Public health report supports harm reduction concept
This was the conclusion reached by the National Board of Health and Welfare in its most recent Public Health Report, published earlier this year. The report - the sixth in the series - gives a broad overview of research relating to the health status of the Swedish population, and was commissioned by the Swedish Government to be used as a basis for health policy.
A survey cited in the section on tobacco habits shows that the proportion of daily smokers has declined steadily in Sweden since the beginning of the 1980s, from around 35 percent of the adult population to todays figure of 17-18 percent. The most dramatic trend has occurred in the male population, and today the proportion of men who smoke on a daily basis is the lowest in Europe.
The report describes the already well-documented risks associated with smoking. Smoking tobacco greatly increases the risk of contracting a large number of illnesses, including various forms of cancer, cardiovascular diseases and diseases of the lungs and respiratory tract. According to the World Health Organizations World Health Report of 2002, tobacco smoking contributes to 12 percent of the sickness burden in Europe.
In Sweden, the number of smoking-related deaths declined among men during the period from 1990-2000, while it increased among women, primarily due to an increased death rate from lung cancer. The explanation for this given in the Public Health Report is that the smoking habits of men and women have followed divergent paths and that it is the smoking habits of 20 years ago that are now being reflected in the statistics.
The unique feature of the trend in Sweden - commonly referred to as the Swedish experience - is that smoking and smoking-related deaths have declined, particularly among men, while snus consumption has increased steadily since the 1970s. According to the National Health Survey of 2004, 22 percent of men and 3 percent of women between the ages of 18 and 84 used snus. In the age groups under 45 years, the proportion of snus users was higher.
Understandably, the question posed in the report is whether the increasing use of snus causes similar health risks to those from smoking. Although the report points out that the long-term health effects of snus have not been fully researched, it also notes that a number of epidemiological studies have been performed that do not show any increased risk of cardiovascular disease or cancer in the oral cavity or stomach. Moreover, a preliminary analysis at the Epidemiological Center was unable to show any excess risk of cardiovascular disease from snus consumption, while smoking was associated with a marked excess risk, states the report.
In the debate on this issue, particularly prior to the examination by the European Court of Justice of the ban on snus sales in the EU, it has sometimes been maintained that snus is an entryway to smoking and should be banned for that reason.
However, the view expressed in the Public Health Report is that snus has the special advantage that it functions as an aid to giving up smoking: A survey of 1,000 former and 985 current daily smokers has shown that those who used snus to help them quit smoking had a 50-percent higher chance of not resuming smoking.
The report also refers to preliminary results from Statistics Sweden which show that although some snus users start smoking, for every such instance there are four smokers who switch to snus after quitting smoking.
Support for the validity of these data can also be obtained from the so-called MONICA study in Northern Sweden, which showed that among men in the age range from 24-34, only 3 percent now smoke daily, while 35 percent use snus - a finding that contradicts the view that snus is an entryway to smoking.
In summary, the authors of the report consider that all the available data indicates that the net effect of the change in tobacco habits in Sweden is positive from a public-health viewpoint, since it is a documented fact that smoking is far more dangerous than using snus.
However, no conclusion is stated as to whether the Swedish Experience is directly transferable to countries that do not have Swedens long tradition of snus consumption.