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Lung cancer mortality: Comparing Sweden with other countries in the European Union



To describe how snus use has reduced smoking among men in Sweden, and to estimate how smoking-attributable lung cancer mortality would decline in other European Union countries if they had the smoking prevalence of Sweden. Lung cancer mortality rates (LCMRs) and numbers of deaths among men and women age 45+ years in 25 EU countries in 2002 were obtained from the World Health Organization mortality database, and the number of lung cancer deaths expected in each country at the LCMR of Sweden was calculated. LCMRs for EU countries were obtained during the period 1950-2004, and per capita consumption of nicotine from cigarettes and snus was estimated for men in Sweden from 1931 to 2004. There were 172,000 lung cancer deaths among men in the EU in 2002. If all EU countries had the LCMR of men in Sweden, there would have been 92,000 (54%) fewer deaths. In contrast, the LCMR among Swedish women was the sixth highest in the EU; at the Swedish rate, deaths among EU women would have increased by 14,500 (26%). These LCMR patterns were in place for most of the last 50 years, and LCMRs among Swedish men can be correlated with snus and cigarette consumption. This study shows that snus use has had a profound effect on smoking prevalence and LCMRs among Swedish men. While it cannot be proven that snus would have the same effect in other EU countries, the potential reduction in smoking-attributable deaths is considerable.
Scandinavian Journal of Public Health, 2009; 37: 481–486
Lung cancer mortality: Comparing Sweden with other countries
in the European Union
School of Medicine, University of Louisville, Louisville, KY, USA and
School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
Aims: To describe how snus use has reduced smoking among men in Sweden, and to estimate how smoking-attributable lung
cancer mortality would decline in other European Union countries if they had the smoking prevalence of Sweden. Methods:
Lung cancer mortality rates (LCMRs) and numbers of deaths among men and women age 45þyears in 25 EU countries in
2002 were obtained from the World Health Organization mortality database, and the number of lung cancer deaths expected
in each country at the LCMR of Sweden was calculated. LCMRs for EU countries were obtained during the period 1950–
2004, and per capita consumption of nicotine from cigarettes and snus was estimated for men in Sweden from 1931 to 2004.
Results: There were 172,000 lung cancer deaths among men in the EU in 2002. If all EU countries had the LCMR of men in
Sweden, there would have been 92,000 (54%) fewer deaths. In contrast, the LCMR among Swedish women was the sixth
highest in the EU; at the Swedish rate, deaths among EU women would have increased by 14,500 (26%). These LCMR
patterns were in place for most of the last 50 years, and LCMRs among Swedish men can be correlated with snus and
cigarette consumption. Conclusions: This study shows that snus use has had a profound effect on smoking
prevalence and LCMRs among Swedish men. While it cannot be proven that snus would have the same effect in
other EU countries, the potential reduction in smoking-attributable deaths is considerable.
Key Words: Cigarette smoking, European Union, lung cancer mortality, snus, Sweden
Background and Aims
For more than two centuries men in Sweden and
other Scandinavian countries have used snus, which
consists of ground tobacco, salt, water and flavouring
agents that undergoes heat treatment to prevent
formation of unwanted contaminants [1]. Snus,
available in loose form and more recently in small
pouches, is placed inside the upper lip.
Several studies have shown that the use of snus has
played a substantial role in the low smoking rate
among Swedish men [2–5]. However, that explana-
tion has been judged as not compelling by some
authorities, such as the European Commission’s
Scientific Committee on Emerging and Newly
Identified Health Risks (SCENIHR). Recently, a
SCENIHR report acknowledged that ‘‘particularly in
Swedish men, there is a clear trend over recent
decades for smoking prevalence to decrease and for
use of oral tobacco (snus) to increase,’’ but it
concluded that ‘‘these trends could also be due to
successful smoking reduction programs or other
socio-cultural factors, and it is therefore not clear
whether or by how much the availability of snus has
influenced smoking prevalence.’’ [1] The report also
stated that ‘‘it is not possible to extrapolate the trends
in prevalence of smoking and use of oral tobacco if it
were made available in a European Union (EU)
country where it is now unavailable.’
The purpose of this study is to clarify how much
the availability of snus has influenced smoking among
men in Sweden, in the context of all other EU
countries. Studying smoking prevalence per se in the
EU is difficult because standardized and comparable
data are not available for all 27 countries. But there is
Correspondence: Brad Rodu, 529 South Jackson Street, School of Medicine, University of Louisville, Louisville, KY 40202, USA. Tel: þ01-502-561-7273.
Fax: þ01-502-561-7280. E-mail:
(Accepted 26 March 2009)
ß2009 the Nordic Societies of Public Health
DOI: 10.1177/1403494809105797
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a measure that reflects differences in smoking among
EU countries: lung cancer mortality. Lung cancer is
the sentinel disease of smoking [6], and a country’s
lung cancer mortality rate (LCMR) in any single year
provides a reasonable indication of the amount
of smoking in that country about 20 years earlier.
While it is not possible to predict to what extent the
availability of snus would reduce smoking prevalence
in EU countries other than Sweden, it is possible to
estimate how smoking-attributable mortality would
decline if these countries had the smoking prevalence
of Sweden.
LCMRs and numbers of deaths were obtained sep-
arately for men and women age 45þyears in 25 EU
countries in 2002 (Denmark, 2001) from the World
Health Organization (WHO) mortality database [7].
No data are available for Cyprus and the latest data
for Belgium are from 1997. LCMRs were age-
adjusted by the WHO to the World Standard
Population and were expressed as deaths per
100,000 person-years. We calculated rate ratios for
each country, expressed as that country’s LCMR
divided by the Swedish LCMR. A rate ratio greater
than one indicates that the country’s LCMR is higher
than that of Sweden; a ratio less than one indicates
that the Swedish rate is higher. For both genders we
calculated the number of lung cancer deaths
expected if each country had the LCMR of Sweden.
