The World Health Organization’s Framework Convention on Tobacco Control (FCTC) aims to combat glo... more The World Health Organization’s Framework Convention on Tobacco Control (FCTC) aims to combat global tobacco-related deaths. While it has reduced smoking in some regions, its overall effectiveness is debated, especially regarding alternative nicotine products like e-cigarettes and Swedish snus. Although the WHO views these as threats, evidence suggests they could aid harm reduction. With differing smoking trends in various countries and emerging evidence supporting alternatives, the upcoming 10th Conference of the Parties (COP10) in Panama represents a crucial juncture to reassess and potentially redefine global tobacco control strategies.
This is an overview of research data that present pieces of evidence indicating that the shift fr... more This is an overview of research data that present pieces of evidence indicating that the shift from cigarettes to snus has made it possible for men in Sweden to achieve Europe's lowest level ov mortality attributed to tobacco.
Sirs, in their article on nicotine dependence Groman and Fagerström point out that it is “unlikel... more Sirs, in their article on nicotine dependence Groman and Fagerström point out that it is “unlikely that nicotine use can be totally abandoned” and that, as an implication thereof, appropriate regulatory systems for different forms of nicotine administration should be adopted [1]. A new category of nicotine delivery systems is nicotine-containing pharmaceuticles [2]. These are subject to careful regulation. But, regulation of tobacco products is less satisfactory. For example, some features of the current European Union regulation of tobacco products appear rather illogical and a revision should therefore be considered. As far as smokeless tobacco is concerned the EU rules put no restrictions on oral chewing tobacco but prescribes a total ban on sale of moist, oral snuff. There is an exemption of that ban for Sweden, where the domestic kind of moist snuff, “snus”, is very commonly used by males. In the general adult male population the prevalence of daily snus use has been rising to 21% in 2002, while the prevalence of daily smoking has been decreasing to 15%. Among male medical doctors the corresponding figures are (in 2001) 16% daily snus use and 8% daily smoking. This quite unique pattern of tobacco use makes it interesting to look at the levels of tobacco-related diseases in Sweden. We then find that tobacco-related diseases among Swedish males have been decreasing for several decades to reach levels lower than those in other developed countries [3]. A major reason for this seems to be the increasing rates of smoking cessation. This development should be attributed to a combination of factors, one of them being the use of snus as a cessation aid, a kind of nicotine replacement therapy. Although slightly more than half of all successful quitters have not used any special cessation aid, snus has been used by more quitters than any other aid. Next come nicotine chewing gum and nicotine patch. Further, among those who have made a quit attempt, those using snus as an aid have higher success rate than those using gum or patch [4]. There is also evidence to suggest that the availability of snus as an alternative to smoking helps keeping down initiation of smoking. In the adult male population of Sweden just 22% of those who had started daily tobacco use with snus have later started daily smoking (and 72% of them have then quit daily smoking), while 46% of other males have started daily smoking. Like all smokeless tobacco products snus is free from the combustion products that are the main health damaging constituents of cigarette smoke. This makes it reasonable to expect a generally lower health risk associated with this product than with cigarettes. Nicotine blood levels in snus users are about the same as in cigarette smokers, not higher as sometimes argued. Further, Swedish snus is manufactured in a different way than most American moist snuff [5]. This results in very low levels of nitrosamines, something that may help explain why epidemiological studies have not found an excess risk for oral cancer among snus users. With respect to CVD there is some uncertainty to what extent snus use is a risk factor. However, it seems clear that any such risk is substantially smaller than that of smoking. The above glimpses of Swedish data suggest that snus is not worsening the health conditions in Sweden, maybe rather helping to reduce tobacco-related diseases. At the same time we see reports from UK on increasing concern about ill-health due to use of such chewing tobacco of South-East Asian type that is known to be associated with high risk for oral cancer. In this perspective the current EU rules appear obviously backward – no restrictions on the most dangerous products and ban on the least harmful or even beneficial one. Also with respect to regulation of cigarettes the EU Directive contains certain backward features. It fails to recognize that smokers intake of nicotine is rather independent of the machine measured nicotine yield, since human smokers tend to adapt their smoking behaviour so as to get an amount of nicotine individually determined by their nicotine dependence. While product regulation cannot very much influence humans’ intake of nicotine, it can influence the intake of other substances, namely by putting upper limits on the amount of various harmful substances that are allowed to accompany each unit of nicotine, i.e. the ratio between for example tar and nicotine. The current system can mean that a cigarette with a beneficially low tar/nicotine ratio is banned if the rather insignificant machine yield of nicotine is high, while a cigarette with a harmful high tar/nicotine ratio is allowed if the machine yield of nicotine is low enough. These conditions represent a backwardness analogous to the one regarding smokeless tobacco. In both cases the implications of nicotine dependence call for revisions of the current regulations. Lars M. Ramström
We may not be able to make you love reading, but the smoking epidemic a matter of worldwide conce... more We may not be able to make you love reading, but the smoking epidemic a matter of worldwide concern proceedings of the fourth world conference on smoking and health stockholm 1979 will lead you to love reading starting from now. Book is the window to open the new world. The world that you want is in the better stage and level. World will always guide you to even the prestige stage of the life. You know, this is some of how reading will give you the kindness. In this case, more books you read more knowledge you know, but it can mean also the bore is full.
