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

Abstract

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.

Health warning labels describing snus as less harmful than smoking: effects on perceptions of risk

“…In a study using survey data from Norwegians aged 16-79 in the years 2003-2018, the harmfulness of daily snus use was rated only somewhat lower than daily smoking. These perceptions did not appear to have changed during the last 16 years [3]. As for specific diseases, another study found that the majority of Norwegian smokers estimated that the risk for cardiovascular disease, oral and stomach cancer was equal or higher for snus users [4].…”

Experiences of tobacco cessation including a prescription approach among patients in Swedish primary health care with a focus on socioeconomically disadvantaged areas

“…However, experiences of other tobacco users may be different [ 36 ]. For example, snus use may be less stigmatizing [ 36 , 45 ] as it is not perceived as harmful as smoking [ 46 ] and does not expose others to second-hand smoke [ 45 ]. Perceived tobacco-related stigma may also be higher in Sweden compared to other settings where the prevalence of tobacco use is higher and more normalized.…”

The greater use of flavoured snus among ever-smokers versus never-smokers in Norway

“…Anyway, if a causal association between snus use and subsequent smoking really exists, ecological trend data indicates that this association must have been dwarfed by other factors protecting against smoking uptake. Because at the population level, an inverse correlation between snus use and smoking has been observed among young adults in Norway [ 10 ], and recently also between vaping and smoking in the USA [ 55 ] and in New Zealand [ 56 ]. Thus, lending support to the "diversion theory" hypothesizing that snus/e-cigarettes might deter cigarette smoking by diverting "high-risk" individuals to snus/e-cigarettes from combustible cigarettes.…”

“…Among young adults (16-24 years), this shift took place around 2006 among men and around 2011 among women [9]. The inverse correlation between the trends in smoking and snus use in the Norwegian population after 2000 has been described in several publications [10][11][12].…”