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1.3 The smoking epidemic 1.3.1 A conceptual model

The onset of mass manufacture of cigarettes precipitated the smoking epidemic.

A four-stage model of the epidemic has been described, based on observations of trends in cigarette consumption and tobacco-related diseases in western countries with the longest history of cigarette use, namely the United Kingdom and the United States (Fig 1.1; Table 1.1).²⁸ The model describes the typical sequence of uptake of smoking in men and women, and the subsequent occurrence of the harmful consequences of smoking. The epidemic begins with a rise in male smoking, followed by a period of stable high rates and then gradual decline. The onset of female smoking typically occurs later but then follows a similar pattern. Tobacco-related mortality among men and women follows the rise and fall of smoking prevalence, but with a lag of about 30–40 years.

The delay between the onset of smoking and its health impacts is a key feature of the epidemic, and one that explains why historically there has been confusion about the health impacts of tobacco. Smoking kills through causing a wide range of diseases, principally cancers, vascular disease and chronic lung disease (see Chapter 6 for further discussion). The delay between the onset of smoking and the occurrence of disease varies at individual and population level and from one disease to another. Death rates from lung cancer in a population do not reach

6 Harm reduction in nicotine addiction

Fig 1.1 The four-stage evolution of the smoking epidemic. Reproduced from Lopez AD, C ollishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed

countries. Tob Control1994;3:242–7, with permission from the BMJ Publishing Group.²⁸ 70

60 50 40 30 20 10 0

40

30

20

10

0 10 20 30 40 50 60 70 80 90 1000

Year

% male smokers % male deaths

% female smokers % female deaths

Stage I Stage II Stage III Stage IV

Percentage of smokers among adults Percentage of deaths caused by smoking

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42

Hvis snus hadde hatt stor betydning som en introduksjonsport til røyking, ville en logisk konsekvens være at den dramatiske økningen i snusbruk blant unge menn etter hvert skulle ført til økning i røyking. Figuren nedenfor viser imidlertid en sterk reduksjon i røyking blant menn i alderen 16–24 år. Det kan likevel forekomme at snus øker risikoen for å røyke for noen.

Daglig bruk av sigaretter og snus blant kvinner og menn i alderen 16–24 år. Kilde:

Statistisk sentralbyrå

5.2.4 Empiriske undersøkelser av snus ved røykeslutt

En rekke svenske (Rodu et al 2002, 2003, Lindström et al 2002, Gilljam & Galanti 2003, Stegmayr et al. 2005, Ramström & Foulds 2006) og norske (Lund et al 2007, Lund et al 2008b) undersøkelser har funnet at slutteraten for røyking er høyere blant nåværende og forhenværende snusbrukere enn blant røykere uten noen bruks erfaring med snus. Dette indikerer at snus øker sannsynligheten for å klare å slutte å røyke. Det betyr selvfølgelig ikke at snus er en nødvendig eller tilstrekkelig forutsetning for røykeslutt.

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R@S5!!

18 Rapport 2006:4 Folkehelseinstituttet

-80-60-40-20020

Menn Kvinner

Lung cancer (15%)

Hjertekarsykdom 57%

Andre sykdommer 13%

Annen røykerelatert kreft (11%)

Annen kreft (3%)

Lung cancer (21%)

Hjertekarsykdom 44%

Andre sykdommer 19%

Annen røykerelatert kreft (12%)

Annen kreft (5%)

Beregnet fra Tabell 3 i Vollset, Tverdal & Gjessing. Ann Intern Med 2006.

Røykedødsfall mellom 40 og 70 år Lungekreft er toppen av isfjellet

%

source("o:\\a\\royketap\\gen_attfrac.spr") 3 april2006

Lungekreft (15%)

Lungekreft (21%)

Figur 5. Viser hvordan dødsfall som kan tilskrives røyking er fordelt på ulike dødsårsaksgrupper. Datagrunnlaget er Vollset, Tverdal og Gjessing³

Rapport2006-4-060524 24-05-06 11:15 Side 18

year, and the rebound in 1999 was probably caused by a 24%

price decrease in August of 1998.