Objective Most studies on health effects of Swedish oral snuff, ”snus”, have dealt with mortality... more Objective Most studies on health effects of Swedish oral snuff, ”snus”, have dealt with mortality. The current study deals with indicators of health during lifetime comparing different groups of tobacco users. Material and methods During the first half of 2008 the FSI survey of a nationwide representative sample of the Swedish population included questions both about tobacco use and about a number of health indicators: perception of own overall, physical and mental health status, and self-reported number of sick days absent from work last year. Results A substantial subgroup of current daily snus users are former daily smokers and their health status can be affected by this. Therefore results are reported separately for current daily snus users with and without a history of daily smoking. Overall health status was perceived as “Satisfactory” by 79% of never tobacco users, 81% of daily snus users without a history of smoking, 74% of daily snus users with a history of daily smoking an...
What can be accomplished by reducing smoking prevalence: the swedish example Background A country... more What can be accomplished by reducing smoking prevalence: the swedish example Background A country’s health burden attributable to tobacco is related to the size and development of the prevalence of smoking. The experience from Sweden can serve as a concrete example of what can be accomplished by reducing the prevalence of smoking. Objectives To review the scope and determinants of the Swedish experience. Methods Analyses of Swedish and International reports and studies. Results In the period from 1963 to 2012 the prevalence of daily smoking has decreased from 49% to 9% in men and from 23% to 12% in women. This results from a combination of decreasing initiation of smoking and increasing cessation of smoking. According to 2012 Eurobarometer data Sweden’s overall quit ratio is highest in Europé, more than double as high as in South-East Europen countries and 63% higher than the EU average. Mortality in tobacco-related diseases has been decreasing, particularly in men. According to the...
Objective: To study to what extent Swedish adults’ understanding of the health risks of Swedish s... more Objective: To study to what extent Swedish adults’ understanding of the health risks of Swedish snus and long term use of nicotine replacement products compared to smoking is consistent with current scientific evidence. Methods: Analysis of data from cross-sectional surveys of representative samples of the Swedish population, age 18-79, in 1996 (n=3237), 2004 (n=2308) and 2006 (n=1242) focusing on differences between subgroups of the population and changes over time. Results: When asked if snus use is almost as harmful as smoking, the proportion of respondents giving the correct answer was about double as great in 2006 as in 1996. This pattern appears in all subgroups, but daily snus users are the only ones where the correct answer is ever given by a majority (61% in 2004 and 2006). When asked if long term use of NRT products is almost as harmful as smoking, the proportion of correct answers fell from 40% in 1996 to 35% in 2006. There was no subgroup with respect to tobacco use in w...
This study investigates the incidence trends of urinary bladder cancer in Sweden from 1960 throug... more This study investigates the incidence trends of urinary bladder cancer in Sweden from 1960 through 1993 (a total of 46,211 cases). Age-standardized incidence rates increased among men from 14.6 per 10(5) in 1960 to 33.5 in 1993 and among women from 4.8 to 8.8, corresponding to an average annual increase of 2.4 percent (95 percent confidence interval [CI]) = 2.0-2.7 percent) and 1.1 percent (CI = 0.9-1.4 percent), respectively. The largest increase occurred in the oldest age-groups. The proportion of patients with transitional cell carcinoma increased in men from 66.0 percent in 1960-64 to 93.6 percent in 1990-93 and in women from 61.0 percent to 89.4 percent. The proportion of patients with papillomas decreased, whereas those with adenocarcinoma and squamous cell carcinoma were stable. Regression modeling (based on the period 1960-89) showed a strong linear effect due to either period and/or cohort. Among men, additional non-linear effects by both period and cohort were obtained. Th...
