Smoking in the European Union: How Swede It Could Be

In 2002 and 2003, I worked with a group of scientists from Umeå University in Sweden on a series of research reports. We documented that use of smokeless tobacco (“snus” in Swedish) has played an impressive role in low smoking rates among Swedish men.

In 2005 we published another study, showing that smoking among Swedish women had started to decline as a result of increased snus use. Our findings were confirmed by studies published by other Swedes in 2005 and 2006 .

Unfortunately, the European Union (EU) Commission’s Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) ignored this evidence when it published a report on smokeless tobacco in 2008 entitled “Health Effects of Smokeless Tobacco Products.” Although the report acknowledged that “…particularly in Swedish men, there is a clear trend over recent decades for smoking prevalence to decrease and for use of oral tobacco (snus) to increase,” it concluded that “…these trends could also be due to successful smoking reduction programs or other socio-cultural factors, and it is therefore not clear whether or by how much the availability of snus has influenced smoking prevalence.” The report also stated that “…it is not possible to extrapolate the trends in prevalence of smoking and use of oral tobacco if it were made available in an EU country where it is now unavailable.”

Along with Phil Cole, an epidemiologist at the University of Alabama at Birmingham, I decided to address the SCENIHR indecision on extrapolation. While it is not possible to predict to what extent the availability of snus would reduce smoking prevalence in EU countries other than Sweden, it is possible to estimate how smoking-attributable deaths would decline if these countries had the smoking prevalence of Sweden.

We looked at lung cancer mortality trends in EU countries, starting about 1950 and ending in 2002. Lung cancer is the sentinel disease of smoking, and a country’s lung cancer mortality rate (LCMR) provides a reasonable indication of the amount of smoking in that country. Our data came from the World Health Organization and the International Agency for Research on Cancer, and our study was published in the Scandinavian Journal of Public Health.

In 2002, there were 172,000 lung cancer deaths among men in the EU. If all EU countries had the LCMR of men in Sweden, there would have been 92,000 fewer lung cancer deaths. Using this data, we can calculate the number of deaths from smoking in EU countries and compare it to the number in Sweden. For men in the EU, 91% of all lung cancer deaths are attributed to smoking, and lung cancer accounts for 31% of all smoking-attributable deaths.

We estimate that there were 509,000 smoking attributable deaths among men in EU countries in 2002. If all EU countries had the smoking rates of Swedish men, there would have been only 237,000 deaths. In other words, 274,000 smoking-attributable EU deaths would have been avoided.

The following table lists the numbers for each EU country (no data was available for Belgium and Cyprus).

Country	Deaths From Smoking, 2002	At Swedish Rate	% Change At Swedish Rate
Austria	7,000	3,900	-44
Bulgaria	7,100	3,800	-46
Czech Republic	12,500	4,500	-64
Denmark	5,700	2,800	-52
Estonia	1,600	600	-66
Finland	4,100	2,600	-36
France	60,000	28,300	-53
Germany	83,700	43,700	-48
Greece	13,900	6,200	-56
Hungary	16,300	4,400	-73
Ireland	2,700	1,600	-43
Italy	75,300	34,200	-55
Latvia	2,600	900	-64
Lithuania	3,500	1,300	-63
Luxembourg	400	200	-53
Malta	400	200	-51
Netherlands	18,700	7,700	-59
Poland	48,500	14,400	-70
Portugal	7,000	5,100	-26
Romania	20,100	9,000	-56
Slovakia	4,900	1,900	-61
Slovenia	2,100	900	-58
Spain	46,100	21,100	-54
Sweden	5,200	5,200	---
United Kingdom	59,500	32,000	-46
All EU Countries	509,000	236,500	-54

The countries with the largest numbers of smoking-attributable deaths are Germany, Italy, France and the UK, which reflects both large populations and high smoking rates. If these countries had access to snus and men used it as frequently as those in Sweden, deaths would be reduced by half. The biggest proportional reductions would come in eastern EU countries like Poland (73%) and Hungary (70%), which have the highest smoking rates in the EU.

The large differences in LCMRs between Sweden and other EU countries occur only in men. For most of the last 50 years, the LCMR among Swedish women was the sixth highest in the EU. This context is important, because it has been suggested that vigorous anti-smoking campaigns since the 1970s are the major determinant of the low Swedish smoking rates. It is implausible that these campaigns were highly effective for Swedish men and almost completely ineffective for Swedish women. The striking difference in the relative EU ranking of Swedish men and women is firm evidence that snus use, not anti-smoking campaigns, has played the primary role in low LCMR rates among men in Sweden for over a half century.

World War II created millions of male smokers, resulting in very high LCMRs throughout Europe in the 1960s and 1970s. Men in Portugal, Spain and Italy, which had LCMRs similar to those in Sweden in the early 1950s, later experienced peak LCMRs that were four to six times higher, while the peak in Sweden represented only a three-fold increase. Even though snus consumption declined until 1969, its use was high enough to suppress smoking by Swedish men and to keep their LCMR among the lowest in the EU. Increasing snus consumption in the last two decades has been accompanied by further declines in smoking. If current trends hold, the LCMR for Swedish men may become lower than that for Swedish women by 2011.

Currently, snus is banned in all EU countries except Sweden. While it cannot be proven that the availability of snus would reduce smoking prevalence in other EU countries, our study shows that snus use has had a profound effect on smoking among Swedish men. It also reveals that 274,000 smoking-attributable deaths would be avoided if all men in all EU countries had the smoking prevalence of men in Sweden.

In 2008, an article in the prestigious medical journal Lancet argued that “…the absence of effective harm reduction options for smokers is perverse, unjust, and acts against the rights and best interests of smokers and the public health.” Our study clearly shows that, snus has the potential to help the EU avoid 274,000 smoking-related deaths every year.

It is time for the European Commission to make snus available to all European smokers.