Effect of smokeless tobacco (snus) on smoking and public health in Sweden

J Foulds; L Ramstrom; M Burke; K Fagerström

doi:10.1136/tc.12.4.349

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Effect of smokeless tobacco (snus) on smoking and public health in Sweden

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Re: RE: Does Snus use have a harm reduction effect in Sweden?
Jonathan Foulds
Published on: 13 May 2016
RE: Does Snus use have a harm reduction effect in Sweden?
Coral E Gartner
Published on: 13 May 2016
Does Snus use have a harm reduction effect in Sweden?
Prakash C Gupta
Published on: 13 May 2016
UK Legislative response
Simon Chapman
Published on: 13 May 2016
Re: South Asian Communities in UK (EU) Brace Themselves Against Smokeless Tobacco Flood
Clive Bates
Published on: 13 May 2016
South Asian Communities in UK (EU) Brace Themselves Against Smokeless Tobacco Flood
Kawaldip S Sehmi
Published on: 13 May 2016

Published on: 13 May 2016
Re: RE: Does Snus use have a harm reduction effect in Sweden?
- Jonathan Foulds, Associate Professor
Dr Gupta’s letter suggests that the reduction in lung cancer in both Sweden and Connecticut is highly likely to be due to a reduction in smoking in both places. This is entirely unsurprising, and as far as Sweden is concerned is precisely what we suggested in the original paper he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in...
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Dr Gupta’s letter suggests that the reduction in lung cancer in both Sweden and Connecticut is highly likely to be due to a reduction in smoking in both places. This is entirely unsurprising, and as far as Sweden is concerned is precisely what we suggested in the original paper he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use.” (p349, abstract)1.
The idea that smoking and lung cancer rates may fall to a similar or greater degree in other places is entirely irrelevant to whether or not snus played a role in smoking reduction in Swedish men. Indeed, in the original paper we stated clearly that:
“Both within and outside Sweden, smoking is primarily influenced by factors other than availability of smokeless tobacco (for example, real price of cigarettes, health education, smoke-free air policies, industry marketing, etc).” (p357)1
It is therefore entirely unsurprising that these types of factors will have influenced smoking and lung cancer rates in the United States and every other country, regardless of whether or not snus is available. A key point in our original paper that distinguished Sweden from other countries was that smoking rates WITHIN that country have fallen significantly faster in men than women, and that this appeared to be related to the fact that men in Sweden use snus much more than women. So although these comparisons between one country in Europe and a state in the US are almost entirely irrelevant to the question of the effect of snus use on lung cancer rates in Sweden, the more appropriate comparison (if one wanted to make one) would be of the difference in decline of lung cancer rates between men and women in Sweden as compared to changes in that difference in the US. It is not clear whether the data presented in Dr Gupta’s letter was for men, women or both.
Since the publication of our original paper there have been subsequent publications that have confirmed that in Sweden, men who start using snus are less likely to become daily smokers, that men who smoke and then start using snus are more likely to stop smoking, and that a higher proportion of men than women in Sweden have quit smoking, with the difference largely attributable to snus use2,3. It had previously been suggested that the men who quit smoking in Sweden are not the same ones who start using snus (and that snus use is therefore not involved in men quitting smoking)4. However, studies have now verified that in fact a sizeable proportion (26-29%) of Swedish men who quit smoking use snus as a smoking cessation aid2,5.
It is now crystal clear that their transfer of nicotine dependence onto snus has accelerated the rate of decline of smoking among Swedish men in substantial numbers. That transfer from an extremely harmful form of tobacco use (cigarette smoking) to a much less harmful form (snus) has contributed to a reduction in the rate of smoking-caused diseases in Swedish men.
