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

A significant decline in smoking, especially among well-educated individuals can be seen worldwide in developed countries [1‐3]. However, there are signs that the use of non-cigarette tobacco products has increased despite tobacco control programs, restriction on marketing of tobacco products and the ban on  trade of smokeless tobacco in Australia, Israel and the European Union, excluding Sweden [3, 4]. The consumption of tobacco products has evolved to include more complex tobacco habits and the dual use of different tobacco products, mainly cigarettes and smokeless tobacco, has become common [5‐11].

The transition from the Swedish type low- nitrosamine smokeless tobacco (snus) to cigarettes and vice versa has mainly been studied in Sweden. According to Galanti et al. (2008), who analyzed several studies from Sweden, Finland and North America, current snus use was mainly associated with non-smokers or former smokers. Smoking induction or the gateway theory only seemed to affected a minority [12]. However, Furberg et al. (2006) discovered that the transition from cigarettes to snus use among males is often incomplete resulting in dual usage [13]. Some research suggests that smokeless tobacco might actually initiate smoking [14‐16].

Snus is most commonly used in Scandinavia and the United States, prominently in Sweden and Norway, where smokeless tobacco trade is legal [17, 18]. A study Hamari et al. (2013) carried out on military recruits in Northern Finland indicated that almost half of daily snus users also smoked [8]. In Sweden, Norway and in the United States dual usage is relatively uncommon, but the pattern is more frequent among young adults and adolescents [7, 19, 20]. Recent studies also show increased awareness, openness and readiness for consuming non-cigarette tobacco products [11, 20‐25].

Snus is perceived as a less harmful product than cigarettes and even as a means of harm reduction [26, 27], but the absorption through the mucous membrane is effective and results in a high dose of nicotine intake. In addition, snus contains a high amount of nicotine, around 20 carcinogens and over 2500 chemicals [17, 28].

The correlation between disadvantaged socioeconomic and socio-educational status and smoking is well acknowledged [29‐32]. This seems to apply to the transition from sporadic use to daily use as well [33]. However, knowledge about the correlations between snus use and socio-educational status is limited. Some studies suggest that use of snus is more often related to favorable social and health profiles than daily smoking [19, 31].

As discussed above, recent developments point towards a transition from exclusive smoking to usage of other tobacco products and complex tobacco habits. We therefore evaluated the prevalence of dual use of cigarettes and snus as well as the transition from one tobacco product to another by reported quitters, among a representative population of young Finnish males entering military service. In addition, we examined the overall prevalence of cigarette and snus usage and the correlation between the educational background of the participants and their smoking habits.

The mean age of the study population of 1916 male conscripts was 19.4 years (±SD 1.1 years) with a range of 18–28 years. A majority, 92% of the study subjects, were 18–20 years. Half (51%) of the respondents had attended upper secondary school, 38% had a vocational education background and 10% had only basic education prior to conscription. Table 1.

We analyzed the prevalence and dual use of cigarettes and snus, as well as transition from one tobacco product to another, among young male adults at the beginning of their military service. We found that dual consumption of cigarettes and snus was common, especially among daily smokers as many as half reported simultaneous snus usage. Interestingly, about one third of former smokers reported daily snus usage and over 40% of reported quitters in the snus-using group smoked daily - showing a transition to another tobacco product instead of quitting.

Limited data is available regarding dual use of cigarettes and snus or transition behavior, particularly in this target group. However, Scandinavian and Northern American studies imply that snus usage is growing among young adults. Dual usage is still uncommon and is mostly associated with current smoking. The prevalence of exclusive snus usage is high in Sweden and Norway where the trade of smokeless tobacco is legal [7, 18, 20, 43, 44].

Our study results are in line with the study conducted on recruits in Northern Finland by Hamari et al.(2013) [8]. Furthermore, the School Health Promotion Study indicated that the dual use of cigarette and snus is currently gaining popularity among Finnish adolescents in their late teens [11]. Some dual users might be at a transitional stage, switching from one product to another, but it is noteworthy that the probability of continuing dual usage is high [6, 7, 45].

We observed that the transition from one tobacco product to another among reported quitters was very common. About one third of former smokers reported daily snus usage. Over 40% of reported quitters in the snus-using group smoked daily instead. For a more accurate understanding of the phenomenon, it would have been valuable to determine the time elapsed in the transition, as well as the time-span after quitting smoking. Unfortunately, we did not collect this data. Based on our findings, the prevalence of both snus usage and smoking was significantly higher than in the Finnish national health surveys [11, 21, 24, 46]. Daily smoking was twice as common in our study and snus usage was three times more common than in the adolescent health and lifestyle survey [21, 24]. On the other hand, the corresponding use of snus among Finnish army recruits in Northern Finland has been shown earlier. This trend is worrying considering that the trade of smokeless tobacco is banned in the European Union (excluding Sweden) and might reflect a wider international trend [3, 8, 44]. Finland’s geographical vicinity to Sweden makes illegal trade compelling.

Large population-based health examination surveys provide a good overall understanding of the tobacco habits of adolescents and the adult population, although the response rates have decreased and rarely exceed 70%. The exceptionally high response rate of over 97% gained in our study might explain the marked difference in the prevalence of smoking between studies.

Smoking was common among the study subjects with a basic educational background. The difference was clear compared to the study subjects with an upper secondary education, of whom only 10% smoked daily. Snus usage was equally common for all educational levels. Our results confirm previous findings associating lower educational status and smoking in Northern European countries [29]. However, we could not confirm any association between the level of education and snus use. This association has not been clear in earlier studies either, although some studies have shown a less prominent association among snus users [19, 47].

The strength of our study was the ability to carry it out in a military setting and to reach a comprehensive portion of young adult males, since all adult Finnish males are liable for military service. The survey was conducted upon arrival during the general health inspection, which motivated the conscripts to answer the questionnaire. The response rate was significantly higher than in most national surveys. Answering the survey was restricted to the first week of the military service to ensure responses that reflected the tobacco habits before the military culture had influenced them.

A common concern is selection bias. Young smoking men with a low education are typically under-represented [24, 46, 48‐50]. A minority of young men are exempted from military service due to suitability or health issues, such as mental health problems, causing a possibility of bias in our results. We do not know the prevalence of tobacco use among these individuals, but we may assume that the prevalence of tobacco usage is likely to be even higher among the non-selected population. As for women, military service is voluntary and only a few women are recruited for service. We therefore excluded women from the results due to the low number of participants.

Our findings showed that exclusive snus use as well as dual usage of cigarettes and snus was significantly higher than expected from previous studies. A statistically significant correlation between educational level and exclusive snus usage could not be demonstrated.

This study provides a better understanding of the complex tobacco habits of young adult males, who are an important target population for health interventions. Young adults are at a transitional and vulnerable age when the usages of tobacco products, as well as other health habits, are yet to be established. The simultaneous usage of multiple tobacco products as well as the high tendency of 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.