Comparison Between Different Pathways of Tobacco Use in Sweden – Implications for the

Prevention of Tobacco Induced Diseases

Lars M. Ramström

Institute for Tobacco Studies

Stockholm, Sweden

6th Annual Conference of ISPTID, Little Rock, Arkansas, 2-4 November, 2007

0 10 20 30 40 50 60 70

2005Ukraine2004Russian Federation2000Albania2005Armenia2005Belarus2001Georgia2003Turkey2002Bosnia and Herzegovina2004Latvia2000Greece2000Serbia2001Bulgaria2005Lithuania2004Estonia2005Poland2002Andorra2005Kyrgyzstan1998Slovakia2004Kazakhstan1999TFYR Macedonia2003Cyprus2005Republic of Moldova2003Germany2003Hungary2005Netherlands2003Spain2003Croatia2003Romania1999Portugal2005Israel2005Luxembourg2002Italy2004Czech Republic2003France2002Malta1997Austria2004Denmark1994San Marino2005Finland2005Norway2004United Kingdom2005Ireland2002Uzbekistan2004Switzerland2005Slovenia2005Belgium2004Iceland2005Sweden

% of regular daily smokers in the population, age 15+, male, Last available

WHO HFA DATABASE Percent of daily smokers in the population age 15+

Countries in the European Region

MEN

SNUS (moist oral snuff)

in portion packages

or

loose

EstoniaEstoniaEstoniaEstoniaEstoniaLithuaniaLithuaniaLithuaniaLithuaniaLithuania

LatviaLatviaLatviaLatviaLatviaFranceFranceFranceFranceFrance

Austria Austria Austria Austria Austria DenmarkDenmarkDenmarkDenmarkDenmarkGermanyGermanyGermanyGermanyGermany

IrelandIrelandIrelandIrelandIrelandBelgium Belgium Belgium Belgium Belgium

LuxembourgLuxembourgLuxembourgLuxembourgLuxembourgSwitzerlandSwitzerlandSwitzerlandSwitzerlandSwitzerland

IcelandIcelandIcelandIcelandIcelandNorwayNorwayNorwayNorwayNorway

United KingdomUnited KingdomUnited KingdomUnited KingdomUnited KingdomCanadaCanadaCanadaCanadaCanada

The NetherlandsThe NetherlandsThe NetherlandsThe NetherlandsThe NetherlandsUnited StatesUnited StatesUnited StatesUnited StatesUnited States

SwedenSwedenSwedenSwedenSweden

0 1 2 3 4 5 6

Cancer of the oral cavityAge adjusted mortality rates per 100 000Men in North America, Northern and Western Europe

Source: GLOBOCAN 2002 database: http://www.-dep.iarc.fr

MEN IN SWEDEN: PATHWAYS OF TOBACCO USE (Percentages in boxes based on “All males” ages 18-79)

Patterns of initiation of tobacco use

Source: FSI/ITS surveys 2003-2006

NevTOB Never started

any daily tobacco use

n=6883 44.7%

PriSNU “Primary Snus

Users” (Started daily

tobacco use as snus users)

n=2712 17.6%

PriSMO “Primary smokers”

(Started daily tobacco use as smokers)

n=5777 37.6%

PriSNU - NevSMO Never started daily

smoking n=2243 14.6%

PriSMO - SecSNU Later started daily

snus use n=1934 12.6%

PriSMO - NevSNU Never started daily

snus use n=3843 25.0%

PriSNU - SecSMO Later started daily

smoking n=469 3.0%

17%

83%

33%

67%

MEN IN SWEDEN: PATHWAYS OF TOBACCO USE (Percentages in boxes based on “All males” ages 18-79)

Patterns of initiation of tobacco use Patterns of current tobacco use

Source: FSI/ITS surveys 2003-2006

NevTOB Never started

any daily tobacco use

n=6883 44.7%

PriSNU “Primary Snus

Users” (Started daily

tobacco use as snus users)

n=2712 17.6%

PriSMO “Primary smokers”

