Mortality attributable to tobacco among men in Sweden and other European countries: an analysis of data in a WHO report
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Institute for Tobacco Studies, Täby, Sweden
Liqusa Research, Åtvidaberg, Sweden
Submission date: 2014-04-24
Acceptance date: 2014-08-28
Publication date: 2014-09-01
Corresponding author
Lars Ramström   

Institute for Tobacco Studies, Kanalvägen 17, 18338 Täby, Sweden
Tobacco Induced Diseases 2014;12(September):14
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 between age groups with respect to tobacco-related mortality were analyzed with respect to differences in terms of development and status of smoking and snus use. The analyses also paid attention to differences between countries regarding tobacco control regulations.

Among men in the European Union Member States the lowest level of mortality attributable to tobacco was consistently found in Sweden, while Swedish women showed levels similar to European average. A strong co-variation was found between the mortality advantage and the degree of dominance of snus use in the different age groups of Swedish men. Among Swedish women there are no age groups with dominant use of snus, and similar observations were therefore not possible for women.

The above findings support the assumption that the widespread use of snus instead of cigarettes among Swedish men may be a major part of the explanation behind their position with Europe’s lowest mortality attributable to tobacco.

Zatoński W, Przewoźniak K, Sulkowska U, West R, Wojtyła A: Tobacco smoking in countries of the European Union. Ann Agric Environ Med. 2012, 19 (2): 181-192.
World Health Organization: WHO Global Report: Mortality Attributable to Tobacco. 2012, Geneva, Available from: accessed on 07/08/14.
Statistics Sweden: Use of alcohol and tobacco. Report no 114, Living Conditions. 2007, Stockholm, Available from: accessed on 07/08/14.
Joossens L, Raw M: The Tobacco Control Scale 2010 in Europe. 2011, Brussels: Association of European Cancer Leagues, Available from: http://www.europeancancerleagu....
Foulds J, Ramström L, Burke M, Fagerström K: Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control. 2003, 12: 349-359. 10.1136/tc.12.4.349.
Engholm G, Ferlay J, Christensen N, Johannesen TB, Khan S, Køtlum JE, Milter MC, Olafsdóttir E, Pukkala E, Storm HH: NORDCAN: Cancer Incidence, Mortality, Prevalence and Survival in the Nordic Countries, Version 6.1 (25.04.2014). Association of the Nordic Cancer Registries. Danish Cancer Society, Available from: accessed on 07/08/14.
Levy DT, Mumford EA, Cummings KM, Gilpin EA, Giovino G, Hyland A, Sweanor D, Warner KE: The relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: estimates of a panel of experts. Cancer Epidemiol Biomarkers Prev. 2004, 13: 2035-2042.
Gartner CE, Hall WH, Vos TH, Bertram MY, Wallace AL, Lim SS: Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet. 2007, 369: 2010-2014. 10.1016/S0140-6736(07)60677-1.
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA): Harm reduction: evidence, impacts and challenges. EMCDDA scientific monograph No.10. 2010, Lisbon: EMCDDA.
Ramström LM, Foulds J: Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob Control. 2006, 15: 210-214. 10.1136/tc.2005.014969.
Furberg H, Bulik CM, Lerman C, Lichtenstein P, Pedersen NL, Sullivan PF: Is Swedish snus associated with smoking initiation or smoking cessation?. Tob Control. 2005, 14: 422-424. 10.1136/tc.2005.012476.
Galanti MR, Rosendahl I, Wickholm S: The development of tobacco use in adolescence among “snus starters” and “cigarette starters”: An analysis of the Swedish “BROMS” cohort. Nicotine Tob Res. 2008, 10: 315-323. 10.1080/14622200701825858.
Stenbeck M, Hagquist C, Rosén M: The association of snus and smoking behaviour: a cohort analysis of Swedish males in the 1990s. Addiction. 2009, 104: 1579-1585. 10.1111/j.1360-0443.2009.02661.x.
Foulds J, Kozlowski L: Snus — what should the public-health response be?. Lancet. 2007, 369: 1976-1978. 10.1016/S0140-6736(07)60679-5.
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