Patterns of dual use of snus and cigarettes in a mature snus market

How do Smokers in a Snus-Prevalent Society Consider E-cigarettes, Snus, and Nicotine Replacement Therapy Products as Relevant Replacements for Cigarettes in the Event They Should Stop Smoking?

INTRODUCTION

Around 50 percent of the tobacco in Norway is consumed in the form of snus, a smokeless oral tobacco. We examined Norwegian smokers' openness, and thereby the potential reach, to use e-cigarettes, nicotine replacement therapy products (NRT), and snus in the event of quitting smoking, in a society where snus use is common.

METHODS

Using data from an online survey of 4073 smokers from 2019 to 2021, we calculated predicted probabilities of smokers' being open, undecided, and not open to use e-cigarettes, snus, and NRT in the event they should quit smoking.

RESULTS

Among daily smokers, the probability of being open to use e-cigarettes in the event of quitting smoking was .32. The corresponding probabilities for using snus and NRT were .22 and .19. Snus was the product with the highest probability of not being open (.60). NRT had the highest probability of being undecided (.39). Among smokers who had never used e-cigarettes or snus, the probabilities of being open were .13 for e-cigarettes, .02 for snus and .11 for NRT.

CONCLUSIONS

In a snus-friendly norm climate where smokers have traditionally used snus as an alternative to cigarettes, the probability of using e-cigarettes in the event of smoking cessation was higher compared to both snus and NRT. However, among smokers who had never used e-cigarettes or snus, the likelihood of being open to use of NRT was similar to e-cigarettes, and higher than snus, which suggests that NRT may still play a role in smoking cessation.

IMPLICATIONS

In a snus-prevalent country in the endgame phase of the cigarette epidemic, where robust infrastructure for tobacco control in combination with the availability of snus has reduced smoking to a minimum, the remaining smokers seem to prefer e-cigarettes to snus if they should quit smoking. This indicates that availability of several nicotine alternatives might increase the likelihood of a future product replacement within the small group of remaining smokers.

Characterization of Ad Libitum Use Behavior of On! Nicotine Pouches

Objectives: Actual use of nicotine pouch products is not well studied. The objectives of this study were to characterize on ® nicotine pouch (Test Products (TP)) use behavior, including association with cigarette and smokeless tobacco (ST) product use. Methods: Adults who smoke cigarettes (AS) and/or adults who use ST (ASTU) (N=1147) that were not planning to quit and had expressed interest in trying and using TP after a 5-day trial were offered ad libitum use of TPs (7 flavors at 5 nicotine levels) for 6 weeks. Results: Participants used a median of ~5-6 pouches/day of a variety of flavors and nicotine levels. In the final week of the study, 27% of AS and 71% of ASTU reported no use of cigarettes or ST respectively, while reporting continued use of TPs. Additionally, 39% of AS and 14% of ASTU reduced consumption of cigarettes or ST products respectively by 50%-99%, compared to reported use at screening. We found a statistically significant inverse relationship between TP flavor varieties and number of cigarettes/ST. Conclusions: These data suggest that TPs can be potential substitutes for cigarettes/ST products, and complete switching may offer harm reduction potential for AS and ASTU not interested in quitting.

Factors associated with initiation and use of snus among adolescents

AIM

We investigated factors associated with the initiation and continuation of snus use in adolescents in Norway. The associations with adolescents' own educational plans, the parents' educational level(s) and tobacco habits were estimated.

METHODS

In this cross-sectional questionnaire-based study, 1465 patients aged 18-20 years participated. The questionnaire was administered at regular dental examinations in the public dental health service. To assess the association between individual factors and the initiation of tobacco habits, a generalised structural equation model with random effects at the clinic level was used. Binary responses were modelled using multilevel binary logistic regression, while the number of snus boxes used per month was modelled using a multilevel Poisson regression model.

RESULTS

Of current (daily and occasional) tobacco users, 85% were snus users, including dual users of both snus and cigarettes. The median age of snus initiation was 16 years. Both parental snus use and smoking were associated with an increased risk of snus initiation, snus use and a higher amount of use. An increased risk of using snus was associated with male gender and with no educational plans or planning for further vocational education. The amount of snus used was higher among current snus users with a prior smoking history and among those planning for further vocational education.

CONCLUSIONS

These findings may aid in developing and targeting tobacco prevention strategies aimed at young people. Tobacco prevention measures should start at the elementary school level. The strong association with parental tobacco habits underlines the importance of parents' influence on their children's tobacco use.

Factors associated with predictors of smoking cessation from a Norwegian internet-based smoking cessation intervention study

INTRODUCTION

We examined if we could identify predictors for smoking cessation at six months post cessation, among smokers enrolled in a large Norwegian population-based intervention study.

METHODS

We followed 4333 (72.1% women) smokers who enrolled in an internet-based smoking cessation intervention during 2010–2012. The baseline questionnaire collected information on sociodemographic and lifestyle factors, including current snus use. The cessation outcome was self-reported no smoking past seven days, at six months. We used logistic regression to estimate odds ratios (ORs) with 95% confidence intervals, to identify predictors of smoking cessation, adjusting for potential confounders.

RESULTS

Women (OR=1.30; 95% CI: 1.01–1.69) compared with men, and those with medium (OR=1.31; 95% CI: 1.02–1.68) and longer (OR=1.42; 95% CI: 1.06–1.90) education compared with those with shorter education, were more likely to be successful quitters.

Overall, being a student (OR=0.56; 95% CI: 0.37–0.85) compared with having full-time work, and a moderate to high Fagerström test for nicotine dependence (FTND) score (OR=0.69; 95% CI: 0.55–0.87) compared with a low score, were predictors for unsuccessful cessation. Current snus use was a predictor for unsuccessful cessation compared to no snus use for both men (OR=0.49; 95% CI: 0.28–0.88) and women (OR=0.49; 95% CI: 0.32–0.75).

