Authors: Lars M. Ramström, Institute for Tobacco Studies (ITS) Tom Wikmans, Research Group for Societal and Information Studies (FSI)

1. Changing tobacco habits in Sweden: Society for Research on Nicotine and Tobacco
14th Annual Meeting, Portland, OR USA, February 27-March 1, 2008
Influence of environmental and psychological Poster presentation by:
Lars Ramström, Institute for Tobacco Studies, Stockholm
factors related to smoking and use of smokeless Tom Wikmans, Research Group for Societal and Information Studies, Stockholm
tobacco (“snus”).
1. BACKGROUND 3.2.2. Attitude to “Daily smoking” vs. Proximity to daily smokers at present
In Sweden male prevalence of daily smoking is lower (12%) than in most Western countries, while male The survey questionnaire also included questions asking whether or not there are/were people in the immedi-
prevalence of daily use of the Swedish kind of smokeless tobacco, “snus”, is record high (20%). This pattern ate everyday environment (at present/during adolescence) who do/did smoke or use snus daily.
has developed as a combination of increasing initiation of snus use accompanied by decreasing initiation of
smoking and increasing cessation of smoking (current overall quit ratio =0.61). Previous publications have Attitude to “Daily smoking” The attitude to “Daily smoking” is
described this development in epidemiological terms. Therefore we know what changes that have taken Proportion of men indicating different judgement associated with “Proximity to daily
Judgement smokers at present” as shown in the
place, while we known less about the environmental and psychological factors behind the changes. The role Proximity to daily smokers at present
of these factors needs further investigation and the current project aims at elucidating some of these matters. Yes No table to the left.
2. MATERIAL AND METHODS Acceptable 43% 16% The attitude to daily smoking is
The design of the study is based on the perspectives of the Symbolic Interactionism Theory that assumes that Hesitant 19% 16% generally more favourable among those
a person's “Self ” is created by interactions with the surrounding context. These interactions also play a major who have proximity to smokers than
Unacceptable 38% 68%
role in whether or not to initiate or maintain or quit a behaviour such as smoking or use of snus. Data collec- among those who have not.
n= 1046 1607
tion started by in-depth interviews. Thereby a number of relevant interaction factors were identified. These
could be studied by participation in the FSI annual Tobacco Survey 2007, covering a nationwide representa-
tive sample of the population in Sweden (N=7010). This survey is a part of the long term survey “Kajsa” that Another potentially influencing factor could be own tobacco use.
started in the early seventies with the purpose to build the database “Your Country and Your Life”. The data-
base now contains time series in various length for about 3500 unique items with a base (N) of approxi- Attitude to “Daily smoking”
mately 10 000 respondents each year and it has become Sweden’s largest database for attitude and behaviour Proportion of men in different categories indicating “ACCEPTABLE”
matters.
58%
2.1. In-depth interviews
Twenty interviews were conducted. The participants were 5 men and 5 women who were daily smokers and
5 men and 5 women who were daily snus users. None of the participants was a dual tobacco user, neither
daily or occasionally. One male and two female snus users had started their tobacco use career as daily smok- 33% 33%
28%
ers and had used snus to quit smoking. Among the smoking participants all ten had started their tobacco
career with smoking and no one had been using snus on a daily basis. The interviews were conducted as a 19%
free conversation based on the theme “Describe yourself and your relationship to tobacco?” and took place
12%
at the participants own home. All interviews were recorded on tape. The interview started with the partici-
pants filling out the same questionnaire as the one used in the survey.
2.2. Survey
Survey data were used to establish detailed tobacco use patterns and to study how respondents with different Current snus users (all) Ex-snus users Never snus users
tobacco use patterns interact with the social context surrounding them. The interaction factors included: Proximity to smokers at present
Yes No
• proximity to daily smokers and daily snus users in the immediate everyday environment, at present and Attitude to “Daily smoking”
during adolescence Proportion of men in different categories indicating “ACCEPTABLE”
• attitude to daily use of depending-producing products such as cigarettes and snus
66%
• tobacco users’ views on own actual use in terms of
- strength of desire to quit
- feeling uncomfortable in the role of smoker/snus user
• non-users’ view on potential use of cigarettes/snus 46%
The processing of data has established various associations between the above interaction factors and differ-
ent categories of tobacco users. On the basis of these patterns of associations some conclusions have been 25%
27%
drawn.
