The Swedish Experience

The risk of a man dying from a tobacco-related illness is less in Sweden than in any other European country, although tobacco consumption is on a comparable level with that of other countries in Europe. Researchers refer to this paradox as “the Swedish Experience”.

It is most likely that the Swedish Experience can be explained by the unique form of tobacco use among Swedish men, which largely takes the form of snus. Total tobacco consumption is about equal in comparable countries, but Swedish men smoke substantially less. The proportion of daily smokers is currently 10 percent among men, the lowest in Europe. To this must be added that 18 percent of men use snus. Thus, the use of snus among Swedish men is more common than smoking.

The positive effect of this phenomenon is a very low frequency of tobacco-related illnesses among Swedish men and low smoking-related mortality rates. This unique situation is documented in a large number of epidemiological studies, which, inter alia, note that Sweden shows the lowest risk of lung cancer among industrial countries. Although the use of snus is not without negative health effects, research results have shown that health risks are substantially lower for the use of snus compared with smoking.

Data on the use of snus

  • In 2011, 10 percent of all adult Swedish men smoked daily. The corresponding figure for Norway was 19 percent, and 22 percent for Denmark, with the European average (2010, latest data) at 32 percent (1).
  • In 2011, 18 percent of all adult Swedish men used snus on a daily basis, compared with 12 percent of men in Norway who used snus daily, while in Denmark 1.5 percent used some form of smokeless tobacco regularly (1).
  • In 2011, 12 percent of all adult Swedish women smoked daily. The corresponding figure for Norway was 19 percent, with 22 percent for Denmark, while the European average (2010, latest data) was 21 percent (1).
  • In 2011, 3 percent of all adult Swedish women used snus daily, with the corresponding figure in Norway being 2 percent, while in Denmark 0.2 percent used some form of smokeless tobacco regularly (1).
  • In 1997, Sweden became the first country worldwide to meet the WHO’s goal for 2000, namely, that the proportion of adult smokers would be less than 20 percent (3). The second country to meet this target was Iceland in 2005, which also has a long tradition of using smokeless tobacco.
  • In 2000, 10 percent of deaths among Swedish men were smoking-related, or the lowest proportion in Europe. The average figure for the 25 EU countries (EU 25) was 23 percent (4).
  • Swedish women showed the same smoking-related mortality rate as the average for the EU’s 25 countries in 2000, namely, 7 percent (4).
  • In 2000, the risk of a 35-yer-old man dying of a smoking-related illness before the age of 70 was 3 percent in Sweden, compared with 5 percent in Norway, 8 percent in Denmark and an average 9 percent for EU 25 (4).
  • Corresponding figures for women were 2.1 percent in Sweden, 2.6 percent in Norway, 5.9 percent in Denmark, and for EU 25 an average of 1.6 percent (4).
  • The incidence of lung cancer among Swedish men has fallen during the past 20 years. Swedish women, however, are displaying a rising trend in terms of lung cancer statistics (5).
  • Two epidemiological studies conducted in Sweden did not show any relationship between the use of Swedish snus and oral cancer (6, 7).
  • Two epidemiological studies on stomach and esophageal cancer did not show any relationship between Swedish snus and a higher risk for any of these cancer forms. (8, 9).
  • The cancer mortality rate is not higher among Swedish users of snus (10).
  • The risk of heart attack is not higher among snus users (11).
  • In a study covering Swedish snus users, researchers find no significant increase in diastolic blood pressure, hemoglobin concentration, white blood cell count, and serum cholesterol or triglyceride levels. These results contrast with similar studies of cigarette smokers (12).
  • Snus users as well smokers run a higher risk of dying from heart or cardiovascular illnesses than non-tobacco users. The risk is lower for a snus user than for a smoker. (10).
  • There is a high probability that the health risks presented by snus are less than the health risks associated with smoking (13, 14).

The figures within parentheses refer to the list of references.

 

REFERENCES 
1. Sweden: Statens Folkhälsoinstitut. Norway: Sosial- og helsedirektoratet. Denmark: Sundhedsstyrelsen. Europa (EU 25+ Iceland, Norway and Switzerland): The European Tobacco Control Report 2007. WHO Regional Office for Europe.
2. Folkhälsa. Lägesrapport 2005, sid 24-25. Socialstyrelsen (Public Health. Status report, pages 24-25 . Swedish National Board of Health and Welfare).
3. Tobacco Statistics 1970-1999. Statistical Report 2000-09-18, VECA HB Statistical Bureau, p. 12.
4. Peto, R.; Lopez, AD.; Boreham, J.; Thun, M.; Heath, C. Mortality from smoking in developed countries 1950-2000 (2nd edition). Oxford, Oxford University Press; 2003. Updated in June 2006.
5. Swedish Cancer Registry, 1998.
6. Lewin, F., Norell, S.E., Johansson, H., Gustavsson, P., Wennerberg, J., Björklund, A., Rutqvist, L.E. Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck. Cancer, 82, 1367-75 (1998).
7. Schildt, E.-B., Eriksson, M., Hardell, L., Magnusson, A. Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. Int. J. Cancer, 77, 341-6 (1998).
8. Ye, W., Ekström, A.M., Hansson, L.-E., Bergström, R., Nyrén, O. Tobacco, alcohol and the risk of gastric cancer by sub-site and histologic type. Int. J. Cancer, 83, 223-9 (1999).
9. Lagergren, J., Bergström, R., Lindgren, A., Nyrén, O. The role of tobacco, snuff and alcohol use in the aetiology of cancer of the oesophagus and gastric cardia. Int. J. Cancer, 85, 340-6 (2000).
10. Bolinder, G., Alfredsson, L., Englund, A., de Faire, U. Smokeless tobacco and increased cardiovascular mortality among Swedish construction workers. Am. J. Public Health, 84, 399-404 (1994).
11. Huhtasaari, F., Lundberg, V., Eliasson, M., Janlert, U., Asplund, K. Smokeless tobacco as a possible risk factor for myocardial infarction: A population-based study in middle-aged men. J. Am. Coll. Cardiol., 34, 1784-90 (1999).
12. Eliasson, M., Lundblad, D., Hägg, E. Cardiovascular risk factors in young snuff-users and cigarette smokers. J. Int. Med., 230, 17-22 (1991).
13. Steen, T. Helserisikoen ved snusbruk. Tidskr. Nor. Laegeforen., 116, 625-7 (1996).
14. Ahlbom, A., Olsson, U.A., Pershagen, G. Hälsorisker med snus (Health risks of snus). SoS-rapport 1997:11, 28 (1997).