CONCLUSIONS

Our study identifies female sex and longer education as predictors for successful smoking cessation, while a medium or high FTND score, being a student, and current snus use, were predictors for unsuccessful smoking cessation. Only current snus use was a predictor for unsuccessful cessation for both sexes. Our results indicate that smokers should be warned that snus use may prevent successful smoking cessation.

A nationwide study of the incidence, prevalence and mortality of Parkinson's disease in the Norwegian population

Epidemiological studies of Parkinson's disease (PD) show variable and partially conflicting findings with regard to incidence, prevalence, and mortality. These differences are commonly attributed to technical and methodological factors, including small sample sizes, differences in diagnostic practices, and population heterogeneity. We leveraged the Norwegian Prescription Database, a population-based registry of drug prescriptions dispensed from Norwegian pharmacies to assess the incidence, prevalence, and mortality of PD in Norway. The diagnosis of PD was defined based on the prescription of dopaminergic drugs for the indication of PD over a continuous time. During 2004-2017, 12,229 males and 9831 females met our definition for PD diagnosis. PD prevalence increased over the observation period, with larger changes observed in the older age groups. Incidence and prevalence of PD increased with age, peaking at 85 years. The male/female prevalence ratio was 1.5 across all ages, whereas the incidence ratio increased with age, from 1.4 in those 60 years, to 2.03 among those >90 years. While PD mortality was generally higher than that of the general population, mortality odds ratios decreased with age, approaching 1.0 among individuals >90 years old. When adjusted for the sex-specific mortality of the general population, the mortality among females with PD was equal to or higher than the mortality among males with PD. Our findings demonstrate that the epidemiological features of PD, including sex-differences, are age and time-period dependent and indicate that sex differences in PD mortality are unlikely to stem from disease-specific negative impact of survival in males.

Snus and Alcohol: Mutually Rewarding Effects in the Brain? A Matched Controlled Population Study

Background:

The use of moist smokeless tobacco (snus) is increasing in the U.S. and other Western countries, and especially among young people. Snus is associated with several health problems, but the relationship between use of snus and alcohol is scarcely explored. Neuro-cognitive and psychological research suggest an association due to possible mutually rewarding effects in the limbic brain. We investigated this issue in a matched controlled population study.

Methods:

Matched control group design where drinking habits and alcohol consumption in a group of users of snus (n = 1043, mean age = 35.20; n men = 749, n women = 294) were compared to a control group of non-users matched on age and gender (n = 1043, mean age = 35.65; n men = 749, n women = 294). In addition, we registered background variables such as level of education, income, self-perceived general, dental health, mental health, current depressive symptoms, and BMI. In estimation of alcohol consumption, the background variables were used as covariates in factorial analyses of variance (ANCOVA).

Results:

Users of snus had lower level of education, lower income, poorer general, dental, and mental health status than non-users, but there were no differences in BMI. Differences in mental health status were related to drinking habits. Users of snus had a higher frequency of drinking, higher frequency of intoxication, and showed more excess drinking. Controlled for background variables users of snus had a 25.2% higher estimated yearly consumption of alcohol in terms of standard units of alcohol on the weekdays, 26.4% higher on weekends and a 60.2% higher yearly excess consumption.

Conclusion:

Users of snus had an elevated alcohol consumption and another drinking style than non-users. The findings are discussed according to neuro-cognitive and psychopharmacological mechanisms, reward learning and conditioning. The results have implications for prevention, treatment and rehabilitation of alcohol and nicotine dependence.

The greater use of flavoured snus among ever-smokers versus never-smokers in Norway

Background

Similar to the debate around e-cigarettes, an increase in snus use among Norwegian adolescents has prompted debate on whether flavour options in snus should be limited. To this end, we compared use of flavoured snus among snus users with different smoking status.

Methods

Questions about flavoured snus use were included in an online omnibus study conducted from 2015 to 2019 (N = 65,445) that included 16,295 ever snus users (aged 15+). Current snus users (N = 9783) were asked “Do you usually use snus that has a flavouring (liquorice, mint, wintergreen, etc.)? Adjusted predicted probabilities and 95% confidence intervals (CI) were calculated from a logistic regression model.

Results

Less than 25% of the snus users reported never having smoked. The overall probability of using flavoured snus was .45 (95% CI .44–.46), highest among daily (.51, 95% CI .47–.54) and former daily smokers (.50, 95% CI .48–.52), and lowest among never (.41, 95% CI .39–.43) and occasional smokers without any prior history of daily smoking (.41, 95% CI .38–.44). Use of flavoured products was higher among female snus users (p = .67, 95% CI .65–.69) compared to males (p = .35, 95% CI .34–.36), highest among the youngest age group, 15–24 years (p = .58, 95% CI .56–.60) and decreased with increasing age.

Conclusion

Regulation that would ban or limit flavoured snus use may affect smokers—an at risk population—more than never smokers. The health authorities should be mindful of the real-world complexity governing potential harms and benefits of flavour restrictions on snus. A further assessment of flavour limitations should acknowledge that flavoured snus products also function as alternatives to cigarettes.

