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A tobacco-free society or tobacco harm reduction? Which objective is best for the remaining smokers in Scandinavia?
No full textENGLISH SUMMARY: Harm reduction means that cigarette smokers who are either unable or unwilling\ud
to stop using nicotine products are encouraged to switch to nicotine products with\ud
much lower health risk.\ud
Harm reduction has previously been debated in various forms in the area of\ud
tobacco when filter cigarettes were introduced in the 1960s, and when so-called\ud
«light cigarettes» with reduced tar and carbon monoxide content were introduced\ud
in the 1980s. However, epidemiological research has shown that the health benefits\ud
associated with switching to such products have been small – perhaps even nonexistent.\ud
The result of such previous negative experience is that the health\ud
authorities in most countries have shown very little enthusiasm for new preventive\ud
strategies that include switching to tobacco and nicotine products that are less\ud
damaging.\ud
However, the current debate about harm reduction is different from the previous\ud
debates in that this time real risk-reducing products (snus, medicinal nicotine\ud
products and other non-medicinal nicotine products) are being discussed. There is\ud
consensus that a switch from cigarettes to such products would involve a significant\ud
reduction in risk for individual smokers. The reason for current scepticism is\ud
primarily uncertainty about what a harm reduction strategy could lead to at the\ud
population level. In addition, the established measures that the authorities in\ud
Scandinavia have introduced to reduce smoking have been very effective, and why\ud
not just intensify their use? If snus were added to the arsenal of harm-reducing\ud
products, for example, this would go against the stated aim of the authorities to\ud
achieve a totally tobacco-free society.\ud
Some of the important areas that are discussed in this report:\ud
• Despite the fact that measures to prevent smoking have been effective, and the\ud
proportion of smokers is decreasing in Scandinavia, the need for harm reduction\ud
measures has become greater because: – There is an imbalance between the motive to stop smoking that the\ud
authorities have created with campaigns, duties, restrictions etc, and the help\ud
that is offered to people who are trying to stop smoking. Nicotine\ud
replacement products are used to a small extent. The amount of assistance\ud
provided by health care personnel is moderate. In addition, the effect of\ud
nicotine replacement products and the effect of interventions provided by\ud
doctors is very limited.\ud
– The remaining group of smokers increasingly contains a higher proportion\ud
of people with social, mental and demographic characteristics associated\ud
with reduced ability to stop smoking.\ud
– For twenty years there has been a social gradient in smoking pattern in\ud
Scandinavia. The search for measures that are tailor-made for smokers with\ud
specific characteristics, for example short education, has been going on for a long\ud
time. Literature reviews have not identified measures that the authorities could\ud
implement in order make the social gradient in smoking pattern less steep.\ud
– In Scandinavia, nearly all the political measures recommended by WHO for\ud
reducing smoking have already been implemented. There is probably little\ud
potential for further reduction by using publically-regulated control of tobacco.\ud
Despite the fact that tobacco control measures are utilized to such a degree,\ud
the proportion of deaths due to smoking among adults is still very high.\ud
– Intensifying the existing measures against smoking that have been effective\ud
up to now would probably give only a moderate return (diminishing\ud
marginal returns).\ud
– Cigarette smoking is ideal for a harm reduction strategy, because the\ud
substance that causes addiction – nicotine – is not the cause of the health\ud
risk. People smoke because of nicotine, but die from tobacco smoke. Much\ud
less hazardous nicotine products are available.\ud
• Harm reduction is an obvious strategy for a many other areas of risk. The reason\ud
why the debate about harm reduction in the area of tobacco has come later, is\ud
probably related to the widespread belief that it is possible to achieve a tobaccofree\ud
society.\ud
• If the authorities in the Scandinavian countries wish to even out future social\ud
differences in health in the population, a harm reduction strategy in the field of\ud
tobacco may be appropriate.\ud
• In order for harm reduction to be successful, consumers must receive correct\ud
information about the relative health risks of different types of nicotine\ud
products. Today, both smokers and general practitioners are misinformed. \ud
The ban that exists in several Scandinavian • countries against «new types of\ud
tobacco and nicotine products» can function today as a barrier to effective harm\ud
reduction in the remaining segment of smokers, and should be replaced with\ud
regulations that control «new» nicotine products.\ud
• Production of nicotine products that have higher potential for use than\ud