(Started daily tobacco use as smokers)

n=5777 37.6%

PriSNU - NevSMO Never started daily

smoking n=2243 14.6%

PriSMO - SecSNU Later started daily

snus use n=1934 12.6%

PriSMO - NevSNU Never started daily

snus use n=3843 25.0%

PriSNU - SecSMO Later started daily

smoking n=469 3.0%

Daily dual use n=84 0.5%

Daily smoking n=26 0.2%

Daily snus use n=232 1.5%

No daily tob use n=127 0.8%

Daily snus use n=1681 10.9%

No daily tob use n=562 3.6%

Daily dual use n=200 1.3%

Daily smoking n=62 0.4%

Daily snus use n=1072 7.0%

No daily tob use n=600 3.9%

Daily smoking n=1657 10.8%

No daily tob use n=2186 14.2%

No daily tob use n=6882 44.8%

Daily dual use n=284 1.8%

Daily smoking n=1745 11.4%

Daily snus use n=2985 19.4%

No daily tob use n=10358 67.4%

18%

6%

49% 27%

75%

25%

10%

3% 55%

32%

43%

57%

17%

83%

33%

67%

PATHWAYS OF TOBACCO USE IN SWEDEN. MEN AGES 18-79. Categories of initiation/transition

Source: FSI/ITS surveys 2003-2006

PriSNU - NevSMO

PriSMO - SecSNU

PriSMO - NevSNU

PriSNU - SecSMO

n=100 3.2%

HE

IGH

T

OF

EA

CH

BO

X P

RO

PO

RT

ION

AL

TO

TH

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MB

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OF

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GO

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PATHWAYS OF TOBACCO USE IN SWEDEN. MEN AGES 18-79. Categories of initiation/transition Categories of current tobacco use

Source: FSI/ITS surveys 2003-2006

PriSNU - NevSMO

PriSMO - SecSNU

PriSMO - NevSNU

PriSNU - SecSMO

n=100 3.2%

18% 6% 49% 27%

75% 25%

10% 3% 55%

32%

43%

57%

HE

IGH

T

OF

EA

CH

BO

X P

RO

PO

RT

ION

AL

TO

TH

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NU

MB

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OF

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LENGTH OF EACH BAR PROPORTIONAL TO THE NUMBER OF INDIVIDUALS IN THE CATEGORY

DUAL DAILY USE

DAILY SMOKING, NO DAILY SNUS USE

PATHWAYS OF TOBACCO USE IN SWEDEN. MEN AGES 18-79. Source: FSI/ITS surveys 2003-2006

Initiation Current tobacco use (Percentages in boxes = fraction of all men) DUAL DAILY USE DAILY SMOKING, NO DAILY SNUS USE

a

n=100 3.2%

0.5% 0.2%

1.5% 0.6%

75% 25%

13%

87%

43%

57%

DAILY SNUS USE, NO DAILY SMOKING NO DAILY TOBACCO USE

24%

76%

SNUS SMO

SNUS (NEVER SMO)

SMO (NEVER SNUS)

SMO SNUS

10.9%

3.6%

1.3% 0.4%

7.0% 3.9%

10.8%

14.2%

1980/81 1984/85 1988/89 1992/93 1996/97 2000/2001 2004/2005

0

10

20

30

40

50

Daily snus use, womenDaily snus use, menDaily smoking, womenDaily smoking, men

Daily tobacco use in Sweden 1980-2005Point observations and least square regression lines

Sources: Smoking data from STATISTICS SWEDEN suveys of Living Conditions Snus use data from NTS-suveys (1980-1987) and ITS/FSI-surveys (2000-2005)

%

The changes of prevalence depend both on – changes of initiation patterns and on – changes of cessation patterns

For an in depth study of the development over time it would have been desirable that the two above parameters had been continuously monitored in the past. However, we can now emulate such a monitoring by retrospective analysis of consecutive birth cohorts from a 50 year period.