LCMRs for EU countries except Cyprus were
obtained for all available years during the period
1950–2004. Based on data availability and general
LCMR trends, the countries were divided into two
groups: the 15 countries comprising the EU in 1995
(EU-1995 countries) and the 11 countries that joined
the EU in either 2004 or 2007 (EU-expansion
countries). Countries with similar LCMRs were
combined, and data are illustrated as three-year
moving averages.
We estimated the annual per capita consumption
of nicotine from cigarettes and snus by men in
Sweden from 1931 to 2004. Annual population
estimates (men and women aged 15þyears) and
annual Swedish tobacco consumption (number of
cigarettes and the amount of snus in grams) were
obtained from Research and Consulting Bureau
VECA (Ha¨sselby, Sweden). It was assumed that all
snus consumption was by men. Cigarette consump-
tion by men in each year was estimated by adjusting
total consumption using gender-specific LCMRs 20
years later. LCMR trends were projected to 2024
to estimate gender-specific cigarette consumption
through 2004. We estimated per capita nicotine
consumption using conversions developed by
Fagerstro¨m [8], 1.4 mg of nicotine per cigarette
and 2.0 mg per g of snus. The snus conversion applies
to traditional snus, which provides more nicotine
than portion-pack forms that became popular
recently [8].
LCMRs among men in the EU
In 2002 the LCMR among men in the 25 EU
countries was 166 (Table I). The LCMR among
men in Sweden was 77, the lowest of all countries.
The LCMR among Portuguese men (105), the
second lowest in the EU, was 36% higher than that
of Sweden, and 17 EU countries had LCMRs
that were over twice as large as that of Sweden. The
number of lung cancer deaths among all men in the
EU was 172,000. If all countries had the LCMR of
Swedish men, 80,000 deaths would have occurred,
representing 92,000 fewer lives lost to lung cancer,
a 54% reduction.
Figure 1a shows the LCMRs among men in
Sweden and among men in other EU-1995 countries
from 1950 to 2004. The LCMR among men in
Sweden was 32 in 1951 and peaked in 1978 at 96,
followed by a gradual decline to 77 in 2002. These
LCMRs were much lower for all years than those for
all but one EU-1995 country. The exception is
Portugal, which had an LCMR of 26 in 1955 and
has experienced a gradual increase ever since, passing
Sweden in 1986. Spain, Italy, France, Ireland,
Denmark and Greece also had low LCMRs initially
(31–64 in 1952), with subsequent peaks between 180
and 220. Data are available for Germany starting in
1973, and the LCMR pattern is consistent with the
overall pattern for this group. Belgium and the
Netherlands had LCMRs of about 100 in the mid-
1950s, with subsequent peaks near 300 in the early to
mid-1980s. Finland and the United Kingdom (UK)
had LCMRs above 150 in 1952, with subsequent
peaks in the early 1970s at 261 and 281 respectively.
No data are available prior to 1973 for Luxembourg,
which had a peak LCMR of 273 in 1982. Austria had
an LCMR similar to Finland in 1955, but its peak at
196 occurred in 1968. Despite the different LCMR
patterns among these countries, there was a conver-
gence of the rates over the last 20 years. By 2002 the
range of LCMRs was from 120 (Finland) to 188 (the
Netherlands) in all countries except Sweden and
Figure 1b shows LCMRs among men in Sweden
compared with those in EU-expansion countries.
482 B. Rodu & P. Cole
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Data from these countries is more limited, but some
trends are apparent. Swedish LCMRs are much
lower than those for all other countries for all years.
Among countries with data from at least 1960,
Romania had an LCMR of 68 in 1959, with a
pattern similar to that in Spain. LCMRs in Poland
and Hungary in 1960 were 62 and 109, with subse-
quent peaks at 269 (1994) and 306 (1996) respec-
tively. By 2002 LCMRs were declining in all of these
countries except Romania and Bulgaria. However, in
2002 only Romania, Bulgaria and Malta had LCMRs
that were lower than 188, the highest LCMR among
EU-1995 countries in that year.
LCMRs among women in the EU
In 2002 the LCMR among women in the 25 EU
countries was 41. The LCMR among women in
Sweden was relatively high at 52; only Denmark,
Hungary, Ireland, the Netherlands and the UK had
higher rates. In 2002, the number of lung cancer
deaths among women in the EU was 55,800.
If women of all countries had the LCMR of
Swedish women, 70,300 lung cancer deaths would
have occurred, a 26% increase.
LCMRs among women in EU-1995 countries
during the period from 1950 to 2004 are shown in
Figure 2a. In the mid-1950s LCMRs ranged from
7 in Portugal to 23 in the UK. Denmark showed the
sharpest increase to a peak of 104 in 1995, with
little decline afterward. Ireland and the UK peaked
at 75–79 in 1988–89, followed by modest declines
to about 70. A peak has not occurred in any
other country, although there are five separate
slopes. The Netherlands’ LCMR was at the level
of that in Ireland and the UK in 2002, while
Sweden had an LCMR of 52, which is fifth highest
in this group. In 2004 Austria, Germany and
Luxembourg had LCMRs around 40; France,
Finland, Greece and Italy had LCMRs of 30;
Portugal and Spain were the lowest among
EU-1995 countries at 20.
Table I. Lung cancer mortality rates.
