A different kind of endgame:

Evidence for the impact of snus on smoking – the Norwegian experience

Karl E. Lund, Research Director, Ph.D.

& Tord F Vedøy, Ph.D

Norwegian Institute for Alcohol and Drug Research (SIRUS)

Smoking status among ever snus usersNorway

Conflict of interest:

- Employed by a Government entity answerable to the Ministry of Health and Care Services

- No ties to pharmaceutical or tobacco industry

- Expert witness in 5 court cases against the tobacco industry

E-mail: kel@sirus.no

Lund KE. Tobacco Harm Reduction in the Real World: has the availability of snus in Norway increased smoking cessation? Drugs and Alcohol Today, 2013; 13 (2): 92-101.

Lund KE, McNeill A. Patterns of dual use of snus and cigarettes in a mature snus market. Nicotine & Tobacco Research, 2013; 15 (3): 678-684.

Lund KE. Association between willingness to use snus to quit smoking and perception of relative risk between snus and cigarettes. Nicotine & Tobacco Research 2012; 14: 1221-1228.

Lund KE, McNeill A, Scheffels J. The use of snus for quitting smoking compared with medicinal products. Nicotine & Tobacco Research 2010; 12 (8): 817-22.

Lund KE, Scheffels J, McNeill. The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction 2010; 106:162-167.

Lund M, Lund KE, Halkjelsvik T. Contrasting smokers' and snus users' perceptions of personal tobacco behavior in Norway. Nicotine & TobaccoResearch. 2014 Dec;16(12):1577-85.

Lund KE. A tobacco-free society or tobacco harm reduction? Norwegian Institute for Alcohol and Drug Research. SIRUS-report 6/2009.

Lund I, Lund KE. How has the availability of snus influenced cigarette smoking in Norway? Int J Environ Research and Public Health 2014; 11.

Larsen E, Rise J, Lund KE. Risk characteristics of adolescent snus users compared to non-users of tobacco, smokers and dual users of snus and cigarettes. Addiction Research and Theory 2013; 38 (7): 2288-2294.

Larsen E, Rise J & Lund KE. The relationship between snus use and smoking cognitions. Addiction Research and Theory, 2012; 20 (6): 447-455.

Scheffels, J., Lund, K.E. & McNeill, A. Contrasting snus and NRT as methods to quit smoking. An observational study. Harm Reduction Journal,2012; Feb 29; 9, 10

Snus in Norway: peer-reviewed scientific articles

The changing nicotine market in Norway

Snus 5%

19852 070 g pr capita

20141 400 g pr capita

Cigarettes 95%

Source: Skretting et al 2014

Public health impact:

The extent and nature of the impact on public health will depend upon

i) the relative risk of snus and cigarettes

ii) the relative uptake and use of snus by smokers and non-smokers

Smoking status among ever-snus-usersAged 16-79 years (N=2240)

Datapool 2004-2014

Dual users….

• Majority (75%) cigarettes first product

• Motive: to reduce cigarette consumption (55%)

• 40% reduction in cigarette consumption(Lund & McNeill 2013, Hatsukami et al 2004, Tomar 2002, Gilljam & Galanti 2003, Lund et al 2010,Ramström & Foulds 2006, Carpenter & Gray 2010, Rae Olmsted 2011)

• Motive: smoking cessation (45%)

• Associated with intention to quit (6 months)

• Associated with smoke-free future identity (5 years from now)

• Transient phenomenon? Terminal point?

• Fraction stable over time

Prevalence of cigarette smoking, use of snusand dual use of cigarettes and snus

Norwegian male population aged 16-74 years 1985-2012

0

10

20

30

40

50

60

70

80

90

100

1985 1990 1995 2000 2005 2010

Non use

Snus exclusive

Dual use

Smoking exclusive

“Evidence for a wide variety of health endpoints does not suggest any special hazard associated with dual use”

(Lee, P. 2014; 69(1): 133

«Dual use does not seem to jeopardize the role of snusin tobacco harm reduction» (Lund KE & McNeill A 2012)

Former smokers

Former smokers….