currently available medicinal nicotine products, and that is more effective in\ud
stopping smoking, should be stimulated.\ud
• Harm reduction policy must be made legitimate by the authorities. It is clearly a\ud
disadvantage and a hindrance for harm reduction if the snus industry is the\ud
most visible proponents of harm reduction.\ud
Snus as a harm-reducing alternative:\ud
• The health authorities in Norway and Sweden – where sale of snus is allowed –\ud
provide information about the health risks associated with the use of snus, but\ud
do not inform smokers about the health benefits that can be achieved by\ud
switching from cigarettes to snus. At worst, this can mean that nicotine-addicts\ud
remain smokers with no motive to try a harm-reducing alternative.\ud
• The cigarette industry are in the process of buying themselves into the snus\ud
industry, and wish to sell snus in addition to – and not instead of – cigarettes.\ud
They regard snus as a so-called «bridging product» that can be used in social\ud
arenas where there are smoking restrictions in order to keep smokers dependent\ud
on nicotine (nicotine maintenance policy). In addition, there are several\ud
examples from Scandinavia that the snus industry are carrying out innovative\ud
product development with a view to recruiting young people of both sexes.\ud
• Reviews of the scientific literature show that snus is substantially less hazardous\ud
than cigarettes. The magnitude of the overall reduction in hazard has been\ud
estimated to at least 90 %.\ud
• Much research remains to be done before we know the precise effects of snus\ud
from a public health perspective. Several issues are not possible to research, but\ud
the pattern of use of snus in Sweden and Norway suggests that availability of\ud
snus must have a positive net effect on public health. This can be an argument\ud
for withdrawing the ban on snus in the EU, but it can also be argued that the\ud
pattern of use observed in Scandinavia not necessarily will occur in other\ud
countries.\ud
• There is little empirical data from Scandinavia to support the hypothesis that\ud
snus increases the risk of starting to smoke. There is some empirical data to\ud
support the hypothesis that snus reduces the risk of starting to smoke. • There are no randomized controlled studies in which the effect of snus on\ud
smoking cessation has been measured. Observational data from Scandinavia\ud
are consistent in demonstrating that snus leads to an increase in the quit rate for\ud
smoking. Self-reports from Norwegian quitters indicates that the effect is greater\ud
than the effect of nicotine replacement products.\ud
• An argument for including snus in the arsenal of harm-reducing products is\ud
that it has great potential for use in marginalized smoking populations, which\ud
include people who have high immunity for traditional preventive measures for\ud
smoking.\ud
The structure of the report\ud
The report starts with a discussion of what should be the overall aim of future\ud
tobacco policy in countries with an advanced tobacco epidemic: a tobacco-free\ud
society or reduction in tobacco-related diseases? Does striving towards a tobaccofree\ud
society hinder harm-reducing measures that could save lives?\ud
In the report, the harm reduction debate is presented. The difficult climate for\ud
discussion, resulting from harm reduction being an ethical issue, is discussed. In a\ud
society where tobacco has become «our worst enemy», that everyone can be united\ud
in fighting against, it is easy to regard harm reduction as an untimely course of\ud
action, and to dismiss it by labelling it as tobacco liberalism.\ud
I then show how harm reduction will become increasingly relevant and appropriate\ud
in Scandinavia, among other things because political measures can have attained\ud
their full effect, while levels of harm remain high. Harm reduction may also become\ud
appropriate because the group of remaining smokers in Scandinavia will consist of\ud
more and more people with the psycho-social characteristics of people who are\ud
difficult to influence just by more intensive use of the traditional preventive\ud
measures against tobacco. I argue that harm reduction will be an appropriate\ud
measure for achieving the aim of the authorities to reduce inequalities in health\ud
between different social groups.\ud
Harm reduction may also become appropriate because there is an imbalance\ud
between the strong desire for smokers to stop smoking that the authorities have\ud
created (with campaigns, restrictions and duties), and the moderate supply and\ud
mediocre effect of the help that is offered to people who are trying to stop smoking.\ud
We also discuss how biased information about the relative health risks associated\ud
with the use of different tobacco products has created misinformed consumers who\ud
are unable to make optimal choices
Blir vi syke av norsk kjøtt? Hvilken betydning har norskprodusert kjøtt og kjøttprodukter som smittekilde: hva vet vi, og hva har vi behov for å vite? Status - 2008
No full textAnbefalinger for bruk av hepatitt B-vaksine i Norge. Arbeidsgruppe for vurdering av bruken av hepatitt B-vaksine i Norge
No full textExpression patterns of Neil3 during embryonic brain development and neoplasia.
