Even Norwegians do not understand how low-risk snus is

by Carl V Phillips

In honor of my launching my Patreon account a few hours ago…

[Inevitable plug: If you like my work and consider it valuable, please consider becoming a patron. There will also be some premium content for donors. Check it out here.]

…I thought I would write about one of the rare good and useful bits of new research in this space. It is “Relative Risk Perceptions between Snus and Cigarettes in a Snus-Prevalent Society—An Observational Study over a 16 Year Period” by Karl Erik Lund and Tord Finne Vedoy, available open-access (kudos!) here. In it they discover that despite Norwegian population becoming one of the small number of THR success stories, perceptions about the risk from snus (the leading low-risk substitute for smoking there) are still way off.

(This is a workaday research review. If you want something deep and epic, please check out the previous post. If you want something incendiary, please stay tuned [or scroll down to the Update].)

For those who may not know, Norway became the second THR success story, after Sweden, thanks to the widespread adoption of snus as a substitute for smoking (both for quitting smoking or as an alternative for young would-be smokers). Lund has been the leading chronicler of that, and there is a graph in the paper that summarizes it. (I am not going to quibble about whether England or Iceland might really be considered second — let’s just all agree those countries are the first four.) Norway was able to follow the lead of its neighbor, Sweden, because unlike Finland and Denmark (where snus is also popular, at least in theory), Norway is not part of the EU and so snus is not banned there.

Lund and Vedoy analyzed existing data, some historical and some recent, where a random sample of Norwegians adults (quite reasonably defined as age 16+) were asked to rate how harmful various tobacco products are. (“Harmful” is the authors’ translation; I am not sure of the nuances of the original word that was used.) The answers were a Likert-type scale — subjects were asked to choose a point on an unquantified scale from 1 (“slightly”) to 7 (“very”) — so care must be taken in interpreting what the results me (see below). But they are sufficient to learn quite a lot.

The authors’ headline result is that cigarettes got an average response of 6.5 (meaning that majority gave them the worst score possible and that few subjects went much below the second-worst), while snus averaged 5.1. Meanwhile, vapes averaged 3.8 and NRT 3.4. While it is not surprising to see such widespread ignorance (propaganda works!), it is quite remarkable to see it exist alongside widespread switching. Your first thought might be the same as mine, that this is the average across time and more recently there must have been greater understanding of the comparative risks. But no. As shown in Figure 2 in the paper, the average score on the scale has remained remarkably close to the same since 2003.

Of course, the right score on that scale for snus, vapes, and NRT is 1. Well, I suppose if a respondent anchors 1 as something like “eating broccoli” (actively the opposite of harmful) then perhaps 2 is reasonable. This illustrates one of the problems with a scale like this: you have no idea how people are interpreting it. Still, it is difficult to imagine an interpretation that allows 3, let alone 5, to be an even remotely accurate assessment of the risks.

Unsurprisingly, snus users came in with a lower average score for snus, but it was still 3.9. Again, we cannot know exactly what someone is thinking when they pick the middle of this scale, though we can be pretty sure that due to context, most of them anchored 7 at “smoking” rather than something like “climbing K2” or “ministering to Ebola victims”. But even with the ambiguity, 4-ish seems high enough that it is difficult to believe that most switchers (or would-be smokers) were primarily motivated by the reduced health effects. This (along with the consistency of perceptions over time) lends support for the hypothesis that — as was the case in Sweden four decades earlier — this was more a cultural phenomenon than a mass pursuit of reduced risk. In that sense, it seems quite different from the UK vaping phenomenon.

The biggest takeaway, then, is that there is remarkably little correlation between people knowing about the potential of THR and people practicing THR. Kind of painful for those of us who have been working on the knowledge side for a few decades.

As already noted, the measurement scale is arbitrary and it is uncertain what respondents mean. This question about risk could be asked in proper quantitative terms, unlike many touchy-feely questions that offer no option but some “none”…”some”…”lots” type scale. Doing so would come at the expense of forcing subject to deal with numbers, which does not always work well, but it seems almost certain it would be better. Since the authors were working with extant data they, of course, could not do anything about this.

However, what they could do was avoid focusing on averages, which I think was unfortunate. Taking an average embeds an assumption that, for example, respondents treat the difference between 1 and 2 the same as between 5 and 6. It seems safe to assume that this is not true, and it is possible to take some reasonable guesses about how they differ. I suspect that the move from 1 to 2 corresponds to merely the difference between harmless or 1% as harmful as smoking versus 5%, while the move from 4 to 5 to 6 covers a range like 50% to 90%. Just a guess, of course, but you see the point. I would have liked to have seen a histogram of the complete distribution of responses (and if I had been a reviewer for the paper, I would have insisted on it).

To their credit, the authors do not rely entirely on the average. Specifically, they report some statistics for those who answered 6 or 7 versus those who answered 1 to 5. From this we learn that 40% of the sample put snus in the high group (compared to 87% for smoking). Unsurprisingly, for regular snus users this is lower, down in the 20% range. Still, this is remarkably high. Smokers came in a bit lower than that 40%, but not much. Needless to say, this is quite a barrier to encouraging them to switch.

I would really have like to have seen a breakout of those who answered 1 or 2 versus 3 to 7. This would roughly parallel the American-style surveys (mostly about vaping) that ask about comparative risk with answers along the lines of “much less harmful than smoking”, “somewhat less…”, “the same as…”, and “worse than….” Those show a painfully tiny percentage falling into the first (accurate) category. There is something to be said for knowing how many people are so misguided that they do not even realize that substantial risk-reduction is an option. But it is also useful to get a read on how many people have accurate beliefs. Even better would have been to see the time-trends for each of these (rather than just the average across time).