Concurrent Daily and Non-Daily Use of Heated Tobacco Products with Combustible Cigarettes: Findings from the 2018 ITC Japan Survey

Use of heated tobacco products (HTPs) among current smokers is becoming increasingly popular in Japan. This study aims to compare characteristics and tobacco-related behaviors among concurrent users of HTPs and combustible cigarettes (n = 644) with exclusive smokers (n = 3194) or exclusive HTP users (n = 164). The secondary aim was to explore heterogeneity within concurrent use subgroups. Data were from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted from February to March 2018. Concurrent cigarette-HTP users were younger and wealthier than exclusive smokers. However, there were no difference in the frequency of smoking, number of cigarettes per day, and smoking cessation behaviors between the two groups, suggesting that HTPs reinforce nicotine dependence. Compared to exclusive HTP users, concurrent cigarette-HTP users reported higher frequency of non-daily HTP use, and lower number of tobacco-containing inserts per day. Almost all concurrent cigarette-HTP users smoked every day (93.9%); 48.4% both smoked and used HTPs daily (dual daily users, n = 396), while 45.5% were daily smokers and non-daily HTP users (predominant smokers, n = 213). Concurrent user subgroups differed from each other on age, tobacco use behaviors, and quit intention. Alongside heterogeneity between concurrent and exclusive product users, differences across concurrent use subgroups highlight the importance of considering frequency of use in characterizing poly-tobacco users.

Association between snus use over time and smoking cessation in Norwegian smokers

BACKGROUND AND AIMS

The effect of snus (Swedish moist snuff) use over time on smoking cessation has not been clearly established. This study aimed to assess whether there is an association between snus use over the life-span and smoking cessation in Norway.

DESIGN AND SETTING

Yearly national cross-sectional surveys (2007-17) among Norwegian adults.

PARTICIPANTS

A total of 5353 ever-daily smokers aged 16-79 years, 61.0% of whom (n = 3268) had quit daily smoking, and 16.9% (n = 903) were ever snus users.

MEASUREMENTS

Retrospective data on smoking and snus use initiation and smoking cessation. Cox proportional hazard models were applied to estimate the association between time from initiation of snus use and quitting smoking.

FINDINGS

There was a significant association between snus use and quitting smoking during the 5 first years after starting using snus (hazard ratio = 1.92, confidence interval = 1.62-2.26), but not thereafter.

CONCLUSION

In Norway, snus use appears to be associated with a higher likelihood of quitting smoking within the first 5 years of initiation of this use.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

Snus and Snuff Use in Switzerland Among Young Men: Are There Beneficial Effects on Smoking?

Introduction

There are few recent longitudinal studies on smokeless tobacco (SLT) products and smoking outside the United States or European Nordic countries. The present longitudinal study tests whether Swedish-type snus and nasal snuff use decreases smoking incidence and prevalence in a central European country.

Methods

The sample consisted of 5198 Swiss men (around 20 years of age). Retention rate was 91.5% over 15 months. Regression models, adjusting for a variety of psychosocial, smoking-related, and other risk factors, assessed whether no, low (less than weekly), and high (weekly or more) use baseline groups showed changes or maintenance in snus and snuff use related to smoking initiation, cessation, and reduction.

Results

Among baseline nonsmokers, snus initiators (OR = 1.90, p = .003) and low baseline maintainers (OR = 4.51, p < .001) were more likely to start smoking (reference: persistent nonusers of snus). Among baseline smokers, initiators (OR = 2.79, p < .001) and low baseline maintainers (OR = 2.71, p = .005) more often continued smoking, whereas snus quitters less frequently continued smoking (OR = 0.57, p = .009). High baseline maintainers were non-significantly less likely to continue smoking (OR = 0.71, p = .315). Among continuing smokers, only snus quitters significantly reduced the number of cigarettes smoked per day (b = -1.61, p = .002) compared with persistent nonusers of snus. Results were similar for snuff.

Conclusions

SLT use did not have any significant beneficial effects on young men in Switzerland but significantly increased the likelihood of smoking initiation and continuation, independent of whether the substance is legally sold (snuff) or not (snus). This does not exclude that there may be beneficial effects at older ages.

Implications

Our research provides evidence that SLT use has no benefits for cigarette smoking initiation, cessation, or reduction among young men in a central European country, where SLT is not highly promoted or receives tax incentives. This is true for both legally sold nasal snuff and Swedish-type snus that cannot be legally sold. Results indicate that without incentives for using it, among young people shifts from smoking to SLT use are questionable and confirms the need for country-specific studies before the global public health community engages in promoting SLT.

Alarming development of dual snus and cigarette usage among young Finnish males

Background

The consumption of tobacco products has evolved to include more complex combinations of different products. We investigated the tobacco habits of a representative population of young Finnish male conscripts in order to evaluate the prevalence of dual use of cigarettes and snus as well as the transition from one tobacco product to another. In addition, we evaluated the correlation between the level of education and the use of cigarettes and snus.

Methods

A questionnaire-based survey was carried out in three out of 17 garrisons among conscripts during their first week of service in 2014. A total of 1971 male conscripts were selected by simple random sampling of the 9013 males in the selected garrisons. Of them 1916 participated and filled in the questionnaire. The response rate was 97.2%. The questionnaire consisted of 25 questions including age, gender, basic education, use of tobacco products as well as questions assessing nicotine dependency.

Results

The amount of dual users of cigarettes and snus was 21%. There was a higher probability of dual use of cigarettes and snus among smokers compared to snus users (p < 0.001). One third (35%) of former smokers reported daily snus use and over 40% of the former snus users smoked daily. One third (34%) of the participants reported snus usage and 14% of the study subjects used snus daily. 40% of the study population were smokers and over 25% smoked daily. Of the participants with basic educational background 57% smoked daily (p < 0.001), however, no association between snus and level of education was found (p = 0.69).

Conclusions

This study provides better understanding of the complex tobacco habits of young adult males. The simultaneous usage of multiple tobacco products as well as the high tendency to transition from one tobacco product to another should be taken into consideration when planning cessation interventions in health care settings and tobacco control policies at societal levels.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7519-1) contains supplementary material, which is available to authorized users.

