Nicotine & Tobacco Research
Nicotine & Tobacco Research Advance Access published July 9, 2010
Original Investigation
The use of snus for quitting smoking
compared with medicinal products
Karl Erik Lund, Ph.D.,1 Ann McNeill, Ph.D.,2 & Janne Scheffels, Ph.D.1
1 Norwegian Institute for Alcohol and Drug Research, Oslo, Norway2 UK Centre for Tobacco Control Studies, Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK Corresponding Author: Karl Erik Lund, Ph.D., Norwegian Institute for Alcohol and Drug Research, PO Box 565 Sentrum, 0105 Oslo, Norway. Telephone: +47-91-73-37-58; Fax: +47-22-34-04-01; E-mail: kel@sirus.no Received April 7, 2010; accepted June 3, 2010 A consistent finding in Swedish (Gilljam & Abstract
and Norwegian ; ) observational studies is Introduction: Given there are few experimental studies com-
that the quit rate for smoking is higher for snus users than for paring the effects of snus and medicinal products for quitting smokers who have no experience of use of snus. To our knowl- smoking, self-reports from smokers who have used different edge, other than a few small pilot studies methods for quitting smoking can be informative.
Methods: Fourteen thousand seven hundred and forty-four controlled trials (RCT) or experimental studies have been car-
Norwegian men aged between 20 and 50 years were selected at ried out to compare the effect of snus and medicinal nicotine random from a national representative web panel and sent a products on quitting smoking. In the absence of such studies, questionnaire by E-mail. Of the 7,170 (48.6%) who responded, self-reported data have been used to shed light on the effect of there were 1,775 former and 1,808 current smokers. They were the different methods for quitting smoking (Ramström & asked about the method they used and the outcome of their last Foulds), although the degree of evidence is lower.
We examined the self-reported outcome of smokers’ Results: In a regression model in which education, number of attempts to quit smoking using the following methods of quitting:
previous attempts to quit smoking, perception of risk, and age snus, nicotine patches, nicotine chewing gum, bupropion were controlled for, the odds ratio (OR) for reporting total absti- nence at the time of the survey was significantly higher for those who had used varenicline (OR = 4.95, p < .006) and snus (OR = 2.68, p < .001) compared with those who had used nicotine chewing gum (reference OR = 1). For smokers who reported An invitation to participate in the survey was sent by E-mail to that they had tried to quit with the help of snus, 62.4% reported 14,744 men aged 20–50 years in 2007, who had been randomly that they still used snus at the time of the survey either daily selected from a web panel of 62,000 Norwegians administrated by (43.8%) or occasionally (18.6%). The proportion who still used the international research agency Synovate. People were recruited medicinal nicotine products at the time of the survey was 9.5%.
to this web panel when they had participated in previous nation-ally representative population surveys, carried out by telephone, Discussion: Compared with medicinal nicotine products, snus post, or personal interview and had agreed to receive future invi-
and varenicline increased the probability of quitting smoking tations to participate in surveys by E-mail. Self-recruitment to the completely, but snus seemed to maintain nicotine dependence.
panel was not possible. Of those invited to participate, 7,170 men (48.6%) responded. No significant differences at the 5% level were detected in the distributions of the national population and Introduction
the respondents when compared by age and region.
In general, the Nordic health authorities do not recommend use The final sample consisted of 1,775 former daily or occa- of snus as a method for quitting smoking sional smokers and 1,808 current daily or occasional smokers, a total of 3,583 people. Former smokers and smokers who had recently agreed that health care personnel can recommend snus tried to quit were asked “Did you use some of these methods in individual cases of inveterate smokers ( when you last tried to quit smoking (multiple answers possi- ). However, studies have shown that snus is the ble)?” Response categories were nicotine gum, nicotine patch, preferred method for quitting among male smokers in Sweden snus, inhaler, Zyban, Champix, called the quitline, attended and Norway, and this method is also used by an increasing a course or consulted health personnel, and read brochures/ self-help material (Table 1). The association between using doi: 10.1093/ntr/ntq105 The Author 2010. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Use of snus for quitting smoking
Table 1. Percentage using different methods for quitting smoking on last quit attempt
among ever smokers, former smokers, and current smokers (multiple choice of methods
possible), and ratio of former/current smokers for each quit-smoking method
different methods was measured by Pearson’s coefficients that respondents who had quit smoking completely were excluded can range in value from −1 (a perfect negative relationship) to +1 (a perfect positive relationship). Use of one method pre-dicts the use of another method if correlation between the two Perception of risk was measured using the question “On a was positive and significantly different from 0 (no relationship). scale from 1 to 7, where 1 is ‘not dangerous’ and 7 is ‘very dan- If use of one method reduced the probability to take up an ad- gerous’, how dangerous to health do you believe use of cigarettes ditional method, the correlation had a negative sign (Table 2). is?” For use in the regression analysis, the scores were grouped Correlation coefficients significant at the .05 level were identi- into three values by splitting the sample in “low” (range 1–5), fied with a single asterisk, and those significant at the .01 level “medium” (6), and “high score” (7). Scores for age and number of attempts to quit were grouped into three values by splitting the sample at the values closest to the 33rd and 66th percentile.
