Tuesday, August 18, 2009

Tobacco Harm Reduction Gets the Nod in Norway

Norway occupies an interesting position in the European political arena, and in European tobacco issues. While it is located in the Scandinavian peninsula next to Sweden and has membership in the European Economic Area, Norway has twice rejected membership in the European Union. Thus, it has not been subject to the ridiculous EU policy in which vastly safer smokeless tobacco products are banned while cigarettes are freely available. In fact, information is now emerging from Norway that the increasing use of snus in the past 20 years has resulted in a substantial decline in smoking among Norwegian men, a virtual reproduction of the Swedish miracle that was documented by me and my colleagues in several published research articles.

The Norwegian tobacco harm reduction information was produced by Dr. Karl Erik Lund, a respected tobacco researcher with SIRUS, the Norwegian Institute for Alcohol and Drug Research. SIRUS is an independent institution, but it is also a government entity answerable to the Ministry of Health and Care Services. Lund has 20 years experience in tobacco research and more than 85 publications in the fields of tobacco epidemiology, evaluation and prevention.

Dr. Lund’s 2008 Presentation

In 2008, Dr. Lund gave a fascinating presentation on Norwegian tobacco use at the 51st conference of the International Council on Alcohol and Addictions. He reported that among Norwegian men age 16-35 years, the prevalence of smoking declined from 50% in 1985, to 30% in 2007, while the prevalence of snus use increased from 10% to 30%.

Lund reported that snus is very popular as a quit-smoking aid among Norwegian men. Among those who quit smoking in 2007, snus was used by 23%, while nicotine gum was used by only 9%; the nicotine patch, Zyban and a quit line were used by even fewer (6%, 3% and 3% respectively).

Lund also presented information about the outcome of the last quit attempt by Norwegian male smokers age 20-50 years in 2007. Of those who used snus, 74% “quit smoking altogether” or experienced a “dramatic reduction in smoking intensity.” It is important to point out that this success rate is essentially identical to the rate that we reported for American men who used smokeless tobacco to quit smoking. The percentages for those who used nicotine gum, patch and Zyban were 50%, 47% and 40% respectively.

We now have clear and compelling evidence that snus is a superior quit-smoking aid for men in Norway, in addition to those in Sweden and the United States.

Dr. Lund’s 2009 Report

Earlier this year Dr. Lund published (in Norwegian) a brilliant report on tobacco harm reduction entitled “A tobacco-free society or tobacco harm reduction? Which objective is best for the remaining smokers in Scandinavia?” Last week, the report was published in English, and it is available at this SIRUS website Following are some of the major findings.

Lund provided five compelling reasons why tobacco harm reduction is important:

(1) “…the effect of nicotine replacement products and the effect of interventions provided by doctors [are] very limited.”

(2) “A higher proportion of [remaining smokers have] social, mental and demographic characteristics associated with reduced ability to stop smoking.”

(3) “In Scandinavia, nearly all the political measures recommended by [the World Health Organization] for reducing smoking have already been implemented. There is probably little potential for further reduction by using publicly-regulated control of tobacco. Despite the fact that tobacco control measures are utilized to such a degree, the proportion of deaths due to smoking among adults is still very high.”

(4) “Intensifying the existing measures against smoking that have been effective up to now would probably give only a moderate return (diminishing marginal returns).”

(5) “Cigarette smoking is ideal for a harm reduction strategy, because the substance that causes addiction – nicotine – is not the cause of the health risk. People smoke because of nicotine, but die from tobacco smoke. Much less hazardous nicotine products are available.”

Lund argued that the slow implementation of tobacco harm reduction “is probably related to the widespread belief that it is possible to achieve a tobacco-free society.” He observed, “In order for harm reduction to be successful, consumers must receive correct information about the relative health risks of different types of nicotine products. Today, both smokers and general practitioners are misinformed.”