Number of deaths observed and number expected at Swedish rates among men and women in
25 European countries, 2002.
Men Women
Country Rate
Austria 138 2,354 1.79 1,313 44 1,002 0.84 1,194
Bulgaria 144 2,388 1.86 1,282 23 500 0.43 1,152
Czech Rep 217 4,242 2.80 1,511 46 1,258 0.87 1,440
Denmark 160 1,938 2.07 934 106 1,467 2.02 727
Estonia 227 551 2.95 187 28 122 0.54 227
Finland 120 1,376 1.55 887 30 462 0.58 803
France 163 20,315 2.12 9,586 29 4,646 0.55 8,437
Germany 148 28,320 1.91 14,793 41 10,077 0.78 12,981
Greece 175 4,715 2.26 2,082 26 858 0.50 1,706
Hungary 287 5,506 3.72 1,482 78 2,169 1.50 1,447
Ireland 135 920 1.75 525 63 533 1.21 442
Italy 170 25,492 2.20 11,582 32 6,344 0.61 10,336
Latvia 214 878 2.78 316 23 176 0.44 398
Lithuania 206 1,198 2.68 448 17 179 0.32 561
Luxembourg 164 145 2.13 68 31 33 0.59 56
Malta 158 122 2.04 60 18 13 0.35 38
Netherlands 188 6,321 2.43 2,599 66 2,425 1.25 1,933
Poland 260 16,426 3.37 4,880 50 4,393 0.96 4,586
Portugal 105 2,370 1.36 1,742 19 552 0.36 1,552
Romania 173 6,814 2.25 3,032 28 1,442 0.53 2,723
Slovakia 199 1,661 2.57 645 26 318 0.50 630
Slovenia 183 701 2.38 295 44 226 0.83 272
Spain 168 15,605 2.18 7,153 17 1,964 0.33 5,937
Sweden 77 1,761 – 1,761 52 1,329 – 1,329
UK 143 20,124 1.86 10,842 74 13,279 1.42 9,347
All 166 172,243 2.15 80,005 41 55,767 0.79 70,254
Deaths per 100,000 person-years, age-adjusted to the World Standard Population.
Country rate/Swedish rate.
At the Swedish rate. UK ¼United Kingdom.
Lung cancer mortality: Sweden compared with other EU countries 483
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Figure 2b shows LCMRs among women in
Sweden compared with those in EU-expansion
countries. Throughout most of the period LCMRs
among Swedish women were lower than those only in
Hungary, which had a rate of 80 in 2003. LCMRs
in the Czech Republic and Poland approached 50
by 2004, and the LCMR in Slovenia was over 40.
LCMRs increased more slowly in Bulgaria, Romania,
Slovakia, Estonia and Latvia, generally staying in the
mid-20s. LCMRs in Malta and Lithuania were
essentially stable at 20.
Nicotine consumption by Swedish men, 1931–2004
Figure 3 shows estimated annual per capita con-
sumption of nicotine from cigarettes and snus by
Swedish men age 15þyears. Prior to 1952, snus was
the dominant nicotine source but was declining while
cigarette consumption was increasing. Cigarettes
were the preferred nicotine source from 1955 to
1985, but consumption peaked by 1975; the nadir
of snus consumption was in 1969. After 1985 snus
regained dominance, and the snus-cigarette gap has
widened ever since.
Nicotine consumption from snus and cigarettes are
strongly and inversely correlated (correlation coeffi-
cient ¼0.86), but annual per capita nicotine con-
sumption from both sources combined was fairly
stable. The mean for all years was 4,600 mg. Nicotine
consumption fell below 4,000 mg only during World
War II (1942–45). Consumption was above 5,000
from about 1972 to 1988; during this period snus use
increased while cigarette smoking had just started to
decline. These usage patterns accelerated afterwards
with total nicotine consumption remaining above
4,000 mg.
Deaths per 100,000 person-years
Deaths per 100,000 person-years
Figure 1. LCMRs among men age 45þyears in Sweden, in
(a) EU-1995, and (b) EU-expansion countries, 1950–2004.
Deaths per 100,000 person-years
Deaths per 100,000 person-years
Figure 2. LCMRs among women age 45þyears in Sweden,
in (a) EU-1995 and (b) EU-expansion countries, 1950–2004.
Figure 3. Estimated annual per capita nicotine consumption
(mg) from cigarettes and snus by men in Sweden, 1931–2004.
484 B. Rodu & P. Cole
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The major finding of this study is that snus use is
inversely correlated with cigarette consumption
among men in Sweden, resulting in the lowest
LCMRs in Europe for most of the past 50 years.
In 2002, there were 172,000 lung cancer deaths
among men in the EU. If all EU countries had the
LCMR of men in Sweden, there would have been
92,000 fewer lung cancer deaths. But the potential
impact of low Swedish smoking rates is not limited to
lung cancer. For men in the EU, 91% of all lung
cancer deaths are attributed to smoking, and lung
cancer accounts for only 31% of all smoking-
attributable deaths [9]. Thus, we estimate that
there were 511,000 smoking-attributable deaths
among men in EU countries in 2002, which is
consistent with other recent estimates [9]. If all EU
countries had the smoking rates of Swedish men,
there would have been only 237,000 deaths from all
smoking-related diseases. In other words, 274,000
smoking-attributable deaths would have been
avoided throughout the EU in 2002. In addition,
longitudinal LCMR trends indicate that the differ-
ence between Swedish men and that of other EU
countries was modest in 2002 compared with previ-
ous years.
The large differences in LCMRs between Sweden
and other EU countries occur only in men. For
most of the last 50 years, the LCMR among Swedish
women was the sixth highest in the EU. This context
is important, because it has been suggested that
vigorous anti-smoking campaigns since the 1970s are
the major determinant of the low Swedish smoking
rates [10]. It is implausible that these campaigns were
highly effective for Swedish men and almost com-
pletely ineffective for Swedish women. The striking
difference in the relative EU ranking of Swedish men
and women is firm evidence that snus use, not anti-
smoking campaigns, has played the primary role in
low LCMR rates among men in Sweden for over a
half century.
World War II created millions of male smokers,
resulting in very high LCMRs throughout Europe in
the 1960s and 1970s. Men in Portugal, Spain and
Italy, which had LCMRs similar to those in Sweden
in the early 1950s, later experienced peak LCMRs
that were four to six times higher, while the peak in
Sweden represented only a three-fold increase. Even
though snus consumption declined until 1969, its use
was high enough to suppress smoking by Swedish
men and to keep their LCMR among the lowest in
the EU. Increasing snus consumption in the last two
decades has been accompanied by further declines
in smoking. If current trends hold, the LCMR
for Swedish men may become lower than that for
Swedish women by 2011. However, there is evidence
that snus has started to become popular among
Swedish women, with a consequential impact on
smoking [3,11].
