Contrasting smokers' and snus users' perceptions of personal tobacco behavior in norway

How do Smokers in a Snus-Prevalent Society Consider E-cigarettes, Snus, and Nicotine Replacement Therapy Products as Relevant Replacements for Cigarettes in the Event They Should Stop Smoking?

INTRODUCTION

Around 50 percent of the tobacco in Norway is consumed in the form of snus, a smokeless oral tobacco. We examined Norwegian smokers' openness, and thereby the potential reach, to use e-cigarettes, nicotine replacement therapy products (NRT), and snus in the event of quitting smoking, in a society where snus use is common.

METHODS

Using data from an online survey of 4073 smokers from 2019 to 2021, we calculated predicted probabilities of smokers' being open, undecided, and not open to use e-cigarettes, snus, and NRT in the event they should quit smoking.

RESULTS

Among daily smokers, the probability of being open to use e-cigarettes in the event of quitting smoking was .32. The corresponding probabilities for using snus and NRT were .22 and .19. Snus was the product with the highest probability of not being open (.60). NRT had the highest probability of being undecided (.39). Among smokers who had never used e-cigarettes or snus, the probabilities of being open were .13 for e-cigarettes, .02 for snus and .11 for NRT.

CONCLUSIONS

In a snus-friendly norm climate where smokers have traditionally used snus as an alternative to cigarettes, the probability of using e-cigarettes in the event of smoking cessation was higher compared to both snus and NRT. However, among smokers who had never used e-cigarettes or snus, the likelihood of being open to use of NRT was similar to e-cigarettes, and higher than snus, which suggests that NRT may still play a role in smoking cessation.

IMPLICATIONS

In a snus-prevalent country in the endgame phase of the cigarette epidemic, where robust infrastructure for tobacco control in combination with the availability of snus has reduced smoking to a minimum, the remaining smokers seem to prefer e-cigarettes to snus if they should quit smoking. This indicates that availability of several nicotine alternatives might increase the likelihood of a future product replacement within the small group of remaining smokers.

Factors associated with initiation and use of snus among adolescents

AIM

We investigated factors associated with the initiation and continuation of snus use in adolescents in Norway. The associations with adolescents' own educational plans, the parents' educational level(s) and tobacco habits were estimated.

METHODS

In this cross-sectional questionnaire-based study, 1465 patients aged 18-20 years participated. The questionnaire was administered at regular dental examinations in the public dental health service. To assess the association between individual factors and the initiation of tobacco habits, a generalised structural equation model with random effects at the clinic level was used. Binary responses were modelled using multilevel binary logistic regression, while the number of snus boxes used per month was modelled using a multilevel Poisson regression model.

RESULTS

Of current (daily and occasional) tobacco users, 85% were snus users, including dual users of both snus and cigarettes. The median age of snus initiation was 16 years. Both parental snus use and smoking were associated with an increased risk of snus initiation, snus use and a higher amount of use. An increased risk of using snus was associated with male gender and with no educational plans or planning for further vocational education. The amount of snus used was higher among current snus users with a prior smoking history and among those planning for further vocational education.

CONCLUSIONS

These findings may aid in developing and targeting tobacco prevention strategies aimed at young people. Tobacco prevention measures should start at the elementary school level. The strong association with parental tobacco habits underlines the importance of parents' influence on their children's tobacco use.

Are smoking cessation behaviours among daily smokers associated with a perceived public stigma of smokers? Cross-sectional analyses of Norwegian data 2011–2013

Introduction

Perceived stigma may be an unintended consequence of tobacco denormalization policies among remaining smokers. Little is known about the role of perceived stigmatization in cessation behaviours.

Aims

To test if perceived public smoker stigma is associated with recent attempts to cease smoking and future cessation plans among adult daily smokers.

Methods

Using merged data from the biennial national survey Norwegian Monitor 2011 and 2013 (N daily smokers = 1,029), we performed multinomial and ordinal regression analyses to study the impact of perceived public stigma (measured as social devaluation and personal devaluation) on recent quit attempts, short-term intention to quit and long-term intention to quit, controlling for confounders. One additional analysis was performed to investigate the relationship between stigma and intention to quit on quit attempts.

Results

A significant association between perceived social devaluation and recent quit attempts was found (OR 1.76). Perceived stigma was not associated with future quit plans. Personal devaluation was not associated with any cessation outcome. The role of perceived social devaluation on quit attempts was mainly found among smokers with intentions to quit.