Lund also made a strong case that “Harm reduction policy must be made legitimate by the authorities. It is clearly a disadvantage and a hindrance for harm reduction if the snus industry [are] the most visible proponents of harm reduction.” He noted, “The health authorities in Norway and Sweden – where sale of snus is allowed – provide information about the health risks associated with the use of snus, but do not inform smokers about the health benefits that can be achieved by switching from cigarettes to snus. At worst, this can mean that nicotine-addicts remain smokers with no motive to try a harm-reducing alternative.”

Lund rejected the allegation that snus use is a gateway to smoking: “There is little empirical data from Scandinavia to support the hypothesis that snus increases the risk of starting to smoke. There is some empirical data to support the hypothesis that snus reduces the risk of starting to smoke.”

Lund concluded with a powerful summary:
Without encouragement to use harm-reducing nicotine products, a large proportion of remaining smokers will continue to smoke, and will thus have a 50 per cent chance of dying from a tobacco-related disease. With the status quo in tobacco/nicotine policy that is given legitimacy by the authorities – that is a policy without an active harm-reduction strategy – use of tobacco will maintain and strengthen future social inequalities in health status.

In Scandinavia up until now there has been little willingness to discuss harm reduction in the area of tobacco. The debate has been hampered by dogmatic statements of principle (particularly about snus) that suppress exchange of opinions and reflections about the ethical implications of harm reduction. Interest for – albeit limited – empirical research that can illuminate the theme has been moderate, taking into consideration the potential that harm reduction has for improving public health. Maybe this report can stimulate less biased debate?

In Scandinavia, the tobacco problem is not substantially less serious now than it was in the 1960s. At that time, doctors did not know the extent of the hazards of smoking, or that cigarettes would be the cause of so many deaths over the next 40 years. We now have knowledge about the extent of the hazards, nearly all conceivable preventive measures have been used, and we can predict future changes in smoking behaviour. In contrast to the doctors in the 1960s, we are now on the brink of a human catastrophe that we have been warned will occur if the reduction in smoking does not speed up. To ignore harm reduction as a future strategy in the area of tobacco can be erroneous in this situation. An uncompromising attitude to a tobacco-free society can deny many nicotine-dependent smokers the possibility to survive, which they could have had if the authorities had assumed a more pragmatic attitude to harm reduction.

The Norwegian Health Directorate Changes Its Views

It is important to point out that Lund’s report has already produced a dramatic change in the Norwegian Health Directorate's attitude toward snus as a quit-smoking aid. In the English translation, Lund added this epilogue:
About half a year before this report was published in English, an almost identical version was published in Norwegian. In Norway, the report received a lot of attention and stimulated a continuation of the debate on harm reduction, both in the media and in professional circles. The Norwegian Directorate of Health and representatives of the Norwegian Medical Association have some new points of view that can be interpreted as more positive to harm reduction ideology. For example, a director of division in the Norwegian Directorate of Health said to the newspaper Bergens Tidende under the headline "The Norwegian Directorate of Health is willing to consider snus":

"The Norwegian Directorate of Health says yes to general practitioners, dentists and other health care personnel being able to recommend health-damaging snus to inveterate smokers. Snus is clearly less damaging to health than smoking. If patients have tried other methods without success, we mean that health care personnel can recommend that they use snus instead," says Knut-Inge Klepp, director of division in the Norwegian Directorate of Health. He stresses that before such a recommendation can be made, other nicotine replacement products, and, if appropriate, medicinal nicotine products, must have been tried. Klepp also stresses that such a recommendation must be made directly by health care personnel to the person who needs advice. He is strongly against a general recommendation.

On the web site of the Norwegian Directorate of Health, a new attitude to use of snus as a harm-reducing product is confirmed:

"We know that a large proportion of people who smoke have contact with a dentist or a general practitioner," says Klepp. "It is important that health care personnel take up the topic of smoking, recommend quitting, and help people who wish to quit. In the first instance they should try established methods such as nicotine chewing gum, nicotine patches or medicinal nicotine products available on prescription. If patients have tried these methods without being successful, the Norwegian Directorate of Health means that health care personnel in individual cases can consider that the patient should try snus instead."

Tobacco harm reduction is happening in Norway, and Norwegian officials recognize that the lives of smokers are a higher priority than the demise of the tobacco industry.

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