Authors: Lars M. Ramström, Institute for Tobacco Studies (ITS) Tom Wikmans, Research Group for Societal and Information Studies (FSI)

1. The Swedish experience of minimizing smoking
a possibly challenging example for large scale smoking cessation in the Asia Pacific region.
Lars M. Ramstrom, Institute for Tobacco Studies (ITS), Stockholm, Sweden, E-mail: lars.ramstrom@tobaccostudies.com.
Tom Wikmans, Research Group for Societal and Information Studies (FSI), Stockholm, Sweden, E-mail: tom@forskningsgruppen.com.
BACKGROUND OBJECTIVE MATERIAL
Sweden has Europe’s highest smoking cessation rate and a record low level of smoking-related mortality In this study, we intend to highlight three main questions related to the Swedish experience: The Research Group for Societal and Information Studies (FSI) annual Survey “Kajsa” is covering a
and morbidity. The prevalence of daily smoking is the lowest in the industrialized world, 11 % in men nationwide representative sample of the population in Sweden. Since 1991 the questionnaires contain
and 14 % in women. This is due to decreasing rates of initiation of smoking and an expansion of smo- • “Has the use of Snus facilitated the decrease of smoking initiation?” questions regarding tobacco habits in Sweden. The description of the Swedish experience in this poster
king cessation practices that has been influenced by several factors, for example the invention and pio- • ”Has the use of Snus facilitated the increase of smoking cessation?” is based on the analysis of data from years 2003 to 2006. The part of this study that illustrates the app-
neer use in Sweden of products for nicotine replacement therapy (NRT-products) and the use, mainly • ”Can the Swedish experience be replicated in countries with no previous experience licability of the Swedish experience to other countries is based on a review of existing scientific studies
among men, of the Swedish kind of oral smokeless tobacco, “Snus”, a moist powder of finely ground and cultural acceptance of smokeless tobacco?” on this topic.
tobacco leaves with low levels of tobacco-specific nitrosamines. The development of this situation has
come to be known as ”The Swedish experience”.
RESULTS
THE SWEDISH EXPERIENCE INTERNATIONAL EXPERIENCES
It is important to both minimize the initiation and maximize the cessation of smoking. At the same time it is important to shorten the time As shown by the Swedish experience Snus has an impact on the initiation of smoking and on cessation of both smoking and tobacco use al-
between the initiation and the cessation or at least shorten the time a person is smoking. By doing this we can get even more health benefits. together. But, is this experience replicable in other countries?
Sweden’s prevalence of daily smoking in adult men has gone from about 40 % in the late 1970s to 11 % year 2008. Male prevalence of daily
Snus use increased from around 10% to around 22% in the period from the late 1970s to the early 2000s. Since then the male Snus preva-
lence has stayed at approximately the same level up to year 2009. Choice of aid at ”Self-help” quit-attempts
Use (daily + occasionaly) of cigarettes and snus among Norwegian men,
INITIATION Norwegian men aged 16-30 years 1985-2009 and outcome of the quit-attempt
In Sweden there are two main tobacco products, cigarettes and Snus, so there can be four alternative patterns of initiation of daily tobacco use.
Initiation of smoking does mainly take place in a limited age span
among young people. Therefore looking at the initiation of tobacco
among different birth cohorts can let retrospective data give a picture
of changes of practices during consecutive past decades. We find that
in later born cohorts the initiation of smoking (sum of the two lowest
sectors of the bars in the diagram) is continuously going down. And
even though the initiation of Snus use is continuously going up, the
total tobacco initiation (sum of the four lower sectors of the bars in
the diagram) among Swedish men has decreased over time in almost
the same rate as the smoking initiation. This observation demonstra-
tes that increasing Snus use does not entail increase of smoking, it
may rather have contributed to the decrease of smoking initiation.
In comparison with Sweden the history of Snus use in Norway is con-
siderably shorter. In the last few decades the development in Norway
is similar to the one found in Sweden. The smoking prevalence has
gone down especially among men and the prevalence of Snus use has Also in Norway Snus is the most commonly used aid, and the one
gone up. that yields higher quit-rates then other alternatives.