Association of snus experimentation in late adolescence with daily cigarette smoking in early adulthood: A longitudinal study among Finnish men

Aims: Swedish smokeless tobacco (snus) is a lower-risk tobacco product than cigarette smoking for individuals. However, the public health impact of snus use is less well studied. Critically, it is uncertain whether use of snus leads to the onset of smoking. This study aimed to investigate prospectively the association between snus experimentation in late adolescence and daily cigarette smoking in early adulthood among Finnish young men. Methods: Data were obtained from 1090 young men within the population-based FinnTwin12 cohort. At baseline (mean age 17 years), we assessed lifetime use of cigarettes and snus, plus other potential predictors of cigarette smoking. At follow-up (mean age 24 years), participants were categorized according to their current smoking status. The final analyses were conducted among 375 young men who were never smokers at baseline with adequate data on follow-up smoking status and other potential predictors of cigarette smoking. Results: Age-adjusted logistic regressions showed an increased risk of becoming a daily smoker at follow-up among those participants who had at least tried snus but had never smoked cigarettes at baseline (odds ratio (OR) 6.48, 95% confidence interval (CI) 2.02-20.7), compared with those who had never used snus. When additionally adjusted for monthly alcohol intoxication, maternal smoking, and peer drug use, the association between snus experimentation and later daily cigarette smoking was attenuated, but remained significant (OR 3.94, 95% CI 1.22-12.7). Conclusions: Our data support the proposition that snus experimentation during late adolescence is longitudinally associated with daily cigarette smoking in early adulthood. Although a causal association cannot be inferred with certainty, snus experimentation might constitute an indicator of the propensity to proceed to regular snus use and initiation of use of other tobacco or nicotine products.

Cute as candy: a qualitative study of perceptions of snus branding and package design among youth in Norway

OBJECTIVES

Snus use has increased among youth in Norway in recent years and is now more prevalent than smoking. Concurrently, a range of new products and package designs have been introduced to the market. The aim of this study was to explore how youth perceive snus branding and package design, and the role, if any, of snus packaging on perceptions of appeal and harm of snus among youth.

PARTICIPANTS

Adolescent tobacco users and non-users (N=35) ages 15-17 years.

DESIGN

We conducted interviews among 6 focus groups (each with 4-7 participants). Participants were shown snus packages with a variety of designs and with different product qualities (flavour additives, slim, regular, white and brown sachets) and group discussions focused on how they perceived packages and products. The focus group discussions were semistructured using a standard guide, and analysed thematically.

RESULTS

The participants in the focus groups narrated distinct images of snus brands and associated user identities. Package design elements such as shapes, colours, images and fonts were described as guiding these perceptions. Packaging elements and flavour additives were associated with perceptions of product harm. The appeal of flavoured snus products and new types of snus sachets seemed to blend in with these processes, reinforcing positive attitudes and contributing to the creation of particular identities for products and their users.

CONCLUSIONS

The findings indicate that packaging is vital to consumer's identification with, and differentiation between, snus brands. In view of this, snus branding and packaging can be seen as fulfilling a similar promotional role as advertising messages: generating preferences and appeal.

Do never smokers make up an increasing share of snus users as cigarette smoking declines? Changes in smoking status among male snus users in Norway 2003-15

AIMS

To examine how the relative size of six groups of male ever snus users (current and former users of snus who were current, former or never cigarette smokers) varied over time in Norway, and how these groups differ with regard to important measures of tobacco behaviour.

DESIGN

Repeated cross-sectional nationally representative surveys of tobacco use. The association between survey year and the six categories of ever snus use was examined using cross-tabulation and multinomial logistic regression. Differences in tobacco behaviour across snus use categories were examined using logistic and ordinary least squares (OLS) regression.

SETTING

Norway, 2003-15.

PARTICIPANTS

A total of 2067 males aged 15-79 years.

MEASUREMENTS

The categories of ever snus use represented all six combinations of cigarette smoking (current, former or never) among current and former users of snus. The variables measuring tobacco behaviour were: order of product uptake (snus or cigarettes first), mean cigarette consumption, reduction from daily to occasional smoking, intention to quit cigarettes, future smoking identity and use of snus in latest quit attempt.

FINDINGS

During the period 2003-15, the relative share of current snus users who had never smoked, and current snus users who were former smokers, increased. The share of dual users, and smokers who were former snus users, decreased. Among men who reported life-time experience with both products, a large majority had initiated their tobacco use with cigarettes. The average number of cigarettes smoked weekly was lower among dual users compared with current smokers who were former snus users or had never used snus.

CONCLUSIONS

During the period 2003-15 in Norway, which has a mature snus market, even though smoking has declined and the relative size of the category of never-smokers among male users of snus has increased, the majority of snus users are still former or current smokers.

Smokeless tobacco use in Sweden and other 17 European countries

INTRODUCTION

The purpose of this study is to report prevalence and determinants of use of smokeless tobacco in a representative sample of men and women from Sweden, where Swedish snus sales are legal, and from 17 other European countries, where sales of smokeless tobacco are restricted.

METHODS

In 2010, a face-to-face survey including information on current smokeless tobacco use was conducted in a representative sample of around 1000 individuals aged ≥15 years per country in Albania, Austria, Bulgaria, Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden.

RESULTS

In Sweden, the overall prevalence of smokeless tobacco use was 12.3% (20.7% in men, 3.5% in women). The corresponding estimate for other European countries combined was 1.1% (1.2% in men, 1.1% in women). Compared with never smokers, former smokers in Sweden were significantly more likely to use smokeless tobacco (odds ratio, OR: 2.67), whereas no difference in use was observed in other countries (OR: 1.04). Use of smokeless tobacco was similar among current smokers in Sweden (OR: 1.96) and in other countries (OR: 2.40) when contrasted to never smokers. In Sweden there were no differences in the number of cigarettes/day between smokers who also use smokeless tobacco (13.3 cigarettes/day) and exclusive cigarette smokers (12.9 cigarettes/day; P = 0.785).