No full textBACKGROUND: The base excision repair pathway is responsible for repairing small DNA base lesions caused by endogenous and exogenous damaging agents. Repair is initiated by DNA glycosylases that recognize and remove the lesions. NEIL3 is one of 11 mammalian DNA glycosylases identified to date and it was discovered on the basis of sequence homology to the E. coli Fpg and Nei glycosylases. Difficulties in purifying the protein have limited its biochemical characterization and in contrast to the other glycosylases, its function remains unclear. RESULTS: In this study we describe the expression pattern of Neil3 during mouse embryonic development with special focus on brain development. We have also looked at the expression of NEIL3 in several normal and tumor tissues. Quantitative real-time PCR and in situ hybridization revealed that Neil3 was highly expressed at embryonic days 12-13, when neurogenesis starts. The expression decreased during development and in the adult brain,Neil3 could not be detected in any of the brain areas examined by quantitative real-time PCR. During embryogenesis and in newborn mice specific expression was observed in areas known to harbour neural stem and progenitor cells such as the subventricular zone and the dentate gyrus. Finally, NEIL3 expression was higher in tumors compared to normal tissues, except for testis and pancreas. CONCLUSION: Our findings indicate that mammalian NEIL3 is specifically expressed in brain areas where neurogenesis takes place during development and that its expression is tightly regulated both temporally and spatially. In addition, NEIL3 seems to be upregulated in tumor tissues compared to normal tissues. Altogether, mammalian NEIL3 seems to be highly expressed in cells with high proliferative potential
SUPPORT Tools for evidence-informed health Policymaking (STP) 2: Improving how your organisation supports the use of research evidence to inform policymaking.
No full textABSTRACT : This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers. In this article, we address ways of organising efforts to support evidence-informed health policymaking. Efforts to link research to action may include a range of activities related to the production of research that is both highly relevant to - and appropriately synthesised for - policymakers. Such activities may include a mix of efforts used to link research to action, as well as the evaluation of such efforts. Little is known about how best to organise the range of activity options available and, until recently, there have been relatively few organisations responsible for supporting the use of research evidence in developing health policy. We suggest five questions that can help guide considerations of how to improve organisational arrangements to support the use of research evidence to inform health policy decision making. These are: 1. What is the capacity of your organisation to use research evidence to inform decision making? 2. What strategies should be used to ensure collaboration between policymakers, researchers and stakeholders? 3. What strategies should be used to ensure independence as well as the effective management of conflicts of interest? 4. What strategies should be used to ensure the use of systematic and transparent methods for accessing, appraising and using research evidence? 5. What strategies should be used to ensure adequate capacity to employ these methods
Limited cash flow on slot machines: Effects of prohibition of note acceptors on adolescent gambling behaviour
No full textSUMMARY: This study addresses the impact of prohibition of note acceptors on gambling behaviour and gambling problems among Norwegian adolescents. Data comprised school surveys at three time points; 2004 and 2005 (before intervention) and 2006 (after intervention). Net samples comprised 20.000 students aged 13–19 years at each data collection. Identical measures of gambling behaviour (gambling frequency and expenditures on slot machines) and indicators of problem gambling (SOGS-RA and Lie/Bet) were assessed at all three time points. No significant changes in gambling behaviour and problem gambling were observed in the period prior to the intervention, whereas slot machine gambling frequency was reduced by 20%, the proportion that gambled frequently on slot machines was reduced by 26%; overall gambling frequency was reduced by 10% and the proportion of problem gamblers (SOGS-RA 4+) was reduced by 20% after the intervention when controlling for potential confounders. It is suggested that these findings can be attributed to the removal of the note acceptors on slot machines.NORSK SAMMENDRAG: Nedgang i pengespill og spilleproblemer blant unge etter seddelforbud på spilleautomater.\ud