There are other risk factors for lung cancer besides
smoking, but the latter is certainly the dominant
cause throughout the EU. Furthermore, the propor-
tion of lung cancer cases due to other causes is
unlikely to differ significantly across countries, with
the possible exception of women in Lithuania, Spain
and Portugal, who have extremely low LCMRs [9].
Thus, while the number of lung cancer deaths
reported here are not entirely due to smoking, other
risk factors play a minor role in the trends seen in this
Nicotine consumption from snus and cigarettes are
strongly and inversely correlated. But the LCMR
decline among Swedish men started just 10 years
after the upturn in snus consumption and only six
years after cigarette consumption peaked. The
expected lag is about 20 years. A possible explanation
relates to differences in the available data; we had
information on snus and cigarette consumption
only for all men (age 15þyears), but lung cancer is
mainly seen in persons age 45þyears. In the 1950s
and 1960s snus use was seen predominantly in
older Swedish men [12], which may have influenced
the timing of the LCMR peak and decline in this
Currently, snus is banned in all EU countries
except Sweden. While it cannot be proven that the
availability of snus would reduce smoking prevalence
in other EU countries, this study shows that snus use
has had a profound effect on smoking among
Swedish men. It also reveals that 274,000 smoking-
attributable deaths would be avoided if all men in all
EU countries had the smoking prevalence of men in
Sweden. Britton and Edwards recently wrote that
‘‘the absence of effective harm reduction options for
smokers is perverse, unjust, and acts against the
rights and best interests of smokers and the public
health.’’ [13]. It is time for the European
Commission to revise the Tobacco Directive to
make snus available to all European smokers.
This study was supported by unrestricted grants from
smokeless tobacco manufacturers (US Smokeless
Tobacco Company and Swedish Match AB) to the
University of Louisville. The terms of the grants
assure that the sponsors are unaware of this study,
and thus had no scientific input or other influence
Lung cancer mortality: Sweden compared with other EU countries 485
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with respect to its design, analysis, interpretation or
preparation of the manuscript. Neither author has
any financial or other personal relationship with
regard to the sponsors.
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... Lung cancer is the leading cause of cancer death among men in all European countries except Sweden, see Fig. 7, taken from [20]. One study [30] estimated that if the Swedish male lung cancer mortality rate was extrapolated to the rest of the EU, there would be a 54% reduction in male mortality from lung cancer. ...
Full-text available
Snus is an oral smokeless tobacco product which is usually placed behind the upper lip, either in a loose form or in portioned sachets, and is primarily used in Sweden and Norway. The purpose of this review is to examine the reported effects of snus use in relation to specified health effects, namely lung cancer, cardiovascular disease, pancreatic cancer, diabetes, oral cancer and non-neoplastic oral disease. The review also examines the harm reduction potential of snus as an alternative to cigarettes by comparing the prevalence of snus use and cigarette smoking, and the reported incidence of tobacco-related diseases across European Union countries. The scientific literature generally indicates that the use of snus is not a significant risk factor for developing lung cancer, cardiovascular disease, pancreatic cancer or oral cancer. Studies investigating snus use and diabetes have reported that high consumption of snus (estimated as being four or more cans per week) may be associated with a higher risk of developing diabetes or components of metabolic syndrome; however, overall results are not conclusive. Snus use is associated with the presence of non-neoplastic oral mucosal lesions which are reported to heal rapidly once use has stopped. The most recent Eurobarometer data from 2017 reported that Sweden had the lowest prevalence of daily cigarette use in the European Union at 5% whilst daily "oral tobacco" use was reported to be 20%. European data published by the World Health Organisation in 2018 indicated that Sweden had the lowest rate of tobacco-related mortality and the lowest incidence of male lung cancer. Overall, prevalence statistics and epidemiological data indicate that the use of snus confers a significant harm reduction benefit which is reflected in the comparatively low levels of tobacco-related disease in Sweden when compared with the rest of Europe. The available scientific data, including long-term population studies conducted by independent bodies, demonstrates that the health risks associated with snus are considerably lower than those associated with cigarette smoking.
... Snus, a smokeless tobacco product with low levels of tobacco-specific nitrosamines, has been available in Sweden for decades. Many Swedish smokers (particularly males) have switched completely from cigarettes to snus, resulting in lower rates of tobaccorelated diseases, including lung cancer rates that are the lowest in Europe (Foulds, Ramstrom, Burke, & Fagerstrom, 2003;Rodu & Cole, 2009). Levy and colleagues estimated that snus presents about 10% of the mortality risk of smoking (Levy, Mumford, Cummings, et al., 2004). ...
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Introduction: Switching from cigarettes to snus by smokers unlikely to quit would be expected to benefit overall population health, with any potential benefit needing to be weighed against potential harms from snus use by tobacco non-users and smokers likely to quit. This study evaluates likelihood of snus use among tobacco users and non-users provided modified-risk information. Methods: An online sample of 11,302 U.S. adults was randomized to view advertisements for snus that either provided modified-risk information or only described snus. Intent to purchase ratings were converted to projected purchase (use) rates using an empirically derived algorithm. Results: Projected product use for snus was significantly higher among current smokers than former or never tobacco users (p < 0.0001) for both the modified-risk and control information. A significant interaction effect between information and tobacco user group (p < 0.0001) indicated the modified-risk information differentially increased projected use among smokers (8.2% vs. 6.9%), with much lower projections for both the test and control information among former (1.2%) and never tobacco users (0.4%). Among never users, projected use was highest among those susceptible to smoking. These findings were generally similar for young adults, ages 18-24. Smokers expecting to quit who viewed modified-risk information had lower projected use (4.2%) than those not expecting to quit (8.7%). Conclusions: Results suggest that providing modified-risk information for snus is unlikely to increase use among those not using tobacco. Interest in snus was greatest among current smokers who would benefit by switching to snus as communicated in the modified-risk advertisement.
