New IARC monograph on smokeless tobacco
Thursday, January 10, 2008
Jonathan Foulds, MA, MAppSci, PhD
For example, on p35 in the intoductory remarks to the report it states:
“Some health scientists have suggested that smokeless tobacco should be used for smoking cessation, and claim that its use would reduce the smokers exposure to carcinogens and risk for cancer. They also attribute declines in smoking in Sweden to increased consumption of moist snuff in that country. However, as discussed in volume 1 of the monograph on smokeless tobacco, these claims are not supported by the available evidence.”
However, the section of the report that reviews the evidence (available in 2004) on snuff use in Sweden ends with the following sentence (p174):
“These findings suggest that snuff use may be associated with smoking cessation among Swedish men but not women.”
Later on in the monograph (p153) it gives another view of the relationship between snuff use and smoking in Sweden:
“ The exact role that snuff has played in reducing the prevalence of smoking in Sweden is unclear, but it has probably been overstated (Tomar et al. 2003).”
(Tomar was one of the IARC report authors).
But now that the report has been released in 2008, we have much more evidence on the relationship between snus use and non-smoking in Sweden, showing that it was unfortunately understated by the IARC expert group. Since 2003/4 (1) there have been subsequent publications that have confirmed that in Sweden, men who start using snus are less likely to become daily smokers, that men who smoke and then start using snus are more likely to stop smoking, and that a higher proportion of men than women in Sweden have quit smoking, with the difference largely attributable to snus use (2,3). It had previously been suggested that the men who quit smoking in Sweden are not the same ones who start using snus (and that snus use is therefore not involved in men quitting smoking) (4). However, studies have now verified that in fact a sizeable proportion (26-30%) of Swedish men who quit smoking use snus as a smoking cessation aid (2,5,6). The latest report found that 30.4% of Swedish men who quit smoking from 2000-2004 did so by switching to snus (compared to 14.8% who quit by using NRT) (6). In northern Sweden, where smokeless use is most prevalent, daily smoking prevalence among male 25-34 year-olds is down to 3%, while daily snus use is 34% (7).
It is now crystal clear (and was fairly clear in 2003) that their transfer of nicotine dependence onto snus has accelerated the rate of decline of smoking among Swedish men in substantial numbers. That transfer from an extremely harmful form of tobacco use (cigarette smoking) to a much less harmful form (snus) has contributed to a reduction in the rate of smoking-caused diseases in Swedish men. Of 100 geographic units (primarily countries) in Europe, Swedish men now have the single lowest rate of lung cancer, and less than a half of the rate of lung cancer in the rest of Europe (IARC).
1. Foulds J, Ramstrom L, Burke M, Fagerstrom K. The effect of smokeless tobacco (snus) on public health in Sweden. Tobacco Control 2003; 12:349-59.
Pdf available at: http://www.tobaccoprogram.org/staffarticles.htm
2. Ramström LM, Foulds J. The role of snus (smokeless tobacco) in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006 Jun;15(3):210-4.
Pdf available at: http://www.tobaccoprogram.org/staffarticles.htm
3. Furberg Furberg H, Bulik C, Lerman C, et al. Is Swedish snus associated with smoking initiation or smoking cessation? Tob Control.2005; 14:422-424.
4. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking in Sweden: Is Swedish Match getting the credit for Swedish tobacco control’s efforts? Tobacco Control2003; 12:368-59
5. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction 2003;98:1183-9.
6. Lindström M. Nicotine replacement therapy, professional therapy, snuff use and tobacco smoking: a study of smoking cessation strategies in southern Sweden. Tob Control. 2007 Dec;16(6):410-6.
7. Stegmayr, B., M. Eliasson, and B. Rodu, The decline of smoking in northern Sweden. Scand J Public Health, 2005. 33(4): 321-4
For further information on smokeless tobacco check out:
Marlboro Snus: what is it? 6/10/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/marlboro-snus-what-is-it.html
Why did Philip Morris’s new smokeless tobacco product (“Taboka”) deliver almost no nicotine? 6/12/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/why-did-philip-morriss-new-smokeless.html
Carcinogens from smoking and smokeless tobacco use (1). 8/27/07 http://www.healthline.com/blogs/smoking_cessation/2007/08/carcinogens-from-smoking-and-smokeless.html
Smoking, smokeless tobacco and cancer (2). 8/28/07 http://www.healthline.com/blogs/smoking_cessation/2007/08/smoking-smokeless-tobacco-and-cancer-2.html
Labels: jonathan foulds, nicotine addiction, nicotine regulation, smokeless, smoking tobacco
6 Comments:
At Thu Jan 10, 01:34:00 PM 2008,
Anonymous said…
I notice that although the report stems from an expert meeting in 2004, it includes a number of more recent citations (e.g. Henley et al, 2005), but none of the ones that add to the evidence showing that male Swedish smokers are switching to snus (e.g. papers by Stegmayr, Ramstrom, or Furberg). Of course that evidence wouldn't be consistent with the position taken in the introduction of the report, would it?
