the long-time scandinavian experience with snus tobacco ... · 1986 •tobacco control community...
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The long-time Scandinavian experience with snus – tobacco harm reduction in the real world
Karl Erik Lund, PhD
Senior Researcher
1986 • Tobacco Control Community increasingly concerned with ‘passive smoking’
• Gradual introduction of indoor smoking regulations…
• Smokers had to step outdoors more often….
Brr, brr…
Welcome to Norway: - 4 months of frost
Welcome to Norway: - 200 days of rain - windy & cold summers
1986 • Tobacco Control community increasingly concerned with ‘passive smoking’
• Regulation on indoor smoking
• Smokers must step outside
• Smokers’ options: • Acquire survival kit for outdoor smoking • Switch to snus
Smokers’ frost-mask Smokers’ mitten
Smokers’ wall
1986 • Tobacco Control community increasingly concerned with ‘passive smoking’
• Regulation on indoor smoking
• Smokers must step outside
• Options: • Survival kits for outdoor smoking • Switch to snus
1986
Brochure on snus: “The Tiny Brownie”
(1989)
Report on snus: “The Big Brownie”
(1989)
Brochure on snus: “The Tiny Brownie”
(1989)
Report on snus: “The Big Brownie”
(1989) - Toxic substances - New epidemic ? - Gateway ? - Dual use ? - Delay smoking cessation? - Cancers ? - Heart-conditions ?
Dr Kjell Bjartveit
- Toxic - Tooth loss - New epidemic - Gateway - Dual use - Delay smoking cessation
- Cancers - Heart-conditions
«…we must choke the epidemic in its initial phase…»
«…better safe than sorry…»
Dr. Karl O Fagerström Dr. Lars Ramström
2006
2006 Nicotine market: - Snus displaces cigarettes - No increase in overall tobacco consumption Snus use associated with changes in smoking behaviour - Reduced initiation - Increased cessation - Lower consumption
- No evidence of a gateway effect
Health: - Snus not associated with the diseases that most smokers die from
1986 2006
Research Director, tobacco Norwegian Institute for Alcohol and Drug Research
(SIRUS)
Lund KE, Vedoy TF, Bauld L. Do never smokers make up an increasing share of snus users as cigarette smoking declines? Changes in smoking status among snus users in Norway 2003-2015. Addiction 2017.
Vedøy TF, Lund KE. Self-reported sources for distribution of cigarettes, snus and e-cigarettes. Tidsskr Nor Laegeforen. 2017 Aug 15;137(16) Lund I, Kvaavik E, Nygård M, Hansen BT. Associations between snus use, body mass index and general health in a cross-sectional population-based sample of women. Scand J Public Health. 2018 Jul;46(5):580-587. Bergsvik D, Rogeberg O. Assessing the effect of public health information by incentivised risk estimation: An example on Swedish snus. Int J Drug Policy. 2018 Apr;54:51-57 Kvaavik E, Lund I, Nygård M, Hansen BT. Lifestyle Correlates of Female Snus Use and Smoking: A Large Population-Based Survey of Women in Norway. Nicotine Tob Res. 2016 Apr;18(4):431-6 Lund I, Scheffels J. Adolescent tobacco use practices and user profiles in a mature Swedish moist snuff (snus) market: Results from a school-based cross-sectional study. Scand J Public Health. 2016 Nov;44(7):646-653 Scheffels J, Lund I. Cute as candy: a qualitative study of perceptions of snus branding and package design among youth in Norway. BMJ Open. 2017 Apr 3;7(4):e012837. Lund I, Scheffels J. Smoking and snus use onset: exploring the influence of snus debut age on the risk for smoking uptake with cross-sectional survey data. Nicotine Tob Res. 2014 Jun;16(6):815-9 Lund KE. Tobacco Harm Reduction in the Real World: has the availability of snus in Norway increased smoking cessation? Drugs and Alcohol Today, 2013; 13 (2): 92-101. Lund KE, McNeill A. Patterns of dual use of snus and cigarettes in a mature snus market. Nicotine & Tobacco Research, 2013; 15 (3): 678-684.
Lund KE. Association between willingness to use snus to quit smoking and perception of relative risk between snus and cigarettes. Nicotine & Tobacco Research 2012; 14: 1221-1228.
Lund KE, McNeill A, Scheffels J. The use of snus for quitting smoking compared with medicinal products. Nicotine & Tobacco Research 2010; 12 (8): 817-22.