CONCLUSIONS

Excluding Sweden, current oral tobacco use was not commonly reported in the European countries surveyed and was similarly rare both in men and in women. In Sweden, however, use of smokeless tobacco was about 10-fold higher than the rest of Europe and more prevalent in men than in women.

Adolescent tobacco use practices and user profiles in a mature Swedish moist snuff (snus) market: Results from a school-based cross-sectional study

AIMS

The aim of this work was to study the diversity of tobacco use among Norwegian adolescent tobacco users and to investigate how different user groups compared with each other in terms of lifestyle and risk correlates. Swedish moist snuff (snus) use has increased dramatically in Norway over the last few years and is now more prevalent than smoking in younger age groups.

METHODS

The participants were 736 15-year-old tobacco users obtained from a large school-based cross-sectional survey (response rate 73%). Leisure time activity and risk behaviour factors were extracted by principal components analysis. Associations between tobacco use, leisure activities, risk behaviours, alcohol use and sex were studied bivariately and by logistic regression.

RESULTS

In total, 41.5% of the tobacco users were dual users (smokers and snus users). Problem behaviour and risk-taking lifestyles were associated with tobacco use frequency and high-frequency dual use, with a low risk profile for all types of occasional users (snus, cigarettes or dual users), a medium risk profile for all types of daily single-product users, including those who occasionally used the other product (i.e. dual users) and a high-risk profile for those who used both products daily (daily dual users).

CONCLUSIONS

Fragmented use patterns in adolescence undermine the dichotomy often applied between smokers and snus users. For associations with lifestyle and risk correlates, use frequency and high-frequency dual use seem to be more important than the choice of product.

Daily Smoking and Subjective Health Complaints in Adolescence

INTRODUCTION

Using data from the Health Behaviour in School-aged Children survey, this study used a repeated cross-sectional design to examine associations between daily smoking, gender, and self-reported health complaints in five cohorts of adolescents over a 16-year period.

METHODS

Data were from nationally representative cohorts of 15-year-old youth in Norway in 1993/1994, 1997/1998, 2001/2002, 2005/2006, and 2009/2010 (n _total = 7761). Dependent variables were psychological, somatic, and total health complaints. A mixed GLM model examined main and interaction effects of smoking (daily, intermittent, nonsmoking), year, and gender in predicting complaints. Time periods were segmented to compare trends across smoking groups in specific periods.

RESULTS

Prevalence of daily smoking declined from 15.5% (1993/1994) to 6.0% (2009/2010). All health complaint scores were significantly higher for smokers and for girls (vs. boys). Smoking status by year interactions were significant for all complaint variables during the period of sharpest decline of daily smoking prevalence (2001/2002-2005/2006), with daily smokers experiencing increases in health complaints while intermittent and nonsmokers did not. Smoking status by gender interactions were significant for all health complaint variables, indicating that the main effect for gender (females higher) was even stronger among smokers compared with nonsmokers. Using year as unit of analysis, the size of mean differences between daily smokers and intermittent/nonsmokers in total complaints was significantly negatively correlated with daily smoking prevalence (-.963, n = 5, p < .01).

CONCLUSIONS

As prevalence of daily smoking declined, daily smokers reported higher levels of complaints, suggesting increasing health problems within this group. Girls who smoke daily had particularly elevated levels of complaints.

IMPLICATIONS

This study indicates that the relationship between daily smoking and concurrent health symptomatology in adolescents is changing over time, with higher levels of health complaints reported as overall smoking prevalence declines. To our knowledge, this finding has not previously been reported. If youth are smoking to cope with distress, pain, or other health concerns, tobacco control objectives will be increasingly difficult to achieve with adolescents. Levels of health complaints are particularly high among girls who are daily smokers. The findings suggest that restrictive measures and persuasive communications may not be sufficient tobacco prevention strategies for adolescent populations. Young smokers may need counseling and support.

Multiple Levels of Influence That Impact Youth Tobacco Use

OBJECTIVE

Multiple levels of influence interplay to impact youth tobacco use. We work towards understanding important policy and environmental strategies that are associated with youth tobacco use behaviors.

METHODS

We utilized data from participants of the Monitoring the Future (MTF) study and linked national data from multiple sources to assess correlates of youth tobacco use behaviors across individual, family, school, community, and state-level policy influences.

RESULTS

Higher cigarette prices had the strongest association with youth tobacco use behaviors. Demographic and socio-economic characteristics at the individual, familial, and community/school-levels were associated with youth tobacco use behaviors.

CONCLUSIONS

In the present study, we confirm that higher cigarette prices could help to reduce youth tobacco use behaviors. Several states are still lagging behind in terms of their low cigarette tax and they should enact tax policies to reduce youth tobacco use.

Prevalence and Sociodemographic Determinants of Any Tobacco Use and Dual Use in Six Countries of the WHO South-East Asia Region: Findings From the Demographic and Health Surveys

BACKGROUND

Tobacco control is an important strategy to reduce the disease burden caused by several noncommunicable diseases. An in-depth understanding of the sociodemographic variations in tobacco use is an important step in achieving effective tobacco control.

AIMS

We aimed to estimate the age-standardized prevalence of any tobacco use and dual tobacco use and determine their association with sociodemographic variables in six countries (Bangladesh, Indonesia, India, Maldives, Nepal, and Timor Leste) of the WHO South-East Asia Region.

METHODS

The main outcome variables "any tobacco use" and "current dual use" were created from the latest available Demographic and Health Surveys data for each country. The prevalence estimates were weighted using sample weights and age standardized using the WHO standard population. Associations between the sociodemographic variables and tobacco use were calculated by performing multivariable logistic regression analysis. Analyses were performed in Stata 12 using "svyset" and "svy" commands.