... There is no evidence that snus has served as a gateway to cigarette smoking and it is also clear that snus has substantially reduced the population prevalence of smoking and not been used by non-smokers in Sweden, where it is widely used [34,35]. It has also substantially reduced tobacco related diseases such as lung cancer [36]. Despite all this evidence, an Australian ban on the sale of smokeless tobacco products, including snus, introduced in 1991 [37] remains in place and no consideration is being given to its repeal. ...
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Australia does not allow adult smokers to buy or use electronic nicotine delivery systems (ENDS) that contain nicotine without a prescription. This paper critically evaluates the empirical and ethical justifications provided for the policy by Federal and State governments, public health advocates and health organisations. These are: (1) that ENDS should only be approved as products for smoking cessation when there is evidence from randomised controlled trials that they are effective; (2) that as a matter of precaution we should not allow the sale of ENDS to smokers as consumer products because we do not know what their long-term effects will be; and (3) that allowing ENDS to be sold as consumer goods will enable the tobacco industry to market ENDS to young people which will also lead to an increase in youth smoking. We show that the arguments and evidence offered in support of all these claims is very weak. We also argue that even if the evidence were stronger, it would not justify denying adult smokers the right to use ENDS either to quit smoking or as a long-term alternative to smoking cigarettes. We outline ENDS policies that would more ethically address the public health concerns that motivated the current policy by allowing adult smokers to access ENDS for smoking cessation or tobacco harm reduction under tight regulations that discourage commercial promotion and adolescent use.
... The great success story of THR is Sweden, where a large portion of would-be smokers returned to traditional ST starting in the 1970s (Rodu and Cole, 2009). While the impetus for this was cultural, over the years it was increasingly recognized as a huge public health gain. ...
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Purpose This paper aims to provide a brief summary of the effectiveness and efficacy of tobacco harm reduction (THR). THR is the substitution for cigarettes of low‐risk alternatives, including Swedish or American‐style smokeless tobacco, pharmaceutical nicotine products, and electronic cigarettes. The paper then very briefly summarizes the current social and political situation regarding THR. Design/methodology/approach This paper is a review of the evidence. Findings The risk from smoke‐free tobacco/nicotine products is so low as to be unmeasurable. For most smokers, adopting THR is a lower risk option than to trying to become nicotine abstinent. THR products have been widely adopted in some populations, providing great public health benefits. There is currently an explosion of interest in electronic cigarettes. However, THR is a threat to the business model of the tobacco control industry, and so they are fighting hard to discourage it. Because they cannot admit their real motives for discouraging THR, anti‐THR activism is an entirely dishonest enterprise. Practical implications Tobacco harm reduction is the greatest untapped public health initiative in the developed world. It is more promising than further attempts to promote tobacco/nicotine abstinence. The future inevitably includes a large portion of the population using low‐risk tobacco/nicotine, but anti‐THR efforts might keep people smoking in the short run. Originality/value While most of the content of this paper is well known to experts on THR, many ostensible experts on health, as well as other opinion leaders and policy makers, are unaware of the truth.
... Among men, lung cancer is the leading cause of cancer death among all European countries, except Sweden, where prostate cancer has been the leading cause [9]. In fact, Sweden has the lowest lung cancer rates among men of all developed countries, while rates are about average for women [10]. The difference between men and women for this important type of cancer is likely linked to the rather unique Swedish smoking pattern. ...
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In the beginning of the 1970s, Sweden was the country where both women and men enjoyed the world's longest life expectancy. While life expectancy continues to be high and increasing, Sweden has been losing ground in relation to other leading countries. We look at life expectancy over the years 1970-2008 for men and women. To assess the relative contributions of age, causes of death, and smoking we decompose differences in life expectancy between Sweden and two leading countries, Japan and France. This study is the first to use this decomposition method to observe how smoking related deaths contribute to life expectancy differences between countries. Sweden has maintained very low mortality at young and working ages for both men and women compared to France and Japan. However, mortality at ages above 65 has become considerably higher in Sweden than in the other leading countries because the decrease has been faster in those countries. Different trends for circulatory diseases were the largest contributor to this development in both sexes but for women also cancer played a role. Mortality from neoplasms has been considerably low for Swedish men. Smoking attributable mortality plays a modest role for women, whereas it is substantially lower in Swedish men than in French and Japanese men. Sweden is losing ground in relation to other leading countries with respect to life expectancy because mortality at high ages improves more slowly than in the leading countries, especially due to trends in cardiovascular disease mortality. Trends in smoking rates may provide a partial explanation for the trends in women; however, it is not possible to isolate one single explanatory factor for why Sweden is losing ground.
... Swedish snus offers another possibility for nicotine replacement. The Swedish experience provides strong indirect support to the notion that snus can promote smoking cessation and help to reduce tobacco related disease9101112. Snus is also generally regarded as less harmful than other smokeless tobacco products [13]. In contrast to Scandinavia, Serbia has no tradition of oral, smokeless tobacco. ...
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ABSTRACT: Epidemiological studies suggest that smokeless tobacco in the form of Swedish snus has been used by many smokers in Scandinavia to quit smoking, but the efficacy of snus has so far not been evaluated in controlled clinical trials. We conducted a randomized, double-blind, placebo-controlled, clinical trial aimed at assessing the efficacy of snus to help adult cigarette smokers in Serbia to substantially reduce, and, eventually, completely stop smoking. The study enrolled 319 healthy smokers aged 20-65 years at two occupational health centers in Belgrade, Serbia. Most of them (81%) expressed an interest to quit rather than just reduce their smoking. Study products were used ad libitum throughout the 48-week study period. The main study objective during the first 24 weeks was smoking reduction. The primary end-point was defined as a biologically verified reduction of ≥ 50% in the average number of smoked cigarettes per day during week 21-24 compared to baseline. During week 25-48 participants were actively instructed to stop smoking completely. Outcome measures of biologically verified, complete smoking cessation included 1-week point prevalence rates at clinical visits after 12, 24, 36, and 48 weeks, as well as 4-, 12- and 24-week continued cessation rates at the week 36 and 48 visits. At the week 24 visit, the proportion of participants who achieved the protocol definition of a ≥ 50% smoking reduction was similar in the two treatment groups. However, the proportion that reported more extreme reductions (≥ 75%) was statistically significantly higher in the snus group than in the placebo group (p < 0.01). The results for biologically verified complete cessation suggested that participants in the snus group were more likely to quit smoking completely than the controls; the odds ratio (snus versus placebo) for the protocol estimates of cessation varied between 1.9 to 3.4, but these ratios were of borderline significance with p-values ranging from 0.04-0.10. Snus was well tolerated and only 2/158 (1.3%) participants in the snus group discontinued treatment due to an adverse event (in both cases unrelated to snus). Swedish snus could promote smoking cessation among smokers in Serbia, that is, in a cultural setting without traditional use of oral, smokeless tobacco., identifier: NCT00601042.
