Rethinking therapeutic and recreational nicotine products: a commentary on Hatsukami et al

Patterns of Smoking and Snus Use in Sweden: Implications for Public Health

There has been concern that the availability of alternative less harmful forms of nicotine might inhibit smoking cessation and/or encourage those who would not otherwise have smoked to do so. The plausibility of such effects can be best assessed by looking at population trends in use of smoking in relation to alternatives. This paper looks at the relationships between snus use and smoking in Sweden. Analyses are based on a data set for the period January 2003 to February 2011 from a long-term study covering nationally representative samples of the Swedish population aged 18–79, with a total study population of 60,675 individuals. Questionnaires made it possible to identify detailed tobacco use categories and use trajectories. The results showed that uptake of snus use is much more common in males than females. Those who began daily tobacco use using snus were much less likely to subsequently take up smoking than those who had not, both among males (17.6% vs. 45.9%), and females (8.2% vs. 40.2%). Further, among those who started using snus after starting as smokers, 76.3% of men and 71.6% of women had stopped smoking completely, including 31.5% of the men and 28.6% of the women who had quit all forms of tobacco. Indeed, those who were primary snus users were also more likely to have quit altogether than those who only ever smoked. Snus was also reported as the most common smoking cessation aid among men and yielded higher success rates than nicotine replacement therapy and other alternatives. As conclusions, snus has both contributed to decreasing initiation of smoking and, when used subsequent to smoking, appears to facilitate smoking cessation. All these effects suggest that the availability and use of snus has been a major factor behind Sweden’s record-low prevalence of smoking and the lowest level of tobacco-related mortality among men in Europe.