RESULTS

The highest prevalence of any tobacco use among men was in Indonesia (76.4%) and among women in Nepal (15.7%). Also, Nepal had the highest prevalence of dual tobacco use in both men (17.9%) and women (1.5%). With regard to sociodemographic determinants, despite the inter-country variations, any and dual tobacco use were significantly associated with age, higher education, greater wealth, rural residence, and ever-married marital status. The poor and uneducated had a higher odds ratio for these practices.

CONCLUSION

Prevalence of dual tobacco use and its underlying socioeconomic disparities should be taken into account for the planning of tobacco control activities in the region.

IMPLICATIONS

The dual tobacco use phenomenon is being increasingly recognized as a distinct entity in the fight against tobacco addiction. When compared with single product users, dual users have a greater risk of developing tobacco related diseases and are less likely to quit their habits. However, this phenomenon has not been studied adequately in the South-East Asia region. In this context, this study has provided a detailed and comprehensive view of dual tobacco use and its sociodemographic determinants in six countries of the region. This study recommends that tobacco control interventions should be targeted specifically at the disadvantaged sections of the society, such as the poor and the uneducated, who are more likely to engage in "dual" as well as "any" tobacco use. This study could prove as an important reference and tool for policy making in the South-East Asia region.

Systematic Review of Tobacco Use after Lung or Head/Neck Cancer Diagnosis: Results and Recommendations for Future Research

Tobacco use after cancer diagnosis is associated with adverse cancer outcomes, yet reliable prevalence estimates for this behavior are lacking. We conducted a systematic literature review of the prevalence of current tobacco use among individuals with a history of lung or head/neck cancer (CRD #42012002625). An extensive search of electronic databases (MEDLINE, EMBASE, Cochrane Library, CINAHL, PsycINFO, and Web of Science) identified 7,777 potentially relevant articles published between 1980 and 2014 and 131 of these yielded pertinent information. Aggregating results across heterogeneous study designs and diverse patient samples, the overall mean prevalence rate of current tobacco use (mostly cigarette smoking) was 33.0% (median, 31.0%). Among current tobacco users at cancer diagnosis, the mean prevalence rate of current tobacco use (mostly cigarette smoking) was 53.8% (median, 50.3%). In many cases, an operational definition of "current" tobacco use was absent, and biochemical verification of self-reported smoking status was infrequent. These and other observed methodologic limitations in the assessment and reporting of cancer patients' tobacco use underscore the necessity of uniform tobacco use assessment in future clinical research and cancer care.

Lifestyle Correlates of Female Snus Use and Smoking: A Large Population-Based Survey of Women in Norway

INTRODUCTION

While smoking in Norway has become less prevalent, snus use has increased, including among women. The aims of this study were to describe female snus use and its correlates, and to contrast patterns of snus use and smoking.

METHODS

In 2011-2012, data on tobacco use, age, education, alcohol consumption, sexual behaviors, and physical activity were collected from a population based sample of 13 756 Norwegian women aged 18-45 years, using a self-administered questionnaire.

RESULTS

Ever-use prevalence of snus ranged from 29.6% to 4.5% among those aged 18-19 years and 40-45 years, respectively. In contrast, the corresponding figures for smoking were 24.1% and 44.1%. Among snus users, 54.1% and 22.8% of 18-19 and 40 to 45-year-olds had never smoked, respectively. Debut age for snus use increased markedly with age, and was higher than debut age for smoking. Female snus use was positively associated with intermediate education, alcohol consumption, number of sexual partners, and hard physical activity. Smoking was also positively associated with alcohol consumption and number of sexual partners, but negatively associated with physical activity and education.

CONCLUSION

While most snus users among older women were former or current smokers, this was not the case among younger women. Low snus debut age and extensive snus use among younger women suggest that measures to reduce snus use should be targeted at young adolescents. The correlates of female snus use and smoking were not identical, and were similar to those previously documented for men.

Dual Trajectories of Cigarette Smoking and Smokeless Tobacco Use From Adolescence to Midlife Among Males in a Midwestern US Community Sample

INTRODUCTION

Identifying trajectories of tobacco use is critical for understanding its natural history and targeting interventions, but research on trajectories of smokeless tobacco and dual use of smokeless tobacco and cigarettes is very limited. This study identified tobacco use trajectories from adolescence to midlife and tested correlates of trajectory group membership.

METHODS

This study included all male participants in a longitudinal study who reported cigarette smoking or smokeless tobacco use in 1987, 1993, 1999, 2005, or 2011 (N = 2230). Group-based trajectory analyses were conducted with zero-inflated Poisson models. Analysis of covariance was used to test adolescent health beliefs associated with trajectory group membership.

RESULTS

Five smoking trajectory groups were identified: (1) consistent abstinence from cigarettes; (2) late onset intermittent, then cessation; (3) early onset regular, then cessation; (4) delayed onset regular, then cessation; and (5) consistent regular. Four smokeless tobacco trajectory groups were identified: (1) early onset, then cessation; (2) consistent abstinence from smokeless tobacco; (3) late onset, escalating; and (4) consistent regular. The proportion of participants in trajectory groups representing dual use was low. Adolescent beliefs favorable to smoking and smokeless tobacco were associated with membership in consistent regular use groups.

CONCLUSIONS

The prevalence of dual use of cigarettes and smokeless tobacco was low, and there was little evidence to suggest switching between tobacco products. Participants who held more positive beliefs about smoking and smokeless tobacco as adolescents were more likely to be consistent regular users of cigarettes and smokeless tobacco into adulthood.

Appropriate and inappropriate methods for investigating the "gateway" hypothesis, with a review of the evidence linking prior snus use to later cigarette smoking

Background

The “gateway hypothesis” usually refers to the possibility that the taking up of habit A, which is considered harmless (or less harmful), may lead to the subsequent taking up of another habit, B, which is considered harmful (or more harmful).

Methods

Possible approaches to designing and analysing studies to test the hypothesis are discussed. Evidence relating to the use of snus (A) as a gateway for smoking (B) is then evaluated in detail.