11% 13%
3. RESULTS
3.1. In-depth interviews
Many interviewees expressed strong awareness that their “Self ” included ”identity aspects” linked to actual
habits e.g. ”I see myself as a snus user, it's a part of who I am.” (male daily snus user, never smoker). Some Ex-smokers
Current smokers (all) Never smokers
snus users expressed aversion towards smoking e.g. “I could never see myself trying a cigarette.” (female snus
user, never smoker), “I don’t understand how I ever could use something that disgusting.” (female snus user, Proximity to smokers at present
former daily smoker), “Even if it is impossible for me to get snus, I could never take a cigarette to reduce the Yes No
cravings.” (male snus user, former daily smoker).
Current smokers do more often than others have a positive attitude to “Daily smoking”, but quite many
The findings from the interviews indicate that daily tobacco users’ definition of their “Self ” includes their smokers have a negative attitude. Snus users are more negative to “Daily smoking” than smokers. In all six
actual kind of tobacco habit as a component, just as their profession etc. A tobacco user sees himself as either categories of tobacco use there is large difference between those with and those without proximity to smok-
a smoker or a snus user, not as a tobacco user in general. A smoker sees himself as a “smoker” rather then ers. This suggests that proximity to smokers plays a major, independent role in establishing positive attitudes
just someone who smokes. We also find that smokers who quit smoking using snus as a cessation aid and to daily smoking.
switch to snus use will see themselves as “snus users” rather than “former smokers”.
3.2.3. Onset of tobacco use vs. Proximity factors during adolescence
3.2. Survey Patterns of initiation of daily tobacco use differ according to proximity factors during adolescence, so as
3.2.1. Attitude to ”Daily smoking” and ”Daily snus use” demonstrated in the table below.
In the survey respondents were asked to express their attitudes to tobacco use by judging “daily use of
cigarettes/cigars/pipe” (daily smoking) and “daily use of snus” as Acceptable or Hesitant or Unacceptable. Rate of onset of different kind of tobacco use
by proximity during adolescence to tobacco users.
Attitude to daily tobacco use among men Proximity during adolescence to
Proportion indicating Proportion indicating smokers but snus users but both smokers no tobacco
different judgements different judgements Type of onset
Judgement not to snus users not to smokers and snus users users
about ”Daily smoking” about “Daily snus use” Primary smoking* 46% 26% 40% 26%
Primary snus use** 17% 28% 29% 14%
Acceptable 27% 38% 37% 46% 30% 60%
No onset
Hesitant 18% 18% n= 801 159 373 800
Unacceptable 55% 44%
* Starting daily smoking without previous daily snus use
n= 2862 2851 ** Starting daily snus use without previous daily smoking
Rate of onset of primary smoking is high (40% – 46%) for those with proximity to smokers, but lower
Daily snus use is judged as a more acceptable societal phenomenon than daily smoking. One potentially in- (26%) in the absence of proximity to smokers, even if there is proximity to snus users. Rate of onset of pri-
fluencing factor could be the presence or absence of proximity to smokers in the everyday environment. mary snus use is highest for those with proximity to snus users. “No onset” is most common among those
without proximity to tobacco users, next highest among those with proximity to snus users only.

2. 3.2.4. View on quitting smoking / snus use vs. Attitude to “Daily smoking” / ”Daily snus use”
Among male current daily smokers (n=307) a large majority, 87%, wish to quit smoking. The view on quit-
ting smoking differs according to attitude to “Daily smoking”. Even among those who think that “Daily
smoking” as such is acceptable, a large majority, 83%, wishes to quit. Among those with a negative attitude
to “Daily smoking” the proportion wishing to quit is as high as 92%.
Among male current daily snus users (n=540) the desire to quit (snus use) is considerably less strong, 71%
having a wish to quit. In analogy with the pattern among smokers there are differences according to attitude Contact details
to “Daily Snus use”. Among those who think that “Daily snus use” as such is acceptable 68% wish to quit,
while 76% of those few who find “Daily snus use” unacceptable have a wish to quit.
Research Group for Societal and Information Studies
3.2.5. View on potential smoking / snus use vs. Attitude to “Daily smoking” / “Daily snus use” Tom Wikmans B.Sc.
Never smokers were asked if they could consider trying to smoke. Vice President, Head of research
Ingemarsgatan 4 B, SE-113 54 Stockholm, Sweden
Phone: +46 8 640 63 82, Mobile: +46 70 422 81 54
Male never smokers’ view Attitude to “Daily smoking” Email: tom@forskningsgruppen.com
on potential smoking Acceptable Hesitant Unacceptable Total www.forskningsgruppen.com
Can consider 8% 6% 3% 4%
Can not consider 92% 94% 97% 98%
n= 180 172 783 1135 Institute for Tobacco Studies
Lars M. Ramström Ph.D.
