Är det farligt att snusa

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Mats WallströmAvd för käkkirurgi

3000 kemiska produkter

• Tobak 40-45%• Vatten 45-60%• Na-karbonate-Högt pH 1.5-3.5%• Salt 1.5-3.5%• Fuktämnen 1.5-3.5%• Smakämnen < 1%• Nikotin

Nikotin-alkaloid

CNS-belöningCNS-belöning

Skelett-Muskelaturen.

Stim Blockad

Skelett-Muskelaturen.

Stim Blockad

AutonomaGanglier

Adremalin Parasymp

AutonomaGanglier

Adremalin Parasymp

Vasomotorisk-Center

Puls,O2, Arrth, Vasocon

Vasomotorisk-Center

Puls,O2, Arrth, Vasocon

BaroreceptorerBaroreceptorer

BinjurebarkenAdrenalin Ökad metabol effekt

Bolinder-1997

Tobaksspecifika nitrosaminer23 st i snus

• TSNA Tobacco-specific N-nitrosamine

• NNN N-nitrosonornicotine

• NNK 4 (metylnitrosamino)-1-(3pyridyl)- 1-butanone

Cancerframkallande

pH är den avgörande faktor hur mycket nikotin sommabsorberas genom slemhinnan och med vilken hastighet

Tomar SL. Tob Control 1997 6(3):219-25.

Snuskonsumption

Sverige: 19 4

Norge: 11 2

USA 15? 2

män % kvinnor %

Snuff-induced lesions - A Clinical Snuff-induced lesions - A Clinical and Experimental Study - Hirsch1983and Experimental Study - Hirsch1983

Lip canal filledwith snuff 10 h per day

Rat incisors

Surgically created canal in the lip

Djurexperiment

Djurexperiment

Johansson Sl et al. Snuff-induced carcinogenisis:Effect of snuff initiated with 4-nitrouinoline N-OxideCancer research-1989

Larsson PA et al. Snuff tumorigenisis: effects of long-term snuff administrat after initiation with 4NQO andHerpes simplex virus type 1. J Oral Pathol Med -1989

Park NH et al. Role of Virus in Oral Cancinogenesis-NIH publication-1993

Grasso. Smokeless Tobacco and Oral Cancer: An Assessment of Evidence Derived from LaboratoryAnimals. Food and Chem Toxicol - 1998

Effekter på kroppen

Lokala effekter SlemhinnanParodontalaKaries

Allmänna VanebildandeHjärta-kärlGraviditetSpädbarnsdödDiabetesCancer

Snus läsioner

1963 – Pindborg undersökte 12 kroniska snusare. Inga dysplasier.

1976 – Axéll delade in snusläsionen i 4 olika kliniska grader.

1982 – Hirsch redogjorde för 50 kroniska snusare. Lätt dysplasi i alla kliniska grader

1991 – Andersson biopserade 250 snusare. Några dysplasier i materialet

2011 – Wallström undersökte reversibiliteten efter 6 månaders snusstopp att läsionen inte läkte ut.

Tandlossning

Gingivala retraktioner:

1965 - van Wyk noterad att angränsande tänder hade gingival retraktioner.

1980 - Modeér en ökad gingivit trots plackkontroll

1989 – Andersson fann att 23% vs 3% hadegingiva retraktioner beroende på förpackningsform

Tandlossning

2004, 2006, 2006. 3 svenska studier fann ingensignifikant ökad bennedbrytning hos snusare jmf med icke tobaksnyttjare

2005. Bland 12 000 snusare I en amerikansk studie var det dubbelt så vanligt med avancerad tandlossningjmf med icke tobaksnyttjare

Karies

USA4 studier hos unga individer. En studie visade på positivkorrelation mellan snusning-karies och gingivit.

SkandinavienHirsch-91 Snusare hade ett significant högre DMFT

Cancer

The working group stated that

“there is sufficient evidence in

humans to establish

smokeless tobacco as

carcinogenic, i.e. smokeless

tobacco causes cancer of the

oral cavity and pancreas.”

Cancer

 Case Age Location Snuff use (years) Smoking G.S. 75 Upper jaw 61 NoN.L. 91 Upper jaw 70 Not for 70 years F.A. 72 Upper jaw 42 NoK-G.B. 75 Upper jaw 71 NoS.W. 50 Upper jaw 8 Prior to snuff useD.D. 85 Upper jaw 20 NoB.W. 79 Lower jaw 45 Not for 30 yearsF.N. 89 Upper jaw 69 NoS.E. 52 Upper jaw 20 Concomitant to snuffS.L. 67 Upper jaw 18 Not for 18 yearsH.G. 78 Lower jaw - NoS-Å.G. 81 Upper jaw 66 NoX.X. 74 Upper jaw 40 NoR.F. 84 Upper jaw 30 NoX.X. 67 Upper jaw 49 Not for 48 years

Clinical data of the 15 patients with snuff induced oral cancer

ORAL CANCER IN SWEDISH SNUFF-DIPPERS Hirsch et al Submitted

Mean age at time of diagnosis: 74,6 50-91  

Median age at time of diagnosis: 75  Mean duration with the snuff habit: 43,5 8-71 Median duration with the snuff habit: 47   Mean age at start of snuff use: 30,8 4-65 Median age at start of snuff use: 31

Years Range

Cancer

Schildt EB: Int J Cancer. 1998: Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. 410p/410c OR 0.7 CI 95% 0.4-1.1

Rosenqvist K: Use of Swedish moist snuff, smoking and alcohol consumption in the aetiology of oral and oropharyngeal squamous cell carcinoma.A population-based case-control study in southern Sweden. 135p/320c OR 1.1 CI 95% 0.5-25

