
(n=205)
20 %
15 %
65 %
Prevalence of combinations of
smoking and use of snus (males)
DAILY SMOKING
Total (n=3205)
Daily smoking AND daily use of snus
Daily smoking AND occasional use of snus
Daily smoking, no use of snus
(Source: ITS/FSI study 2001/2002)
15 %
2%
2%
11 %
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
smokers who have …
Men Women
continued to smoke daily
34%
• cut down to occasional smoking 7%
• quit completely
59%
45%
6%
49%
Percentage of ever daily
snus users who have …
●
continued to use snus daily
74%
• cut down to occasional snus use 3%
• quit completely
23%
65%
5%
30%
●
SCORES FOR WISH TO QUIT
(Scale from 1 to 3)
SMOKERS
SNUS USERS
Men
Observed score for wish to quit
2.16
1.64
Women
Observed 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..