When looking at the above review of changes and trends in cigarette consumption some summary conc... more When looking at the above review of changes and trends in cigarette consumption some summary conclusions can be drawn: a continued growth in cigarette consumption will mainly take place in developing countries; price increases may have complex and unexpected effects, such as changing the brand structure of the market rather than reducing its size on a long-term basis; future studies of cigarette consumption trends will have to give increased attention to generic and hand-rolled cigarettes; in the future it will be irrelevant to look at the distinction between filter cigarettes and nonfilter ones; the important distinction will be between different types of filter cigarettes; an increasing taste consciousness among large groups of smokers will most probably constitute an additional obstacle to low-tar cigarettes ever becoming a viable vehicle for the limitation of smoking-related health risks.
Motivational and psychosocial treatments for tobacco dependence, while valuable, are not sufficie... more Motivational and psychosocial treatments for tobacco dependence, while valuable, are not sufficient to solve nicotine-related problems, which usually require a pharmacological approach. There is also a need for training programmes for health workers and major educational campaigns on the nature of tobacco dependence to be directed at opinion leaders, teachers and the public at large.
It is well known that Swedish men have lower tobacco-related mortality than men in other European... more It is well known that Swedish men have lower tobacco-related mortality than men in other European countries, but there are questions that need further investigation to what extent this is related to the specific patterns of tobacco use in Sweden, where use of snus, the Swedish low-nitrosamine oral tobacco, dominates over smoking in men but not in women. The recent WHO Global Report: Mortality Attributable to Tobacco provides a unique set of estimates of the health burden of tobacco in all countries of the world in the year 2004, and these data can help elucidating the above-mentioned questions. For Sweden and all other European Union Member States mortality data for a number of tobacco-related causes of death were extracted from the WHO Report. The size of the mortality advantage for selected causes of death in different age groups of Swedish men compared to men of the same age in Europe as a whole was calculated in terms of ratios of death rates attributable to tobacco. Differences...
The World Health Organization’s Framework Convention on Tobacco Control (FCTC) aims to combat glo... more The World Health Organization’s Framework Convention on Tobacco Control (FCTC) aims to combat global tobacco-related deaths. While it has reduced smoking in some regions, its overall effectiveness is debated, especially regarding alternative nicotine products like e-cigarettes and Swedish snus. Although the WHO views these as threats, evidence suggests they could aid harm reduction. With differing smoking trends in various countries and emerging evidence supporting alternatives, the upcoming 10th Conference of the Parties (COP10) in Panama represents a crucial juncture to reassess and potentially redefine global tobacco control strategies.
This is an overview of research data that present pieces of evidence indicating that the shift fr... more This is an overview of research data that present pieces of evidence indicating that the shift from cigarettes to snus has made it possible for men in Sweden to achieve Europe's lowest level ov mortality attributed to tobacco.
Sirs, in their article on nicotine dependence Groman and Fagerström point out that it is “unlikel... more Sirs, in their article on nicotine dependence Groman and Fagerström point out that it is “unlikely that nicotine use can be totally abandoned” and that, as an implication thereof, appropriate regulatory systems for different forms of nicotine administration should be adopted [1]. A new category of nicotine delivery systems is nicotine-containing pharmaceuticles [2]. These are subject to careful regulation. But, regulation of tobacco products is less satisfactory. For example, some features of the current European Union regulation of tobacco products appear rather illogical and a revision should therefore be considered. As far as smokeless tobacco is concerned the EU rules put no restrictions on oral chewing tobacco but prescribes a total ban on sale of moist, oral snuff. There is an exemption of that ban for Sweden, where the domestic kind of moist snuff, “snus”, is very commonly used by males. In the general adult male population the prevalence of daily snus use has been rising to 21% in 2002, while the prevalence of daily smoking has been decreasing to 15%. Among male medical doctors the corresponding figures are (in 2001) 16% daily snus use and 8% daily smoking. This quite unique pattern of tobacco use makes it interesting to look at the levels of tobacco-related diseases in Sweden. We then find that tobacco-related diseases among Swedish males have been decreasing for several decades to reach levels lower than those in other developed countries [3]. A major reason for this seems to be the increasing rates of smoking cessation. This development should be attributed to a combination of factors, one of them being the use of snus as a cessation aid, a kind of nicotine replacement therapy. Although slightly more than half of all successful quitters have not used any special cessation aid, snus has been used by more quitters than any other aid. Next come nicotine chewing gum and nicotine patch. Further, among those who have made a quit attempt, those using snus as an aid have