Conclusion

These findings indicate that stigma measured as social devaluation of smokers is associated with recent quit attempts, but not with future quit plans.

Alarming development of dual snus and cigarette usage among young Finnish males

Background

The consumption of tobacco products has evolved to include more complex combinations of different products. We investigated the tobacco habits of a representative population of young Finnish male conscripts in order to evaluate the prevalence of dual use of cigarettes and snus as well as the transition from one tobacco product to another. In addition, we evaluated the correlation between the level of education and the use of cigarettes and snus.

Methods

A questionnaire-based survey was carried out in three out of 17 garrisons among conscripts during their first week of service in 2014. A total of 1971 male conscripts were selected by simple random sampling of the 9013 males in the selected garrisons. Of them 1916 participated and filled in the questionnaire. The response rate was 97.2%. The questionnaire consisted of 25 questions including age, gender, basic education, use of tobacco products as well as questions assessing nicotine dependency.

Results

The amount of dual users of cigarettes and snus was 21%. There was a higher probability of dual use of cigarettes and snus among smokers compared to snus users (p < 0.001). One third (35%) of former smokers reported daily snus use and over 40% of the former snus users smoked daily. One third (34%) of the participants reported snus usage and 14% of the study subjects used snus daily. 40% of the study population were smokers and over 25% smoked daily. Of the participants with basic educational background 57% smoked daily (p < 0.001), however, no association between snus and level of education was found (p = 0.69).

Conclusions

This study provides better understanding of the complex tobacco habits of young adult males. The simultaneous usage of multiple tobacco products as well as the high tendency to transition from one tobacco product to another should be taken into consideration when planning cessation interventions in health care settings and tobacco control policies at societal levels.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7519-1) contains supplementary material, which is available to authorized users.

Relative Risk Perceptions between Snus and Cigarettes in a Snus-Prevalent Society-An Observational Study over a 16 Year Period

Background: Most studies on perceived risks of smokeless tobacco products (SLT) have been conducted in the U.S., and the vast majority conclude that perceptions of the relative harmfulness of SLT versus cigarettes in the population are inconsistent with epidemiologically-based risk estimates, and typically conflated to that of cigarettes. We tested whether such inaccuracies also existed in Norway, where SLT-products are less toxic (Swedish snus) and SLT use is more prevalent than in the U.S. Methods: Over a 16 years period (2003⁻2018), 13,381 respondents (aged 16⁻79 years) answered questions about risk perceptions in Statistics Norway's nationally representative survey of tobacco behavior. We applied an indirect measure of comparative harm where risk beliefs for eight nicotine products were assessed independently of other products and then compared the answers. The wording of the question was: "We will now mention a variety of nicotine products and ask you how harmful you think daily use of these are. Use a scale from 1 to 7, where 1 is slightly harmful and 7 is very harmful". Mean scores with 95% confidence intervals were calculated. Results: The overall risk score for cigarettes was 6.48. The risk score for snus was 5.14⁻79.3% of the risk score of cigarettes. The relative risk scores for e-cigarettes (3.78) and NRT products (3.39) was 58.4% and 52.3% when compared to cigarettes. Perceptions of risk were stable over time. A strong association was observed between perceived risk of snus and having used snus in attempts to quit smoking. Conclusion: Perceptions of relative risk between snus and cigarettes is inconsistent with estimates from medical expert committees, which assess the overall health risk from use of Swedish snus to be minor when compared to the risk from smoking. Like the situation in the US, incorrect beliefs about SLT risks seem to be prevalent also in the snus-prevalent Norwegian setting. Accurate information on differential harms needs to be communicated. Future research should try to identify reasons why health authorities in the US and Scandinavia allow these well-documented misconceptions to persist.

Nye bruksmønstre i et tobakksmarked i endring – kombinert bruk av sigaretter, snus og e-sigaretter blant ungdom

Objectives:

There is limited research on combined use of cigarettes, snus and e-cigarettes in the Nordic countries. This study will investigate whether this pattern of use occurs among adolescents in Norway. In addition, we will investigate the association between combined use of several tobacco products, e-cigarettes and socio-demographic and psychosocial factors (SPF).

Method:

A school-based cross-sectional survey of adolescents in the 8th to the 12th grade (N = 875) in 2014. Information on the use of cigarettes, snus, e-cigarettes and SPF was collected using an electronic questionnaire.

