Points of interest


ITS’ comments to the report SOU 2015:6 on proposals for legislation to implement the EU Directive on Tobacco Products.


Mortality attributable to tobacco among men in Sweden and other European countries: an analysis of data in a WHO report.


Death by regulation: the EU ban on low-risk oral tobacco

Clive Bates makes strong arguments for lifting the EU-ban on smokeless tobacco.

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Swedish tobacco experts in double seats

Doctors help to lobby against snus – and for Pfizer’s drugs

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Read more (Swe) >


Cut out the smoke, reduce the risks


Articles in scientific journals


Mortality attributable to tobacco among men in Sweden and other European countries: an analysis of data in a WHO report

Ramström L, Wikmans T. Tob Induc Dis. 2014 Sep 1;12(1):14

Abstract
Background
It is well known that Swedish men have lower tobacco-related mortality than men in other European countries, but there are questions that need further investigation to what extent this is related to the specific patterns of tobacco use in Sweden, where use of snus, the Swedish low-nitrosamine oral tobacco, dominates over smoking in men but not in women. The recent WHO Global Report: Mortality Attributable to Tobacco provides a unique set of estimates of the health burden of tobacco in all countries of the world in the year 2004, and these data can help elucidating the above-mentioned questions.

Methods
For Sweden and all other European Union Member States mortality data for a number of tobacco-related causes of death were extracted from the WHO Report. The size of the mortality advantage for selected causes of death in different age groups of Swedish men compared to men of the same age in Europe as a whole was calculated in terms of ratios of death rates attributable to tobacco. Differences between age groups with respect to tobacco-related mortality were analyzed with respect to differences in terms of development and status of smoking and snus use. The analyses also paid attention to differences between countries regarding tobacco control regulations.

Findings
Among men in the European Union Member States the lowest level of mortality attributable to tobacco was consistently found in Sweden, while Swedish women showed levels similar to European average. A strong co-variation was found between the mortality advantage and the degree of dominance of snus use in the different age groups of Swedish men. Among Swedish women there are no age groups with dominant use of snus, and similar observations were therefore not possible for women.

Conclusion
The above findings support the assumption that the widespread use of snus instead of cigarettes among Swedish men may be a major part of the explanation behind their position with Europe’s lowest mortality attributable to tobacco.

Keywords
Mortality; Snus; Smoking; Sweden; Europe

How to Cite
Ramström L, Wikmans T. Mortality attributable to tobacco among men in Sweden and other European countries: an analysis of data in a WHO report. Tob Induc Dis. 2014 Sep 1;12(1):14. doi: 10.1186/1617-9625-12-14.

Consolidating the evidence on effectiveness of snus for smoking cessation – implications for public health

Ramström, L. Addiction, 2011 Jan;106(1):168–169.

Full text

SUMMARY
The Swedish type of low-toxicity smokeless tobacco, snus, has been used extensively for smoking cessation and a high degree of effectiveness has been demonstrated, both for men and women.

The paper, Lund et al., The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction 2011; 106: 162–7, confirms earlier Swedish research data and, together with another recent paper by the same lead author, it also widens the perspective by demonstrating that the same patterns can actually develop in a country where snus has not such an old tradition as in Sweden.

Studies from Sweden and the United States have demonstrated that misbeliefs regarding snus and other nicotine products are very common. This is likely to discourage many smokers from adopting effective cessation practices with use of nicotine-containing aids in ‘real-life’ attempts to quit smoking. The current Norwegian study consolidates the evidence on the effectiveness of snus for smoking cessation. This should encourage the use of effective smoking cessation methods to the benefit of public health.

How to Cite.
Ramström, L. Commentary on Lund et al. Consolidating the evidence on effectiveness of snus for smoking cessation – implications for public health. Addiction, 2011 Jan; 106(1):168–169.


FCTC Background Report On Smokeless Tobacco Is Incompatible With WHO Scientific Reports.

Borland, R., Fagerström, K., Foulds, J., Mcneill, A., Ramström, L. Addiction, 2011 Jan;106(1): 225–227

Full text

SUMMARY
Letter to the Editor from 15 international tobacco researchers drawing attention to the Fourth session of the Conference of the Parties to the WHO Framework Convention on Tobacco Control, COP4, 15–20 November 2010.

An excellent scientific basis for the discussions under the agenda item regarding smokeless tobaccos has been provided by the WHO Study Group on Tobacco Product Regulation. However, the FCTC Secretariat has prepared a separate background report. Surprisingly, this report is incompatible with the WHO scientific reports.

The Letter reviews the weaknesses of that background report and makes brief references to pertinent pieces of evidence published in the scientific literature.

The authors conclude that it would be unfortunate if the credibility of the FCTC is questioned because of weaknesses in the material provided as a basis for discussions and decisions and hope that the current background report will be replaced by a comprehensive summary of the reports of the scientific Study Group.

How to Cite.
Borland, R., Fagerström, K., Foulds, J., Mcneill, A., Ramström, L. FCTC Background Report On Smokeless Tobacco Is Incompatible With WHO Scientific Reports. Addiction, 2011 Jan; 106(1): 225–227.