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El tabaco causa más de 5 millones de muertes por año y se estima que, en el 2030, el tabaco matará a 10 millones de personas, y siete de cada diez de esas defunciones ocurrirán en los países en desarrollo. El consumo de tabaco es la principal causa evitable de muerte en América, en donde se calcula que la fracción evitable es de 625.000 muertes por año (430.000 en Estados Unidos, 150.000 en América Latina y el Caribe y 45.000 en Canadá). En América Latina mueren más personas por enfermedades no transmisibles, muchas de ellas causadas por el tabaco, que por el conjunto de enfermedades transmisibles, afecciones maternas, perinatales y carencias nutricionales. En América Latina, la carga de morbilidad atribuible al consumo de tabaco no se ha modificado de manera sustancial desde 2004. La proporción de años de vida ajustados por discapacidad (AVAD) que se pierden cada año a consecuencia del consumo de tabaco aún es muy elevada. Seguramente, la falta adecuada de información por parte del consumidor, hace que no se asuman los riesgos involucrados con el consumo de tabaco, lo que genera actitudes inadecuadas con el afán de continuar con el uso del tabaco y termina en prácticas que menoscaban la salud de los involucrados y su entorno familiar. Por otro lado, se asume que, si además de educar al individuo respecto a los problemas derivados del tabaquismo, se pone en su conocimiento las alternativas que existen para disminuir el riesgo antes mencionado, se le va a dar la posibilidad de tomar una decisión con mayor viabilidad y, por ende, con un impacto mucho mayor en salud pública. En Ecuador, de acuerdo al Ministerio de Salud Pública a través de la ENSANUT-2012, se encontró que el consumo de tabaco en la población adulta es un poco mayor al 50%, mientras que 26.4% de los adolescentes entre 15 y 19 años ya ha fumado. Esto podría significar, a priori, un fracaso de cualquiera de las estrategias propuestas y actualmente implementadas por el Ministerio de Salud Pública, en concordancia con la posición radical de la Organización Mundial de la Salud frente al consumo de tabaco. Con estos antecedentes, la Escuela de Medicina de la Universidad San Francisco de Quito USFQ llevó a cabo el evento titulado “¿Dejar de fumar?… el verdadero problema de salud pública ahora…”, en el cual expertos nacionales e internacionales revisaron desde los aspectos químicos de la nicotina, hasta la problemática del individuo que no puede abandonar el cigarrillo, pasando por los efectos neuro-psiquiátricos y, por supuesto, las posibles alternativas existentes. Este evento académico dirigido principalmente a profesionales de la salud fue posible realizarlo de manera gratuita gracias a una beca educacional irrestricta provista por ITABSA, y con la finalidad de poder ampliar su difusión, se elaboraron las memorias de este evento mediante una colaboración establecida con ILADIBA, editorial médico-científica de Colombia.
Directive 2014/40—the new Tobacco Products Directive—was unsuccessfully challenged in three cases, Philip Morris , Poland v. European Parliament and Council , and Pillbox 38 . This Article examines provisions of the Directive relating to some alternative tobacco and related products, both in terms of exercise of EU competence and substantive regulation of these products. The main flavored tobacco products can no longer be placed on the market. Electronic cigarettes are regulated by the Directive, as the initial provisions of the Commission proposal were substantially amended. The new Tobacco Products Directive reproduced the prohibition of tobacco for oral use, already at issue in the Swedish Match and Arnold André cases, and again subject of another preliminary ruling reference by Swedish Match, the Advocate General's Opinion having concluded in its validity. The Directive also provides the possibility for Member States to prohibit categories of tobacco or related products. Parallel to its analysis of their substance in terms of health regulation, this Article considers European Union competence issues relating to these provisions and examines the adequacy of the Article 114 TFEU internal market legal basis as well as compliance with the principles of proportionality and subsidiarity.
Nicotine and tobacco abstinence is the basis for conventional smoking-cessation strategies, but it is unachievable for inveterate smokers. Nicotine does not cause any smoking-related illness. Tobacco harm reduction is the permanent substitution of smoke-free nicotine and tobacco products, including electronic cigarettes and smokeless tobacco (ST) by smokers. ST products are commonly used in Scandinavia and the USA. Moist snuff is the most popular form of ST in the USA and in Sweden (i.e., snus). ST products deliver nicotine via absorption through the oral mucosa. Long-term ST users have minimal to no risks for all diseases, including oral cancer. All forms of nicotine and tobacco use should be avoided during pregnancy. In Sweden snus use has been linked to low prevalence of smoking and low smoking-attributable mortality. There is no evidence that ST is a gateway to smoking in Sweden or the USA. Clinical trials provide evidence that ST is a satisfying substitute for cigarettes.