Quit all tobacco 14%

• Comprises 35% of ever-snus users

• 21% current snus users• 82% of these quit smoking by use of snus (N=173)

• 14% quit all tobacco• 45% of these quit smoking by snus (N=204)

Lund I & Lund KE (2014). How has the availability of snus influenced cigarette smoking in Norway?

Int. J. Environ. Res. Public Health. 2014; 11.

Lund, McNeill, ScheffelsNicotine & Tobacco Research 2010

Consistent findings from observational studies in Norway/Sweden:

Snus is the most preferred method for quitting smoking (after unassisted attempts)(Lund & McNeill 2012, Ramström & Foulds 2006, Giljam & Galanti 2003, Scheffels et al 2012, Lund et al 2011)

Former smokers make up a large segment among snus users(Lund et al 2010, Lund & McNeill 2012, Ramström & Foulds 2006, Giljam & Galanti 2003, Norberg et al 2110, Norberg et al 2011, Stenbeck et al 2009,

Rodu et al 2002, 2003, Stegmayr et al 2005, Lindström et al 2002, 2007, Furberg et al 2008)

Quit ratio for cigarette smoking higher among snus users than non-users (Lund et al 2010, Lund & McNeill 2012, Ramström & Foulds 2006, Giljam & Galanti 2003, Norberg et al 2110, Norberg et al 2011, Stenbeck et al 2009,

Rodu et al 2002, 2003, Stegmayr et al 2005, Lindström et al 2002, 2007, Furberg et al 2008)

Those who used snus at latest quit attempt more likely to have quit smoking than those who used NRT (Lund et al 2011, Scheffels et al 2012, Ramström & Foulds 2006)

Also observed in experimental studies (Caldwell et al 2010, Fagerström et al 2012, Lunell & Curvall 2011, Kotlyear et al 2011)

Effectiveness = Use * Efficacysnus > NRT snus > NRT

Never smokers

Never smokers..- among ever-snus-users

Never smokers• Younger than the other segments

• Mean age of onset 18 years

• In the absence of snus:• Smokers or tobacco-free???

Has quit snus8%

Still using snus18%

41% intend toquit within 6 months

Use (daily + occasionally) of cigarettes and snusNorwegians aged 16-30 years 1985-2013

(Three yearly moving average)

20

0

10

20

30

40

50

60

1985 1990 1995 2000 2005 2010

0

10

20

30

40

50

60

1985 1990 1995 2000 2005 2010

Males Females

r = - 0.900, p<0.001 r = - 0.811, p<0.001

Never smokers who…

Never smokers

Smokers who have quit snus

Dual users

25%

Former smokers

35%

Never smokers

26%

Former snus, current smoke

14%

Smokers who have quit snus

14% of ever-users of snus

- 79% started with cigarettes

- Relapsed to cigarettes after trying toquit smoking with snus

Conclusion:

Given the i) risk difference and the ii) user-configuration, the availability to snus has produced a net gain to public health.

The combined numbers who have i) quit smoking for snus, ii) reduced smoking intensity by snus, iii) picked up snus instead of cigarettes, have outnumbered iv) snus users who otherwise would have been tobacco-free

Health gains from smoking cessation, smoking reduction and smoking substitution produced by snus, has more than out-weighted the (marginal) health loss in the small fraction of never-smokers taking up snus.

WHO, 2012

Never smokers

Smokinginitiation

Smokingcessation

Smokingprevalence

& =

Effect from snus:sustained

Effect from snus:temporary/fading

“…. it is not so much the efficacy of new nicotine

delivery systems as temporary aids to cessation,

but their potential as long-term alternatives to

tobacco that makes the virtual elimination of

tobacco a realistic future target”. (p 653)

kel@sirus.no