1. Lars M. Ramström PhD Director, Institute for Tobacco Studies Stockholm, Sweden Email: lars.ramstrom@tobaccostudies.com The Swedish experience the role of snus in the decrease of smoking Presentation at ROUND TABLE MEETING THE EMBASSY OF SWEDEN MOSCOW, 2011-12-08

4. Changes of smoking prevalence are due to the combined effect of - changes of initiation practices, and - changes of cessation practices. Both these practices are influenced by snus use.

5. Source: FSI / ITS surveys 2003 - 2011 Category Boys who did not use snus (n = 23281) Boys who used snus (n = 5021) Girls who did not use snus (n = 31846) Girls who used snus (n = 527) 46% started smoking 18% started smoking 40% started smoking 8% started smoking HOW DOES SNUS USE INFLUENCE INITIATION OF SMOKING?

6. Snus use is associated with a substantially reduced probability of starting to smoke.

7. HOW DOES INCREASING INITIATION OF SNUS USE INFLUENCE TOTAL INITIATION OF TOBACCO USE?

8. During the later half of the last century an increasing initiation of snus use was accompanied by - increasing proportion of those not initiating any tobacco use - decreasing initiation of smoking (suggesting that most snus users would have started smoking if there had been no snus)

9. WHAT HAPPENS AFTER SMOKERS HAVE TAKEN UP SNUS USE?

10. Among smokers who take up snus use - 87% become smoke-free (48% snus only, 39% no tobacco at all) - very few, 6 – 8 %, become dual users

11. HOW DOES SWITCHING FROM SMOKING TO SNUS INFLUENCE NICOTINE DEPENDENCE? Smokers not using snus Snus users having switched from smoking Sources: VAKT-smoke, Vakt-snus surveys

12. Among those who have switched from smoking to snus the proportion with high dependence levels is smaller than among smokers not using snus. This suggests that smokers who switch to snus do rather weaken than strengthen their dependence. This is also consistent with the finding that many switchers eventually quit all tobacco/nicotine use. A lower level of dependence in snus users may be due to the slower delivery of nicotine from snus compared to cigarettes.

13. WHAT IS THE OVERALL ASSOCIATION BETWEEN SNUS USE AND SMOKING CESSATION?

14. Both in men and women quit rates are distinctively higher among former and current snus users than among never snus users. The difference between ”All men” and ”All women” is a consequence of the lower prevalence of snus use in women. Gender itself does not influence smoking cessation, but snus use does favour smoking cessation.

15. WHAT ARE THE BENEFITS OF USING SNUS AS A SMOKING CESSATION AID?

16. Use of snus as a smoking cessation aid provides double benefits over nicotine gum and patch: - among men, snus is the most widely used aid (51% of all quit attempts) - both among men and women snus yields the highest quit rates (indicated numerically in the lower part of each bar). Consequently, snus appears to be a more effective cessation aid than nicotine gum or patch.

17. DOES SWEDISH SNUS HAVE A POTENTIAL TO YIELD AN OVERALL PUBLIC HEALTH BENEFIT? Sweden has developed record-low levels of smoking and record-low levels of all tobacco-induced diseases. Increasing snus use has been accompanied by – decreased initiation of smoking, and – increased cessation of smoking. By helping to reduce smoking, snus has been an important contributory factor for the favorable development of public health in Sweden. Similar development should be possible in other countries, but only if prevailing knowledge gaps are filled and common misperceptions are corrected by appropriate public information.