Authors: Lars M. Ramström, Institute for Tobacco Studies (ITS) Tom Wikmans, Research Group for Societal and Information Studies (FSI)

1. Swedish adults’ understanding of the health risks of long term use of nicotine
replacement products and of using Swedish snus compared to smoking
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 RESULTS Trade union membership
In Sweden the prevalence of daily smoking in adult males has gone down Both data from 1996 and data from 2004/2006 show an overall low pro-
from around 40% in the late 1970s to 11% in 2007. In adult women portion of Consistent answers, still lower regarding Snus than NRT. The Rating the statments below as ”True” or ”False”
the corresponding decline has gone from around 30% to 14%. This de- proportion of Don’t know answers is substantially higher regarding NRT Percentage distribution of answers by trade union membership
velopment has been influenced by several factors. One such factor is the than regarding Snus. These patterns persist in the different subgroups Inconsistent with Consistent with
the scientific evidence the scientific evidence Don't know
invention and pioneer use in Sweden of nicotine replacement products that have been studied.
(NRT), and another one is the increased use of snus (the Swedish kind 11% 8% 6%
19%
of low-nitrosamine oral snuff) among males. In the above period many Changes over time 36%
30%
29%
messages regarding these products have been disseminated from different 28% 39%
sources. Therefore it is important to find out how people in the general Rating the statments below as ”True” or ”False”
Swedish population perceive the health risks of using different kinds of Percentage distribution of answers by year of survey 30% 38% 63%
nicotine delivery devices. Inconsistent with Consistent with 61% 63%
the scientific evidence the scientific evidence Don't know 55%
34% 32%
OBJECTIVE 18%
8%
To study to what extent Swedish adults’ understanding of the health risks 11%
15% 33% LO TCO SACO LO TCO SACO
of long term use of nicotine replacement products and of using Swed- 36% (Blue collar) (White collar) (Confederation (Blue collar) (White collar) (Confederation
28% of Academics) of Academics)
ish snus compared to smoking is consistent with current scientific evi-
Snus use is almost as harmful to Long term use of nicotine gum or
dence. health as smoking. nicotine patches is almost as
35%
40% harmful to health as smoking.
77%
MATERIAL AND METHODS 61%
Health risk comparisons - scientific evidence
32% When the material is divided with respect to trade union membership we
Comparisons of health risk between smoking and each one of the above 24%
types of nicotine delivery devices have attracted international attention find similar patterns as for income. Both for Snus and for NRT the an-
and the accumulated evidence can be illustrated by various statements in 1996 2004/2006 1996 2004/2006 swers from academics are Consistent to a larger degree than answers from
scientific publications, for example: Snus use is almost as harmful to Long term use of nicotine gum or others. Analogous patterns were also found when comparing people with
health as smoking. nicotine patches is almost as
harmful to health as smoking.
different level of education (details not shown here).
“Some smokeless tobacco products and pharmaceutical nicotine may
offer substantial reductions in harm compared to smoking.”1 Other subgroups
In 1996 a majority, 77 %, of the answers regarding Snus were Inconsis- When looking at subgroups with different tobacco use status we find that
“As a way of using nicotine, the consumption of non-combustible to- tent. In 2004/2006 these answers were less common but still a majority. daily snus users stand out giving Consistent answers to a higher degree
bacco is of the order of 10–1,000 times less hazardous than smoking, Regarding NRT just 22 % of the answers were Inconsistent in 1996, but than others. With rising age the proportion of Inconsistent answers in-
depending on the product.” 1 in 2004/2006 we found an increase to 32 %. Both for Snus and NRT creases regarding Snus but not regarding NRT. Both for Snus and NRT
“This form of tobacco (snus) is substantially lower risk than cigarettes the proportion of Don’t know answers is almost the same in 2004/2006 the proportion of Don’t know answers is quite similar in all age groups.
and is one reason why there is a lower cancer rate in Sweden.” 1 as in 1996.
“Hence these results indicate that the net effects of using snuff as a way DISCUSSION
of stopping smoking can be positive since smoking is so much more Men & Women The current study demonstrates that Swedish adults’ understanding of
hazardous to health than snuff-taking.” 2 the health risks of long term use of nicotine replacement products and
“Snus is a lot less harmful than cigarettes.” 3 Rating the statments below as ”True” or ”False”
of using Swedish snus compared to smoking is to a large extent incon-
Percentage distribution of answers by gender sistent with the scientific evidence, particularly with regard to snus use.