Norway has not, like Sweden, a historical tradition of Snus use but shows similar patterns. This suggests that the Swedish experience could
CESSATION work also in other countries without a tradition of Snus use. Recently published studies by Rodu & Phillips, 2008 and Rodu & Cole, 2010
The Swedish experience shows that Snus has had a great impact on smoking prevalence by facilitating smoking cessation. show signs of similar developments emerging in the United States. A recent survey in Australia (Gartner et al. Tobacco Control, 2010) studied
if Australian smokers are interested in using low-nitrosamine smokeless tobacco, LNSLT, (for example Snus), for harm reduction. It found
Choice of aid at ”Self-help” quit-attempts among Quit rate of daily smoking and all kind of tobacco that: ”Although nearly half of the smokers surveyed were willing to purchase an LNSLT product, most were interested in using these products
Swedish men, and outcome of the quit-attempt use in groups with different initiation pattern. for cessation rather than as a long-term substitute or for dual use with cigarettes.”
SWEDISH SNUS
Snus is a form of low-nitrosamine smokeless tobacco (LNSLT) containing finely ground tobacco leaves. The
All people with experience of Snus use show significantly higher quit Swedish snus is moist with a water content of 40 % - 60 %. The main feature of the Swedish manufacturing
rates than those without experience Snus. procedure is a heating process where no fermentation takes place. In the absence of fermentation there is no
formation of nitrites and consequently no continued formation of tobacco-specific nitrosamines, TSNAs.
In all categories of “ever Snus use” substantial proportions, 25% - The originally present bacteria are killed by the heat, and the end product is virtually sterile. Therefore the
31%, have become completely free of daily tobacco use, illustrating risk for formation of TSNAs during storage is greatly reduced.
that uptake of Snus use does not have to entail an unbreakable de-
pendence. Snus is typically sold in pocket-size boxes containing small, tea-bag like pouches with snus. It is not a chew-
ing product. Instead, the snus user puts a pouch under the upper lip and lets it stay there for approximately
half an hour. There is no “spitting”.
The usefulness of Snus as a non medical smoking cessation aid is two-
fold. It is the most commonly used aid, among Swedish men, and, it
yields higher quit-rates then other alternatives. This gives Snus a po-
tential for facilitating large scale smoking cessation without requiring
professional assistance.
DISCUSSION
Snus is a major contributing factor to Sweden’s unique position as one of the countries in the world where smoking prevention has been most advanced. It is clear that smokers with previous or current experience of Snus are significantly more likely to succeed in quitting smoking. As much as 38% of those who quit smoking
using Snus proceed to become completely tobacco-free. This reinforces the image of positive impact that Snus has had, not only as a non-medical smoking cessation aid, but also as a steppingstone towards becoming completely tobacco free. Especially results from Norway show that the Swedish experience is working outside
Sweden, but also in countries like USA and Australia there are indications that the Swedish experience could function outside of Scandinavia. However, just as different countries spice the same dish differently, smokers in other countries might prefer slightly different versions of Snus than those used by most Swedish smokers
as non-medical smoking cessation aids. But the obvious benefits of using Snus as a final step in the process of getting people to quit smoking are the same in all countries and cultures. Especially for those smokers who try to quit smoking by them selves without seeking counselling or other professional assistance. For them
the Swedish Snus could be the difference between a successful or unsuccessful quit attempt.
CONCLUSIONS
THE SWEDISH EXPERIENCE INTERNATIONAL EXPERIENCE SNUS AS A NON MEDICAL QUITTING-AID IN OTHER REGIONS
• Snus has not increased the total initiation of tobacco use in Sweden • Snus is both the most preferred and most effective quitting aid in Norway • All evidence points out the effectiveness and relative harmlessness of Swedish Snus
• Snus is both the most preferred and most effective quitting aid in Sweden • Snus has increased the cessation rate in Norway as a non medical quitting-aid. This would justify a policy that not just allows the
• Snus has increased the cessation rate in Sweden sale of this non medical quitting-aid but actively encourages the use of it where
other quitting aids have failed to be effective.