Snus as a Substitution for Smoking: The Swedish Experience Lars M. Ramström Institute for tobacco studies Stockholm, Sweden

Current study: ”Tobacco use in Sweden : Prevalence data, initiation and cessation practices” Study population: A nationwide representative sample of 6,700 people age 16-79

Key prevalence data, Sweden MALES FEMALES (2001/2002; n=3205) (2001/2002; n=3507) (1996; n=1481) (1996; n=1497) Daily Daily Daily Daily smoking snus use smoking snus use YEAR 2001/ %20 % 19 % 2 % %15 % 19 % 2 %

Prevalence of combinations of smoking and use of snus (males) DAILY SMOKING Total (n=3205)15 % Daily smoking AND daily use of snus 2 % Daily smoking AND occasional use of snus 2 % Daily smoking, no use of snus11 % DAILY USE OF SNUS Total (n=3205)20 % Daily use of snus AND daily smoking 2 % Daily use of snus AND occasional smoking 4 % Daily use of snus, no smoking14 %

Initiation of tobacco use: Categories of onset patterns

”PRIMARY DAILY SNUS USERS” (PDSNU) (Have started daily snus use without previous daily smoking and have either never started daily smoking or done so AFTER the start of daily snus use) ALL MALES (n=2756) PDSNU15 % Started daily smoking 3 % Not started daily smoking12 % Non-PDSNU85 % Started daily smoking37 % Not started daily smoking48 %

Proportion of males who have ever started daily smoking All males (n=2756) 40 % PDSNU (n=397) 20 % Non-PDSNU (n=2359) 43 %

CURRENT SMOKING STATUS Male ever daily smokers Primary daily snus user? Yes No (n=80) (n=1022) Still smoking daily 26 % 33 % Reduced to occ.nl smoking 14 % 6 % Quit smoking completely 60 % 61 %

CURRENT SMOKING STATUS Male ever daily smokers Ever daily snus user? Yes No (n=498) (n=775) Still smoking daily 17 % 42 % Reduced to occ.nl smoking 12 % 4 % Quit smoking completely 71 % 54 %

CURRENT SMOKING STATUS Ever daily smokers who report having made an attempt to quit MalesFemales Have used particular aid ? Yes No Yes No (n=447) (n=583) (n=426) (n=743) Still smoking daily35 % 33 % 57 %39 % Red. to occ.nl smo. 11 % 6 % 8 % 6 % Quit smo. compl.54 % 61 % 35 % 55 %

Cessation aid used at latest quit attempt Males Females (n=447) (n=426) Nicotine gum36 % 55 % Nicotine patch 20 % 42 % Snus 55 % 15 % All other (together)13 % 24 %

CURRENT SMOKING STATUS Male ever daily smokers who have used an aid at latest quit attempt Gum Patch Snus All aid only only only users (n=85) (n=41) (n=205) (n=447) Still smoking daily 44 % 66 % 20 % 35 % Red. to occ.nl smo. 11 % 2 % 15 % 11 % Quit smo. compl. 46 % 32 % 65 % 54 %

CURRENT SMOKING STATUS Female ever daily smokers who have used an aid at latest quit attempt Gum Patch Snus All aid only only only users (n=134) (n=88) (n=46) (n=426) Still smoking daily 54 % 68 % 30 % 57 % Red. to occ.nl smo. 8 % 2 % 17 % 8 % Quit smo. compl. 37 % 30 % 52 % 35 %

SUMMARY In Sweden use of snus is more common than smoking among males but less common among females. Snus seems to serve as a substitution for smoking thereby contributing to — less initiation of smoking. — more cessation of smoking. Snus seems to be an effective smoking cessation aid that is commonly used by males.

CONCLUSION Findings from the current study suggest that snus, although not a ”health product” by itself,can, by serving as a substitution for smoking, have been one of the many factors contributing to the current situation in Sweden with low smoking rates and accordingly low rates of tobacco-related morbidity and mortality..