Rising Uptake of Alternative Nicotine Products (ANPs) by Smoking-Naïve Individuals Is Not Necessarily a Threat to Public Health: The Case of Diversion by Snus in Norway

PRESENTED AT THE ANNUAL MEETING OF THE SOCIETY FOR RESEARCH ON NICOTINE AND TOBACCO, MARCH 2024, EDINBURGH. Significance: Nicotine products exist on a continuum of harm. Adults who smoke combustible tobacco can benefit by switching to less-harmful alternative nicotine products (ANPs) such as snus and electronic nicotine delivery systems (ENDS), but uptake by smoking-naïve individuals is a concern. Rising ANDS use among non-smoking individuals is often interpreted pessimistically as ANPs attracting new populations of users; however, this interpretation is contradicted in some cases by historic declines in smoking prevalence that accompany rising ANP use. The interplay of ANP use and tobacco smoking trends, and their joint impact on the proportion of smoking-naïve ANP use is examined in the case of Norway, where snus gradually displaced smoking over the 1990s and 2000s. Methods: Data were drawn from the Smoking Habits Survey, an annual cross-sectional survey of tobacco behavior conducted by Statistics Norway. Analyses focus on individuals aged 16-74 between 1985-2022. Trends in current snus use prevalence and current tobacco smoking prevalence (cigarettes or roll-your-own) were examined. Trends in smoking-naïve snus use were also examined, defined as the proportion of snus-using individuals who did not currently smoke tobacco. Results: Current snus use prevalence increased from 3.3% in 1985 to 19.2% in 2022, while current smoking decreased from 45.9% to 15.0% over the same period. Over this gradual displacement of tobacco smoking by snus, smoking-naïve snus use increased: in 1985, 45.9% of snus-using individuals in 1985 did not currently smoke, and this increased to 83.5% in 2022. Conclusion: As nicotine use in Norway shifted away from smoked tobacco and towards snus, the proportion of smoking-naïve snus use increased dramatically. However, in this case, rather than being a public health concern (i.e., representing uptake by new populations and higher net nicotine use), rising smoking-naïve snus use is a natural mathematical consequence of simultaneous ANP uptake and falling smoking rates. Thus, the public health implications of rising smoking-naïve ANP use are ambiguous when interpreted in isolation; it is necessary to also examine population-level prevalence trends to disambiguate the extent to which ANPs are being taken up by new populations vs. may be displacing more harmful tobacco smoking.