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It is imperative that public policy be based on the most thorough, balanced, and critical appraisal of the available evidence. Regrettably, the two papers1,2 on which we were invited to comment fall short of those criteria.
DID SNUFF REALLY REDUCE SMOKING IN SWEDEN?
Bates et al2 concluded snus played a “positive public health role” but did not weigh all available evidence nor critically appraise the methodologies, funding sources, or interpretations of the studies they included. Their “Evidence from Sweden” section included only an unpublished survey with unknown methodology,3 a newspaper article,4 and a study from northern Sweden.5 Foulds et al1 concluded that snus had “...a direct effect on the changes in male smoking and health” with little additional evidence. However, both papers ignored published studies and selectively reported findings. A consideration of all the available evidence suggests snus played, at best, a minor role in reducing smoking in Sweden.
A one year Swedish cohort study of persons aged 45–69 years at baseline in 1992–94 examined predictors of smoking cessation or change to non-daily smoking among baseline daily smokers (n = 3550).6 At baseline, 7.0% of men and 0.4% of women used snuff. At follow up, 7.2% of daily smokers had quit and 6.5% were non-daily smokers. The study found: snus use was not associated with smoking cessation; snuff use by non-daily smokers neither predicted cessation nor prevented transition to daily smoking7; and even if snuff helped some smokers to quit, it accounted for a small fraction of cessation.
In another prospective study, 5104 persons aged 16–84 years were interviewed in 1980–81 and followed up in 1988–89.8 These included 1546 daily smokers, 418 men who used snuff daily, and 129 men who used both snuff and cigarettes. By follow up, 26% of female and 28% of male …
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