This document summarizes a study comparing self-reported health perceptions among different groups of tobacco users in Sweden. The study found that: 1) Current daily smokers reported poorer satisfaction with their health, life, and higher numbers of sick days than other groups. 2) Daily snus users, both with and without a history of smoking, reported health perceptions similar to non-users and better than current smokers. 3) Former smokers who now use snus daily reported better mental health and life satisfaction than current smokers. The results suggest that smoking impairs perceived health while switching from smoking to snus may improve it.

1. Perception of health status among different groups of tobacco users in Sweden
Lars M. Ramstrom, Institute for Tobacco Studies (ITS), Stockholm, Sweden, E-mail: lars.ramstrom@tobaccostudies.com.
Tom Wikmans, Research Group for Societal and Information Studies (FSI), Stockholm, Sweden, E-mail: tom@forskningsgruppen.com.
BACKGROUND
In Sweden the prevalence of daily smoking in adult males has gone down from around 40% in the late 1970s to Similar patterns appear for the perception of current physical health as for overall health status. In the group
11% in 2007. In adult women the corresponding decline has gone from around 30% to 14%. This development “Never tobacco users” 77 % answered “Good” and among “Daily snus users without a history of smoking” 73%
has been influenced by several factors. One such factor is the invention and pioneer use in Sweden of nicotine answered “Good”. In the group “Daily snus users, former daily smokers” 63 % answered “Good”, and the lowest
replacement products (NRT), and another one is the increased use of snus (the Swedish kind of low-nitrosamine proportion of people answering “Good” is found in the group “Current daily smokers”, 61 %.
oral snuff, see fact box below) among males. The research about the health effects from the use of different tobacco
products has mostly dealt with mortality. Not so many studies have addressed people’s own perceptions of health Perception of own mental health
status during lifetime, such as differences according to different tobacco products or changes after transition from
one product to another. On the basis of The Thomas -Theorem that states that “If men define situations as real, How do you perceive your mental health at the moment?
they are real in their consequences” (The child in America: Behavior problems and programs. W.I. Thomas and D.S. Percentage of those who answered " Good"
Thomas. New York: Knopf, 1928: 571-572) it is of interest to study the self-experienced and self-reported percep-
tions of own health in order to elucidate the everyday health consequences of different kinds of tobacco use. Even 90%
if an individual is not sick in the clinical sense, his actual perception has real consequences for him in his daily life.
80%
At the same time improvement of self-perceived health will have positive effects on a person’s life.
70%
82%
OBJECTIVE
60%
The current study aims at elucidating the health consequences of different kinds of tobacco use by comparing dif-
79%
ferent groups of tobacco users with respect to self-reported perceptions of a number of health indicators. 50% 73% 70%
MATERIAL AND METHODS 40%
In the present study data on people’s perceptions of their own health status were derived from the 2008 FSI an-
30%
nual tobacco survey V.A.K.T (Habits, attitudes and beliefs regarding tobacco), which covers a nationwide repre-
sentative sample of the population, age 18-79, in Sweden. The analysis is based on respondents’ answers to ques- 20%
tionnaire items regarding perception of own physical and mental health, how satisfied or dissatisfied they are with
their health and their life today and number of days reported sick. The number of responses included in the study 10%
is 3345.
0%
Never tobacco Daily snus users without a Daily snus users, former Current daily smokers
Results are reported for the following categories:
users history of smoking daily smokers
“Never tobacco users”, which consists of individuals who stated that they never have tried any kind of tobacco,
“Daily snus users without a history of smoking”, which consists of individuals who use snus daily, but has With regard to perceived mental health the answering pattern differs from that regarding physical health. Still the
never smoked cigarettes. group “Current daily smokers” is the one where the smallest proportion has given a positive answer (70 %). In
“Daily snus users, former daily smokers”, which consists of individuals who have stopped smoking and the group “Daily snus users, former daily smokers” 79 % perceive their health as good, which is a higher reading
switched to daily snus use. than the one for “Snus users without a history of smoking”.
“Current daily smokers” which consists of individuals who smoke cigarettes daily.
Daily snus users have been split in two separate categories, because a substantial proportion of current daily snus Days reported sick
users are former daily smokers. Remaining health effects of their previous smoking would constitute a confound- While the individual perception of own health status is affected by various subjective conditions, the number of
ing factor in category comparisons if they were not handled separately. sick-days absent from work, even when being self-reported, may be a more objective measure of health. The oc-
currence of large numbers of sick-days (>14) may be indicative of more serious health problems and therefore
RESULTS particularly interesting.
Satisfaction with own life
Have you been reported sick over the last 12 month?