Chewing tobacco is also available in Sweden, but the total amount sold is less than 1% of the quantity of snus sold.

Similarly, in addition to cigarettes, cigars, cigarillos, pipe tobacco and ‘‘roll-your-own’’ (RYO) tobacco are available in Sweden. These represent a relatively small and diminishing segment of the smoking market. For example, 125 million cigars/cigarillos were sold in 1983, as compared with 58 million in 1999 (less than 1% of the number of cigarettes sold); 1510 metric tons of pipe/RYO tobacco were sold in 1983, compared with 906 tons in 1999 (and 4479 tons of cigarettes sold in 1999).

A more detailed picture of recent trends can be seen by examining prevalence of daily smoking and daily snus use by sex (fig 3). This shows a much larger drop in male smoking (from 40% in 1976 to 15% in 2002) compared with the fall in female daily smoking (34% in 1976 to 20% in 2002) coinciding with an increase in male daily snus use from around 10% in 1976 to 23% in 2002. Other surveys of tobacco use in Sweden such as those carried out by the Swedish government, or as part of the WHO MONICA project (discussed below), similarly show a greater reduction in male smoking prevalence than female smoking prevalence in Sweden from the 1980s (when more men than women smoked) to the late 1990s (when more women than men smoked).^{52 53}

One recent study has specifically examined whether snus use appears to have directly influenced smoking rates in northern Sweden.⁵³This study used the dataset developed for the northern Sweden component of the WHO MONICA study. This involved collection of data from four representa- tive population based surveys conducted in 1986, 1990, 1994, and 1999, including detailed questions on tobacco use among approximately 1500 adults at each time point. This study found stable prevalence of ‘‘all tobacco use’’ among men (at around 40%) over the 13 year period, but with male smoking decreasing from 23% to 14% and snus use increasing from 22% to 30%, as the proportion of snus using ex-smokers increased from 9% to 14%. In women, smoking prevalence remained stable from 1986 to 1994 at 27% then dropped to 22% in 1999 when snus use rose from 2% to 6% (fig 4).

A more detailed picture of the likely role of snus in smoking cessation in Sweden can be gained by examining the prevalence of ex-smoking among ever smokers by history

of snus use and by sex in the Rodu study.⁵³As shown in fig 5, a higher proportion of male than female ever smokers had quit, and most of these had also used snus. The data from this study provide strong support for the role of snus in promoting smoking cessation among Swedish men (fig 5).

The same research group has recently published a prospective follow up study of over 70% of the participants in 1986, 1990, and 1994 who were successfully followed up in 1999 (n = 1651).⁵⁶ This study found a continuing trend away from smoking among men in northern Sweden, moving to a smoking prevalence around 10% in those followed up in 1999. Of those men who were smokers (no snus use) in the 1986–94 surveys, 39% had quit smoking by 1999, one third of whom had switched to snus use. Among women who were smokers at the baseline surveys, 30% had quit by 1999, only 10% of whom had switched to snus. This study concluded:

‘‘use of snus played a major role in the decline of smoking rates amongst men in northern Sweden. The evolution from smoking to snus use occurred in the absence of a specific public health policy encouraging such a transition.’’

It should be noted that fig 4 (consistent with fig 3) shows that while cigarette smoking has fallen dramatically among Swedish men, overall tobacco use has not. Some may view this as a failure of tobacco control (compared with some other countries). We view changes in tobacco caused disease as the decisive factor when evaluating the effects of tobacco control, and as discussed below, these changes have been very positive for Swedish men. It could also be argued that this reduction in male smoking may have occurred without snus. Here we regard the comparison with Swedish women (little snus use, smaller smoking reduction, smaller health improvement) and the characteristics of male ex-smokers (large proportion switching to snus when quitting smoking) as strongly suggestive of snus having a direct effect on the changes in male smoking and health.

