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

Electronic cigarettes

Waterpipe (Hookah, Hubble-Bubble)

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)

Loose snus Pouches ofportion packed snus

Putting in a keeping it

pouch of snus and under the lip

%%

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.