Smoking cessation aided by low-toxicity smokeless

tobacco can save many lives

Lars M. RamströmInstitute for Tobacco Studies

Täby, Sweden

UKNSCC 2014 Thursday 12th June - Friday 13th June 2014

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Recommendations for regulation of smokeless tobacco●The combined concentration of NNN plus NNK in smokeless tobacco should be limited to 2 μg/g dry weight of tobacco.●The concentration of benzo[a]pyrene in smokeless tobacco should be limited to 5 ng/g dry weight of tobacco.

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

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

Gartner et al. Lancet 2007

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.

Among boys WITHOUT primary daily snus use:

- 46% start daily smoking

Among boys WITH primary daily snus use:

- 18% start daily smoking

Source: FSI / ITS surveys 2003 - 2011

Among all boys who have started daily smoking…

- 92% come from the group of never daily snus users

- 8% come from the group of primary daily snus-users

Source: FSI / ITS surveys 2003 - 2011

1920 1930 1940 1950 1960 1970 1980 1990 20000

2500

5000

7500

Annual sales of snus in Sweden (metric tons)

Smoking and Hea th, RCP 1962

Smoking and Hea th, US Surgeon General 1964

The upturn of snus use at this particular time appears to reflect an awareness of the harmfulness of cigarettes raised by the 1962 and 1964 reports and a subsequent demand for less harmful alternatives.

0

25

50

75

100

Around 1960

Around 2000

Smoking NoneSnus use

Source: FSI / ITS surveys 2003-2006

Around 1970

Around 1980

Around 1990

Boys in Sweden: Initiation of daily tobacco use

QUIT RATES IN SWEDEN (Proportion of ”Ever daily smokers” having quit

completely)

• All men 63%All women 54%

• Men WITHOUT a history of daily snus use 55%Women WITHOUT a history of daily snus use 54%

• Men WITH a history of daily snus use 74%Women WITH a history of daily snus use 71%

Snus use and cessation of smoking

The numbers in green sectors indicate aid-specific quit ratios (successfulness)

Source: FSI /ITS surveys 2003-2006

Part of the primary daily smokers do eventually take up daily snus use, others do not.

What do the endpoints look like in each category?

ENDPOINTS (MEN)Primary daily smokers who have NOT

taken up daily snus use

53% no smoking 4% occasional smoking43% continued daily smoking

Primary daily smokers who HAVE taken up daily snus use

78% no smoking

9% occasional smoking

4% daily smoking, no daily snus use 9% daily smoking and snus use

“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.

DEATH RATES (PER 100,000) ATTRIBUTABLE TO TOBACCO 2004. Men and women age 60-69

SwedenEuropean Union Member States

other than Sweden

Min Median Max

MEN

Lung cancer 87 91 220 399

Other cancer 36 41 105 217

All cardiovascular 72 107 170 618

All causes 222 378 550 1388

WOMEN

Lung cancer 61 5 39 127

Other cancer 17 1 10 39

All cardiovascular 63 5 50 222

All causes 173 14 115 690

Statement from specialists in nicotine science and public health policy

Dr Margaret Chan Director General World Health Organisation Geneva

CC: FCTC Secretariat, Parties to the FCTC, WHO Regional Offices

26 May 2014

Dear Dr Chan

Reducing the toll of death and disease from tobacco – tobacco harm reduction and the Framework Convention on Tobacco Control (FCTC)

We are writing in advance of important negotiations on tobacco policy later in the year at the FCTC Sixth Conference of the Parties. …

Letter from 53 scientists in 18 countries all over the worldavailable at http://nicotinepolicy.net/documents/letters/MargaretChan.pdf

…There are now rapid developments in nicotine-based products that can effectively substitute for cigarettes but with very low risks. These include for example, e-cigarettes and other vapour products, low-nitrosamine smokeless tobacco such as snus, and other low-risk non-combustible nicotine or tobacco products that may become viable alternatives to smoking in the future. Taken together, these tobacco harm reduction products could play a significant role in meeting the 2025 UN non- communicable disease (NCD) objectives by driving down smoking prevalence and cigarette consumption. …

…Indeed, similar arguments have been made about the use of smokeless tobacco in Scandinavia but the evidence is now clear that this product has made a significant contribution to reducing both smoking rates and tobacco-related disease, particularly among males. …

…The potential for tobacco harm reduction products to reduce the burden of smoking related disease is very large, and these products could be among the most significant health innovations of the 21st Century – perhaps saving hundreds of millions of lives.

SUMMARY

Some kinds of smokeless tobacco

can be a ”quiet killer”

but

Low-toxicity smokeless tobacco can save many lives