Ingeborg Lund

The Population Mean and the Proportion of Frequent Gamblers: Is the Theory of Total Consumption Valid for Gambling?

The study looks at three representative samples of Norwegians in different age groups with the aim of finding evidence for the validity of the total consumption model for the area of gambling. The results show that gambling was distributed in the population in a way consistent with the predictions of the total consumption theory. Populations with a low mean gambling frequency had a lower proportion of frequent gamblers than populations with a high mean gambling frequency. It was also shown that in a population with a low mean gambling frequency, consumers along the whole consumption continuum gambled less frequently, than in a population with a high mean gambling frequency. It is concluded that the total consumption model seems to be valid for gambling, and that gambling consequently needs to be understood as a public health issue. The actions and behaviours of the normal majority can then not be regarded as irrelevant for the development in problem gambling prevalences.

Gambling and problem gambling in Norway: What part does the gambling machine play?

In this article, the findings of a Norwegian national gambling survey carried out in 2002 among the adult population (aged 15–74 years) are discussed. While the survey shows a high level of gambling in the population as a whole (80.6% participation over the last 12 months), problem gambling levels are comparatively low (1.4% over the lifetime). This article suggests that this may partly be the result of a bias in the sample, and should be considered a conservative estimate. However, it also suggests that the scarcity of social arenas may have contributed to holding problem gambling levels down. This article concludes that further investigation should focus on the role of the social aspects of gambling in the problem-generating process. Problem gambling occurs more frequently among young people, men and people born outside Norway. The most common type of gambling for problem gamblers is playing on gambling machines; non-problem gamblers seem to prefer lotteries.

The impact of cigarette branding and plain packaging on perceptions of product appeal and risk among young adults in Norway: A between-subjects experimental survey

Objectives This study examined the perceptions of cigarette packaging and the potential impact of plain packaging regulations. The hypothesis was that the branded cigarette packages would be rated more positively than the corresponding plain packs with and without descriptors. Design Between-subjects experimental online survey. Male and female participants were separately randomised to one of the three experimental conditions: fully branded cigarette packs, plain packs with descriptors and plain packs without descriptors; participants were asked to evaluate 12 individual cigarette packages. The participants were also asked to compare five pairs of packs from the same brand family. Setting Norway. Participants 1010 youths and adults aged 15–22. Primary outcome measures Ratings of appeal, taste and harmfulness for individual packages. Ratings of taste, harm, quality, ‘would rather try’ and ‘easier to quit’ for pairs of packages. Results Plain with and without descriptors packs were rated less positively than the branded packs on appeal (index score 1.63/1.61 vs 2.42, p<0.001), taste (index score 1.21/1.12 vs 1.70, p<0.001) and as less harmful (index score 1.0.34/0.36 vs 0.82, p<0.001) among females. Among males, the difference between the plain with and without descriptors versus branded condition was significant for appeal (index score 2.08/1.92 vs 2.58, p<0.005) and between the plain without descriptors versus branded condition for taste (index score 1.18 vs 1.70, p<0.00). The pack comparison task showed that the packs with descriptors suggesting a lower content of harmful substances, together with lighter colours, were more positively rated in the branded compared with the plain condition on dimensions less harmful (β −0.77, 95% CI −0.97 to −0.56), would rather try (β −0.32, 95% CI −0.50 to −0.14) and easier to quit (β −0.58, 95% CI −0.76 to −0.39). Conclusions The results indicate that a shift from branded to plain cigarette packaging could lead to a reduction in positive perceptions of cigarettes among young people.