Results:

Of the adolescents, 31% reported having tried or used one or more tobacco product and/or e-cigarette. Of these, over half reported having tried or used one product, 1/3 two products and 1/10 three products. There were more boys among poly-users (63%) than among single-users (44%). Compared to single-users, poly-users also reported weaker school performance (30% and 11%, respectively), more often reported drinking alcohol to intoxication (91% and 75%, respectively), and having tried cannabis (28% and 9%, respectively). Poly-users also scored higher on impulsivity, sensation-seeking and depression.

Conclusion:

The study shows that combined use of tobacco products and e-cigarettes occurs among young people in Norway. Such use was associated with psychosocial and socio-demographic risk factors. There is a need to investigate this phenomenon in more details in representative samples.

Video-based kinetic analysis of calcification in live osteogenic human embryonic stem cell cultures reveals the developmentally toxic effect of Snus tobacco extract

Epidemiological studies suggest tobacco consumption as a probable environmental factor for a variety of congenital anomalies, including low bone mass and increased fracture risk. Despite intensive public health initiatives to publicize the detrimental effects of tobacco use during pregnancy, approximately 10-20% of women in the United States still consume tobacco during pregnancy, some opting for so-called harm-reduction tobacco. These include Snus, a type of orally-consumed yet spit-free chewing tobacco, which is purported to expose users to fewer harmful chemicals. Concerns remain from a developmental health perspective since Snus has not reduced overall health risk to consumers and virtually nothing is known about whether skeletal problems from intrauterine exposure arise in the embryo. Utilizing a newly developed video-based calcification assay we determined that extracts from Snus tobacco hindered calcification of osteoblasts derived from pluripotent stem cells early on in their differentiation. Nicotine, a major component of tobacco products, had no measurable effect in the tested concentration range. However, through the extraction of video data, we determined that the tobacco-specific nitrosamine N'-nitrosonornicotine caused a reduction in calcification with similar kinetics as the complete Snus extract. From measurements of actual nitrosamine concentrations in Snus tobacco extract we furthermore conclude that N'-nitrosonornicotine has the potential to be a major trigger of developmental osteotoxicity caused by Snus tobacco.

Snus undermines quit attempts but not abstinence: a randomised clinical trial among US smokers

BACKGROUND

Observational studies and a few clinical trials suggest that use of low nitrosamine smokeless tobacco (snus) can facilitate smoking cessation. To better understand the real-world impact of snus on smoking behaviour, a large-scale, long-term clinical trial of naturalistic snus use among smokers is needed.

STUDY DESIGN

A nationwide clinical trial compared abstinence outcomes among smokers who were randomised to receive free samples of snus versus not. Participants (N=1236) were recruited throughout the US and assessed for 1 year following a 6-week naturalistic sampling period, with high retention throughout. Primary outcomes included self-reported quit attempts, floating abstinence (any 7-day period of non-smoking) and 7-day point-prevalence abstinence at 6 months and 12 months. Secondary outcomes were changes in smoking, motivation and confidence to quit and adverse events. No tobacco industry support was provided.

RESULTS

Within snus group, 82% used at least once, and 16% were using regularly at end of sampling period. Compared to control participants, smokers in the snus group were less likely to make any quit attempt (RR=0.83; 95% CI 0.70 to 1.00), and any 24 h quit attempt (RR=0.77; 95% CI 0.63 to 0.95). There were no group differences on any measure of abstinence.

CONCLUSIONS

Provision of snus in a naturalistic context resulted in minimal uptake, and as a whole, undermined quit attempts and did not increase smoking abstinence. Results do not support the unguided, free provision of snus among smokers not motivated to quit as a means to facilitate quit attempts.

TRIAL REGISTRATION NUMBER

NCT01509586, Results.

Exploring smokers' opposition to proposed tobacco control strategies

Background

Tobacco control (TC) advocates are searching for new TC strategies to decrease smoking rates further.

Aims

The aim of this study is to explore smokers' opposition to 16 TC strategies, including the attitudes in the sample as a whole. The results are discussed in relation to the importance of public versus smoker support, and the need for legitimate TC strategies.