Director of ITS
Chairman of the ICAA Tobacco Dependence Section
Among never smokers there is a very solid resistance against trying to smoke. However, among those with
acceptance of “Daily smoking” the readiness to try smoking is, although modest, significantly higher than Ingemarsgatan 4 B, SE-113 54 Stockholm, Sweden
the readiness among those with a negative attitude. Phone: +46 8 642 06 75
Email: ramstrom@tobaccostudies.com
When male never snus users are asked if they could consider trying to use snus, we find an equally solid resis-
tance. The numerical pattern is almost identical with the one for smoking in the table above.
3.2.6. Feeling uncomfortable as tobacco user vs. Type of tobacco use
In the survey tobacco users were asked: “Does it occur that you feel uncomfortable in your role as
smoker/snus user?”
Type of tobacco use 4. SUMMARY AND CONCLUSIONS
Ever feeling uncomfortable Male daily snus users Male daily smokers The interview data illustrate that a person’s use of a certain tobacco product represents a component of his or
(non smoking) (non snus users) her “Self ” (identity). A tobacco user sees himself as either a smoker or a snus user, not as a tobacco user in
general. The interviews also show that a person who has used snus as a means to quit smoking, and then con-
Yes 45% 80% tinued with a daily snus use, defines him or herself as a snus user rather than as a former smoker.
Never 55% 20%
n= 508 301 A person’s behaviour is determined by the way that the responses from his surrounding correspond with his
definition of his “Self ”, which in turn is a product of interactions with the social context surrounding him.
This involves a number of psychological and environmental interaction factors.
Less than half of the daily snus users ever feel uncomfortable in their role as snus users, while a large majority
of smokers have that experience. The survey data from the current study illustrate some important features of the interaction factors that in-
fluence the development of an individual’s tobacco use behaviour. Two interaction factors appear to play a
3.2.7. Desire to quit smoking vs. Feeling uncomfortable as smoker particularly central role, namely; proximity to tobacco users, and attitude to smoking and snus use as an ac-
The desire to quit smoking was studied in relation to the experience of feeling uncomfortable as smoker. ceptable or unacceptable phenomenon in the society.
Feeling uncomfortable as smoker Among Swedish men...
Desire to quit smoking No Yes • the proportion finding snus use acceptable is larger than the proportion finding smoking acceptable.
Strong 9% 43% • the proportion finding smoking acceptable is larger among those with, than among those without
Some 60% 50% proximity to smokers, irrespective of the type of own tobacco use.
No 31% 7%
n= 75 293 • onset of primary smoking is promoted by proximity during adolescence to smokers, but not by
proximity during adolescence to snus users.
With respect to the small number of smokers not feeling uncomfortable no firm conclusions can be drawn. • desire to quit smoking is higher among those with a negative attitude to smoking than among those
It does, however, seem probable that smokers who report feeling uncomfortable have a stronger desire to with a positive attitude to smoking. The corresponding pattern applies to snus users.
quit smoking than those who do not.
• never smokers have a strong resistance against considering trying to smoke, but the resistance is weaker
3.2.8. Desire to quit snus use vs. Feeling uncomfortable as snus user than average among those with a positive attitude. The corresponding pattern applies to snus users.
The desire to quit snus use was also studied in relation to the experience of feeling uncomfortable as snus
user. • a majority of smokers have experience of feeling uncomfortable in their role as smoker, while less than
half of the snus users have a corresponding experience.
Feeling uncomfortable as snus user
Desire to quit snus use No Yes • both among smokers and snus users those who have experience of feeling uncomfortable have stronger
desire to quit than those without such experience.
Strong 7% 17%
Some 46% 66%
No 47% 17% The above findings can help assessing the consequences of a continued development such as the one that has
n= 286 288 taken place in Sweden with increasing snus use and decreasing smoking. A continued such development
would decrease overall proximity to smokers and thereby increase non- acceptance of smoking, a factor that
appears to promote cessation of smoking. The inherent increase of proximity to snus users does not appear
Snus users who report feeling uncomfortable have (in analogy with their counterparts among smokers) a to promote onset of smoking. The combination of all these interactions may therefore accelerate a downward
stronger desire to quit snus than those who do not, but the difference is smaller than the corresponding dif- trend in smoking with subsequent public health benefits.
ference among smokers.