Harm perception among Swedish daily smokers regarding nicotine, NRT-products and Swedish Snus.

Wikmans T, Ramström L. Tob Induc Dis. 2010 Aug 13;8:9.

Full text

ABSTRACT

Background:
In Sweden NRT-products and Snus, are easily available and used as smoking cessation aids. However, most quit attempts are made without any cessation aids. The limited use of these products as cessation aids may be influenced by the way smokers perceive the harmfulness of NRT-products and Snus compared to smoking. The present study examines these perceptions and their association with perceptions of the harmfulness of nicotine itself.

Methods:
The study is based on the Swedish part of a two-nation web-based survey of daily smokers in Sweden (n = 1016) and Norway (n = 1000). Questionnaire items addressed perceptions of NRT-products’ and Snus’ harmfulness and nicotine’s part of the health risks of smoking. Data analyses included cross-tabulations and logistic regressions.

Results:
A majority, 59% of the answers to the question about harmfulness of NRT-products, and 75% of the answers about harmfulness of Snus, were inconsistent with the scientific evidence by demonstrating exaggerated perceptions of harmfulness. The strongest predictor of consistent answers was the perception of the harmfulness of nicotine. There were also significant associations with own experience of successful use of the products in question. Overall the perceptions of the harmfulness of nicotine were considerably exaggerated. This pattern was more pronounced among women than men. Prevailing misperceptions may be related to the way that different tobacco and nicotine products are presented in the media and other publicly available information sources.

Conclusions:
Public information about smoking and health should be expanded to include objective and unambiguous information regarding nicotine’s part in the harmfulness of smoking and the harmfulness of different nicotine-containing products compared to smoking. This is essential in order to preclude that misperceptions regarding these matters could discourage smokers from adopting effective cessation practices with use of nicotine-containing aids.

How to Cite.
Wikmans T, Ramström L. Harm perception among Swedish daily smokers regarding nicotine, NRT-products and Swedish Snus. Tob Induc Dis. 2010 Aug 13; 8:9.


Role of snus in initiation and cessation of tobacco smoking in Sweden.

Ramström LM, Foulds J. Tob Control. 2006 Jun;15(3):210-4.

Full text

ABSTRACT

Objective:
To examine patterns of smoking and snus use and identify individual pathways of Swedish tobacco users in order to clarify whether snus use is associated with increased or decreased smoking.

Methods:
Retrospective analysis of data from a cross-sectional survey completed by 6752 adult Swedes in 2001-2 focusing on identifying tobacco use history by survey items on current and prior tobacco use and smoking initiation and cessation procedures.

Results:
15% of the men and 19% of the women completing the survey were daily smokers. 21% of the men and 2% of the women were daily snus users. Almost all (91%) male daily smoking began before the age of 23 years, whereas initiation of daily snus use continued throughout the age range (33% of initiation after age 22). 20% of male primary snus users started daily smoking compared to 47% of non-primary snus users. Thus, the odds of initiating daily smoking were significantly lower for men who had started using snus than for those who had not (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.22 to 0.36). Among male primary smokers, 28% started secondary daily snus use and 73% did not. 88% of those secondary snus users had ceased daily smoking completely by the time of the survey as compared with 56% of those primary daily smokers who never became daily snus users (OR 5.7, 95% CI 4.9 to 8.1). Among men who made attempts to quit smoking, snus was the most commonly used cessation aid, being used by 24% on their latest quit attempt. Of those men who had used one single cessation aid 58% had used snus, as compared with 38% for all nicotine replacement therapy products together. Among men who used snus as a single aid, 66% succeeded in quitting completely, as compared with 47% of those using nicotine gum (OR 2.2, 95% CI 1.3 to 3.7) or 32% for those using the nicotine patch (OR 4.2, 95% CI 2.1 to 8.6). Women using snus as an aid were also significantly more likely to quit smoking successfully than those using nicotine patches or gum.

Conclusions:
Use of snus in Sweden is associated with a reduced risk of becoming a daily smoker and an increased likelihood of stopping smoking

How to Cite.
Ramström LM, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob Control. 2006 Jun; 15(3):210-4.


Causal effects of smokeless tobacco on mortality in CPS-I and CPS-II?

Foulds J, Ramström L. Cancer Causes Control. 2006 Mar;17(2):227-8. No abstract available.

SUMMARY:
Letter to the Editor discussing a study byHenleyet al.which concludes that the findings suggest a causal relationship between smokeless tobacco use and lung and oral cancer mortality. However, various potential confounders raise questions about that interpretation.

How to Cite.
Foulds J, Ramström L. Causal effects of smokeless tobacco on mortality in CPS-I and CPS-II? Cancer Causes Control. 2006 Mar; 17(2):227-8.


Re: ”Smokeless tobacco use and risk of cancer of the pancreas and other organs” by Boffetta et al.

Ramström L. Int J Cancer. 2006 Mar 15;118(6):1584; author reply 1586-7.