Purpose Despite substantial declines in cigarette smoking in England since the 1970s, around 20 per cent of the adult population still smokes. In Sweden, 10 per cent of adult males and 12 per cent of adult females smoke cigarettes, while snus use is prevalent among 19 per cent of adult males and 4 per cent of adult females. Traditional cessation‐only approaches may need to be supplemented with broader tobacco harm reduction measures to reduce smoking prevalence further. General practitioners (GPs) are well placed to give patients advice on tobacco harm reduction. This paper seeks to address these issues. Design/methodology/approach The authors administered an online survey to assess knowledge, perceptions and attitudes to tobacco and nicotine products to 220 GPs (100 in England and 120 in Sweden). Findings Most GPs (96 [96 per cent] England, 115 [98 per cent] Sweden) addressed smoking cessation with patients as part of their regular practice. Most GPs (87 [87 per cent] England, 102 [85 per cent] Sweden) felt extremely or fairly knowledgeable about the risks associated with cigarettes, but less so about nicotine in tobacco products and pharmaceutical nicotine. When asked to rank various products on a risk continuum, GPs rated cigarettes as riskiest and tobacco cessation and nicotine‐containing products as least risky. However, when asked to rank components of cigarettes based on their health risks, GPs ranked nicotine as the third riskiest (74 [74 per cent] England, 104 [87 per cent] Sweden), after tar and carbon monoxide, but before smoke or tobacco. When asked questions about a hypothetical nicotine replacement therapy (NRT) product that looks like a cigarette and is licensed for harm reduction, GPs perceived that sensory experience and tobacco harm reduction could be benefits to patients, but perceived appeal to children and risk for abuse could be drawbacks. Originality/value Most respondent GPs are well informed about the relative risks of nicotine and tobacco, but more research needs to be done to investigate their concerns over the long‐term substitution of cigarettes with alternative nicotine products.
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It is imperative that public policy be based on the most thorough, balanced, and critical appraisal of the available evidence. Regrettably, the two papers1,2 on which we were invited to comment fall short of those criteria. Bates et al 2 concluded snus played a “positive public health role” but did not weigh all available evidence nor critically appraise the methodologies, funding sources, or interpretations of the studies they included. Their “Evidence from Sweden” section included only an unpublished survey with unknown methodology,3 a newspaper article,4 and a study from northern Sweden.5 Foulds et al 1 concluded that snus had “...a direct effect on the changes in male smoking and health” with little additional evidence. However, both papers ignored published studies and selectively reported findings. A consideration of all the available evidence suggests snus played, at best, a minor role in reducing smoking in Sweden. A one year Swedish cohort study of persons aged 45–69 years at baseline in 1992–94 examined predictors of smoking cessation or change to non-daily smoking among baseline daily smokers (n = 3550).6 At baseline, 7.0% of men and 0.4% of women used snuff. At follow up, 7.2% of daily smokers had quit and 6.5% were non-daily smokers. The study found: snus use was not associated with smoking cessation; snuff use by non-daily smokers neither predicted cessation nor prevented transition to daily smoking7; and even if snuff helped some smokers to quit, it accounted for a small fraction of cessation. In another prospective study, 5104 persons aged 16–84 years were interviewed in 1980–81 and followed up in 1988–89.8 These included 1546 daily smokers, 418 men who used snuff daily, and 129 men who used both snuff and cigarettes. By follow up, 26% of female and 28% of male …
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Tobacco--particularly smoked products--has been associated with great harm and growing public disapproval and can be expected to suffer in the marketplace. This situation has created opportunities for other less harmful nicotine-containing products such as smokeless tobacco and nicotine replacement products, which are gaining public support. Little is known about the level of nicotine intake in our society. Tobacco sales are known, but how much nicotine is extracted and actually absorbed by users is largely unknown. The present study is a first attempt to estimate uptake of nicotine from tobacco and nicotine replacement products and to map nicotine consumption in a few countries, with special emphasis on Sweden. Relevant pharmacokinetic studies for three types of nicotine-containing products (cigarettes, smokeless tobacco, and nicotine replacement products) were analyzed for bioavailable nicotine. Estimates of nicotine intake from each category were made. These were then multiplied by the amount consumed in the respective countries. Tobacco consumption statistics were usually from official records of taxed sales. In Sweden about 54% of all nicotine intake comes from smoked sources, 45% from nonsmoked tobacco, and 1.3% from nicotine replacement products. For men, 63% of the nicotine consumed comes from nonsmoked tobacco. Per-capita nicotine intake per year for adults aged 15 years or older is 3,321 mg for Austria, 3,043 mg for Sweden, 3,014 mg for Denmark, 2,955 mg for the United States, 2,244 mg for Norway, and 2,023 mg for Finland. Compared with cigarette smokers, snus users seem to have a somewhat higher daily intake (34 mg vs. 25 mg). The cleanest nicotine products, nicotine replacement products, represent a negligible part (about 1%) of the total nicotine consumption in most countries.
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For decades men in Sweden have smoked at far lower rates than those in comparable countries. Previous studies showed that snus use played a major role in low smoking rates among men in northern Sweden; daily smoking declined from 19% (95% CI 16-22%) in 1986 to 11% (CI 8.9-14%) in 1999. The prevalence of smoking among all men is now 9% (CI 7.0-11%) and only 3% (CI 0.1-5.4%) among men age 25-34 years; the prevalence of exclusive snus use is 27% (CI 24-30%) and 34% (CI 27-42%) respectively. Combined smoking and snus use, an unstable and transient category, was under 5% in all surveys and was 2.2% (CI 1.4-3.4%) by 2004. For the first time snus use is also associated with a decrease in smoking prevalence among women. These patterns of tobacco use have implications for all smoking-dominated societies.
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Nicotine replacement therapies (NRT) are an effective treatment for tobacco dependence, yet most smokers do not quit or remain abstinent. We investigated whether Swedish snus (snuff) use was associated with smoking cessation among males participating in a large population based twin study in Sweden. Snus use was associated with smoking cessation but not initiation. Given that snus delivers comparable nicotine concentrations but carries lesser cancer risk than cigarettes, snus may be a widely used, non-medical form of NRT. Evaluation of the efficacy of snus for smoking cessation should be evaluated in randomised clinical trials.
