The Swedish Experience

The risk of dying from a tobacco-related illness is lower in Sweden than in any other European country despite tobacco consumption being on a comparable level with other European countries. This paradox is often referred to as the Swedish Experience and is primarily explained by the fact that snus, a smokeless tobacco product, has served as a viable and less harmful alternative to cigarettes for Swedish men.

Total tobacco consumption is about the same as in comparable countries, but Swedish men smoke considerably less. The proportion of daily smokers is currently 12 percent among men, which is the lowest in Europe. In addition, 19 percent of Swedish men use snus (2). In Sweden, snus is thus more common than smoking.

Sources: 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 FHI, 2007. The National Institute of Public Health, FHI, 2007.

Same total tobacco consumption and lowest mortality in Sweden

*EU 25 refers to the 25 EU member states before expansion on January 1, 2007.

The diagram shows the proportion of smokers and snus users among men and the risk of dying in a smoking-related disease. Despite the fact that tobacco consumption is at least as high in Sweden as in other European countries, the risk of being afflicted by a smoking-related fatal disease is significantly lower. Many researchers believe that this is because snus replaces more harmful cigarettes in Sweden.

Sources: Proportion of daily smokers among men: WHO, European Commission and national statistics authorities for the Nordic countries.
Proportion of daily snus users among men: Public Health Institute in Sweden, Directorate of Health in Norway and the Public Health Institute in Finland. The diagram does not take into consideration that the same persons may be both smokers and snus users. In Sweden, about two percent of the male population both smoke and use snus daily.
Risk for a 35-year old man to be affl icted by a smoking-related fatal disease before the age of 70: Pelo, R.; Lopez, AO; Boreham, J; Thun, M.; Heath, C.

Tobacco usage in Sweden

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, 12% and 19%, respectively. 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, 16% and 4%, respectively. Smokeless tobacco products permitted for use in other EU member states, chewing tobacco and nasal snuff, have very low prevalence.

Source: FHI, 2007. The National Institute of Public Health, FHI, 2007.

Public health in Sweden

  • In 1997, Sweden became the first country in the world that achieved WHO’s target for 2000, that the proportion of adult smokers shall be below 20 percent. The other country in Europe to achieve the percentage target was Iceland in 2005, which also has a long tradition of using smokefree tobacco.
  • In 2000, 10 percent of the deaths among Swedish men were smoke-related, which was the lowest proportion in Europe. The average figure for the EU 25 was 23 percent.
  • Swedish women were at the average EU 25 level in 2000; 7 percent of the deaths were smoke-related.
  • In 2000, the risk of a 35-year-old man dying from a smoke-related illness before the age of 70 was 3 percent in Sweden compared with 5 percent in Norway, 8 percent in Denmark and 9 percent on average for EU 25.
  • The corresponding figure for women was 2.1 percent for Sweden, 2.6 percent for Norway, 5.9 percent for Denmark and 1.6 percent on average for EU 25.

Sources:
Sweden: Swedish National Institute of Public Health.
Norway: The Directorate for Health and Social AffairsDenmark: Sundhedsstyrelsen.
Europe (EU 25 + Iceland, Norway and Switzerland): The European Tobacco Control Report 2007. WHO Regional Office for Europe.
2. Public Health. Status Report 2005, page 24-25. The Swedish Board of Health and Welfare
3. Tobacco Statistics 1970-1999. Statistical Report 2000-09-18, VECA HB Statistical Bureau, p. 12.
4. Peto, R.; Lopez, AD.; Boreham, J.; Thun, M.; Heath, C. Mortality from smoking in developed countries 1950-2000 (2nd edition). Oxford, Oxford University Press; 2003. Updated in June 2006.

Health effects of snus

  • 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.
    Source: 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:
    • 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.

International attention for the Swedish experience

The Swedish experience has received major attention and currently plays an important role in international health debates. For a growing number of researchers within the tobacco area, it is becoming increasingly evident that snus could function as an alternative to cigarettes and that it results in considerably reduced health risks.

The internationally known tobacco researchers, Jonathan Foulds and Lynn Kozlowski, wrote in an editorial in the medical magazine, The Lancet, in May 2007, that it is “perverted” public health politics to make tobacco available in its most harmful form, namely cigarettes, while neglecting to inform consumers that tobacco is available in a significantly less harmful form, namely snus.

At the end of 2006, the independent organization, American Council on Science and Health (ACSH) published a report “Helping Smokers Quit: A Role for Smokeless Tobacco?” The ACSH discusses the strategies that have been used to date by authorities and others to reduce the harmful effects of tobacco smoking. The authorities’ strategies are often based on an irreconcilable attitude against all types of tobacco products. In the report, these strategies are compared with harm reduction, which is based on most smokefree tobacco products, for example, Swedish snus, and is dramatically much less harmful than cigarettes. The ACSH believes that this is the attitude that the authorities should adopt, and points to the Swedish Experience, among others.

Conclusion

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): "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."

Source: 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.

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