Lars M. Ramström | 15 February 2014
The ‘WHO Global Report: Mortality Attributable to Tobacco’ has provided estimates of death rates specifically attributable to tobacco. These estimates directly represent the size of each country’s health burden of tobacco, overall and with respect to the different diseases. The current study has extracted data for all European Union Member States and made inter-country comparisons for different age groups and diseases. In these comparisons men in Sweden stand out by exhibiting lower death rates attributable to tobacco than men in any other EU country.
- The current WHO report  measures the health burden of tobacco in all countries by providing, for different diseases, estimates of death rates that are specifically attributable to tobacco.
- There are large differences between countries with regard to death rates attributable to tobacco. For example 60-69 year old men in the European Union Member States exhibit a variation of between 72/100.000 and 618/100.000 for “All cardiovascular”.
- Among men in the European Union Member States the lowest level of mortality attributable to tobacco is consistently found in Sweden, while Swedish women do not have an equally favourable position (Table 1).
- The unique position of Swedish men can not be explained by outstanding political action, since Sweden has scored quite modestly in a Europe-wide assessment of these matters. 
- A possible explanation should contain elements that distinguish Swedish men from men in Europe and Swedish women, e.g. the use of low-nitrosamine oral tobacco, snus, instead of cigarettes. 
- The Sweden/European differences in mortality attributable to tobacco are larger in younger than in older men (Table 2).
- In Swedish men the shift from cigarettes has been more pronounced in younger than in older men  (Table 3).
- The above co-variation between mortality advantage and snus dominance lends further support to the assumption that the use of snus instead of cigarettes is a major part of the explanation of the favourable position of Swedish men with regard to mortality attributable to tobacco.
- The reference list here below gives examples of scientific studies that conclude that use of snus instead of cigarettes can yield health benefits both on individuals [5-7] and population level. The above analysis of data from the current WHO report adds further strength to those conclusions.
The scope of the WHO Report
The World Health Organization, WHO Global Report: Mortality Attributable to Tobacco, has provided a unique set of estimates of the health burden of tobacco in all countries of the world in the year 2004. Death rates are reported for the main tobacco-related diseases and for “All causes”. In this report we find not only observed overall death rates for each disease but also estimates of the part of the death rate that is attributable to tobacco. These estimates are based on the SIR (Smoking Impact Ratio) method developed by Professor Richard Peto, Oxford University. Technical details are described in the report. The SIR method eliminates uncertainties that could occur with use of prevalence data which often are incomplete and lacking full comparability between countries. The use of this method will therefore contribute to maximum validity of the results.
The estimated death rates attributable to tobacco directly represent the size of each country’s health burden of tobacco with respect to the different diseases and “All causes”. Estimates are given for men and women in different age groups and for the total population. The data for total population are not age standardized, so they cannot be used for comparison between countries, but such comparisons can be made for specific age groups.
Table 1 shows, for the age group 60-69, some comparisons between Sweden and the other European Union Member States.
These data demonstrate that Swedish men stand out in a uniquely favourable position in comparison with other European Union Member States. Among Swedish men the death rates attributable to tobacco are lower than among men in any other EU country, while Swedish women do not exhibit a similar position.
What can explain the unique position of Swedish men?
The position of a country in a comparison of death rates attributable to tobacco is influenced by various national conditions with regard to political action and personal practices.
The implementation of political tobacco control measures has been assessed in 30 European countries.  Six policy areas were taken into account: pricing, smoking restrictions public information, advertising bans, warning labels and treatment opportunities. The top ranking country got 77 points out of 100 possible, the lowest ranking country got 32. Sweden got just 51 points. This suggests that the national political action can not explain the uniquely low level of tobacco-related mortality for Swedish men. The main explanation must rather come from some Swedish-men-specific factor that was not taken into account in the above assessment. One such factor is easily identifiable, namely the use by Swedish men of the Swedish low-nitrosamine oral tobacco, snus, instead of cigarettes.