The respondents were also asked “What was the result of your latest attempt to quit smoking?” The response categories were quit smoking completely, greatly reduced their cigarette consumption, reduced their cigarette consumption somewhat, and smoked about the same as before. The odds ratios (ORs) Snus was the most common method for quitting smoking, fol- for reporting “quit smoking completely” (table 3), and then in lowed by nicotine chewing gum, self-help materials, and nico- another model “greatly reduced cigarette consumption” (table 4), tine patches (Table 1). The proportion of current smokers (and were calculated using logistic regression controlling for method thus unsuccessful quitters) was greater than the proportion of for quitting, length of highest completed education, number former smokers (and thus successful quitters) for all methods of previous attempts to quit, risk perception, and age. Only for quitting smoking. However, the ratio of successful to unsuc- people who reported using only one of nicotine chewing gum, cessful quitters was higher for snus than for the other methods nicotine patches, snus, bupropion, or varenicline were included in the regression analysis. However, these respondents could have used other methods for quitting smoking, such as self- Just under half (n = 1,727, 48.2%) of current or former help materials, a telephone helpline for smoking, or consulta- smokers reported that they had used at least one of the nine tion with health care personnel. In the model for Table 4, specified methods to try to quit smoking on their last attempt. Table 2. Relationship between methods of quitting. Bivariate correlations (Pearson) with
asterisks identifying significant associations
Note. **Correlation at .01 (two tailed), *correlation at .05 (two tailed).
Nicotine & Tobacco Research
Table 3. Percentage (bivariate) and
Table 4. Percentage (bivariate) and
adjusted odds ratios (AORs) for having quit
adjusted odds ratio (AOR) for having greatly
smoking completely at the last attempt for
reduced cigarette consumption at the last
men aged 20–50 years. Odds ratio is
attempt for men aged 20-50 years. OR is
adjusted for method of quitting, length of
adjusted for method of quitting, length of
education, number of previous attempts to
education, number of previous attempts to
quit, risk perception, and age group
quit, risk perception and age group
While use of a conventional method, recommended by the authorities, consistently increased the probability for also using The study has shown that snus is the preferred method for quit- one of the other recommended methods, use of snus was sig- ting smoking for men in the age group 20–50 years. In addition, nificantly negatively correlated with all the other methods of those using snus were more likely to have quit smoking com- pletely or considerably reduced their cigarette smoking than users of medicinal smoking cessation products. This is the case The OR of reporting total abstinence at the time of the survey, despite the fact that users of medicinal nicotine products had a when controlling for the other factors, was significantly higher greater tendency to use additional methods for quitting smoking, for use of snus only than for use of one of any of the other methods which would normally increase the probability of a positive re- for quitting. Fewer previous attempts to quit, concern about the sult. Use of snus seemed to be a more solitary method and might health risks, and increasing age also increased the probability for appear convenient for smokers who for some reason do not having quit smoking (Table 3). In a model predicting “greatly want to make use of the nicotine replacement therapy medicinal reduced cigarette consumption,” the significant predictors were products. However, the survey indicates that use of snus as a reduced to use of snus as the method for quitting and length of method for quitting smoking may result in continued use after the attempt to quit. Such prolonged use of snus not only oc-curred among those who quit smoking or who greatly reduced Of those smokers who reported that they had tried to quit their cigarette consumption but also among those who man- by using snus, 62.4% reported that they still used snus at the aged to change their cigarette consumption to a lesser extent.