At Wed Jan 16, 10:13:00 AM 2008,
Scott Tomar said…
No, those statements concerning the role of snus in reducing smoking in Sweden are not inconsistent. Yes, there is evidence that men (but few women) have quit smoking by using snus. But the trends in smoking prevalence, smoking cessation, and smoking initiation are nearly identical among Swedish women. Take a look at smoking quit ratios by sex and age using official Swedish statistics, and don't ignore the 40% of smokers of either sex who smoke on a less than daily basis. I guess snus is such a powerful agent that it actually prevents or treats smoking among those who don't use it.
At Thu Jan 17, 08:01:00 PM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
Dear Professor Tomar,
I'm glad to see that you read this blog and have taken the trouble to comment.
As has been pointed out in many studies, there is no doubt that smoking has fallen faster in Swedish men than women. The Swedish national statistics have some problems in this regard because they changed the form and wording of the questions asked in 1981-2. You seem to have a problem with analyses based on daily smokers, but I'm sure you will agree that (a) these account for the vast majority of smokers and (b) these are the smokers likely to suffer by far the greatest health effects from continued smoking.
I'm afraid I didn't fully understand your last sentence, but yes, the evidence is most consistent with the idea that Swedes who start using snus first, are less likely to become daily smokers. This preventive effect may be an important positive effect in addition to its effect of helping smokers quit (which you now appear to accept as being the case). I've got a feeling we're not going to agree on this subject.
Those who are interested can read some of these issues being debated in more detail at:
http://tobaccocontrol.bmj.com/cgi/eletters/12/4/368#110
If you are really interested you can download slides on this subject from:
http://www.tobaccoprogram.org/fouldstma.htm
Slide 47 shows how unique Sweden is as the only country in Europe in which male daily smoking is clearly lower than female daily smoking. Now why would that be if there was a gateway turning all those young male snus users into smokers? Clearly thats not the way it is working - its quite the opposite.
I prefer to take the word of the 30% of Swedish male ex-smokers who say they used snus to quit smoking.
Now you may ask why this many Americans havn't quit smoking by using smokeless. Part of the explanation is that health experts in this country have told the public that smokeless is just as harmful as smoking - so what would be the point in switching if that were true? Nice job. Philip Morris loved that little bit of misinformation.
At Sun Jan 20, 01:28:00 PM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
Hi,
Here is a quote from the latest (2007) Swedish government report on tobacco use (p81):
"Over the past 25 years, the proportion of daily smokers has decreased from 35 percent to 14 percent among men and from 28% to 18% among women."
This doesn't look like a "nearly identical" pattern to me.
For those who want to read the report (mainly in Swedish), it can be found at:
http://www.scb.se/statistik/_publikationer/LE0101_2004I05_BR_LE114SA0701.pdf
At Tue Jan 22, 06:44:00 AM 2008,
Scott Tomar said…
Using official Swedish data for smoking for 2004 (from the ULF survey conducted by Statistics Sweden), smoking quit rates (or what some call smoking quit ratios, defined as the proportion of ever smokers who are now former smokers), by age group and sex are:
Age 16–24
Men 13.2%
Women 14.6%
Age 25–44
Men 37.8%
Women 38.3%
Age 45–64
Men 54.5%
Women 51.7%
Please explain why the quit rates in Sweden are so similar for men and women within each age stratum if snus had such a dramatic effect on cessation? That was what I meant in the last line of my initial post; snus use for smoking cessation or any other purpose remains quite low among Swedish women.
You are probably correct, we probably won't agree on this subject, and it's fine that we can respectfully agree to disagree. What I'm trying to reconcile is your public statements that clinicians should not recommend that their patients who smoke try using smokeless tobacco to quit, while castigating the public health community for not promoting these products for harm reduction.
At Tue Jan 22, 09:56:00 PM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
Hi,
For further discussion of these issues, see my post of January 22nd, 2008.
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