How has the availability of snus influenced cigarette smoking in Norway

Background: In Norway, low-nitrosamine smokeless tobacco (snus) is allowed to compete with cigarettes for market share. We aimed to study how the availability of snus influenced overall tobacco consumption, smoking initiation and smoking cessation. We discuss whether the Norwegian experience with snus can have any transfer value for e-cigarettes. Methods: We analysed consumption data from registered and unregistered supply sources of tobacco. We calculated quit-smoking ratios across snus use status in nine datasets comprising a total of 19,269 ever-smokers. Trends in snus use and smoking were derived from time-series of annual; cross-sectional; nationally representative surveys for the period 1985–2013. Results: The market share for snus increased from 4% in 1985 to 28% in 2012, but overall tobacco consumption decreased by 20.3% over this same period. Snus was the most common method for smoking cessation. Compared with smokers with no experience of using snus, the quit ratio for smoking was significantly higher for daily snus users in seven of the nine datasets analysed. Among young male adults, the prevalence of smoking (daily + occasional) was reduced from 50% in 1985 to 21% in 2013. Over the same period, use of snus increased from 9% to 33%. This negative correlation (r = −0.900, p < 0.001) was also observed among young females (r = −0.811, p < 0.001), but the trend shift in tobacco preferences occurred some years later. Conclusions: The experience with snus in Norway might indicate what will happen when alternative nicotine products––are allowed to compete with cigarettes in the nicotine market.

Irrational beliefs revisited: Exploring the role of gambling preferences in the development of misconceptions in gamblers

This study looks at the association between irrational beliefs and gambling and gambling preferences in 4963 adults (15–74 years old). The results from a hierarchical linear regression showed that increased gambling frequency was associated with increased irrational beliefs for all gamblers, but that this effect was stronger for gamblers who preferred gambling machines, bingo automats, card games and Internet gambling. It is suggested that these games have structural characteristics that encourage superstitious thinking more. Finally, it is suggested that a more rapid increase in irrational thinking associated with increased gambling frequency is one of the mechanisms that makes these games more risky.

Lifestyle Correlates of Female Snus Use and Smoking: A Large Population-Based Survey of Women in Norway

INTRODUCTION While smoking in Norway has become less prevalent, snus use has increased, including among women. The aims of this study were to describe female snus use and its correlates, and to contrast patterns of snus use and smoking. METHODS In 2011-2012, data on tobacco use, age, education, alcohol consumption, sexual behaviors, and physical activity were collected from a population based sample of 13 756 Norwegian women aged 18-45 years, using a self-administered questionnaire. RESULTS Ever-use prevalence of snus ranged from 29.6% to 4.5% among those aged 18-19 years and 40-45 years, respectively. In contrast, the corresponding figures for smoking were 24.1% and 44.1%. Among snus users, 54.1% and 22.8% of 18-19 and 40 to 45-year-olds had never smoked, respectively. Debut age for snus use increased markedly with age, and was higher than debut age for smoking. Female snus use was positively associated with intermediate education, alcohol consumption, number of sexual partners, and hard physical activity. Smoking was also positively associated with alcohol consumption and number of sexual partners, but negatively associated with physical activity and education. CONCLUSION While most snus users among older women were former or current smokers, this was not the case among younger women. Low snus debut age and extensive snus use among younger women suggest that measures to reduce snus use should be targeted at young adolescents. The correlates of female snus use and smoking were not identical, and were similar to those previously documented for men.

Lifetime smoking habits among Norwegian men and women born between 1890 and 1994: a cohort analysis using cross-sectional data

Objectives Providing lifetime smoking prevalence data and gender-specific cigarette consumption data for use in epidemiological studies of tobacco-induced cancer in Norway. Characterising smoking patterns in birth cohorts is essential for evaluating the impact of tobacco control interventions and predicting smoking-related mortality. Setting Norway. Participants Previously analysed annual surveys of smoking habits from 1954 to 1992, and individual lifetime smoking histories collected in 1965 from a sample of people born in 1893–1927, were supplemented with new annual surveys of smoking habits from 1993 to 2013. Age range 15–74 years. Primary outcome measure Current smoking proportions in 5-year gender-and-birth cohorts of people born between 1890 and 1994. Results The proportion of smokers increased in male cohorts until the 1950s, when the highest proportion of male smokers (76–78%) was observed among those born in 1915–1934. Among women, the peak (52%) occurred 20 years later, in women born in 1940–1949. After 1970 smoking has declined in all cohorts of men and women. In the 1890–1894 cohorts, male smoking prevalence was several times higher than female, but the gap declined until no gender difference was present among those born after 1950. Gender-specific per capita consumption was even more skewed, and men have consumed over 70% of all cigarettes since 1930. The incidence of lung cancer for men peaked at around 2000, with the highest incidence rate estimated at ca. 38%. The incidence of lung cancer for women is still increasing, and estimated incidence rate for 2011 was 25.2%. Conclusions In an epidemiological perspective, men have had a longer and more intense exposure to cigarettes than women. The gender-specific incidence of lung cancer reflects the gender difference in consumption over time.