1. Foulds J, Ramstrom L, Burke M, Fagerstrom K. The effect of smokeless tobacco (snus) on public health in Sweden. Tobacco Control 2003; 12:349-59. 2. Ramström LM, Foulds J. The role of snus (smokeless tobacco) in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006 Jun;15(3):210-4.Pdf available at: http://www.tobaccoprogram.org/staffarticles.htm 3. Furberg Furberg H, Bulik C, Lerman C, et al. Is Swedish snus associated with smoking initiation or smoking cessation? Tob Control.2005; 14:422- 424. 4. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking in Sweden: Is Swedish Match getting the credit for Swedish tobacco control’s efforts? Tobacco Control2003; 12:368-59 5. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction 2003;98:1183-9.
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
RE: Does Snus use have a harm reduction effect in Sweden?
- Coral E Gartner, Research Officer
- Other Contributors:
  Wayne D Hall
Dr Gupta’s comparison of trends in lung cancer mortality and smoking prevalence in Sweden and Connecticut purports to undermine the claim that increasing snus use in Sweden has contributed to declining lung cancer rates there.
Dr Gupta argues that some factor other than snus must have been at work because the ratio of lung cancers between Sweden and Connecticut has remained constant despite the large differenc...
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Dr Gupta’s comparison of trends in lung cancer mortality and smoking prevalence in Sweden and Connecticut purports to undermine the claim that increasing snus use in Sweden has contributed to declining lung cancer rates there.
Dr Gupta argues that some factor other than snus must have been at work because the ratio of lung cancers between Sweden and Connecticut has remained constant despite the large difference in snus use between the two places. He identifies this “other factor” as a declining cigarette smoking prevalence that he attributes to tobacco control policies.
We agree that a decline in cigarette smoking in both countries explains the lung cancer trends but we don’t see how this rules out a role for snus. This is exactly the mechanism by which proponents of snus would claim that snus use reduces smoking prevalence, namely, that population smoking prevalence declines because existing smokers switch to snus and new tobacco users use snus rather than cigarettes (Ramström and Foulds 2006).
The fact that smoking prevalence declined in Connecticut as a result of more traditional tobacco control policies simply shows that there is more than one way to reduce smoking prevalence. The fact that the decline in cigarette smoking over the time period examined was greater in Sweden ( -13%) than in Connecticut (-8%) supports the hypothesis that the addition of snus to more conventional tobacco control policies has increased the decline in smoking prevalence.
We concede that the comparison does not prove that snus was responsible for the decline in lung cancer rates in Sweden, but it is much more supportive of the claims for snus than Dr Gupta allows.
Yours sincerely
Coral Gartner and Wayne Hall
References
Ramström, L. M. and J. Foulds (2006). "Role of snus in initiation and cessation of tobacco smoking in Sweden." Tobacco Control 15(3): 210-214.
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
Does Snus use have a harm reduction effect in Sweden?
- Prakash C Gupta, Research Scientist
Dear Editor
Some tobacco control community members believe that advocating the use of snus, a form of Swedish smokeless tobacco said to be less harmful than cigarettes, would prove an effective harm reduction strategy against tobacco related diseases. One important basis for such a claim is the fact that snus is widely used in Sweden (23% men used snus daily in 2002), where the incidence of cancer caused by tob...
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Dear Editor
Some tobacco control community members believe that advocating the use of snus, a form of Swedish smokeless tobacco said to be less harmful than cigarettes, would prove an effective harm reduction strategy against tobacco related diseases. One important basis for such a claim is the fact that snus is widely used in Sweden (23% men used snus daily in 2002), where the incidence of cancer caused by tobacco is relatively low, and the observation that the Swedish are switching from smoked tobacco to snus. One way of looking at this claim of harm reduction through the use of snus is to compare tobacco related cancer rates in Sweden to those in the state of Connecticut, where use of any kind of smokeless tobacco including snus has been consistently rare.