Spill på spilleautomater har inntil nylig vært det pengespillet som har vært mest utbredt blant barn og unge i Norge. Første juli 2006 ble det innført forbud mot bruk av sedler på alle spilleautomater. Dette skyldtes blant annet bekymring knyttet til barn og unges pengespillvaner og behovet for å dempe det økende omfanget av pengespill i befolkningen. Forbudet innebar at man bare kunne benytte mynter og derfor også fikk avbrudd i spillet når myntene tok slutt. Selv om man kunne satse like mye penger per spill som tidligere, ble det likevel mer tungvint å spille.\ud
\ud
Om studien\ud
Denne studien har belyst i hvilken grad dette forbudet har hatt betydning for hvor mye og ofte norske ungdommer spiller pengespill – både på automater og ellers – og hvorvidt det har hatt betydning for omfanget av spilleproblemer blant ungdom.\ud
Data ble samlet inn i tre skoleundersøkelser med ett års mellomrom. Hver undersøkelse omfattet vel 20 000 ungdommer mellom 13 og 19 år. De to første undersøkelsene var i 2004 og 2005, før seddelinntak ble forbudt, og den siste i 2006, etter innføringen av forbudet.\ud
\ud
Ingen endring før forbud\ud
Ved alle tre tidspunktene ble spillefrekvens og forbruk, sammen med indikatorer på spilleproblemer kartlagt. Det ble ikke observert noen signifikante endringer i spilleatferd og spilleproblemer i perioden før forbudet ble innført.\ud
\ud
Nedgang etter forbud\ud
Etter at seddelinntakene var fjernet ble spilleautomatfrekvensen redusert med 20 prosent. Andelen som spilte ukentlig eller oftere, gikk ned med 26 prosent og den totale spillefrekvensen for alle typer spill, gikk ned med 10 prosent. Andelen ungdommer med spilleproblemer (SOGS-RA 4+) gikk ned med 20 prosent. Endringene er beregnet etter å ha kontrollert for kjønn, alder og en mulig trend i spillemarkedet fra 2004 til 2005. Analysene peker derfor i retning av at nedgangen kan tilskrives forbudet av seddelinntak på pengespillautomatene
Fasting før operasjon hos eldre, ortopediske pasienter. Litteratursøk
No full textNORSK: Kunnskapssenteret fikk i oppdrag å finne den beste tilgjengelige vitenskapelige dokumentasjonen om komplikasjoner og velbefinnende ved ulike fasterutiner hos eldre, ortopediske pasienter før operasjon, med særlig vekt på eldre med hoftebrudd. Disse pasientene har ofte andre plager, og mange er underernærte.\ud
\ud
Det finnes retningslinjer for faste før planlagt (elektiv) kirurgi ved norske sykehus i dag. Når det gjelder pasienter som kommer inn for øyeblikkelig hjelp, finnes det ingen felles retningslinjer. Eldre, ortopediske pasienter kommer ofte inn som øyeblikkelig hjelp, og en aktuell problemstilling kan være om det er behov for andre fasteregimer og -rutiner for denne pasientgruppen enn det som anbefales i sykehus i dag. I dag er det slik at Norsk Anestesiologisk forening har et eget fagutvalg som gir råd i situasjoner der litteratur og dokumentasjon ikke er tilstrekkelig eller god nok.\ud
\ud
Vi gjorde et systematisk litteratursøk bygd på en systematisk oversikt fra 2003 som omhandler faste i tilknytning til operasjon (preoperativ faste for å forebygge perioperative komplikasjoner). Vi søkte i følgende databaser: Ovid MEDLINE, Ovid EM-BASE, Ovid British Nursing Index, Cochrane Central Register of Controlled Trials og National Institute for Health Research (tidligere National Research Register). Vi søkte etter randomiserte kontrollerte studier. Tiltakene vi ønsket å undersøke var fastelengde – fra midnatt eller forkortet to timers faste – samt hva og eventuelt i hvilket omfang pasienten kunne spise og drikke ved forkortet faste. Aktuelle utfall var sikkerhet og pasienttilfredshet, både direkte og indirekte, målt som for eksempel aspirasjon av ventrikkelinnhold til lungene, hypoglykemi (lavt blodsukker), angst, sult, mistrivsel og smerteopplevelse. Søket var ikke begrenset i forhold til populasjon eller utfallsmål.\ud
