From Norway: Snus Risk Perception Can Drive Smoking Cessation; The Right to Truth and Health

Norway has been documented recently as the second European country to embrace the substitution of snus for cigarettes, confirming the “Swedish experience” of tobacco harm reduction. Karl Erik Lund, a researcher at the Norwegian Institute for Alcohol and Drug Research, has published a series of studies illustrating the “Norwegian experience” (here and here). His newest study shows that a smoker’s willingness to try snus is closely correlated with one’s perception of the product’s health risks relative to cigarettes. The study appears in Nicotine & Tobacco Research (abstract here).

Dr. Lund used a survey of 14,700 men age 20-50 years with a 49% response rate. Participants included 1,155 former smokers and 1,417 current smokers (80% of whom had tried to quit).

Snus, used by 32% of former smokers, was the most common method used to quit smoking. Nicotine gum was a distant second, at 14%.

Dr. Lund measured perceptions among current and former smokers of the risks of snus compared with cigarettes. Here are the results for former smokers:

Perception of Snus Risk Among Former Smokers
	Percent
Far more or somewhat more risky	3
About the same	31
Somewhat less risky	35
Far less risky	32

Compared with former smokers who incorrectly believed that snus has the same or higher risks compared to cigarettes, the 32% of smokers who correctly believed that snus was “far less risky” were 11 times more likely to have used snus to quit smoking. In addition, the “somewhat less risky” group was 3.5 times as likely to have used snus.

Perceptions among current smokers also had important implications:

Perception of Snus Risk Among Current Smokers
	Percent
Far more or somewhat more risky	3
About the same	37
Somewhat less risky	37
Far less risky	23

Compared with smokers who incorrectly believed that snus has the same or higher risks than cigarettes, the 23% of smokers who correctly believed that snus was “far less risky” were five times more willing to try snus in a future quit attempt. In addition, the “somewhat less risky” group was over twice as likely to try snus.

Dr. Lund described the implications: “The main finding in our study was that correct perception of the relative risk between snus and cigarettes was positively correlated with having used snus when quitting smoking. Likewise, among current smokers, correct beliefs of differential risks between the two products were positively correlated with the willingness to use snus in future quit attempts. Thus, providing accurate risk estimates to smokers may not only have an ethical justification, dissemination of such information might also result in increased quit rates for smoking.

“Lacking any compelling evidence of net harm to society from correcting misperceptions of the relative risk between cigarettes and snus, the human right for the individual to receive accurate information about options to reduce risk should prevail. Going beyond the no-safe-tobacco message to provide better informa¬tion … is necessary to respect the individual right to health relevant information and smokers’ autonomy and may also—as our study indicates—result in increased quit rates for cigarette smoking. Some have argued that failure to disseminate infor¬mation about reduced risks for fear that population nicotine use may increase could be regarded as paternalism and create public mistrust of health messages about tobacco use. To prevent uptake of snus among youth, public health and tobacco control professionals could use other methods than withholding information about relative risks, including taxation, restrictions, and information campaigns aiming to change the cultural symbolism of snus use…Devising a way to inform smokers about the risk contin¬uum of tobacco products (without anyone decoding this infor¬mation as snus being risk free) should be an important research priority in countries where snus is allowed to compete with cigarettes for market share.”

In the U.S., where smokeless tobacco products compete with cigarettes, public health authorities must begin to communicate truthful information about the differential risks to smokers. Disinformation and obfuscation about the relative risks of varying tobacco products costs lives and disgraces those who pursue such actions. Truthful communication about tobacco harm reduction is a public health imperative.

Noteworthy News From Norway: Snus is Superior Cigarette Substitute

In 2008, the European Commission released a report entitled “Health Effects of Smokeless Tobacco Products.” (available here). Except for one small part discussing tobacco harm reduction (Section 3.8, pages 111-118), most of the report was very negative, even denying that snus use has had any effect on smoking in Sweden and Norway.

The report concluded: “It is difficult to envision any significant impact of snus use on smoking cessation in Norway…” This was especially baffling, as Figures 19-22 (pages 42-43) show clearly that increased snus use over the last 20 years was concomitant with decreased smoking.

The Commission report also surprised Dr. Karl Erik Lund, a respected tobacco researcher with SIRUS, the Norwegian Institute for Alcohol and Drug Research. Lund has 20 years experience in tobacco research and has authored more than 85 journal articles in the fields of tobacco epidemiology, evaluation and prevention. This year, he published landmark studies showing unequivocally that snus use has had a profound impact on smoking in Norway.

Lund’s current study was published in Addiction (abstract here). He compared quit rates, defined as the percentage of ever smokers who are now former smokers, among snus users and never users in seven previously published Norwegian surveys.

Lund Survey No.	Quit Rate- Snus Users (%)	Quit Rate- Never Snus Users (%)
1	80	52
2	55	23
3	81	63
4	62	53
5	75	45
6	90	50
7	73	43

As seen in the table, the quit rates for snus users were always higher than for those who had never used snus; the results are statistically significant for all surveys except number 4. This is compelling evidence that snus has played a powerful role in smoking cessation among Norwegians. As Lund notes, it is consistent with the Swedish evidence. Equally important, it is consistent with evidence I have published from federal surveys in the U.S. (discussed in this March blog post).

Earlier this year, Lund published evidence in Nicotine & Tobacco Research that Norwegian men preferred snus over ALL other methods to quit smoking (abstract here).

The SIRUS survey asked 3,583 former or current smokers age 20-50 years what method they used when they last tried successfully (former) or unsuccessfully (current) to quit. Snus was used by 32% of all respondents, making it the most popular method by far. Other methods that enjoyed modest popularity were nicotine gum (18%), self-help material (12%), and the nicotine patch (10%). Nicotine inhaler, Zyban, Champix, telephone quit line, and help from health care professionals were also included in the survey, but they had negligible usage rates.

Lund reported an adjusted odds ratio (AOR) to indicate effectiveness of products compared with nicotine gum, the reference product. For quitting completely, the AOR for snus was 2.7, meaning that it was nearly three times more effective than gum. Snus was also three times more effective than nicotine gum in “greatly reducing cigarette consumption” among continuing smokers (AOR = 3).

Lund observed: “Of those smokers who reported that they had tried to quit by using snus, 62.4% reported that they still used snus at the time of the survey, either daily (43.8%) or occasionally (18.6%)…In comparison, only 9.5% who had used nicotine chewing gum or nicotine patches at the last attempt to quit were still using these medicinal nicotine products at the time of the survey.” In other words, snus was effective precisely because it was a satisfying and enjoyable substitute, rather than an unsatisfying and distasteful temporary medication. This represents the fundamental advantage of a recreational approach to smoking cessation, compared to treating smokers’ nicotine addiction with medications. Smokers aren’t sick; they just want to have safer alternatives.

There is no question that snus is an effective and PERMANENT nicotine substitute for many former smokers. This is important, because a dominant theme in the U.S. is that quit-smoking methods must all eventually lead to permanent nicotine and tobacco abstinence. Given that the outcome measure for all smoking cessation trials in the U.S. is complete abstinence, it is no wonder that most cessation methods are deemed failures. For successful tobacco regulation, the FDA must break the public health community’s addiction to abstinence promotion. Unfortunately, the FDA is still focused on abstinence (here).

Norwegian authorities have a more realistic and rational strategy. Lund and colleagues noted that in 2009, the Norwegian Health Directorate “agreed that health care personnel can recommend snus in individual cases of inveterate smokers.” It is refreshing that the directorate recognizes that saving smokers’ lives is more worthy and achievable than simply breaking the chain of tobacco addiction.

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.