higher success rate than those using gum or patch [4]. There is also evidence to suggest that the availability of snus as an alternative to smoking helps keeping down initiation of smoking. In the adult male population of Sweden just 22% of those who had started daily tobacco use with snus have later started daily smoking (and 72% of them have then quit daily smoking), while 46% of other males have started daily smoking. Like all smokeless tobacco products snus is free from the combustion products that are the main health damaging constituents of cigarette smoke. This makes it reasonable to expect a generally lower health risk associated with this product than with cigarettes. Nicotine blood levels in snus users are about the same as in cigarette smokers, not higher as sometimes argued. Further, Swedish snus is manufactured in a different way than most American moist snuff [5]. This results in very low levels of nitrosamines, something that may help explain why epidemiological studies have not found an excess risk for oral cancer among snus users. With respect to CVD there is some uncertainty to what extent snus use is a risk factor. However, it seems clear that any such risk is substantially smaller than that of smoking. The above glimpses of Swedish data suggest that snus is not worsening the health conditions in Sweden, maybe rather helping to reduce tobacco-related diseases. At the same time we see reports from UK on increasing concern about ill-health due to use of such chewing tobacco of South-East Asian type that is known to be associated with high risk for oral cancer. In this perspective the current EU rules appear obviously backward – no restrictions on the most dangerous products and ban on the least harmful or even beneficial one. Also with respect to regulation of cigarettes the EU Directive contains certain backward features. It fails to recognize that smokers intake of nicotine is rather independent of the machine measured nicotine yield, since human smokers tend to adapt their smoking behaviour so as to get an amount of nicotine individually determined by their nicotine dependence. While product regulation cannot very much influence humans’ intake of nicotine, it can influence the intake of other substances, namely by putting upper limits on the amount of various harmful substances that are allowed to accompany each unit of nicotine, i.e. the ratio between for example tar and nicotine. The current system can mean that a cigarette with a beneficially low tar/nicotine ratio is banned if the rather insignificant machine yield of nicotine is high, while a cigarette with a harmful high tar/nicotine ratio is allowed if the machine yield of nicotine is low enough. These conditions represent a backwardness analogous to the one regarding smokeless tobacco. In both cases the implications of nicotine dependence call for revisions of the current regulations. Lars M. Ramström
We may not be able to make you love reading, but the smoking epidemic a matter of worldwide conce... more We may not be able to make you love reading, but the smoking epidemic a matter of worldwide concern proceedings of the fourth world conference on smoking and health stockholm 1979 will lead you to love reading starting from now. Book is the window to open the new world. The world that you want is in the better stage and level. World will always guide you to even the prestige stage of the life. You know, this is some of how reading will give you the kindness. In this case, more books you read more knowledge you know, but it can mean also the bore is full.
Objective Most studies on health effects of Swedish oral snuff, ”snus”, have dealt with mortality... more Objective Most studies on health effects of Swedish oral snuff, ”snus”, have dealt with mortality. The current study deals with indicators of health during lifetime comparing different groups of tobacco users. Material and methods During the first half of 2008 the FSI survey of a nationwide representative sample of the Swedish population included questions both about tobacco use and about a number of health indicators: perception of own overall, physical and mental health status, and self-reported number of sick days absent from work last year. Results A substantial subgroup of current daily snus users are former daily smokers and their health status can be affected by this. Therefore results are reported separately for current daily snus users with and without a history of daily smoking. Overall health status was perceived as “Satisfactory” by 79% of never tobacco users, 81% of daily snus users without a history of smoking, 74% of daily snus users with a history of daily smoking an...
What can be accomplished by reducing smoking prevalence: the swedish example Background A country... more What can be accomplished by reducing smoking prevalence: the swedish example Background A country’s health burden attributable to tobacco is related to the size and development of the prevalence of smoking. The experience from Sweden can serve as a concrete example of what can be accomplished by reducing the prevalence of smoking. Objectives To review the scope and determinants of the Swedish experience. Methods Analyses of Swedish and International reports and studies. Results In the period from 1963 to 2012 the prevalence of daily smoking has decreased from 49% to 9% in men and from 23% to 12% in women. This results from a combination of decreasing initiation of smoking and increasing cessation of smoking. According to 2012 Eurobarometer data Sweden’s overall quit ratio is highest in Europé, more than double as high as in South-East Europen countries and 63% higher than the EU average. Mortality in tobacco-related diseases has been decreasing, particularly in men. According to the...