Smoking and Snus Use Onset: Exploring the Influence of Snus Debut Age on the Risk for Smoking Uptake With Cross-Sectional Survey Data

INTRODUCTION Snus use has become increasingly prevalent among young people in Norway, while smoking has declined. Little is known about the transitions between snus and other tobacco products, particularly among younger users. A major concern involves the association between snus initiation and future smoking uptake. METHODS A total of 409 lifetime snus users who had started with snus before cigarettes or were never-smokers were selected from a national sample of participants in annually repeated cross-sectional surveys (2005-2011) of Norwegian men and women aged 15-74 years. About 30% of them were lifetime smokers, 84% were men, and the mean age was 29.4 years. Logistic regression was applied to investigate the association between age of snus uptake and the risk for becoming a smoker later on. RESULTS Respondents who started using snus before the age of 16 years had an odds ratio of 3.1 (confidence interval = 1.98-4.76) of being lifetime smokers compared with those who initiated snus later. The prevalence of current smoking among early snus initiators (22.9%) was comparable to that found among never-snus-users (29.6%). Among late snus initiators, current smoking prevalence was 5.9%. CONCLUSION In this study, snus debut age was an important factor for the association between snus use and smoking.

Post-ban self-reports on economic impact of smoke-free bars and restaurants are biased by pre-ban attitudes. A longitudinal study among employees.

Introduction: Objective sales data have indicated that the Norwegian indoor smoke-free regime implemented in June 2004 did not affect the hospitality business negatively. This paper investigates whether self-reports on the economic impact of the smoking ban from employees in the hospitality sector gave similar results, and whether post-ban self-reports on the economic impact of the ban were influenced by pre-ban attitudes towards smoke-free policies. Methods: A random sample of 516 employees in bars and restaurants stated their attitudes towards smoke-free policies shortly before the ban became effective. One year later, the same respondents gave their perceptions of changes in patronage for their workplace. Data were collected using self-administered questionnaires and telephone interviews. Results: 56.4% of the hospitality workers stated that the ban on smoking had led to a large reduction (28.2%) or some reduction (28.2%) in the number of patrons, a result inconsistent with analysis of sales data. After adjusting for demographic and smoking-related variables, a negative pre-ban attitude significantly increased the odds for reporting a negative economic impact post ban (odds ratio 2.48, confidence interval 1.48—4.14). Conclusions: Subjective reports of the economic impact from an indoor ban on smoking are influenced by attitudes towards smoke-free policies and should not be considered as a valid measure of the economic effect.

The Relative Risk to Health From Snus and Cigarettes: Response to Grimsrud et al.’s Commentary on “Perceptions of the Relative Harmfulness of Snus Among Norwegian General Practitioners and Their Effect on the Tendency to Recommend Snus in Smoking Cessation”