Results—design and analysis considerations

The importance of having appropriate data available on the sequence of use of A and B and on other potential confounding factors that may lead to the taking up of B is emphasised. Where randomised trials are impractical, the preferred designs include the prospective cohort study in which ever use of A and of B is recorded at regular intervals, and the cross-sectional survey in which time of starting to use A and B is recorded. Both approaches allow time-stratified analytical methods to be used, in which, in each time period, risk of initiating B among never users of B at the start of the interval is compared according to prior use of A. Adjustment in analysis for the potential confounding factors is essential.

Results—review of evidence

Of 11 studies of possible relevance conducted in Sweden, Finland or Norway, only one seriously addresses potential confounding by those other factors involved in the initiation of smoking. Furthermore, 5 of the 11 studies are of a design that does not allow proper testing of the gateway hypothesis for various reasons, and the analysis is unsatisfactory, sometimes seriously, in all the remaining six.

Conclusions

While better analyses could be attempted for some of the six studies identified as having appropriate design, the issues of confounding remain, and more studies are clearly needed. To obtain a rapid answer, a properly designed cross-sectional survey is recommended.

Dual use of smokeless tobacco or e-cigarettes with cigarettes and cessation

OBJECTIVES

To evaluate predictors of dual use of cigarettes with smokeless tobacco or e-cigarettes.

METHODS

Adult smokers (N = 1324) completed online cross-sectional surveys. Logistic regression evaluated predictors of dual use and cigarette quit attempts.

RESULTS

Smokeless tobacco dual use was associated with past attempts to quit smoking by switching to smokeless products. E-cigarette dual use was associated with using stop-smoking medication and strong anti-tobacco industry attitudes. Ever use of stop-smoking medication was associated with quit attempts among dual e-cigarette users and cigarette-only users.

CONCLUSIONS

Dual users are more likely than cigarette-only users to endorse certain cessation-related attitudes and behaviors. This may provide an opportunity for clinicians or others to discuss evidence-based strategies for smoking cessation.

Magnitudes of biomarker reductions in response to controlled reductions in cigarettes smoked per day: a one-week clinical confinement study

Tobacco toxicant-related exposure reduction is an important tool in harm reduction. Cigarette per day reduction (CPDR) occurs as smokers migrate from smoking cigarettes to using alternative tobacco/nicotine products, or quit smoking. Few reports characterize the dose-response relationships between CPDR and effects on exposure biomarkers, especially at the low end of CPD exposure (e.g., 5 CPD). We present data on CPDR by characterizing magnitudes of biomarker reductions. We present data from a well-controlled, one-week clinical confinement study in healthy smokers who were switched from smoking 19-25 CPD to smoking 20, 10, 5 or 0 CPD. Biomarkers were measured in blood, plasma, urine, and breath, and included smoke-related toxicants, urine mutagenicity, smoked cigarette filter analyses (mouth level exposure), and vital signs. Many of the biomarkers (e.g., plasma nicotine) showed strong CPDR dose-response reductions, while others (e.g., plasma thiocyanate) showed weaker dose-response reductions. Factors that lead to lower biomarker reductions include non-CPD related contributors to the measured response (e.g., other exposure sources from environment, life style, occupation; inter-individual variability). This study confirms CPDR dose-responsive biomarkers and suggests that a one-week design is appropriate for characterizing exposure reductions when smokers switch from cigarettes to new tobacco products.

How has the availability of snus influenced cigarette smoking in Norway?

BACKGROUND

In Norway, low-nitrosamine smokeless tobacco (snus) is allowed to compete with cigarettes for market share. We aimed to study how the availability of snus influenced overall tobacco consumption, smoking initiation and smoking cessation. We discuss whether the Norwegian experience with snus can have any transfer value for e-cigarettes.

METHODS

We analysed consumption data from registered and unregistered supply sources of tobacco. We calculated quit-smoking ratios across snus use status in nine datasets comprising a total of 19,269 ever-smokers. Trends in snus use and smoking were derived from time-series of annual; cross-sectional; nationally representative surveys for the period 1985-2013.

RESULTS

The market share for snus increased from 4% in 1985 to 28% in 2012, but overall tobacco consumption decreased by 20.3% over this same period. Snus was the most common method for smoking cessation. Compared with smokers with no experience of using snus, the quit ratio for smoking was significantly higher for daily snus users in seven of the nine datasets analysed. Among young male adults, the prevalence of smoking (daily + occasional) was reduced from 50% in 1985 to 21% in 2013. Over the same period, use of snus increased from 9% to 33%. This negative correlation (r = -0.900, p < 0.001) was also observed among young females (r = -0.811, p < 0.001), but the trend shift in tobacco preferences occurred some years later.

CONCLUSIONS

The experience with snus in Norway might indicate what will happen when alternative nicotine products--are allowed to compete with cigarettes in the nicotine market.

Contrasting smokers' and snus users' perceptions of personal tobacco behavior in norway

INTRODUCTION

In Norway, snus use and cigarette smoking are at different developmental stages as described by the diffusion of innovation model. Concomitant with declining smoking rates, the use of snus is increasing. In light of these differences in use trends, we assumed that snus users and cigarette smokers would have different perceptions of their personal tobacco use.

METHODS

A total of 4,852 smokers and snus users were recruited from a large sample of online panelists (n = 62,000) and a postal database (n = 15,000). The responses to 16 evaluative statements assessing perceptions about tobacco use were compared between exclusive snus users and exclusive smokers and within dual users. The statements concerned self-evaluative emotions, moral judgments, social disapproval, and benefits of quitting.

RESULTS

The perceptions of personal tobacco use differed greatly between exclusive smokers and exclusive snus users, even after controlling for age and sex. Smoker's perceptions were more negative compared with snus users' perception. The differences between smoking and snus use were particularly large for indices of social disapproval (Cohen's d = 1.56) and benefits from quitting use of the product (Cohen's d = 1.47) between exclusive users. Dual users exhibited a similar pattern.