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To examine patterns of smoking and snus use and identify individual pathways of Swedish tobacco users in order to clarify whether snus use is associated with increased or decreased smoking. Retrospective analysis of data from a cross-sectional survey completed by 6752 adult Swedes in 2001-2 focusing on identifying tobacco use history by survey items on current and prior tobacco use and smoking initiation and cessation procedures. 15% of the men and 19% of the women completing the survey were daily smokers. 21% of the men and 2% of the women were daily snus users. Almost all (91%) male daily smoking began before the age of 23 years, whereas initiation of daily snus use continued throughout the age range (33% of initiation after age 22). 20% of male primary snus users started daily smoking compared to 47% of non-primary snus users. Thus, the odds of initiating daily smoking were significantly lower for men who had started using snus than for those who had not (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.22 to 0.36). Among male primary smokers, 28% started secondary daily snus use and 73% did not. 88% of those secondary snus users had ceased daily smoking completely by the time of the survey as compared with 56% of those primary daily smokers who never became daily snus users (OR 5.7, 95% CI 4.9 to 8.1). Among men who made attempts to quit smoking, snus was the most commonly used cessation aid, being used by 24% on their latest quit attempt. Of those men who had used one single cessation aid 58% had used snus, as compared with 38% for all nicotine replacement therapy products together. Among men who used snus as a single aid, 66% succeeded in quitting completely, as compared with 47% of those using nicotine gum (OR 2.2, 95% CI 1.3 to 3.7) or 32% for those using the nicotine patch (OR 4.2, 95% CI 2.1 to 8.6). Women using snus as an aid were also significantly more likely to quit smoking successfully than those using nicotine patches or gum. Use of snus in Sweden is associated with a reduced risk of becoming a daily smoker and an increased likelihood of stopping smoking.
Snuff-dipping was already widespread in Sweden in the 19th century. After the 1920s snuff sales went down, but Sweden still kept its position as world leader in per capita consumption of moist snuff. Following a major advertising campaign snuff consumption began rising again in the late 1960s. The Swedish Tobacco Company claims that Swedish snuff is a 'less harmful' alternative to cigarettes. Swedish epidemiological studies indicate that there is a cancer risk from snuff-dipping, but it is low compared with smoking. Accordingly, the STC claims to "do a good job replacing cigarettes with snuff". However, an analysis of the trends in tobacco usage patterns in Sweden during the last few decades does not support this claim. The marketing of moist snuff has not primarily attracted older smokers who would seek help in order to stop smoking, but young people. The use of snuff is no prerequisite and no guarantee for a decrease of smoking. On the contrary, taking up snuff must be seen as an introduction to the tobacco habit and possibly a first step towards taking up cigarettes.
Customary statistics on smoking practices are limited because they do not correlate well with the frequency of smoking-related diseases. Our study developed outcome measures based on lung cancer mortality and used them to assess the anti-smoking campaign. Changes in mortality from lung cancer were used to assess significant smoking among 5-year birth cohorts of white men born from 1901 to 1942. We used each cohort's lung cancer mortality rate at ages 40-44 to indicate its earlier smoking. A lung cancer mortality ratio was developed to describe each cohort's continued smoking from ages 40-44 to 55-59. These ratios were then compared with the durations of the cohorts' exposure to the anti-smoking campaign that began in 1965. Lung cancer mortality in white men ages 40-44 peaked in 1970 and declined continuously thereafter, indicating that the anti-smoking campaign promptly reduced significant smoking among younger men. However, the lung cancer mortality ratio indicates that only half of smokers in the specified birth cohorts were able to quit by ages 55-59, despite receiving ever more intense anti-smoking messages. The anti-smoking campaign produced moderate benefits among younger white male smokers but fewer benefits among older smokers because of the existence of a large number of inveterate smokers.
For many years Swedish men have had the world's lowest rates of smoking and smoking-related mortality. Despite these facts, a thorough analysis of tobacco use patterns in Sweden has not been performed. The purpose of this study was to examine the prevalence and interaction of cigarette smoking and use of Swedish moist snuff (snus) in the population of northern Sweden. The study cohort of 2998 men and 3092 women aged 25-64 was derived from the northern Sweden MONICA study, consisting of population-based surveys in 1986, 1990, 1994 and 1999. Detailed information on tobacco use was used to develop prevalence data, and the prevalence ratio was used to compare rates amongst various subgroups. Amongst men ever-tobacco use was stable in all survey years at about 65%, but the prevalence of smoking declined from 23% in 1986 to 14% in 1999, whilst snus use increased from 22% to 30%. In women the prevalence of smoking was more stable in the first three surveys (approximately 27%) but was 22% in 1999, when snus use was 6%. In all years men showed higher prevalence of ex-smoking than women. A dominant factor was a history of snus (PR = 6.18, CI = 4.96-7.70), which was more prevalent at younger ages. The recent transition from smoking to snus use amongst men, and incipiently amongst women, in northern Sweden is remarkable and relevant to the global discussion on strategies to reduce smoking.
Cross-sectional data from northern Sweden suggest that the increased use of Swedish moist snuff (snus) may have contributed to a decline in the prevalence of smoking, especially amongst men. This study describes the evolving patterns of tobacco use in this population over the period 1986-1999. This is a prospective follow-up study of 1651 men and 1756 women, aged 25-64 years, who were enrolled in the northern Sweden MONICA project (entry in 1986, 1990, 1994) and who were followed-up in 1999. Information on tobacco use at entry and at follow-up was used to describe the stability of tobacco use over a period of 5-13 years ending in 1999. Snus was the most stable form of tobacco use amongst men (75%); only 2% of users switched to cigarettes and 20% quit tobacco altogether. Smoking was less stable (54%); 27% of smokers were tobacco-free and 12% used snus at follow-up. Combined use (smoking and snus) was the least stable (39%), as 43% switched to snus and 6% switched to cigarettes. Former users of both products were much less stable than former users of either cigarettes or snus. The stability of smoking amongst women was 69%, which was higher than that amongst men (P < 0.05). The use of snus played a major role in the decline of smoking rates amongst men in northern Sweden. The evolution from smoking to snus use occurred in the absence of a specific public health policy encouraging such a transition and probably resulted from historical and societal influences.