In their letter to the editor, Grimsrud, Gallefoss, and Lochen (2012) criticize us for putting too little emphasis on the health hazards of snus in our study (Lund & Scheffels, 2012) and suggest that our scientific consensus that snus is much less harmful than cigarettes is faulty. Furthermore, they warn us about the risk of becoming useful tools for the tobacco industry and imply that we have been too selective in our choice of references. It seems timely for us to try and clarify a few misunderstandings in this respect. First, in our article, we do not recommend the use of snus in general. Instead, we suggest that snus might serve as an alternative to other cessation aids for highly nicotine-addicted or heavy smokers if other available aids fail to lead to smoking cessation. We do not claim that snus is risk free. The interesting question is, therefore, not whether the use of snus increases the risk for diseases in general or specific illnesses in particular, but rather how the risks from snus use compare to the risks from smoking. From a harm-reduction perspective, replacing cigarettes with less harmful nicotine products can in some instances be encouraged. In our study, we have looked specifically at how general practitioners (GPs) in Norway perceive the relative health risks of snus and cigarettes in general. There are two very important words in that sentence. The first important word is “relative.” Is snus harmful? Yes, but this was not the question we asked the GPs. What we did ask was “How harmful is daily use of snus compared to daily use of cigarettes?” “Daily use” is meant to function as a general indication of dose. In the report from the Royal College of Physicians (RCP, 2007, ch. 8.5), it is concluded, “In relation to cigarette smoking, the hazard profile of the lower-risk smokeless products is very favourable.” The Scientific Committee on Emerging and Newly-Identified Health Risks (SCENIHR, 2008, ch. 3.81) similarly states that “Overall, snus is clearly less hazardous, and in relation to respiratory and cardiovascular disease substantially less hazardous.” Furthermore, SCENIHR (2008) argues that there is no evidence that snus is associated with any major health hazard that does not also arise from smoking and that a substitution of smokeless tobacco (ST) for cigarettes would have the following public health benefits: Respiratory disease: No risk from ST, 100% risk reduction. In all, 46% of deaths from smoking are caused by respiratory diseases. A complete substitution of smokeless tobacco for cigarettes would prevent nearly half of all deaths caused by smoking. Cardiovascular disease (CVD): Accounts for 28% of all deaths caused by smoking; a substitution of smoking by snus would reduce mortality by at least 50%. Oral and gastrointestinal cancer: Responsible for relatively few smoking-related deaths. At least 50% risk reduction, but modest public health impact since numbers of deaths are relatively small. Passive smoking: 100% risk reduction. The focus on relative risks in our study also explains why we did not include a reference to the International Agency for Research on Cancer (IARC, 2007) working group, where ST risks are discussed in absolute terms. However, we do not feel that the IARC findings render our conclusions invalid. We do not in any way argue that snus is harmless. The other important word is “general.” Snus increases the risk for some diseases and not for others. However, our study was not primarily concerned with specific diseases, and the GPs were not asked to specify which diseases they thought snus use might cause. They were asked a global question about relative risk, and we have chosen to interpret their answers as their ideas of how the general risk tendencies of the two products compare. A 90% risk reduction estimate is used as a default in the research literature, including the RCP (2007), SCENIHR (2008), and Levy et al. (2004). This assessment of the total risk reduction is calculated by weighting the relative risks for specific diseases into one single measure. As demonstrated earlier, the size of the risk reductions will vary for different diseases; although there is room for discretion when assessing this global relative risk, the 90% estimate can be considered to be more on the conservative side. Some scientists believe that a better estimate would be around 95%–99% (Rodu, 2011). As our focus was on general risks, we chose not to include any discussion of specific groups, for example, pregnant women, adolescents, or light and nondaily smokers. The summary of health risks in our article was meant as an illustration more than a complete and exhaustive list. Nevertheless, a few words on the diseases Grimsrud et al. (2012) felt should have been given more weight: pancreatic cancer and CVD. Several studies have found an elevated risk of pancreatic cancer for snus users, with Boffetta, Hecht, Gray, Gupta, and Straif (2008) as an often cited study. However, these findings have been challenged by other more recent studies (Lee & Hamling, 2009; Sponsiello-Wang, Weitkunat, & Lee, 2008). Importantly, Boffetta and his team recently published a new study where they found no increased risk for pancreatic cancer for snus users (Bertuccio et al., 2011). As regards CVD, the risk profile of snus is highly favorable to the risk profile of cigarettes. Grimsrud et al. find it timely to remind us that CVD remains the most common cause of death in Norway. We will return the favor and remind them that current smokers have an estimated relative risk of 2.60–2.80 for myocardial infarction (Hergens, Ahlbom, Andersson, & Pershagen, 2005; Wennberg et al., 2007) and 3.6 for fatal myocardial infarction (Hergens et al., 2005), much higher than the snus/ST figure, which has been found to lie between 1.13 and 1.40 (Boffetta & Straif, 2009). Currently, CVD accounts for approximately 28% of deaths caused by smoking in the European Union (SCENIHR, 2008). A reduction in relative risk from 3.6 to 1.40 following a substitution of snus for cigarettes would make a substantial impression on the mortality statistics. Grimsrud et al. appear to think that our conclusion that Norwegian GPs are at odds with science was somehow influenced by a desire to achieve press coverage and that we just as well could have concluded that they were in agreement with science. We would like to refute that idea as strongly as we can. The conclusions of the three reports that have addressed the risk differences between snus and cigarettes, the RCP (2007), SCENHIR (2008), and Levy et al. (2004), clearly suggest that the potential harm from snus is much lower than that from cigarette smoking.