time of the survey, either daily (43.8%) or occasionally (18.6%). People who had quit completely or greatly reduced their ciga-rette consumption with the help of snus were more likely to use Limitations
snus on a daily basis than people whose attempt to quit had The study has weaknesses common to other cross-sectional resulted in less change in cigarette consumption. In compari- surveys using self-reported data. In contrast to an RCT, our study son, only 9.5% who had used nicotine chewing gum or nicotine design does not ensure comparability of different groups. Thus, patches at the last attempt to quit were still using these medicinal the possibility cannot be excluded that there are differences nicotine products at the time of the survey (Table 5).
between the groups with regard to variables that can influence Use of snus for quitting smoking
Table 5. Proportion of men 20–50 years old who used snus or medicinal nicotine products
to quit smoking who were using these products at the time of the survey
Outcome of last quit attempt Quitted smoking completely Great reduction in cigarette consumption the outcome of an attempt to quit smoking, such as smoking ), and the price is only a bit lower than intensity, smoking history, degree of nicotine dependence, and the price of cigarettes. Some of the reasons why snus still has strength of intention to quit smoking. We have controlled for greater potential for use than medicinal nicotine products are some variables (age, number of previous attempts to quit smok- that the nicotine dose is almost the same as for cigarettes ing, perception of risk, and education), which compensate to some extent—but not fully—for the absence of randomization. choice of brand, aesthetic rituals of use, and visibility can repre- However, the current kind of observational studies are superior sent social positioning and self presentation ( to RCT when it comes to evaluate effectiveness under real life ). Use of snus can thus—in contrast to nicotine chewing conditions for different smoking cessation methods.
gum and nicotine patches—have functions that are identical to those offered by cigarettes. In addition, snus, similar to ciga- Another weakness is that we do not have data about the rettes, tastes of tobacco and thus has a sensory effect that me- length of time from the attempt to quit smoking to the time of dicinal nicotine products perhaps lack. This suggests that snus is the survey. We cannot exclude the possibility that there are the only nicotine product on the Norwegian market that can systematic differences between smokers who use the different compete in popularity with cigarettes The like- methods, with regard to length of time between attempts to quit ability of snus implies that the impact on smoking cessation at smoking or recall of quit attempts, but there is not any obvious the population level (effectiveness) will be higher than medicinal reason that this would be the case. Respondents with an over- nicotine products. This would be the case even if, hypothetically, average interest in smoking cessation might be overrepresented future RCTs should moderate our results in finding that use of in studies like this, but again, we find no reason that this interest snus results in no increase in rates of abstinence (efficacy).
should be systematically imbalanced between users of the differ-ent methods. Finally, the outcomes studied here are self-reports, The higher rates of snus use among those using snus on and these are not validated with biochemical markers. Thus, their last quit attempt may be an indication that use of snus there is a need to carry out experimental studies that can when quitting smoking contributes to maintaining dependence on nicotine and that the method can result in dual use for those whose attempt to quit has been unsuccessful. Against this back- Use of snus for smoking cessation
ground, advice against using snus as a method for quitting smoking as a general strategy seems to be sensible. However, the rather than medicinal products
method could be particularly relevant for intransigent smokers who are seriously addicted to nicotine and who have been ), our study shows that medicinal nicotine products unsuccessful in quitting using conventional methods. For these are not the most popular method chosen by Norwegian smok- people, as for all other smokers, nicotine uptake from snus ers to quit smoking. This is the case even though the pharma- instead of from cigarettes has the potential for reducing harm by ceutical companies have, for nearly 25 years, widely advertised at least 90% (It should also be emphasized these products as effective stop-smoking aids, that they are that a substantial fraction (37.6%) of those using snus as widely accessible over-the-counter products, and given recom- a method for quitting in fact ended up tobacco free, as also mendations by the health authorities. The low utilization is re- lated to, among other things, the fact that they are deliberately made unattractive in order to avoid misuse and that they give a A possible negative consequence of allowing use of snus as a much lower dose of nicotine than cigarettes. The first genera- method for quitting among inveterate smokers is that the method tion of nicotine chewing gum was made with an unpleasant would not only be used by these highly nicotine-dependent taste in order for it to be authorized for sale but is now on the smokers. A partial approval of snus as a potential quit smoking market with flavors of mint, fruit, or liquorice.
method might result in many smokers, who otherwise would have been able to quit using tobacco completely, would be With regard to snus, its effect on quitting smoking is not recruited into prolonged nicotine dependence from snus. In this connection, a relevant challenge for further research is to find out whether transition from cigarettes to snus will increase the health authorities advise against its use, the percep- or decrease the risk of future relapse to smoking as compared tion of health risks are exaggerated in the population ( Nicotine & Tobacco Research
Why is snus more effective than
medicinal nicotine products?