Since I have detoured into expressing my disappointments about the paper, I will also mention the disturbing claim in the abstract that Norwegian/Swedish smokeless tobacco products are “less toxic” than American ones. There is no evidence of different health effects, and while it is plausible there is a difference in the stated direction, it is almost certainly not so great that Scandinavian products should score a 1 while American products should be 2. They would both be slightly different shades of 1. As I have documented at length, this myth of substantially different risks was fabricated by American tobacco controllers in the early 2000s, as an anti-THR rearguard action against the explosion of evidence from Sweden about the low risks. The game was to say, “sure, maybe those Swedish products are safe, but American snuff and chew are still Just As Bad As Smoking!” Of course, if they had really believed that (and if they really cared about people rather than companies and products), they would have pushed for a big influx of Swedish-style products into the American market. (Spoiler: A bit later when some companies tried such a push, tobacco controllers attacked it with every fiber of their being.)

Anyway, the point is that truth-seeking authors should not help perpetuate that engineered myth, even if they believe there is a slight difference in the particular direction.

Returning to what is good about the paper, the Discussion section is the rare such section in a public health paper that is actually worth reading and is a legitimate discussion of the study (as opposed to being a tangential political screed). If you read the paper, go ahead and skip the Introduction (as you almost always should), but in this case do read the Discussion (which you usually should skip).

The authors propose the hypothesis that smoke-free place laws and general anti-smoking sentiment explain the pattern of switching. They only touch on the cultural aspect with the observation that snus users do not suffer from much anti sentiment in Norway. These authors, of course, know a lot more about Norwegian cultural attitudes than I do, so I must concede that I may have overstated the above hypothesis about a cultural phenomenon. Still, there are smoke-free laws and anti-smoking sentiment most everywhere, and they have not made a measurable dent in smoking in most places.

Perhaps it is the combination. Those anti factors are not enough to make many smokers go abstinent, but if snus (or vapes) are locally popular then perhaps those factors are enough to push someone to switch. This, of course, is an existing hypothesis that many people believe, and some use in policy advocacy. It is consistent with the population modeling I did years ago. Policies that take advantage of this, however, are nasty: They still involve intentionally punishing people for making a particular personal choice in order to reduce freedom and use police powers to force changes in behavior. It is anathema to harm reduction, though it may serve the goals of public health activists.

The authors go on to discuss a point I make often, the fact that there is a huge body of solid evidence about the (lack of) harms from Western smokeless tobacco, whereas the evidence about vaping is more tentative. They do not quite go on to say that the respondents demonstrated a profound misunderstanding of the science when they put snus more than a point above vaping on that scale. But that is definitely the case. There is approximately zero room for vaping to be lower risk than snus, and various ways in which it could be higher risk.

Following on this is what I expect my American readers will agree is the best part of the paper:

The explanation might be that the risk concept for snus also include a concern for the much-discussed increase in snus use among youth, which the health authorities have labeled an epidemic.

I can’t think of anything to say about that other than to sit back and let it wash over you.

The Discussion continues with a back-of-the-envelope calculation of the impact on population health of better knowledge. It is the usual calculation of how many nonusers would take up snus if they knew how low risk it is, versus how many more smokers would switch. They got the numbers wrong, way overestimating the risk from snus for the former group, but even with this they reach the inevitable conclusion that better knowledge is good for population-average health.

It is better still when you acknowledge that if someone chooses to use a low-risk product upon learning of the low risk, then this is a benefit, not a cost. They are making a choice, so obviously the net effects for them must be positive, even if (if!) the health effects are negative. But that is a topic for a different post, or a few dozen of them.

UPDATE (what follows was added the next day):

Only after posting the above did I see the Twitter chatter about this paper. It was mostly along the theme of “it is criminal that tobacco controllers have misled people so badly.” I have to admit that while I alluded to that, it never occurred to me to focus on it. It is scandal fatigue: I have become so used to tobacco controllers lying to people — often effectively — that I can write this analysis with even thinking to discuss it. I realize this is a bit ironic on a blog that got its start and its title focusing on calling out the lies.

So, yes, it is criminal that tobacco controllers have intentionally caused people to believe these falsehoods. But that is not because of the effects of the false perceptions, as is so often stated. It does not matter whether the disinformation causes physical harm or has no material effect, or even if it were actually creating material benefit. Lying to people is unethical. Moreover, the liars in question were almost 100% funded by our tax dollars, and the most influential among them are/were government employees. And it is not as if a few people just blurted out a lie and it somehow stuck; our tax dollars were used to produced sustained and intentional disinformation campaigns.

Don’t let scandal fatigue let you forget this, like I briefly did.

So what is up with Norway specifically? Why does a smokeless-tobacco-friendly population grossly misperceive the risks, to the point that even authors of a paper lamenting that repeat some of the misperceptions as if they were fact. The easiest answer (from the perspective of someone who knows very little about what goes on in Norway) is that there is nothing specific. Norwegians are subject to the usual anti-snus propaganda from their larger neighbor and from the Anglophone barrage of such messages from the US and WHO. The authors of the paper could presumably improve on my flyover answer. Unfortunately, what they wrote as the last sentence of their abstract was:

Future research should try to identify reasons why health authorities in the US and Scandinavia allow these well-documented misconceptions to persist.

Um, guys, plenty of past research in the US and Sweden tells us exactly why. More specifically it tells us why they intentionally cause (not “allow”) these well-documented misconceptions to persist. This is a good start on the topic. As for why Norwegian health authorities allow it, um, you are Norwegian health authorities. So why do you allow it?

I would guess their answer would be the same as mine: “we trying to do something about it, but the criminal forces supporting the disinformation are far more powerful.”

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