The table below provides a comparison of age adjusted incidence rates for Sweden and Connecticut. As the data show, the incidence of tobacco related cancer is much lower in Sweden, about one half that of Connecticut. Trend data for Sweden seemingly provide further supportive evidence to the harm reduction hypothesis, as a dramatic increase in snus use in Sweden (0.4 kg/person in 1970 to 0.9kg/person in 2000) coincides with a decreasing cigarette consumption (1.1kg/person in 1970 to 0.6kg/person in 2000) resulting in a decrease of tobacco related cancer from 97.8 per 100,000 in 1966-1970 to 56.7 per 100,000 in 1993-1997.1,
However, if snus has a harm reduction effect, the incidence of tobacco related cancers should not only decline in Sweden as snus use increases, but it should decrease more in Sweden than in Connecticut, where the consumption of smokeless tobacco has remained <1% over 1990s. However, the data below demonstrate that the ratio of the incidence of tobacco related cancer in Sweden and Connecticut has remained constant at about 0.5 since 1973, and the same ratio for lung cancer has been stable at about 0.4 since1960. Rather than snus causing the decrease in tobacco related cancer in Sweden, these data suggest that another factor was responsible in reducing cancer incidence in both Sweden and Connecticut. That factor is likely to be the decline in cigarette use, which fell in men from about 28% to 15% (Sweden) and 26.7% to 18.7% (Connecticut) from 1985-2003.1,3 During the period of 1970s to 1990s, both populations were exposed to smoking reduction strategies such as increased awareness of health risks, increased prices, a change in social norms regarding tobacco use, etc but both places did not have an increase in snus use. Thus, the data do not seem to support the hypothesis that the decrease in tobacco related cancers in Sweden is due to increasing use of snus.
References
1. Foulds, J., Ramstrom, L., Burke, M., Fogerstrom K. Effect of Smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 2003; 12:349–359.
2. Cancer Incidence in Five Continents. Vol. I-VIII. Lyon: International Agency for Research on Cancer.
3. CDC. State System: State Tobacco Activities tracking and evaluation system. Tobacco Use Supplement to the Current Population Survey. 2006. Available at http://apps.nccd.cdc.gov/statesystem/. Accessed January 17, 2007.
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
UK Legislative response
- Simon Chapman, Editor
Readers should note the following motion placed before the UK parliament on this topic on 10 December 2003:
SMOKELESS TOBACCO 10.12.03 Flynn/Paul That this House welcomes the confirmation from Cancer Research UK Action on Smoking and Health and the Royal College of Physicians that some forms of smokeless tobacco are between 500 and 1,000 times less hazardous than smoking tobacco; agrees with the conclusion tha...
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Readers should note the following motion placed before the UK parliament on this topic on 10 December 2003:
SMOKELESS TOBACCO 10.12.03 Flynn/Paul That this House welcomes the confirmation from Cancer Research UK Action on Smoking and Health and the Royal College of Physicians that some forms of smokeless tobacco are between 500 and 1,000 times less hazardous than smoking tobacco; agrees with the conclusion that, if Britain followed the Swedish pattern of smokeless tobacco use, tobacco-related deaths among men would be cut by 44,000 a year; and urges the Government to end the ban on the sale of snus which will allow inveterate smokers access to a safer alternative that would add several years to their life expectancies.
See: http://edm.ais.co.uk/weblink/html/motion.html/ref=261
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
Re: South Asian Communities in UK (EU) Brace Themselves Against Smokeless Tobacco Flood
- Clive Bates, Personal
Kawaldip Sehmi's letter seems to advocate ignorance and a kind of book-burning attitude to understanding this area. But in fact, better knowledge of the science might help his cause.
The paper by Enstrom and Kabat caused problems not because its findings conflicted with the established evidence base, but because it was flawed and the BMJ failed to put its contribution in context with the rest of the large evidenc...
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Kawaldip Sehmi's letter seems to advocate ignorance and a kind of book-burning attitude to understanding this area. But in fact, better knowledge of the science might help his cause.
The paper by Enstrom and Kabat caused problems not because its findings conflicted with the established evidence base, but because it was flawed and the BMJ failed to put its contribution in context with the rest of the large evidence base. In contrast, Jonathan Foulds and his colleagues have done a good job at dispassionately examining and presenting the evidence on snus in Sweden, and the comparison with Enstrom and Kabat is unjustified.