\ud
Søket ga 1045 treff på mulig relevante artikler. Ved gjennomgang av artikkelsammendrag og fulltekstartikler fant vi ingen artikler som tilfredsstilte våre oppsatte inklusjonskriterier. Vi fant ingen randomiserte kontrollerte studier med primærfokus på forskjellige fasterutiner hos eldre ortopediske pasienter. Den forskningen som eksisterer på området, er hovedsakelig utført på pasienter uten kjente risikofaktorer, eller på spesielle risikogrupper som pasienter med tarmsykdommer, og ikke på eldre generelt.\ud
\ud
Dette litteratursøket viser at det finnes lite forskning om hvilke fasteregimer som er best egnet for eldre ortopediske pasienter
SUPPORT Tools for evidence-informed health Policymaking (STP) 17: Dealing with insufficient research evidence
No full textAbstract This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers. In this article, we address the issue of decision making in situations in which there is insufficient evidence at hand. Policymakers often have insufficient evidence to know with certainty what the impacts of a health policy or programme option will be, but they must still make decisions. We suggest four questions that can be considered when there may be insufficient evidence to be confident about the impacts of implementing an option. These are: 1. Is there a systematic review of the impacts of the option? 2. Has inconclusive evidence been misinterpreted as evidence of no effect? 3. Is it possible to be confident about a decision despite a lack of evidence? 4. Is the option potentially harmful, ineffective or not worth the cost
The effect of alternative summary statistics for communicating risk reduction on decisions about taking statins: a randomized trial.
No full textBACKGROUND: While different ways of presenting treatment effects can affect health care decisions, little is known about which presentations best help people make decisions consistent with their own values. We compared six summary statistics for communicating coronary heart disease (CHD) risk reduction with statins: relative risk reduction and five absolute summary measures-absolute risk reduction, number needed to treat, event rates, tablets needed to take, and natural frequencies. METHODS AND FINDINGS: We conducted a randomized trial to determine which presentation resulted in choices most consistent with participants' values. We recruited adult volunteers who participated through an interactive Web site. Participants rated the relative importance of outcomes using visual analogue scales (VAS). We then randomized participants to one of the six summary statistics and asked them to choose whether to take statins based on this information. We calculated a relative importance score (RIS) by subtracting the VAS scores for the downsides of taking statins from the VAS score for CHD. We used logistic regression to determine the association between participants' RIS and their choice. 2,978 participants completed the study. Relative risk reduction resulted in a 21% higher probability of choosing to take statins over all values of RIS compared to the absolute summary statistics. This corresponds to a number needed to treat (NNT) of 5; i.e., for every five participants shown the relative risk reduction one additional participant chose to take statins, compared to the other summary statistics. There were no significant differences among the absolute summary statistics in the association between RIS and participants' decisions whether to take statins. Natural frequencies were best understood (86% reported they understood them well or very well), and participants were most satisfied with this information. CONCLUSIONS: Presenting the benefits of taking statins as a relative risk reduction increases the likelihood of people accepting treatment compared to presenting absolute summary statistics, independent of the relative importance they attach to the consequences. Natural frequencies may be the most suitable summary statistic for presenting treatment effects, based on self-reported preference, understanding of and satisfaction with the information, and confidence in the decision. CLINICAL TRIALS REGISTRATION: ISRCTN85194921
Tobakksfritt samfunn eller skadereduksjon? Hvilken målsetting tjener de gjenstående røykerne?