WHAT HAVE BEEN THE NET EFFECTS OF SNUS ON PUBLIC HEALTH IN SWEDEN

The reductions in male smoking prevalence that have occurred in Sweden over the past 25 years have been the largest of any developed nation in the world. At the same time, Swedish men have also experienced a notable reduction in the incidence of the major smoking caused diseases. To exemplify this, fig 6 shows the pattern of changes in lung cancer incidence in Sweden and its near neighbour, Norway, from 1960 to 1999. Since the mid 1970s there has been a Figure 2 Sales of snus and cigarettes in Sweden 1916–2002 (source:

Swedish Match 2003). Note that cigarette sales may not precisely reflect true domestic consumption in the same year, particularly during periods with price changes (for example, after 1996). Other discrepancies between consumption and registered sales have occurred, especially in the period after 1998, because of increasing sales in Sweden to consumers in neighbouring countries and large changes in the ‘‘market share’’ for cigarettes imported by organised illegal trade. Note also that the population in Sweden has increased by approximately 60% from 1916 to 2000.

Figure 3 Prevalence of daily smoking for men and women (ages 18–

70 years) in Sweden 1976–2002 and prevalence of daily snus use for men (age 18–70 years) in Sweden 1976–2002 with observation points (markers) and least square regression lines. 1976–1983 data were obtained from National Smoking and Health Association (NTS)⁵⁴and 1988, 1996, 2000, and 2002 data were obtained from surveys performed as collaborative research projects by the Institute for Tobacco Studies and Research Group for Information and Societal Studies (ITS/

FSI).⁵⁵

354 Foulds, Ramstrom, Burke, et al

www.tobaccocontrol.com

group.bmj.com on December 21, 2011 - Published by

tobaccocontrol.bmj.com Downloaded from

(15)

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Interestingly Swedish men have also had a significant improvement in cardiovascular health over the same period.

For example, Rosen and colleagues studied trends in heart attacks in Sweden over the years 1987 to 1995 (amounting to 360 000 separate heart attacks in total).⁵⁹They found a 22%

drop in heart attacks in men aged 30–64 years during that period, roughly double the decline among same aged women over the same period (fig 8).

It is noteworthy that these improvements in tobacco caused illnesses have occurred primarily in men, despite a stable consumption of tobacco among men during that time period. The main factor that has changed is that many Swedish men have switched from smoked tobacco to snus. Of course one cannot state with absolute certainty that if snus had not been available in Sweden that just as many men would have quit smoking either without assistance or perhaps by switching to nicotine replacement therapy.

However, the pattern of sex differences in smoking cessation and snus use within Sweden, together with the between- country differences in smoking prevalence changes and health changes (comparing Sweden with other similar countries that have lower snus use, such as Norway),

strongly suggests that a significant portion of the health improvement among Swedish men over the past 20 years has been due to a large proportion quitting smoking or never starting to smoke, but using snus instead.

IS SNUS A ‘‘GATEWAY’’ TO SMOKING OR A PATHWAY FROM SMOKING IN SWEDEN?

It has been argued that smokeless tobacco could become a

‘‘gateway’’ product, hooking young people on nicotine from a cheaper and more easily concealed product, before they more easily move on to yet more addictive and harmful products such as cigarettes. For many reasons, the evidence from Sweden is not supportive of such a view. Firstly, if snus was acting to attract young people towards smoking one might expect the only country in Europe with a sizable snus market to have had the worst record for reducing smoking prevalence rather than the best. Secondly, when one examines the sex differences in tobacco use patterns, if snus was attracting young men towards smoking, one would expect the change in smoking prevalence to have been worse for men than for women, whereas it has been significantly better (that is, smoking prevalence has fallen more for men

Figure 6 Lung cancer incidence for men and women in Sweden and Norway from 1960–1999 for age standardised rates per 100 000 inhabitants based upon census population in each country. Based upon an original figure from cancer registry sources compiled by Wicklin.⁵⁷

Figure 7 Age standardised rate of lung cancer and oral cavity cancer for males and females in selected countries and a global average for more developed countries based upon age standardised rates for 100 000 based upon world population census.⁵⁸

(16)

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Interestingly Swedish men have also had a significant improvement in cardiovascular health over the same period.

For example, Rosen and colleagues studied trends in heart attacks in Sweden over the years 1987 to 1995 (amounting to 360 000 separate heart attacks in total).⁵⁹They found a 22%

drop in heart attacks in men aged 30–64 years during that period, roughly double the decline among same aged women over the same period (fig 8).