“In comparison with smoking, experts perceive at least a 90% reduction The observation that snus users have given an above average proportion
in the relative risk of Low Nitrosamine SmokeLess Tobacco use.” 4 Inconsistent with
the scientific evidence
Consistent with
the scientific evidence Don't know of Consistent answers regarding Snus raises the question whether they
have been seeking and assimilating scientific information more actively
In summary, a literature review demonstrates a scientific consensus that 11% 11% than others or rather express confidence in the product they actually use.
use of NRT products or snus is not just slightly less harmful to health 19%
31% 34% This question requires more research. The observation that high educa-
compared with smoking, but substantially less harmful than smoking. 37% tion level favours Consistent answers and tends to lower the otherwise
high degree of Don’t-know-answers suggests that prevailing public infor-
Data on people´s perceptions 29%
41%
mation/education plays a crucial role. The Swedish public may well have
In the present study data on people´s perceptions of health risks of differ- 70% been confused by contradictory and unclear messages in various media.
ent products were derived from the FSI annual tobacco survey V.A.K.T 51%
It is obvious that clear scientific data has not reached out to the general
37%
(Habits, attitudes and beliefs regarding tobacco), which covers a nation- 28%
public. Efforts for better public information is therefore needed.
wide representative sample of the population, age 18-79, in Sweden. In
the 1996, 2004 and 2006 survey some questions had the purpose to mea- Men Women Men Women
SUMMARY AND CONCLUSIONS
sure the Swedish people´s understandings in different areas. The respon- Snus use is almost as harmful Long term use of nicotine gum or
The overall picture indicates low awareness of the scientific evidence,
to health as smoking. nicotine patches is almost as
dents were asked to rate a number of statements as true or false. These harmful to health as smoking. even lower regarding Snus than regarding NRT. Reported uncertainty is
statements cover various areas such as the European Union, criminality high regarding NRT, while the beliefs about Snus are more definite
and immigrants, the Swedish stock market, harmfulness to health of dif- (although Inconsistent).
ferent nicotine products compared to smoking. This study is based on the A narrow majority, 51 %, of answers from men and a vast majority of
analysis of data from the questions regarding peoples understanding of answers from women were Inconsistent regarding Snus. Also regarding • Regarding NRT the proportion of Inconsistent answers is
the harmfulness to health of different nicotine products in comparison to NRT answers from women were Inconsistent to a larger extent than an- higher in 2004/2006 than in 1996.
smoking. The number of responses was in 1996 n=3237, 2004 n=2308 swers from men. Both for Snus and NRT the proportion of Don’t know • Regarding Snus the proportion of Inconsistent answers is
and 2006 n=1242. The study focuses on differences between subgroups answers is almost the same for men and women. lower in 2004/2006 than in 1996.
of the population and changes over time.
Income • Both regarding NRT and Snus, the proportion of Inconsis-
EXCERPT FROM THE QUESTIONNAIRE tent answers is:
Rating the statments below as ”True” or ”False” • lower among men than among women.
Here below you find some statements regarding issues where Percentage distribution of answers by personal income in SEK
• lower in high income groups than in low income groups.
contradictory messages occur. Can you, for each statement, Inconsistent with Consistent with
decide whether it is true or false? the scientific evidence the scientific evidence Don't know • lower among academics than among others.
10% 11% 10% 9% 7%
14%
• Regarding Snus but not NRT the proportion of inconsistent
“Snus use is almost as harmful to health as smoking.” 29% 33% 27% answers is lower among young people than among old.
20% 36%
(In the text below referred to as Snus) 26%
34% 38% 44% Information on the scientific evidence regarding NRT and Snus has not
reached out to the general public in Sweden. The observed influence of
“Long term use of nicotine gum or nicotine patches is almost 34% 32% 39% 63%
32% education level suggests that further large scale educational efforts would
as harmful to health as smoking.” be potentially effective to fulfill the need for increased awareness of actual
69%
(In the text below referred to as NRT) 63%
56% 54% facts and rectify prevailing misinterpretations.
49%
37% 35% 32% 33%
23%
Both statments were included in the 1996 questionnaire. The NRT
REFERENCES
statement was excluded in 2004 and reinstated in 2006. 100'-174' 175'-239' 240'-299' 300'-374' >374' 100'-174' 175'-239' 240'-299' 300'-374' >374' 1. Royal College of Physicians of London. Protecting smokers, saving lives. The case
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The poster (Handout version) can be downloaded at www.forskningsgruppen.com