No full textHvis målet er å utjevne sosiale forskjeller i helsestatus, bør framtidens tobakksforebyggende politikk ta i bruk skadereduksjon som en strategi. Visjonen om et tobakksfritt samfunn bør ikke stå i veien for å redusere tobakksrelaterte sykdommer med en pragmatisk innstilling til skadereduserende nikotinprodukter som f.eks. snus, konkluderer forskningsleder Karl Erik Lund i denne rapporten.\ud
\ud
Lund diskuterer hvordan man skal unngå at røykere som ikke kan eller vil slutte med nikotin fratas overlevelsesmuligheter fordi de ikke oppfordres til bruk av mindre farlige tobakksprodukter. Derfor ønsker han en debatt om skadereduksjon på tobakksområdet. Som ett av flere tiltak mener han at man bør vurdere å oppheve loven som setter forbud mot nye nikotinprodukter som for eksempel elektroniske sigaretter.\ud
\ud
Lund utfordrer i rapporten myndighetenes tobakkspolitiske framtidsstrategier. Han ønsker å stimulere til en debatt om overgang til mindre farlige nikotinprodukter bør vurderes som en tilleggsstrategi i tobakkspolitikken. Han løfter i rapporten fram en rekke forhold som taler for dette.\ud
\ud
Røykerne får stadig dårligere evne til å slutte\ud
De gjenstående røykerne er overrepresentert av personer med kort utdanning, de er oftere enn før involvert i annen risikoatferd og har høyere frekvens av psykiske sykdomstilstander. Etter hvert som andel røykere minker er det sannsynlig at det snart vil stå igjen en hard kjerne med mindre evne til å mestre et slutteforsøk. For disse kan overgang til snus eller e-sigaretten være et livreddende alternativ.\ud
\ud
Fortsatt høye tapstall\ud
Norge har tatt i bruk så å si alle virkemidlene som Verdens helseorganisasjon anbefaler, men fortsatt dør 6700 personer hvert år av røyking. Det blir stadig vanskeligere å identifisere nye tiltak som kan forventes å få samme effekt som de som allerede er innført. Intensivering av de eksisterende virkemidlene er både politisk vanskelig og vil trolig ha redusert nytteverdi på sikt.\ud
\ud
Nikotinlegemidlene er ineffektive\ud
Bruk av nikotintyggegummi eller nikotinplaster dobler sannsynligheten for å lykkes ved et slutteforsøk. Til tross for at de har vært tilgjenglig på markedet i 25 år, blir legemidlene kun brukt av 10-12 prosent av røykeslutterne. Den lave bruksfrekvensen kombinert med den moderate effekten gjør at legemidlene ikke har hatt noen vesentlig betydning for nedgangen i røyking.\ud
\ud
En hard kjerne av nikotinavhengige røykere vil kunne trenge tilgang til produkter med høyere nikotininnhold og større bruksverdi, selv om det kan innebære risiko for fortsatt avhengighet. Nikotin i ren form er imidlertid ikke spesielt farlig. Dessuten intervenerer helsepersonell kun i begrenset grad overfor røykere, og effekten av slike intervensjoner er moderat.\ud
\ud
Misforhold mellom motivasjon og hjelpetilbud\ud
75 prosent av de gjenstående røykerne har et ønske om å slutte, og svært mange av disse har utført gjentatte mislykkede slutteforsøk. Lund drøfter i rapporten om det er et etisk dilemma at røykerne i så stor grad eksponeres for røykenegative impulser samtidig som hjelpen som tilbys fra helsepersonell og legemidler er så lite effektiv.\ud
\ud
Skadereduserende alternativer\ud
Sigarettrøyking innbyr til en skadereduksjonsstrategi fordi det finnes mindre farlige alternativer på markedet. Våre om lag 800 000 røykere inhalerer for nikotinen, mens den halvpart som kommer til å dø vil gjøre det som følge av giftstoffene i tobakksrøyken. Dette bør være unødvendig, konkluderer Lund i rapporten.ENGLISH SUMMARY: Harm reduction means that cigarette smokers who are either unable or unwilling\ud
to stop using nicotine products are encouraged to switch to nicotine products with\ud
much lower health risk.\ud
Harm reduction has previously been debated in various forms in the area of\ud
tobacco when filter cigarettes were introduced in the 1960s, and when so-called\ud
«light cigarettes» with reduced tar and carbon monoxide content were introduced\ud
in the 1980s. However, epidemiological research has shown that the health benefits\ud
associated with switching to such products have been small – perhaps even nonexistent.\ud
The result of such previous negative experience is that the health\ud
authorities in most countries have shown very little enthusiasm for new preventive\ud
strategies that include switching to tobacco and nicotine products that are less\ud
damaging.\ud
However, the current debate about harm reduction is different from the previous\ud