CONCLUSIONS

Smokers have a more negative perception of their own use compared to snus users. Dual users also devaluated smoking in comparison to their snus use. This finding may have important values for prevention strategies targeting smokers, snus users, and dual users.

Tobacco use among Norwegian adolescents: from cigarettes to snus

AIMS

To: (i) investigate the development of smoking and snus use among Norwegian adolescents, and (ii) describe the users in each group.

DESIGN

Two population-based surveys with identical procedures in 2002 (response rate 91.0%) and 2010 (response rate 84.3%).

SETTING

Norway.

PARTICIPANTS

A total of 6217 respondents, aged 16-17 years.

MEASUREMENTS

Data were collected on smoking and snus use, socio-demographic factors, school adjustment, social network, sport activities, alcohol and cannabis use and depression symptoms.

FINDINGS

Prevalence of daily smoking fell from 23.6% in 2002 to 6.8% in 2010 (P < 0.001), while the prevalence of daily snus use increased from 4.3 to 11.9% (P < 0.001). Dual daily use of cigarettes and snus remained at 1%. The relative proportion of non-daily smokers using snus increased steeply. Both snus users and smokers reported more adverse socio-economic backgrounds, less favourable school adjustment and higher levels of alcohol intoxication and cannabis use than non-users of tobacco. However, snus users were better adjusted to school and used cannabis less often than smokers.

CONCLUSIONS

Adolescent smoking prevalence has fallen dramatically in Norway, accompanied by a smaller increase in snus use. Young snus users in Norway have many of the same risk factors as smokers, but to a lesser degree.

Health risks related to dual use of cigarettes and snus - a systematic review

Reviews show that using snus (Swedish-type moist snuff) is much safer than smoking, with no increased risk from snus of cancer or circulatory disease yet demonstrated, but have not investigated possible health effects from dual use of cigarettes and snus. This review considers studies where health risks can be compared in dual users, those who only use snus or only smoke, and those who use neither product. The interaction RR, the ratio of RRs associated with snus use in smokers and in non-smokers, was used to test for special effects of dual use. Of 51 interaction RRs presented, only one (for gestational hypertension in a study based on the Swedish Medical Register) was significantly (p<0.05) above 1.0, and RRs below 1.0 were commoner, perhaps as cigarette consumption is lower in dual users than those who only smoke. Dual users more often initiate tobacco use with cigarettes than snus. Dual use is much commoner in adolescents than adults, possibly because many tobacco users try both products, eventually settling on one. Epidemiological evidence from various sources, though suffering from weaknesses, consistently suggests concomitant snus use increases smoking quit rates, and aligns with evidence from RCTs using snus to aid smoking cessation.

Nondaily smoking: a population-based, longitudinal study of stability and predictors

Background

Nondaily smoking appears to have remained stable in Western countries in recent years, alongside a steep decline in daily smoking. Nondaily smoking increases the risk of several diseases and premature mortality, but our knowledge about nondaily smoking is limited. The present study was designed to examine the stability of nondaily smoking during young adulthood, and to identify adolescent factors predictive of nondaily smoking compared with nonsmoking and non-nicotine-dependent and nicotine-dependent daily smoking.

Methods

A population-based sample (n = 942) of Norwegians was followed up by surveys for 13 years, from adolescence to young adulthood. Information about smoking patterns, nicotine dependence, school achievement, parents’ and peers’ smoking, and parental monitoring was collected. Data on parental and participants’ education were obtained from a national register.

Results

Of all nondaily smokers at age 21 years, 26% were still nondaily smokers at 27 years, while 17% had become daily smokers and 57% had quit. Bivariate analyses revealed that young adult nondaily smokers did not differ from nonsmokers on any of the included variables, while a number of differences in parental, peers’ and individual characteristics were observed between nondaily smokers and the two categories of smokers in young adulthood. Longitudinal analyses revealed that unorganized leisure time activities and peers’ smoking differentiated nondaily smoking from nonsmoking. Higher educational achievement and less parental binge drinking predicted nondaily smoking and differentiated it from both categories of daily smoking.

Conclusions

The degree of nondaily smoking-stability from 21 to 27 years of age was modest, and most nondaily smokers quit smoking in the course of young adulthood. Young adult nondaily smokers were quite similar to nonsmokers, but differed substantially from both nicotine-dependent and nondependent daily smokers. The study suggests that nondaily smoking—at least in the absence of traditional risk factors for smoking—is usually a transitory behavior, with most people returning to nonsmoking.

Smoking and snus use onset: exploring the influence of snus debut age on the risk for smoking uptake with cross-sectional survey data

INTRODUCTION

Snus use has become increasingly prevalent among young people in Norway, while smoking has declined. Little is known about the transitions between snus and other tobacco products, particularly among younger users. A major concern involves the association between snus initiation and future smoking uptake.

METHODS

A total of 409 lifetime snus users who had started with snus before cigarettes or were never-smokers were selected from a national sample of participants in annually repeated cross-sectional surveys (2005-2011) of Norwegian men and women aged 15-74 years. About 30% of them were lifetime smokers, 84% were men, and the mean age was 29.4 years. Logistic regression was applied to investigate the association between age of snus uptake and the risk for becoming a smoker later on.

RESULTS

Respondents who started using snus before the age of 16 years had an odds ratio of 3.1 (confidence interval = 1.98-4.76) of being lifetime smokers compared with those who initiated snus later. The prevalence of current smoking among early snus initiators (22.9%) was comparable to that found among never-snus-users (29.6%). Among late snus initiators, current smoking prevalence was 5.9%.

CONCLUSION

In this study, snus debut age was an important factor for the association between snus use and smoking.