Methods

An Internet panel with 35,000 registered users was accessed to invite participants to join a survey on attitudes towards TC strategies. In addition, 1253 participants were recruited directly from mobile phone lists. Of the 5543 participants recruited, 5250 adults aged 20 years or older were eligible for analysis. Respondents' attitudes were measured on a five-point Likert scale, and mean values, standard deviations and percentages of those who opposed TC regulations were reported.

Results

In the total sample, there was some support for regulating smoking in specific outdoors areas. Smokers opposed all of the proposed strategies except banning smoking in cars carrying children, increasing the age limit for purchasing cigarettes and banning smoking at transportation stops. Smokers seemed to accept regulations that protected others from the health risks of smoking, but defended their right to smoke in some specific outdoor areas.

Conclusions

Smokers opposed most of the proposed TC strategies. Smokers' support may be more important in TC areas that aim to denormalise smoking and where enforcement is more complex.

Daily Smoking and Subjective Health Complaints in Adolescence

INTRODUCTION

Using data from the Health Behaviour in School-aged Children survey, this study used a repeated cross-sectional design to examine associations between daily smoking, gender, and self-reported health complaints in five cohorts of adolescents over a 16-year period.

METHODS

Data were from nationally representative cohorts of 15-year-old youth in Norway in 1993/1994, 1997/1998, 2001/2002, 2005/2006, and 2009/2010 (n _total = 7761). Dependent variables were psychological, somatic, and total health complaints. A mixed GLM model examined main and interaction effects of smoking (daily, intermittent, nonsmoking), year, and gender in predicting complaints. Time periods were segmented to compare trends across smoking groups in specific periods.

RESULTS

Prevalence of daily smoking declined from 15.5% (1993/1994) to 6.0% (2009/2010). All health complaint scores were significantly higher for smokers and for girls (vs. boys). Smoking status by year interactions were significant for all complaint variables during the period of sharpest decline of daily smoking prevalence (2001/2002-2005/2006), with daily smokers experiencing increases in health complaints while intermittent and nonsmokers did not. Smoking status by gender interactions were significant for all health complaint variables, indicating that the main effect for gender (females higher) was even stronger among smokers compared with nonsmokers. Using year as unit of analysis, the size of mean differences between daily smokers and intermittent/nonsmokers in total complaints was significantly negatively correlated with daily smoking prevalence (-.963, n = 5, p < .01).

CONCLUSIONS

As prevalence of daily smoking declined, daily smokers reported higher levels of complaints, suggesting increasing health problems within this group. Girls who smoke daily had particularly elevated levels of complaints.

IMPLICATIONS

This study indicates that the relationship between daily smoking and concurrent health symptomatology in adolescents is changing over time, with higher levels of health complaints reported as overall smoking prevalence declines. To our knowledge, this finding has not previously been reported. If youth are smoking to cope with distress, pain, or other health concerns, tobacco control objectives will be increasingly difficult to achieve with adolescents. Levels of health complaints are particularly high among girls who are daily smokers. The findings suggest that restrictive measures and persuasive communications may not be sufficient tobacco prevention strategies for adolescent populations. Young smokers may need counseling and support.

Lifestyle Correlates of Female Snus Use and Smoking: A Large Population-Based Survey of Women in Norway

INTRODUCTION

While smoking in Norway has become less prevalent, snus use has increased, including among women. The aims of this study were to describe female snus use and its correlates, and to contrast patterns of snus use and smoking.

METHODS

In 2011-2012, data on tobacco use, age, education, alcohol consumption, sexual behaviors, and physical activity were collected from a population based sample of 13 756 Norwegian women aged 18-45 years, using a self-administered questionnaire.

RESULTS

Ever-use prevalence of snus ranged from 29.6% to 4.5% among those aged 18-19 years and 40-45 years, respectively. In contrast, the corresponding figures for smoking were 24.1% and 44.1%. Among snus users, 54.1% and 22.8% of 18-19 and 40 to 45-year-olds had never smoked, respectively. Debut age for snus use increased markedly with age, and was higher than debut age for smoking. Female snus use was positively associated with intermediate education, alcohol consumption, number of sexual partners, and hard physical activity. Smoking was also positively associated with alcohol consumption and number of sexual partners, but negatively associated with physical activity and education.

CONCLUSION

While most snus users among older women were former or current smokers, this was not the case among younger women. Low snus debut age and extensive snus use among younger women suggest that measures to reduce snus use should be targeted at young adolescents. The correlates of female snus use and smoking were not identical, and were similar to those previously documented for men.