Lund KE, Scheffels J, McNeill. The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction 2010; 106:162-167. Lund M, Lund KE, Halkjelsvik T. Contrasting smokers' and snus users' perceptions of personal tobacco behavior in Norway. Nicotine & Tobacco Research. 2014 Dec;16(12):1577-85. Lund KE. A tobacco-free society or tobacco harm reduction? Norwegian Institute for Alcohol and Drug Research. SIRUS-report 6/2009. Lund I, Lund KE. How has the availability of snus influenced cigarette smoking in Norway? Int J Environ Research and Public Health 2014; 11. Larsen E, Rise J, Lund KE. Risk characteristics of adolescent snus users compared to non-users of tobacco, smokers and dual users of snus and cigarettes. Addiction Research and Theory 2013; 38 (7): 2288-2294. Larsen E, Rise J & Lund KE. The relationship between snus use and smoking cognitions. Addiction Research and Theory, 2012; 20 (6): 447-455. Scheffels, J., Lund, K.E. & McNeill, A. Contrasting snus and NRT as methods to quit smoking. An observational study. Harm Reduction Journal, 2012; Feb 29; 9, 10 Lund I, Scheffels J. Perceptions of relative risk of disease and addiction from cigarettes and snus. Psychol Addict Behav. 2014 Jun;28(2):367-75
Snus-use in Norway: peer-reviewed scientific articles 2006 ->
1985-87 2015-17 1997-99 2000 gram pr capita
2015-17 1200 gram pr capita
bbbbbbbbbbbbbbbbbb
The changing nicotine market in Sweden
Diffusion phase of snus in Sweden and Norway
Cigarettes Cigarettes Snus
Snus
Males Females
1987 2017 2000 2017 2000 1987
Transition from cigarettes to snus…. …in spite of:
small price difference misperceptions about risk difference no risk-proportionate regulation no advertising not recommended in smoking cessation
… not embedded in tobacco control policy
Aids used in most recent quit attempt for smoking Norway 1997-2017
SNUS
Quit-line
Web-site
Champix/Zyban
GP/Nurse
Transition from cigarettes to snus…. … partly climate driven
…partly consumer driven more pleasurable alternative than NRTs … partly industry driven product innovation (Gothiatek standard)
less toxins variety flavours fancy packaging
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Prevalence of daily snus use among never smokers Norwegian males & females aged 16–74 years 1985 – 2017
Source: SSB/NIPH (age standardized)
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Prevalence of daily snus use among never smokers Norwegian males aged 16–35 years 1985 – 2017
Source: SSB/NIPH
Males aged 16-35 years
Plain packaging cigarettes & snus From 2018 in Norway (not in Sweden)
Minister of Health
Snus – an epidemic.. strong actions required
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Prevalence of daily snus use among never smokers and ever smokers Norwegian males aged 16–35 years 1985 – 2017
Source: SSB/NIPH
Never-smokers
Males aged 16-35 years
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2004 2007 2010 2014
Dual users
Former smokers
Never-smokers
Former snus users, current smokers
Ever-Snus-users across smoking status Males 16-74 years, 2004-2014
Majority
Experimental use
Current use Minority
Harm from snus in
relation to tobacco
cigarettes
(%)
1 1 100 0
2 1 50 0
5 1 20 0
10 1 10 0
15 1 6,7 0
20 1 5 0
25 1 4 0
Risk-use equilibrium
Harm from snus in
relation to tobacco
cigarettes
(%)
Number of
smokers who switch
to snus
1 1 100 0
2 1 50 0
5 % 1 20 0
10 1 10 0
15 1 6,7 0
20 1 5 0
25 1 4 0
Risk-use equilibrium
Harm from snus in
relation to tobacco
cigarettes
(%)
Number of
smokers who switch
to snus
Number of never-
smokers that have to
pick up snus
Net result on public
health
1 1 100 0
2 1 50 0
5 1 20 0
10 1 10 0
15 1 6,7 0
20 1 5 0
25 1 4 0
Risk-use equilibrium
…demotivates ONE smoker from switching to snus,
can be ‘restored’ if…
..TWENTY never-smokers also will be demotivated from snus uptake
If plain packs….
Could happen only if…. • ..never-smokers were more ‘sensitive’ to plain packs (effect size)
• No evidence
• ..the population of snus-prone never-smokers were much higher than the population of
snus-prone smokers (group-size)
• Evidence of the opposite
Given the ‘snus-user-configuration’ – and the risk difference between snus and cigarettes –
The availability to snus has produced a net gain to public health The combined numbers who have i) quit smoking for snus, ii) reduced smoking intensity by snus, iii) picked up snus instead of cigarettes have outnumbered iv) snus users who otherwise would have been tobacco-free Health gains from smoking cessation, smoking reduction and smoking substitution produced by snus, has more than out-weighted the (marginal) health loss in the fraction of never-smokers taking up snus
Make up for..
Huge risk- difference
Risk- proportionate
regulation
Tax difference
Accurate information
Gateway ?? Correct misperceptions
Snus has saved more lives than it has taken
Minister of Health
While I try to protect the kids….
..dr. Lund has chosen to serve the industry's interests !
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Smoking Prevalence
2017
Tobacco Control Score 2016
Smoking prevalence (2017) vs Tobacco Control Score (2016) in Europe Eurobarometer March 2017; 458: 11 & Ass. Eur Cancer Leagues 2017
Norway
Sweden
UK
France
Greece
Finland Denmark Irland
Iceland
Spain
Netherlands
Poland
Outliers
Much lower
Lung cancer incidence 1960-2015 among Swedish men and women
Age-adjusted rates per 100 000 (Source: Nordcan)
Men
Women
It is difficult for us in tobacco control to realize and accept that snus and e-cigarettes may have greater potential to make smoking obsolete than the regulations we have spent a lifetime fighting for
Soon in Norway & Sweden
• …smoking prevalence below 5% …no need for harm-reduction products ?
• …smoking initiation insignificant … no need for alternatives if no youth is smoking susceptible ?
• New debate: can we accept recreational use of nicotine? .. when smoking obsolete – gateway-argument not valid
2018
To be continued at……..
Welcome to Oslo, Norway !
10 £
Conflict of interest:
- employed by a Government entity answerable to the Ministry of Health and Care Services
- no ties to nicotine industry
- expert witness in 5 litigation cases against the tobacco industry
E-mail: [email protected]