A different story

Introduction

When thinking of tobacco, one thinks of cigarettes. Cigarettes are the most commonly used tobacco product in the world. Global consumption of cigarettes has been steadily rising since cigarettes were launched widely at the beginning of the 20th century. Today, there are approximately 46 million daily smokers in the U.S. and 1.2 billion daily smokers in the world. Cigarettes are considered to be responsible for the deaths of half of all lifetime smokers.

In the U.S., 400,000 smokers are estimated to die annually due to cigarette smoking. However, the tobacco consumption pattern in Sweden is unique. The monopoly of cigarettes as the major tobacco product used has been broken among adult males in Sweden. There has been an interesting transformation during the past 50 years in Sweden.

Among adult males, Sweden has:

  • Europe’s highest per capita consumption of smokeless tobacco
  • Lowest cigarette consumption in Europe
  • Lowest lung cancer mortality rate in Europe
  • Among the lowest oral cancer mortality rate in Europe
  • Lowest percentage of smoking-related deaths among developed countries
  • Total tobacco consumption similar to neighboring countries (Norway, Denmark and Finland)

Smokeless tobacco products

There are a great variety of oral tobacco products around the world, many of which differ widely in chemical composition. The most unwanted constituents in all tobacco products are the Tobacco-Specific Nitrosamines (TSNA). The International Agency for Research on Cancer (IARC) classifies two of the tobacco-specific nitrosamines, NNN and NNK10, as possibly carcinogenic to humans. Hence, it is essential to eliminate or minimize the levels of these hazardous constituents in tobacco.

A study by Nyren11 states, “The smokeless tobacco used in the Third World may contain considerably higher levels of carcinogenic substances. A recent comparison between Swedish moist snuff and Sudanese toombaak reveals that the levels of NNN, NNK and NAT, respectively, were 100-200-fold, 600-4000-fold and 10-60-fold higher in the latter”.

Smokeless tobacco in Sweden - snus

Swedish snus is a traditional product in Sweden, dating back to the early 1800s. Swedish snus is a ground, heat-processed (non-fermented), spit-less, oral tobacco product. It is used by placing a pouch between the upper lip and gum.

Snus use is more common than cigarette smoking among Swedish men, 22% vs. 14% in 20047. Approximately 50% of the snus users today in Sweden are ex-smokers. In the case of oral cancer, smoking (and alcohol) is a well-established risk factor. Several studies conducted in the 1990s, Schildt, et.al. (1998)8 and Lewin, et.al. (1998)9, found no evidence of an increased risk of oral cancer among users of Swedish snus. These findings offer an explanation why the incidence of oral cancer, as shown in Figure 5, is very low among men in Sweden compared with that in other countries, despite the high rate of snus use in Sweden. (Swedes are the only ones using smokeless tobacco extensively in Europe).

Figure5: Age-Standardized (World) Incidence Rates in Males of Oral Cancer (ICD 141; 143-145 per 100,000.

Source: Extract from Cancer Incidence in Five Continents, Volume VII, IARC Sci. Publ. 143, Lyon, France, 1997

The risk for Swedish females of dying from a tobacco-related disease is in line with the risk for women in the rest of the Europe. Their tobacco consumption pattern is also in line with the general tobacco consumption (cigarette smoking) pattern among European females.

Cigarette smoking in Sweden

Sweden was the first and only country in the western world to reach the World Health Organization’s (WHO) goal of reducing the percentage of smokers in the adult population (men and women) to below 20% by 2000. This is mainly due to the fact that the Swedish male population smokes considerably less than the male populations in other European countries as shown in Figure 1.

Figure1: Smoking Prevalence (%) Among Men, 2002-2003

SOURCE: Joossens, L. 2004. Effective tobacco control policies in 28 European countries. Presented at The Open Forum – Health in the enlarged Europe, Brussels, 17 May 2004. European Network for Smoking Prevention.

The following statistics and scientific studies from Sweden demonstrate how this unique tobacco consumption pattern can have a positive impact on cigarette consumption and tobacco-related diseases.

This data offers an explanation for the fact that the incidence of bronchus and lung cancer is lower among Swedish men than among men in most other developed countries. Figure 2 below presents the Lung Cancer Death Rates, Men age 40+, Europe 2002.

Figure2: Lung Cancer Death Rates, Men Age 40+, Europe 2002

SOURCE: WHO-IARC Worldwide Cancer Mortality Database

Figure 3 illustrates that the risk of dying from a smoking related disease is very low for Swedish men compared to men in other western countries.

Figure3: The Risk, at the age of 35, of Dying from a Smoking Related Disease before the age of 70

SOURCE: Peto et al, Mortality from Smoking in Developed Countries 1950-2000. Oxford University Press

Rodu and Cole (2004)1 developed a systematic approach for estimating smoking prevalence and its impact on mortality in all EU countries. They conclude that 200,000 smoking related deaths would be avoided if all EU males smoked at the age-specific prevalence rates of Swedish men.

Rodu, et.al. (2002)2, Foulds, et.al. (2003)3, Rodu, et.al. (2003)4, Henningfield and Fagerstrom (2001)5, and Ault, et.al. (2004)6 have suggested that the low prevalence of smoking in Sweden is directly related to the availability of Swedish snus. Figure 4 shows the sales of snus and cigarettes as a function of time.

Figure4: Sales of Snus and Cigarettes in Sweden 1916-2001

SOURCE: Swedish Match 2001