Post on 25-Dec-2015
Current challenges in tobacco prevention – do new products pose
threats or opportunities?
Lars M. RamströmInstitute for Tobacco Studies
Stockholm, Sweden
52nd International ICAA Conference on dependenciesEstoril, Portugal, 11 to 16 October 2009
New nicotine delivery devices
• ”Ultra-light” cigarettes• Electronic cigarettes• Water pipe• Nicotine water• Nicotine disolvables
- strips- sticks- pellets
• Swedish snus
New nicotine delivery devices
• ”Ultra-light” cigarettes• Electronic cigarettes• Water pipe• Nicotine water• Nicotine disolvables
- strips- sticks- pellets
• Swedish snus
Swedish snusFine ground tobacco leaves predominantly from air-cured dark tobacco
Manufactured by a pasteurizing-like heating process (without any fermentation so as used in most manufacturing procedures for American snuff)
∎ TSNA content: < 5 mg/kg∎ BaP content: < 10 g/kg
(TSNA content of American snuff: 16-130 mg/kg)
%%
0
5
10
15
20
25
30
35
40
45
50
1976 1980 1985 1988 1996 2000 2002
0
5
10
15
20
25
30
35
40
45
50
Daily snus use, womenDaily snus use, men
Daily smoking, womenDaily smoking, men
1976-1988 NTS-surveys, 1996-2002 ITS/FSI-surveys
Ramström 2003
Prevalence of daily moking and daily snus useMen and women (age 18-70) in Sweden 1976-2002
Observations (bars) and least square regression lines
EstoniaEstoniaEstoniaEstoniaEstoniaLithuaniaLithuaniaLithuaniaLithuaniaLithuania
LatviaLatviaLatviaLatviaLatviaFranceFranceFranceFranceFrance
Austria Austria Austria Austria Austria DenmarkDenmarkDenmarkDenmarkDenmarkGermanyGermanyGermanyGermanyGermany
IrelandIrelandIrelandIrelandIrelandBelgium Belgium Belgium Belgium Belgium
LuxembourgLuxembourgLuxembourgLuxembourgLuxembourgSwitzerlandSwitzerlandSwitzerlandSwitzerlandSwitzerland
IcelandIcelandIcelandIcelandIcelandNorwayNorwayNorwayNorwayNorway
United KingdomUnited KingdomUnited KingdomUnited KingdomUnited KingdomCanadaCanadaCanadaCanadaCanada
The NetherlandsThe NetherlandsThe NetherlandsThe NetherlandsThe NetherlandsUnited StatesUnited StatesUnited StatesUnited StatesUnited States
SwedenSwedenSwedenSwedenSweden
0 1 2 3 4 5 6
Cancer of the oral cavityAge adjusted mortality rates per 100 000Men in North America, Northern and Western Europe
Source: GLOBOCAN 2002 database: http://www.-dep.iarc.fr
Cigarette smokers
Snus users
Never-smokers
0,0 0,5 1,0 1,5 2,0 2,5
Relative risk of death for male tobacco users (whole bar)
Green sector: Never-smokers' death risk (reference) Red sector: Excess risk (above Never-smokers)
Less than 9% of
Data derived from:Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarfettes per day. Tobacco Control 2005;14:315-320.Levy D T et.al. The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product Compared with Smoking Cigarettes: Estimats of a Panel of Experts. Cancer Epidemiol Biomarkers Prev 2004;13(12):2035-2041.
Reduction of life expectancy: Tobacco users, age 40, in comparison with ”Never tobacco users” Estimated number of years lost Men Women Current smokers who continue to smoke 5.04 4.09
Current smokers who quit all tobacco use 0.53 0.34
Current smokers who switch to snus 0.77 0.52
Current snus users who never smoked 0.28 0.19
Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014
ONSET RATE OF DAILY SMOKINGBy presence or absence of primary use of snus
All males (n=2756) 40 %
With primary snus use (n=397) 20 % Without primary snus use (n=2359) 43 %
(Source: ITS/FSI study 2001/2002)
Gum onlyPatch onlySnus only
Gum onlyPatch onlySnus only
0 25 50 75 100
Quit smoking completelyQuit daily Continuing daily smoking
Outcome of latest attempt to quit smokingby type of cessation aid used
smoking, continuing to smoke occasionally
Men
Women
47%
32%
66%
37%
29%
55%
10%
2%
15%
8%
2%
16%
43%
66%
19%
55%
69%
29%
Data from 2001/2002 ITS/FSI study (Ramström & Foulds 2006)
QUIT RATES IN SWEDEN (Proportion of ”Ever daily smokers” having quit completely)
• All men 59%All women 49%
• Men WITHOUT a history of daily snus use 51%Women WITHOUT a history of daily snus use 48%
• Men WITH a history of daily snus use 72%Women WITH a history of daily snus use 71%
• All WITHOUT a history of daily snus use 49%All WITH a history of daily snus use 72%
“In Sweden, the availability and use by men of an oral tobacco product called snus, one of the less hazardous smokeless tobacco products, is widely recognised to have contributed to the low prevalence of smoking in Swedish men and consequent low rates of lung cancer.”
Excerpt from:
Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.
Summary• E-cigarette smoking may be substantially less harmful
to health than cigarette smoking, but more research is needed before definitve conclusions can be drawn.
• Water pipe smoking appears to be even more harmful to health than cigarette smoking.
• Snus use appears to- decrease juvenile onset of smoking- help smokers to quit all tobacco use- offer a substantially less harmful alternative for those who are unable or unwilling to quit completely.