SUMMARY:
Letter to the Editor discussing a study by Bofetta et al. which concludes that smokeless tobacco products may be carcinogenic on the pancreas. However, a number of methodological weaknesses challenge the validity of that conclusion.

How to Cite.
Ramström L. Re: ”Smokeless tobacco use and risk of cancer of the pancreas and other organs” by Boffetta et al. Int J Cancer. 2006 Mar 15; 118(6):1584; author reply 1586-7.


European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health.

Bates C, Fagerström K, Jarvis MJ, Kunze M, McNeill A, Ramström L. Tob Control. 2003 Dec;12(4):360-7.

Full text

ABSTRACT

Rationale:
This statement is an updated version of one released by the same authors in February 2003. The statement was produced to follow up the Royal College of Physicians (RCP) Tobacco Advisory Group report ”Protecting smokers, saving lives: the case for a tobacco and nicotine regulatory authority”, which argued for an evidence based regulatory approach to smokeless tobacco and harm reduction and posed a series of questions that regulators must address in relation to smokeless tobacco. The purpose of this statement is to provide arguments of fact and principle to follow the RCP’s report and to outline the public health case for changing existing European Union (EU) regulation in this area. A review of regulation in relation to harm reduction and regulation of tobacco products other than cigarettes is required in Article 11 of EU directive 2001/37/EC, and this is a contribution towards forming a consensus in the European public health community about what policy the EU should adopt in the light of this review, or following ongoing legal action that may potentially strike out the existing regulation altogether.

Public health case:
We believe that the partial ban applied to some forms of smokeless tobacco in the EU should be replaced by regulation of the toxicity of all smokeless tobacco. We hold this view for public health reasons: smokeless tobacco is substantially less harmful than smoking and evidence from Sweden suggests it is used as a substitute for smoking and for smoking cessation. To the extent there is a ”gateway” it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease inEurope. We think it is wrong to deny other Europeans this option for risk reduction and that the current ban violates rights of smokers to control their own risks. For smokers that are addicted to nicotine and cannot or will not stop, it is important that they can take advantage of much less hazardous forms of nicotine and tobacco-the alternative being to ”quit or die”. and many die. While nicotine replacement therapies (NRT) may have a role in harm reduction, tobacco based harm reduction options may reach more smokers and in a different, market based, way. Chewing tobacco is not banned or regulated in the EU but is often highly toxic, and our proposal could remove more products from the market than it permitted.

Regulatory options:
We believe that the EU policy on smokeless tobacco should adapt to new scientific knowledge and that the European Commission should bring forward proposals to amend or replace Article 8 of directive 2001/37/EC with a new regulatory framework.Canadahas developed testing regimens for tobacco constituents and these could be readily adapted to the European situation. A review of EU policy in this area is required no later than December 2004, and we believe the Commission should expedite the part of its review that deals with harm reduction and regulation of tobacco products other than cigarettes so as to reconsider its policy on smokeless tobacco. We held this view before Swedish Match brought its legal proceedings to challenge EU legislation and we will continue to hold these views if its action fails.

How to Cite.
Bates C, Fagerström K, Jarvis MJ, Kunze M, McNeill A, Ramström L. European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tob Control. 2003 Dec; 12(4):360-7.


Effect of smokeless tobacco (snus) on smoking and public health in Sweden.

Foulds J, Ramström L, Burke M, Fagerström K. Tob Control. 2003 Dec;12(4):349-59. Review.

Full text

ABSTRACT

Objective:
To review the evidence on the effects of moist smokeless tobacco (snus) on smoking and ill health in Sweden.

Methods:
Narrative review of published papers and other data sources (for example, conference abstracts and internet based information) on snus use, use of other tobacco products, and changes in health status in Sweden.

Results:
Snus is manufactured and stored in a manner that causes it to deliver lower concentrations of some harmful chemicals than other tobacco products, although it can deliver high doses of nicotine. It is dependence forming, but does not appear to cause cancer or respiratory diseases. It may cause a slight increase in cardiovascular risks and is likely to be harmful to the unborn fetus, although these risks are lower than those caused by smoking. There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use.

Conclusions:
Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.

How to Cite.
Foulds J, Ramström L, Burke M, Fagerström K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control. 2003 Dec; 12(4):349-59. Review.


Snus: part of the problem or part of the solution?

Ramström L. Addiction. 2003 Sep;98(9):1198-9; discussion 1204-7.

SUMMARY:
Invited commentary discussing matters regarding the use of snus in Sweden in connection with articles by Galanti/Gilljam and Fagerström/Schildt. Some tobacco control advocates fear that snus poses problems in terms in terms of “overload” of nicotine and increase of nicotine dependence, but actual evidence does not support that idea. On the other hand Swedish experiences suggest that snus use can keep down initiation of smoking and support smoking cessation and thereby contribute to the solution of the problem.

How to Cite.
Ramström L. Snus: part of the problem or part of the solution? Addiction. 2003 Sep; 98(9):1198-9; discussion 1204-7.