How satisfied or dissatisfied are you with Your own life today? Percentage of those who have reported more than 14 sick days
Percentage of those who answered "Satisfied"
30%
90%
25%
80%
70%
86% 86% 20%
18%
60%
82% 76%
15%
50%
10%
8%
40%
10%
30%
7%
5%
20%
10%
0%
0% Never tobacco Daily snus users without a Daily snus users, former Current daily smokers
users history of smoking daily smokers
Never tobacco Daily snus users without a Daily snus users, former Current daily smokers
users history of smoking daily smokers
The proportions reporting large number of sick days (>14) in the different categories are: 7% in “Never tobacco
In general Swedish people are quite satisfied with there own life today. In the group “Never tobacco users” a large users”, 8% in “Daily snus users without a history of smoking”, 10% in “Daily snus users, former daily smokers”
proportion, 86 %, has given the answer “Satisfied”. One group, “Current daily smokers”, stands out as different and 17% in “Current daily smokers. The only inter-category difference that is statistically significant at the 95%
from the rest, only 76 % has given the answer “Satisfied”. It is also worth noting that the group “Daily snus users, level is the one between “Never tobacco users” and “Current daily smokers”. However, when merging the sub-
former daily smokers” has the same proportion reporting satisfaction with life as “Never tobacco users”, 86 %. groups of daily snus users, we get the group of all daily snus users where 9% report more than 14 sick-days absent
from work the last year, which is significantly lower than the 18% figure for “Current daily smokers”.
Satisfaction with own health
How satisfied or dissatisfied are you with Your health? DISCUSSION
The current study has demonstrated that the proportion of respondents who feel that they are satisfied with their
Percentage of those who answered "Satisfied"
health and own life today is lower among “Current daily smokers” than among others. We also find that current
daily smokers tend to have a larger proportion of days with reported sickness over the last 12 month than others.
100%
The consistency by which all observed health indicators single out “Current daily smokers” in less favorable posi-
90% tions than others lends support to the conclusion that daily smoking does impair perceived health in people’s daily
life.
80%
70% In general, “Current snus users without a history of smoking” are more similar to the group of never tobacco users
regarding self reported health than they are to the group of current daily smokers.
60%
79% 81%
74% Another consistent pattern demonstrates that “Daily snus users, former daily smokers”, i.e. people who have used
66%
50%
snus as support in their efforts to quit smoking, are in a more favorable position than continuing daily smokers.
40% This confirms the well-known benefits of quitting smoking and it also suggests that their switching to snus does
not eliminate those benefits.
30%
20% The pattern regarding perception of current mental health is similar to the one for satisfaction with own life. This
may suggest that the two questions tend to measure the same dimension. This could lead to the assumption that,
10%
when asked about how satisfied or dissatisfied a person is with his or her life, he will put more weight to the mental
0% than to the physical health aspects.
Never tobacco Daily snus users without a Daily snus users, former Current daily smokers
users history of smoking daily smokers The group “Daily snus user, former daily smokers” have had a better self-reported mental health and satisfaction
with their lives today than other tobacco users. This may be a result of satisfaction resulting from the fact that the
Those who perceive that they are “Satisfied” with their overall health status are 79% of “Never tobacco users”, person has managed to become smoke-free. This satisfaction may lead to further benefits.
81% of “Daily snus users without a history of smoking”, 74% of “Daily snus users with a history of daily smok-
ing” and 66% of “Daily smokers”. Both subcategories of daily snus users have given answers similar to those from CONCLUSIONS
“Never tobacco users”, while “Current daily smokers” are less satisfied with their health than others. The findings in this study are based on self-reported data. However, as mentioned earlier, the Thomas-Theorem
states that self-reported perceptions can lead to real consequences. These self-reported perceptions can be seen as
Perception of own physical health markers of real conditions. Therefore, we may assume that the findings reflect reality. Consequently, we can con-
clude that our findings suggest that:
How do you perceive your physical health at the moment? - daily smoking does impair health in people’s daily life.
Percentage of those who answered "Good" - daily snus use does not noticeably impair health in daily life
- switching from smoking to snus use yields a viable improvement of health.
90%
No external funding
80%
70%
60% 77%
SWEDISH SNUS
50%
73%
63% 61%
Snus is a form of smokeless tobacco containing finely ground tobacco leaves. The Swedish snus is moist with
40% a water content of 40 % - 60 %. The main feature of the Swedish manufacturing procedure is a heating
process where no fermentation takes place. In the absence of fermentation there is no formation of nitrites
30% and consequently no continued formation of tobacco-specific nitrosamines, TSNAs. The originally present
bacteria are killed by the heat, and the end product is virtually sterile. Therefore the risk for formation of
20%
TSNAs during storage is greatly reduced.
10%
Snus is typically sold in pocket-size boxes containing small, tea-bag like pouches with snus. It is not a chew-
0% ing product. Instead, the snus user puts a pouch under the upper lip and lets it stay there for approximately
Never tobacco Daily snus users without a Daily snus users, former Current daily smokers half an hour. There is no “spitting”.
users history of smoking daily smokers
Wikmans Poster Bangkok.indd 1 2008-10-21 21:24:08