Objective: To study to what extent Swedish adults’ understanding of the health risks of Swedish s... more Objective: To study to what extent Swedish adults’ understanding of the health risks of Swedish snus and long term use of nicotine replacement products compared to smoking is consistent with current scientific evidence. Methods: Analysis of data from cross-sectional surveys of representative samples of the Swedish population, age 18-79, in 1996 (n=3237), 2004 (n=2308) and 2006 (n=1242) focusing on differences between subgroups of the population and changes over time. Results: When asked if snus use is almost as harmful as smoking, the proportion of respondents giving the correct answer was about double as great in 2006 as in 1996. This pattern appears in all subgroups, but daily snus users are the only ones where the correct answer is ever given by a majority (61% in 2004 and 2006). When asked if long term use of NRT products is almost as harmful as smoking, the proportion of correct answers fell from 40% in 1996 to 35% in 2006. There was no subgroup with respect to tobacco use in w...
This study investigates the incidence trends of urinary bladder cancer in Sweden from 1960 throug... more This study investigates the incidence trends of urinary bladder cancer in Sweden from 1960 through 1993 (a total of 46,211 cases). Age-standardized incidence rates increased among men from 14.6 per 10(5) in 1960 to 33.5 in 1993 and among women from 4.8 to 8.8, corresponding to an average annual increase of 2.4 percent (95 percent confidence interval [CI]) = 2.0-2.7 percent) and 1.1 percent (CI = 0.9-1.4 percent), respectively. The largest increase occurred in the oldest age-groups. The proportion of patients with transitional cell carcinoma increased in men from 66.0 percent in 1960-64 to 93.6 percent in 1990-93 and in women from 61.0 percent to 89.4 percent. The proportion of patients with papillomas decreased, whereas those with adenocarcinoma and squamous cell carcinoma were stable. Regression modeling (based on the period 1960-89) showed a strong linear effect due to either period and/or cohort. Among men, additional non-linear effects by both period and cohort were obtained. Th...
When looking at the above review of changes and trends in cigarette consumption some summary conc... more When looking at the above review of changes and trends in cigarette consumption some summary conclusions can be drawn: a continued growth in cigarette consumption will mainly take place in developing countries; price increases may have complex and unexpected effects, such as changing the brand structure of the market rather than reducing its size on a long-term basis; future studies of cigarette consumption trends will have to give increased attention to generic and hand-rolled cigarettes; in the future it will be irrelevant to look at the distinction between filter cigarettes and nonfilter ones; the important distinction will be between different types of filter cigarettes; an increasing taste consciousness among large groups of smokers will most probably constitute an additional obstacle to low-tar cigarettes ever becoming a viable vehicle for the limitation of smoking-related health risks.
Motivational and psychosocial treatments for tobacco dependence, while valuable, are not sufficie... more Motivational and psychosocial treatments for tobacco dependence, while valuable, are not sufficient to solve nicotine-related problems, which usually require a pharmacological approach. There is also a need for training programmes for health workers and major educational campaigns on the nature of tobacco dependence to be directed at opinion leaders, teachers and the public at large.
It is well known that Swedish men have lower tobacco-related mortality than men in other European... more It is well known that Swedish men have lower tobacco-related mortality than men in other European countries, but there are questions that need further investigation to what extent this is related to the specific patterns of tobacco use in Sweden, where use of snus, the Swedish low-nitrosamine oral tobacco, dominates over smoking in men but not in women. The recent WHO Global Report: Mortality Attributable to Tobacco provides a unique set of estimates of the health burden of tobacco in all countries of the world in the year 2004, and these data can help elucidating the above-mentioned questions. For Sweden and all other European Union Member States mortality data for a number of tobacco-related causes of death were extracted from the WHO Report. The size of the mortality advantage for selected causes of death in different age groups of Swedish men compared to men of the same age in Europe as a whole was calculated in terms of ratios of death rates attributable to tobacco. Differences...
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Papers by Lars Ramström