REVIEW

Effect of smokeless tobacco (snus) on smoking and public health in Sweden

J Foulds¹, L Ramstrom², M Burke¹, K Fagerström³

¹ University of Medicine and Dentistry of New Jersey- School of Public Health, Tobacco Dependence Program, New Brunswick, New Jersey, USA
² Institute for Tobacco Studies, Stockholm, Sweden
³ Fagerstrom Consulting and The Smokers Information Center, Helsingborg, Sweden

Correspondence to:
Correspondence to:
Jonathan Foulds PhD
UMDNJ-School of Public Health, Tobacco Dependence Program, 317 George Street, New Brunswick, NJ 08852, USA; jonathan.foulds{at}umdnj.edu

Objective: To review the evidence on the effects of moist smokeless tobacco (snus) on smoking and ill health in Sweden.

Method: Narrative review of published papers and other data sources (for example, conference abstracts and internet based information) on snus use, use of other tobacco products, and changes in health status in Sweden.

Results: Snus is manufactured and stored in a manner that causes it to deliver lower concentrations of some harmful chemicals than other tobacco products, although it can deliver high doses of nicotine. It is dependence forming, but does not appear to cause cancer or respiratory diseases. It may cause a slight increase in cardiovascular risks and is likely to be harmful to the unborn fetus, although these risks are lower than those caused by smoking. There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use.

Conclusions: Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.

Keywords: smokeless tobacco; Sweden; nicotine; cancer

Abbreviations: CI, confidence interval; IOM, US Institute of Medicine; MI, myocardial infarction; OR, odds ratio; OSCC, oesophageal squamous cell carcinoma; RR, relative risk; TSNAs, tobacco specific nitrosamines

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