1930-19391940-1949

1950-19591960-1969

1970-19790

25

50

75

100

NonePrimary smokingPrimary snus use

Y e a r o f b i r t h

Initiation of primary daily tobacco use.Swedish men in different birth cohorts.

%

Source: FSI/ITS surveys 2003-2006

1930-19391940-1949

1950-19591960-1969

1970-19790

25

50

75

100

NonePrimary smokingPrimary snus use

Y e a r o f b i r t h

Initiation of primary daily tobacco use.Swedish women in different birth cohorts.

%

Source: FSI/ITS surveys 2003-2006

1930-1939 1940-1949 1950-1959 1960-1969 1970-19790

10

20

30

40

50

WomenMen

Y e a r o f b i r t h

Initiation of secondary snus use among Primary smokersMen and women in different birth cohorts.%

Source: FSI/ITS surveys 2003-2006

1930-1939 1940-1949 1950-1959 1960-1969 1970-19790,00

0,25

0,50

0,75

1,00PriSmo-SecSnusPriSmo-NevSnus

Y e a r o f b i r t h

Quit rates (fraction of Ever-daily-smokers having quit smoking completely)without or with initiation of secondary snus use.Swedish men in different birth cohorts.

Source: FSI/ITS surveys 2003-2006

1930-1939 1940-1949 1950-1959 1960-1969 1970-19790,00

0,25

0,50

0,75

1,00PriSmo-SecSnusPriSmo-NevSnus

Y e a r o f b i r t h

Source: FSI/ITS surveys 2003-2006

Quit rates (fraction of Ever-daily-smokers having quit smoking completely)without or with initiation of secondary snus use.Swedish women in different birth cohorts.

Ever-Daily-Smokers who have tried to quit smoking.Percentage having used different cessation aids at latest quit attempt.

Category of aidMEN

(n=4528)

WOMEN (n=538

8)

Nicotine gum only 7% 12%

Nicotine patch only 5% 8%

Snus only 21% 5%

Snus and gum 1% 1%

Other single aid 3% 4%

Bupropion only 1% 2%

Gum and patch 2% 4%

Other combination 2% 2%

No particular aid 57% 61%Source: FSI/ITS surveys 2003-2006

1930-1939 1940-1949 1950-1959 1960-1969 1970-19790

10

20

30

40Snus onlyPatch onlyGum only

Y e a r o f b i r t h

Quit attempts with use of different aidsSwedish men in different birth cohorts.

Source: FSI/ITS surveys 2003-2006

%

1930-1939 1940-1949 1950-1959 1960-1969 1970-19790

10

20

30

40Snus onlyPatch onlyGum only

Y e a r o f b i r t h

Quit attempts with use of different aidsSwedish women in different birth cohorts.

Source: FSI/ITS surveys 2003-2006

%

Gum onlyPatch only

Snus onlyGum only

Patch onlySnus only

0

25

50

75

100

Smoke dailySmoke just occasionallyDo not smoke at all

C e s s a t i o n a i d u s e dSource: FSI/ITS surveys 2003-2006

WomenMen

Outcome of latest quit attemptby cessation aid used

p.161“The epidemiology of tobacco use in Sweden suggests that if the public isoffered a substantially less harmful smokeless tobacco product along with accessto accurate information on relative risks, a substantial proportion can switch tothe less harmful product. This has clear implications for public health.”

Conclusions• Prevention of Tobacco Induced Diseases is first of all a

matter of reducing cigarette smoking• Comparisons between different pathways of

tobacco use in Sweden suggest that the use of snus has contributed to lower smoking rates by– reducing initiation of smoking– helping smokers to quit smoking (switching to snus or quitting all tobacco)

• This suggests that the use of snus has had implications for public health in a way that has contributed to the Prevention of Tobacco Induced Diseases in Sweden