Here are two examples where the developments that flow from this analysis may work to the advantage of the community Kawaldip Sehmi is concerned about (and where his ideas might cause more harm)...
If a regulatory framework was introduced in Europe for smokeless tobacco as part of unbanning snus (and this is what the harm reduction supporters are pressing for), it is likely many of the South Asian imported products would not meet the standard and have to come off the market. There may be a market response that reduced the hazardousness of the range of products available to the S. Asian community - either becase the S. Asian manufacturers would comply, or because other compliant products would enter the market to meet the gap. This would be an improvement on the status quo.
Science might also help re-think the evidence-free campaign to get these other smokeless tobacco products banned - in the UK or in S. Asia. How do the campaigners know that the former smokeless tobacco users would turn to the much higher risk smoking products? How do they know that those that would have started to use smokeless products would not just start to smoke instead? (and this would be a great opportunity for predatory cigarette companies). If they do, then they will be at much higher risk. In taking that gamble, what are the campaigners hoping to achieve through a prohibition and do they mind if some people are at greatly increased risk as a result of their idea? When Sweden joined the EU it was granted an exemption from the ban on oral tobacco - and it is a good thing too, because there would be more Swedish smokers now if the ban had been imposed. From reading Foulds et al's paper even the most extreme flat earth "quit or die" advocates cannot think that the EU's ban should be extended to Sweden - surely! But if not, why not? And if not in Sweden, should that give prohibitionist campaigners pause for thought about their campaigns to achieve this elsewhere? Sweden's experience issn't necessarily applicable everywhere - but it is a reason for caution about banning smokeless tobacco anywhere.
Please let's have less talk of editorial orifices and recognise that Tobacco Control journal and its editor are doing public health a service by shining light on this murky former no-go area and challenging some ill- considered orthodoxies.
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
South Asian Communities in UK (EU) Brace Themselves Against Smokeless Tobacco Flood
- Kawaldip S Sehmi, Asst Director- Head of Ethnic Minority Services
Last week in the BMJ 2003; 327 (6 December), after seeing his comments on the Enstrom and Kabat paper on second-hand smoke being used by Forest to advance the tobacco industry’s position, the BMJ Editor says in a fair and frank admission:
"Reading the quote on a Forest advertisement tightens my anus, but I wrote it and can't deny it."
Health Professionals who have been working hard towards getting che...
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Last week in the BMJ 2003; 327 (6 December), after seeing his comments on the Enstrom and Kabat paper on second-hand smoke being used by Forest to advance the tobacco industry’s position, the BMJ Editor says in a fair and frank admission:
"Reading the quote on a Forest advertisement tightens my anus, but I wrote it and can't deny it."
Health Professionals who have been working hard towards getting chewing tobaccos banned in the many South Asian Communities in the UK had been using the Snus ban to advance their argument. Many now feel that the Tobacco Industry will use this paper, as was the Enstrom/Kabat paper in the reversal of Second Hand Smoke Ban Policies, to undermine the whole smokeless tobacco ban strategy.
In our experience, chewing tobaccos (many are packaged in shining packets to entice kids) are the gateway to up taking of smoking later. The child starts by using a "mouth freshener" pack of Gutkha tobacco and then after getting addicted to nicotine in the smokeless tobacco, advances to taking up smoking.
At the 12th World Conference on Tobacco and Health in Helsinki (3-8 August 03), the last smokeless tobacco session was heated and electric. Bengali, Indian and Pakistani health professionals were concerned about the impact the lifting of the flood gates of an EU ban would have on their public health efforts to get gutka, zarda and other smokeless tobacco banned.
UK South Asian Communities and their use of smokeless tobacco were seen as the crack/ loophole in EU/UK Tobacco Control Legislation. The Snus vehicle/bandwagon could be driven through this. This study has just given the tobacco industry the starter key.
We brace ourselves now. What orifice will the BMJ Editor tighten next time when this study is used in the undermining of smokeless tobacco use in the future?
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Conflict of Interest:
None declared.
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