Of 100 people who try to quit smoking, about 95 will relapse
Aubin, H. J., Bobak, A., Britton, J. R., Oncken, C., Billing, C. B. Jr., within 6 months without using medicinal nicotine products. Gong, J., et al. (2008). Varenicline versus transdermal nicotine At best, only five more people will quit smoking completely by patch for smoking cessation: Results from a randomised open label trial. Thorax, 63, 717–724.
). It has been calculated that availability of nonpre- Cummings, K. M., & Hyland, A. (2005). Impact of nicotine scription medicinal nicotine products has had no measurable ef- replacement therapy on smoking behavior. Annual Review of fect on the quit rate for smoking in the United States ( Public Health, 26, 583–599.
. This is primarily because so few smokers use these products but also because the effect of medicinal nicotine Etter, J. F., & Stapleton, J. A. (2006). Nicotine replacement ther- products is quite low when measured after 12 months ( apy for long-term smoking cessation: A meta-analysis. Tobacco Control, 15, 280–285.
(). So snus does not need to have a very Gilljam, H., & Galanti, M. R. (2003). Role of snus (oral moist great effect on the quit rate in order to produce better results snuff) in smoking cessation and smoking reduction in Sweden. than medicinal nicotine products. Studies have shown that Addiction, 98, 1183–1189.
varenicline (Champix) has a much better effect than medicinal nicotine products ()—which our study has Hatsukami, D. K., Ebbert, J. O., Feuer, R. M., Stepanov, I., & also shown—but this product is only available on prescription, Hecht, S. S. (2007). Changing smokeless tobacco products. New is relatively new and not widely used, and will thus not have a tobacco-delivery systems. American Journal of Preventive Medi- great effect on the quit rate at the population level unless there cine, 33, S368–S378.
Helgason, A. R., Tomson, T., Lund, K. E., Galanti, R., Ahnve, S., & We must assume that the most important reason why snus is Gilliam, H. (2004). Factors related to abstinence in a telephone reported to be more effective for quitting smoking than medicinal helpline for smoking cessation. European Journal of Public nicotine products is that it provides a high enough dose of nico- Health, 14, 306–310.
tine so that it feels satisfying for smokers ).
Holm, L. E., Fisker, J., Larsen, B. I., Puska, P., & Halldórsson, M. (2009). Snus does not save lives: Quitting smoking does! Since snus contains carcinogenic substances and increases Tobacco Control, 18, 250–251.
the risk of cancer of the esophagus and the pancreas—though lower than for smoking (would be Hughes, J. R., Shiffman, S., Callas, P., & Zhang, J. (2003). ethical objections to carrying out an RCT. An alternative design A meta-analysis of the efficacy of over-the-counter nicotine would be to divide people who call the quitline according to replacement. Tobacco Control, 12, 21–27.
method for quitting smoking, to measure other variables that Levy, D. T., Mumford, E. A., Cummings, K. M., Gilpin, E. A., have significance for quitting smoking at the baseline, and then Giovino, G., Hyland, A., et al. (2004). The relative risks of a low- to follow up these people prospectively, as has been done in nitrosamine smokeless tobacco product compared with smoking cigarettes: Estimates of a panel of experts. Cancer Epidemiology, The study indicates that use of varenicline and snus increases Biomarkers & Prevention, 13, 2035–2042.
the probability of a positive outcome of an attempt to quit Lund, K. E. (2009a). A tobacco-free society or tobacco harm re- smoking compared with medicinal nicotine products. This is duction? Which objective is best for the remaining smokers in the case despite the fact that users of medicinal nicotine products Scandinavia? SIRUS-report 6/2009. Oslo: Norwegian Institute have a greater tendency than snus users to use other additional methods that have a positive effect on quitting smoking. Further studies should be carried out with a design that can provide better Lund, K. E. (2009b). The role of snus in the decline of smoking in evidence. Prolonged use of snus was also widespread among Norway. [Online presentation]. Mumbai, India: 14th World Con- smokers who made unsuccessful attempts to quit smoking. As a ference on Tobacco or Health. Retrieved May 26, 2010, from http method for quitting smoking, snus should only be considered ://www.14twctoh.org/speaker.htm?spkname=Karl E Lund&fdr= for seriously nicotine-dependent smokers who have previously abstract/Trident/09-March/1530–1630 hrs/Rooftop&spk=lund been unsuccessful with other methods.
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Declaration of Interests
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