1. a specific MRTP ─ Snus ─ a low-toxicity oral tobacco product.
Presentation to:
FDA Conference Center, Silver Spring, MD 20993, August
Experiences of the Swedish MRTP ─ Snus
Elucidating some questions at this workshop by means of data from scientific studies (the FSI / ITS survey)* of the use in Sweden of
a specific MRTP ─ Snus ─ a low-toxicity oral tobacco product.
*Postal survey conducted from January 2001 to February 2011 reaching a nationally representative sample
of approximately respondents during every year. The study is conducted in collaboration between the Research Group for Societal and Information Studies (FSI) and the Institute for Tobacco Studies (ITS).
The presentation will elucidate some questions at this workshop by means of data from scientific studies of the longstanding and widespread use in Sweden of a specific MRTP ─ Snus ─ a low-toxicity oral tobacco product.
Lars M. Ramström PhD
Director, Institute for Tobacco Studies
Stockholm, Sweden

2. Experiences of the Swedish MRTP — Snus
What is the likelihood to start smoking for those who have started tobacco usage with Snus, the “primary snus users”?
Particular attention has been given to those who have started daily tobacco usage with Snus, the ”primary snus users” . Do they have an increased or decreased likelihood for initiation of smoking. This table shows data from a Swedish study where individual trajectories of tobacco use were established for each participant. The rates of initiation of smoking are substantially lower for those with, than for those without primary snus use, 18% vs 45% for men, and 8% vs 40% for women. These data indicate that primary snus use keeps back initiation of smoking rather than being a gateway to smoking.
Source: FSI / ITS surveys

3. Experiences of the Swedish MRTP — Snus
How does increasing initiation of Snus use influence total initiation of tobacco use?
Data for specific birth-cohorts show that patterns of initiation have changed substantially over the last five decades of the 20th century. There has been a striking increase of initiation of snus use associated with a distinct increase of non-initiation of tobacco use. This indicates that increasing initiation of snus use is well compatible with decrease of total recruitment to tobacco use, and that primary snus users are rather recruited among presumptive smokers than among presumptively stable non-tobacco-users. .

4. What happens after smokers have taken up Snus use?
Experiences of the Swedish MRTP — Snus
What happens after smokers have taken up Snus use?
Many smokers take up Snus-use after having smoked for some time, maybe several years. The vast majority, 87%, of these ”secondary” Snus-users quit smoking completely and almost half of them do eventually quit Snus-use as well becoming free of daily tobacco use. A small fraction will be daily dual users. They have lower cigarette consumption than pure smokers and may therefore have decreased rather than increased their health risk. Another very small fraction has abandoned snus and continues smoking as before.

5. Experiences of the Swedish MRTP — Snus
What is the overall association between Snus use and smoking cessation?
Quit rates for smoking cessation in Sweden differ distinctively between those who have never been daily Snus-users and those who are or have been daily Snus-users. Quit rates, 0.85 vs 0.60, do not differ between men and women with same background of Snus-use. The difference between ”All men” and ”All women” is a consequence of the lower prevalence of snus use in women. Gender itself does not influence smoking cessation, but snus use does.
Source: FSI / ITS surveys

6. Experiences of the Swedish MRTP — Snus
What are the benefits of the use of Snus compared to products approved to treat nicotine dependence?
In the FSI /ITS surveys all participants who reported having made a Self-help quit-attempt were asked about what aid, if any, they had used. As indicated by the height of the bars in this diagram, snus was by far the most widely used aid among men, while nicotine gum was most used by women. In each bar the proportion between green part, success, and red part, failure, represents the quit rate achieved with each aid, as indicated numerically in each green segment. Both among men and women the quit rate is markedly higher with snus as aid than with gum or patch. It appears that snus has double benefits over gum and patch - higher usage among men and higher effectiveness among both men and women.

7. Experiences of the Swedish MRTP — Snus
Do MRTPs like Swedish Snus use have a potential to achieve an overall public health benefit?
Sweden has developed record-low levels of smoking and all tobacco-induced diseases.
It has been shown that Snus use in Sweden has both decreased initiation of tobacco use and increased cessation of smoking. This means that the use of snus has achieved an overall public health benefit by serving as an important contributory factor for the favorable development in Sweden.
Similar development should be possible in other countries, but only if prevailing knowledge gaps are filled and common misperceptions are corrected by appropriate public information.