Swedish experience

(1.) Peto, R., Lopez, A. D., Boreham, J., and Thun, M. 2003. Mortality from Smoking in Developed Countries 1950-2000, 2nd edition, data updated June 2006, http://www.ctsu.ox.ac.uk/~tobacco

• Snus was the predominant tobacco product in Sweden in the beginning of the 20th century. Cigarette volumes began to increase in the 1940s and snus volumes dropped. In the 1970s sales of snus started to increase, while cigarette volumes levelled out and began to decrease in the 1990s.

• Currently, Swedish men have the lowest prevalence of smoking in the EU, but they also have a high rate of snus use, 14% and 23%, respectively(2). The rate of smoking among Swedish women is more on par with that in other EU member states and usage of snus is of low prevalence, 19% and 3%, respectively(2). Smokeless tobacco products permitted for use in other EU member states, chewing tobacco and nasal snuff, have very low prevalence.
  
  (2). World Health Organization. 2006. Tobacco Control Database. Accessed 10 February 2006. http://data.euro.who.int/Default.aspx?TabID=2444
  
  Smoking Prevalence (%) Among Male Adults in EU Countries
  Source:  WHO 2006.  Note that data on prevalence of smoking in Greece, Portugal, Slovakia and Slovenia in 2002-2005 were not available.

• One way to exemplify the different usage patterns was made by Fagerström (3), who estimated that snus use accounts for almost 50% of all nicotine consumed in Sweden and over 60% of all nicotine consumed by Swedish men. In most other western countries almost all nicotine consumed is derived from tobacco combustion.
  
  (3.) Fagerström, K. 2005. The nicotine market: an attempt to estimate the nicotine intake from various sources and the total nicotine consumption in some countries. Nic. Tob. Res./:343-350.

Studies in Sweden are consistent in their conclusion that snus is not an entry or gateway to, but rather an exit from cigarette smoking.

• Instructive data, suggesting that snus use has had a strong impact on smoking rates, have been obtained from a study in northern Sweden. The results show that the prevalence of all tobacco use among men was stable at about 40% during the period 1986-2004. The smoking rate decreased from 19% to 9% and the snus rate increased from 18% to 27% during this period. The major transition was from smoking to use of snus. Among women the prevalence of all tobacco use was steady at 27-28%. The smoking rate declined from 25% in 1986 to 16% in 2004. During this period the prevalence of snus use increased from 0.5% to 8.9% (4, 5, 6)
  
  (4.) Rodu, B., Stegmayr, B., Nasic, and Asplund, K. 2002.  Impact of smokeless tobacco use on smoking in northern Sweden.  J. Int. Med. 252:398-404.
  
  (5.) Rodu, B., Stegmayr, B., Nasic, S., Cole, P., and Asplund, K. 2003.  Evolving patterns of tobacco use in northern Sweden.  J. Int. Med. 253:1-6.
  
  (6.) Stegmayr, B., Eliasson, M., and Rodu, B.  2005.  The decline of smoking in northern Sweden.  Scand. J. Public Health 33:321-324.
  
  
• In a large population-based study comprising some 15,000 male twins, Furberg et al (2005)(7). examined smoking cessation among men who used snus after they started smoking compared to men who never used snus in relation to smoking. They found that snus use was associated with smoking cessation but not with smoking initiation. Both regular and occasional snus use was protective against ever having smoked.
  
  

  (7.) Furberg, H., Bulik, C.M., Lerman, C., Lichtenstein, P., Pedersen, N.L., and Sullivan, P.F.  2005.  Is Swedish snus associated with smoking initiation or smoking cessation?  Tobacco Control  14:422-424.
  

• Retrospective analysis of data from a cross-sectional survey completed by more than 6,000 Swedes in 2001-2 showed that use of snus is associated with a reduced risk of becoming a daily smoker and an increased likelihood of quit smoking. Among men snus is the most commonly used smoking cessation aid and a higher proportion of men who use snus are actually more successful in quitting smoking as compared with men using other cessation aids(8).
  
  

  (8.) Ramström, L. and Foulds, J. 2006. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob. Control 15:210-214.

• The rate of nicotine intake in the body is slower in habitual snus users than in cigarette smokers, but both the average plasma steady-state levels and the total nicotine intake per 24 hours, the dose, are similar. These facts may help to explain that snus has evolved as an effective alternative to cigarettes for many Swedish cigarette smokers (9-13).
  
  (9.) Holm, H., Jarvis, M.J., Russell, M.A.H., and Feyerabend, C. 1992. Nicotine intake and dependence in Swedish snuff takers. Psychopharmacology 108:507-511.
  
  (10.) Andersson, G., Björnberg, G., and Curvall, M. 1994. Oral mucosal changes and nicotine disposition in users of Swedish smokeless tobacco products: A comparative study. J. Oral Pathol. Med. 23:161-167.
  
  (11.) Andersson, G., Vala E.K., and Curvall, M. 1997. The influence of cigarette consumption and smoking machine yields of tar and nicotine on the nicotine uptake and oral mucosal lesions in smokers. J. Oral Pathol. Med. 26:117-123.
  
  (12.) Larsson, I., Curvall, M., and Enzell, C.R. 1987. Disposition of nicotine and cotinine in plasma, saliva and urine of snuff-users. Proceedings from Third European Congress of Biopharmaceutics and Pharmacokinetics: pp. 318-24.
  
  (13.) Lunell, E. and Lunell, M. 2005. Steady-state nicotine plasma levels following use of four different types of Swedish snus compared with 2-mg Nicorette chewing gum: A crossover study. Nic. Tob. Res. 7:397-403.

• It has been estimated that some 650,000 smokers will die each year in the EU from smoking-related diseases such as lung and other cancers, cardiovascular and respiratory diseases(14).
  
  (14.) Kyprianou, M. EU and US Health concerns and policies. Speech at lunch hosted by the European Institute, Washington, 20 April, 2005.
  
  
• The health effects associated with the use of smokeless tobacco manufactured in the western world are significantly lower than those associated with smoking. This conclusion is primarily based on results of epidemiological studies, many of which have been conducted in Sweden. As shown in the summary below , snus use has not been shown to be associated with oral, lung, stomach, kidney or bladder cancer. Whether snus use may increase the risk of pancreatic cancer has been debated and needs to be confirmed or refuted in future studies. Snus use may lead to oral mucosal lesions but these are harmless, reversible and disappear when snus use is stopped. Snus use does not increase the incidence of myocardial infarction or stroke, but the risk of dying from a myocardial infarction is higher for snus users than for non-tobacco users. There is conflicting conclusions whether snus is a risk factor for diabetes. Snus should not be used by pregnant or breastfeeding women.
  
  Snus -- Summary of Fact Sheets 6-15-07 (PDF, 26 kb)

• The lower health risks of snus use as compared with smoking and the fact that the availability of snus has kept the smoking rate down in Sweden offers a reasonable explanation for the low incidence of smoking-related disease in Sweden - or, as amply formulated in a policy paper by Bates et al (2003)(15). "To the extent that there is a "gateway" it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease in Europe."
  
  (15.) Bates, C., Fagerström, K., Jarvis, M., Kunze, M., McNeill, A., and Ramström, L. 2003. European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tob. Control 12:360-367.