It is noteworthy that these improvements in tobacco caused illnesses have occurred primarily in men, despite a stable consumption of tobacco among men during that time period. The main factor that has changed is that many Swedish men have switched from smoked tobacco to snus. Of course one cannot state with absolute certainty that if snus had not been available in Sweden that just as many men would have quit smoking either without assistance or perhaps by switching to nicotine replacement therapy.

However, the pattern of sex differences in smoking cessation and snus use within Sweden, together with the between- country differences in smoking prevalence changes and health changes (comparing Sweden with other similar countries that have lower snus use, such as Norway),

strongly suggests that a significant portion of the health improvement among Swedish men over the past 20 years has been due to a large proportion quitting smoking or never starting to smoke, but using snus instead.

IS SNUS A ‘‘GATEWAY’’ TO SMOKING OR A PATHWAY FROM SMOKING IN SWEDEN?

It has been argued that smokeless tobacco could become a

‘‘gateway’’ product, hooking young people on nicotine from a cheaper and more easily concealed product, before they more easily move on to yet more addictive and harmful products such as cigarettes. For many reasons, the evidence from Sweden is not supportive of such a view. Firstly, if snus was acting to attract young people towards smoking one might expect the only country in Europe with a sizable snus market to have had the worst record for reducing smoking prevalence rather than the best. Secondly, when one examines the sex differences in tobacco use patterns, if snus was attracting young men towards smoking, one would expect the change in smoking prevalence to have been worse for men than for women, whereas it has been significantly better (that is, smoking prevalence has fallen more for men

Figure 6 Lung cancer incidence for men and women in Sweden and Norway from 1960–1999 for age standardised rates per 100 000 inhabitants based upon census population in each country. Based upon an original figure from cancer registry sources compiled by Wicklin.⁵⁷

Figure 7 Age standardised rate of lung cancer and oral cavity cancer for males and females in selected countries and a global average for more developed countries based upon age standardised rates for 100 000 based upon world population census.⁵⁸

0.008 0.017

1950 1960 1970 1980 1990 2000 Year:

0 0.05 0.10

Lung cancer mortality per 1000 aged 35−39 Male

Female

0.49 0.40

1950 1960 1970 1980 1990 2000 Year:

0 0.5 1.0 1.5 2.0 2.5

Lung cancer mortality per 1000 aged 55−59

Male Female

2.6

1.0

1950 1960 1970 1980 1990 2000 Year:

0 2.5 5.0 7.5

Lung cancer mortality per 1000 aged 75−79

Male Female

0.008 0.003 1950 1960 1970 1980 1990 2000 Year:

0 0.05 0.10

Upper aero−digestive cancer mortality per 1000 aged 35−39

Male Female

0.15 0.04 1950 1960 1970 1980 1990 2000 Year:

0 0.5 1.0 1.5 2.0 2.5

Male Female

0.5 0.2 1950 1960 1970 1980 1990 2000 Year:

0 2.5 5.0 7.5

Male Female

0.14 0.22

1950 1960 1970 1980 1990 2000 Year:

0 0.2 0.4 0.6

Other cancer mortality per 1000 aged 35−39 Male

Female

1.6 1.9

1950 1960 1970 1980 1990 2000 Year:

0 2 4 6

Female

12.5

7.7

1950 1960 1970 1980 1990 2000 Year:

0 5 10 15 20 25

Female

0.16 0.24

1950 1960 1970 1980 1990 2000 Year:

0 0.2 0.4 0.6

All cancer mortality per 1000 aged 35−39 Male

Female

* Annual mortality per 1000: averages of years available in 1950−54,....,1995−99; year 2000 on pages 458−459

2.2 2.4

1950 1960 1970 1980 1990 2000 Year:

0 2 4 6

Female

15.5

8.9

1950 1960 1970 1980 1990 2000 Year:

0 5 10 15 20 25

Female

**Mortality* trends at selected ages: 35−39, 55−59 & 75−79**

Peto, Lopez et al 468

SWEDEN: 1951-2000

June 2006

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