During the last 50 years the initially high smoking rates in men have been drastically reduced, and snus use has become the dominating kind of tobacco use among men, while female use of snus is still on a low level.
Sweden/Europe mortality comparisons by age groups
A broader picture can be derived by comparing, for different specific age groups, the death rate attributable to tobacco for men in Sweden with corresponding rate for men in Europe as a whole. Such a comparison can be provided by calculating ratios between death rates attributable to tobacco in Sweden and those in Europe as a whole.
Table 2 gives some examples of such ratios. For each cause of death they show much lower mortality attributable to tobacco for men in Sweden than for men of same age in Europe as a whole. Further, the contrast is substantially larger in younger age groups than in older ones. Th is raises the question if differences between age groups with respect to snus use may play a role for the differences with respect to ratios of death rates.
Tobacco use among Swedish men in different age groups
The death rates attributable to tobacco that are presented in the WHO report are determined by the development of the tobacco use up to the year 2004.  Th is development in Sweden is demonstrated by the data shown in Table 3.
In all age groups the prevalence of smoking has gone down and the prevalence of snus use has gone up. Thereby snus use has become an increasing proportion of the total tobacco use. Further, the shift from cigarettes to snus is substantially more pronounced in younger than in older age groups. Th is suggests that the use of snus instead of smoking is an important part of the explanation why younger age groups stand out even more favourably than older ones in the comparison with Europe as a whole.
Impact on public health
The very low toxicity of Swedish snus is well recognized, [5-7] but questions have been raised about the magnitude of the eff ectson public health. However, scientific studies in Sweden have found that snus use among men has contributed both to less initiation of smoking and to more cessation of smoking. [8-11] These findings in combination with the low toxicity suggest a potential for public health benefits. The above data from the new WHO report appear to support the assumption that the use of snus among Swedish men has yielded public health benefits by contributing to their minimum level of death rates attributable to tobacco.
This article was presented at SRNT 2014, on Thursday, February 6, 2014, during the Poster Session 1 (POS1-37)
- World Health Organization. WHO Global Report: Mortality Attributable to Tobacco. Geneva, 2012. Retrieved from http://who.int/tobacco/publications/surveillance/rep_mortality_attibutable/en/index.html
- Joossens L, Raw M. Tobacco Control Scale 2010 in Europe. Association of European Cancer Leagues. Brussels 2011. Retrieved from http://www.europeancancerleagues.org/images/stories/The_TCS_2010_in_Europe_Final_4.pdf
- Foulds J, Ramström L, Burke M, Fagerström K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control 2003; 12:349–59.
- Statistics Sweden. Use of alcohol and tobacco. Report no 114, Living Conditions. Stockholm, 2007. Retrieved from http://www.scb.se/statistik/_publikationer/LE0101_2004I05_BR_LE114SA0701.pdf
- Levy DT, Mumford EA, Cummings KM, et al. relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: estimates of a panel of experts. Cancer Epidemiol Biomarkers Prev 2004;13:2035–42.
- Gartner CE, Hall WH, Vos TH, et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007;369:2010–4.
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Harm reduction: evidence, impacts and challenges. EMCDDA scientific monograph No.10, 2010. Lisbon.
- Ramström LM, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob Control 2006;15:210–14.
- Furberg H, Bulik CM, Lerman C, et al. Is Swedish snus assciated with smoking initiation or smoking cessation? Tob Control 2005;14:422–4.
- Galanti MR, Rosendahl I, Wickholm S. development of tobacco use in adolescence among ‘‘snus starters’’ and ‘‘cigarette starters’’: An analysis of the Swedish ‘‘BROMS’’ cohort. Nicotine Tob Res 2008; 10:315–23.
- Stenbeck M, Hagquist C, Rosén M. The association of snus and smoking behaviour: a cohort analysis of Swedish males in the 1990s. Addiction. 2009; 104:1579–85.
- Foulds J, Kozlowski L. Snus - what should the public-health response be? The Lancet 2007; 369: 1976–8.