Key prevalence data, Sweden (Source: ITS/FSI study 2001/2002) MALES FEMALES (n=3205) (n=3507) Daily Daily Daily Daily smoking snus use smoking snus use 15 % 20 % 19 % 2 %

Tobacco consumption per year in Sweden per person 15 years and older Cigarettes Snus (kg) (kg) Around Around Around

Swedish snus Fine ground tobacco leaves predominantly from air-cured dark tobacco Manufactured by a pasteurizing-like heating process (without any fermentation so as used in most manufacturing procedures for American snuff) ∎ TSNA content: < 5 mg/kg ∎ BaP content: < 10  g/kg (TSNA content of American snuff: mg/kg)

Oral cancer incidence rates per (age standardized to world population) Males in Northern and Western Europé Source: Cancer Incidence, Mortality and Prevalence Worldwide, Version 1.0. IARC CancerBase No. 5. Lyon, IARCPress, Countries with highest rates France14.94 Germany13.19 Belgium10.78 Luxembourg10.43 Austria10.39 Countries with lowest rates The Netherlands5.79 Norway5.77 Iceland4.81 Sweden4.52 United Kingdom4.40

Has the use of snus had an influence on the smoking habits in Sweden?

Initiation of tobacco use: Snus, is it a gate leading to smoking, or a vaccination against smoking? Which is the onset rate of smoking in those who have, respectively have not, taken snus as a primary tobacco use?

ONSET RATE OF DAILY SMOKING By presence or absence of primary use of snus All males (n=2756) 40 % With primary snus use (n=397) 20 % Without primary snus use (n=2359) 43 % (Source: ITS/FSI study 2001/2002)

Pathway after start of daily smoking By history of daily use of snus Males Females History of daily use of snus ? Yes No Yes No (n=498) (n=775) (n=84) (n=1240) Still smoking daily17 % 42 % 14 %43 % Red. to occ.nl smo. 12 % 4 % 14 % 6 % Quit smo. compl.71 % 54 % 71 % 51 % (Source: ITS/FSI study 2001/2002)

Cessation aid used at latest quit attempt Kind of aid Males Females (n=447) (n=426) Nicotine gum36 % 55 % Nicotine patch 20 % 42 % Snus 55 % 15 % All other (together)13 % 24 % (Source: ITS/FSI study 2001/2002)

Outcome of latest quit attempt. ( Male ever daily smokers who have used an aid at latest quit attempt) Gum Patch Snus only only only (n=85) (n=41) (n=205) Still smoking daily 44 % 66 % 20 % Red. to occ.nl smo. 11 % 2 % 15 % Quit smo. compl. 46 % 32 % 65 % (Source: ITS/FSI study 2001/2002)

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 % (Source: ITS/FSI study 2001/2002)

MEAN SCORE OF NICOTINE DEPENDENCE (scale from 0 to 2) Users of single aid Gum Patch Snus No aid MEN WOMEN

24 hour systemic intake of nicotine Measured in: users of loose snus (≈ 2g pinches): around 25 mg (same as in smokers of cigarettes per day) Source: Andersson et al 1994, Andersson et al 1997

OVERVIEW OF CESSATION ACHIEVEMENTS Percentage of ever daily Men Women smokers who have … ● continued to smoke daily34%45% cut down to occasional smoking 7% 6% quit completely59%49% Percentage of ever daily snus users who have … ● continued to use snus daily74%65% cut down to occasional snus use 3% 5% quit completely23%30%

SCORES FOR WISH TO QUIT (Scale from 1 to 3) SMOKERS SNUS USERS Men Observed score for wish to quit Women Observed score for wish to quit

Reproduced from: Lunell E.: SRNT Europe 2003

SUMMARY/CONCLUSIONS (1) In Sweden use of snus is more common than smoking among males but less common among females. Use of 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 and it is commonly used as such by males. Use of snus seems not to result in an ”overload” of nicotine. Use of snus produces nicotine dependence but probably less strongly so than smoking.

SUMMARY/CONCLUSIONS (2) Findings from current studies suggest that snus, although not a ”health product” by itself, can, by serving as a substitution for smoking, be one of the many factors that have contributed to the current situation in Sweden with low smoking rates and accordingly low rates of tobacco-related morbidity and mortality..