debates in that this time real risk-reducing products (snus, medicinal nicotine\ud
products and other non-medicinal nicotine products) are being discussed. There is\ud
consensus that a switch from cigarettes to such products would involve a significant\ud
reduction in risk for individual smokers. The reason for current scepticism is\ud
primarily uncertainty about what a harm reduction strategy could lead to at the\ud
population level. In addition, the established measures that the authorities in\ud
Scandinavia have introduced to reduce smoking have been very effective, and why\ud
not just intensify their use? If snus were added to the arsenal of harm-reducing\ud
products, for example, this would go against the stated aim of the authorities to\ud
achieve a totally tobacco-free society.\ud
Some of the important areas that are discussed in this report:\ud
• Despite the fact that measures to prevent smoking have been effective, and the\ud
proportion of smokers is decreasing in Scandinavia, the need for harm reduction\ud
measures has become greater because:– There is an imbalance between the motive to stop smoking that the\ud
authorities have created with campaigns, duties, restrictions etc, and the help\ud
that is offered to people who are trying to stop smoking. Nicotine\ud
replacement products are used to a small extent. The amount of assistance\ud
provided by health care personnel is moderate. In addition, the effect of\ud
nicotine replacement products and the effect of interventions provided by\ud
doctors is very limited.\ud
– The remaining group of smokers increasingly contains a higher proportion\ud
of people with social, mental and demographic characteristics associated\ud
with reduced ability to stop smoking.\ud
– For twenty years there has been a social gradient in smoking pattern in\ud
Scandinavia. The search for measures that are tailor-made for smokers with\ud
specific characteristics, for example short education, has been going on for a long\ud
time. Literature reviews have not identified measures that the authorities could\ud
implement in order make the social gradient in smoking pattern less steep.\ud
– In Scandinavia, nearly all the political measures recommended by WHO for\ud
reducing smoking have already been implemented. There is probably little\ud
potential for further reduction by using publically-regulated control of tobacco.\ud
Despite the fact that tobacco control measures are utilized to such a degree,\ud
the proportion of deaths due to smoking among adults is still very high.\ud
– Intensifying the existing measures against smoking that have been effective\ud
up to now would probably give only a moderate return (diminishing\ud
marginal returns).\ud
– Cigarette smoking is ideal for a harm reduction strategy, because the\ud
substance that causes addiction – nicotine – is not the cause of the health\ud
risk. People smoke because of nicotine, but die from tobacco smoke. Much\ud
less hazardous nicotine products are available.\ud
• Harm reduction is an obvious strategy for a many other areas of risk. The reason\ud
why the debate about harm reduction in the area of tobacco has come later, is\ud
probably related to the widespread belief that it is possible to achieve a tobaccofree\ud
society.\ud
• If the authorities in the Scandinavian countries wish to even out future social\ud
differences in health in the population, a harm reduction strategy in the field of\ud
tobacco may be appropriate.\ud
• In order for harm reduction to be successful, consumers must receive correct\ud
information about the relative health risks of different types of nicotine\ud
products. Today, both smokers and general practitioners are misinformed.The ban that exists in several Scandinavian • countries against «new types of\ud
tobacco and nicotine products» can function today as a barrier to effective harm\ud
reduction in the remaining segment of smokers, and should be replaced with\ud
regulations that control «new» nicotine products.\ud
• Production of nicotine products that have higher potential for use than\ud
currently available medicinal nicotine products, and that is more effective in\ud
stopping smoking, should be stimulated.\ud
• Harm reduction policy must be made legitimate by the authorities. It is clearly a\ud
disadvantage and a hindrance for harm reduction if the snus industry is the\ud
most visible proponents of harm reduction.\ud
Snus as a harm-reducing alternative:\ud
• The health authorities in Norway and Sweden – where sale of snus is allowed –\ud
provide information about the health risks associated with the use of snus, but\ud
do not inform smokers about the health benefits that can be achieved by\ud
switching from cigarettes to snus. At worst, this can mean that nicotine-addicts\ud
remain smokers with no motive to try a harm-reducing alternative.\ud
• The cigarette industry are in the process of buying themselves into the snus\ud
industry, and wish to sell snus in addition to – and not instead of – cigarettes.\ud
They regard snus as a so-called «bridging product» that can be used in social\ud
arenas where there are smoking restrictions in order to keep smokers dependent\ud
on nicotine (nicotine maintenance policy). In addition, there are several\ud
examples from Scandinavia that the snus industry are carrying out innovative\ud
product development with a view to recruiting young people of both sexes.\ud
• Reviews of the scientific literature show that snus is substantially less hazardous\ud
than cigarettes. The magnitude of the overall reduction in hazard has been\ud
estimated to at least 90 %.\ud
• Much research remains to be done before we know the precise effects of snus\ud
from a public health perspective. Several issues are not possible to research, but\ud
the pattern of use of snus in Sweden and Norway suggests that availability of\ud
snus must have a positive net effect on public health. This can be an argument\ud
for withdrawing the ban on snus in the EU, but it can also be argued that the\ud
pattern of use observed in Scandinavia not necessarily will occur in other\ud
countries.\ud
• There is little empirical data from Scandinavia to support the hypothesis that\ud
snus increases the risk of starting to smoke. There is some empirical data to\ud
support the hypothesis that snus reduces the risk of starting to smoke.• There are no randomized controlled studies in which the effect of snus on\ud
smoking cessation has been measured. Observational data from Scandinavia\ud
are consistent in demonstrating that snus leads to an increase in the quit rate for\ud
smoking. Self-reports from Norwegian quitters indicates that the effect is greater\ud
than the effect of nicotine replacement products.\ud
• An argument for including snus in the arsenal of harm-reducing products is\ud
that it has great potential for use in marginalized smoking populations, which\ud
include people who have high immunity for traditional preventive measures for\ud
smoking.\ud
The structure of the report\ud
The report starts with a discussion of what should be the overall aim of future\ud
tobacco policy in countries with an advanced tobacco epidemic: a tobacco-free\ud
society or reduction in tobacco-related diseases? Does striving towards a tobaccofree\ud
society hinder harm-reducing measures that could save lives?\ud
In the report, the harm reduction debate is presented. The difficult climate for\ud
discussion, resulting from harm reduction being an ethical issue, is discussed. In a\ud
society where tobacco has become «our worst enemy», that everyone can be united\ud
in fighting against, it is easy to regard harm reduction as an untimely course of\ud
action, and to dismiss it by labelling it as tobacco liberalism.\ud
I then show how harm reduction will become increasingly relevant and appropriate\ud
in Scandinavia, among other things because political measures can have attained\ud
their full effect, while levels of harm remain high. Harm reduction may also become\ud
appropriate because the group of remaining smokers in Scandinavia will consist of\ud
more and more people with the psycho-social characteristics of people who are\ud
difficult to influence just by more intensive use of the traditional preventive\ud
measures against tobacco. I argue that harm reduction will be an appropriate\ud
measure for achieving the aim of the authorities to reduce inequalities in health\ud
between different social groups.\ud
Harm reduction may also become appropriate because there is an imbalance\ud
between the strong desire for smokers to stop smoking that the authorities have\ud
created (with campaigns, restrictions and duties), and the moderate supply and\ud
mediocre effect of the help that is offered to people who are trying to stop smoking.\ud
We also discuss how biased information about the relative health risks associated\ud
with the use of different tobacco products has created misinformed consumers who\ud
are unable to make optimal choices