Lewin F: Cancer. 1998: Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck:a population-based case-referent study in Sweden. 605p/756c RR 4.7 for ever users CI 95% 1.6-13.8

Cancer

3 svenska studier

Roosaar A et al. 2008 Int J Cancer Cancer and mortality among users and nonusers of snus. Cohort 9976p 1973-2002. Ökad cancerrisk oral och orofaryngeal RR 3.1 CI 95% 1.5-6.6Ökad dödlighet: HR 1.10 CI 95% 1.01-1.21

Luo J et al. 2007 Lancet: Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: aretrospective cohort study. 279897pPancreascancer RR 2.0 CI 95% 1.2-3.3

1 norsk studieBoffetta P. 2005- In J Cancer . Smokeless tobacco use and risk of cancer of the pancreas and other organs. Cohort 10136pPancreas cancer: RR 1.67 CI 95% 1.12-2.5

Cancer

2 svenska studier

Long-term use of smokeless of smokeless tobacco

Målsättning:Öka kunskapen om snusningens hälsoeffekter,Främst avseende risken för hjärt- och kärlsjukdom

Bolinder G, Avhandling -97

Long-term use of smokeless of smokeless tobacco

Material och metod:1971-78 hälsoundersöktes totalt 135 036 byggnadsarbetare av bygghälsan.- 32 546 hade aldrig nyttjat tobak- 14 983 rökte > 15cig/dag- 6 297 var enbart snusare

Bolinder G, Avhandling -97

Long-term use of smokeless of smokeless tobacco

1. Symptom, sjukfrånvaro och förtidspensionering hos snusare jämfört med rökare och tobaksfria I byggbranschen.

2. Ökad risk för död I hjärt-och kärl sjukdom hos snusare.

3. Fysisk arbetsförmåga vid långvarigt snusbruk.

4. Metabola riskfaktorer för hjärt-kärlsjukdom vid snusning.

5. Snusning och åderförkalkning-ultraljudsundersökning av intima-media-tjocklek I arteria carotis.

6. 24-timmars blodtrycksmätning hos snusare, rökare ochicke-tobaksbrukare.

Bolinder G, Avhandling -97

Long-term use of smokeless of smokeless tobacco

En av slutsatserna:

50% av alla dödsfall beror på hjärtkärl –sjukdommar.Vid en måttlig riskökning med en relativ risk på 1.4 och då 20% av svenska män snusar betyder det att ca 1300 dödsfall om året kan tillskrivas snusningen.

Bolinder G, Avhandling -97

Hjärt-kärlsjukdomar

Scandinavien

Cohort studie OR CIBolinder-94 34-54år Angina-typ 2.0 1.49-2.9

Stroke 1.9 0.6-5.7 H-K död 2.1 1.5-2.9

55-64år Angina 1.2 1.0-1.5 Stroke 1.2 0.7-1.8 H-K död 1.0 1.0-1.4

Fall-kontroll studierMONICA 2 studier som inte visade på någon ökad risk för snusare att få hjärtinfarkt jmf med icke-snusare

Hjärt-kärlsjukdomar

Kliniska epidemiologiska studier fokuserar på hjärt-kärlsjukdommar, Hjärtinfarkt, aterioskleros, stroke, högt blodtryck och metabola syndrom.

Boffetta P, Straif K 2009 Lancet. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis.Dödlig hjärtinfarkt RR 1.13 95% CI 1.06-1.21 Dödlig stroke 1.40 1.28-1.54

Hergens 2007 J I Medicin Long-term use of Swedish moist snuff and the risk of myocardial infarction amongst men.Dödlig myocard RR 1.96 95% CI 1.08-3.58

Henley 2005 Cancer Causes Contro. lTwo large prospective studies of mortality among men who use snuff or chewing tobacco. Ökad dödlighet HR 1.17 1.11-1.23, HR 1.18 1.08-1.29

Metabolt syndrom/ diabetes

Norberg, 2006, Scand J Public Health. Contribution of Swedish moistsnuff to the metabolic syndrome: a wolf in sheep's clothing?Longitudinell cohort 16492p efter 10 år. Metsy bland snusare OR 1.6 (1.26-2.15)höga triglycerider OR 1.6 (1.30-1.95), obesitas 1.7 (1.36-2.18)

Persson, 2000 J Intern Med.. Cigarette smoking, oral moist snuff use and glucose intolerance. J Intern Med. 2000Cross sectional study 3128 män där 52% hade en ärftlig belastningMer än 3 dosor/vecka OR 2.7 (1.3-5.5)

Eliasson M, Rodu B. 2004 J Intern Med. Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study.Snusare OR 1.34 (0.65-2.)7 and Har snusat OR 1.18 (0.48-2.9)

OBJECTIVE:To compare the effects of Swedish snuff and cigarette smoking on risks of preterm birth.

DESIGN:Population-based cohort study.All live, singleton births in Sweden 1999-2006.

MAIN OUTCOME MEASURES: Very (<32 weeks) and moderately (32-36 weeks) preterm birth.

Effect of Swedish snuff on preterm birth

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.

METHODS:

Odds ratios (OR) with 95% confidence intervals (CI) were used to estimate relative risks for preterm birth insnuff users (n = 7607),light smokers (1-9 cigarettes/day; n = 41 436) heavy smokers (ten or more cigarettes/day; n = 16 951) non-tobacco users (n = 503 957) as reference.

Effect of Swedish snuff on preterm birth

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.

RESULTS:

Compared with non-tobacco users, snuff users had increased risks of both very (adjusted OR 1.38; 95% CI 1.04-1.83) and

moderately (adjusted OR 1.25; 95% CI 1.12-1.40) preterm birth.

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.

Effect of Swedish snuff on preterm birth

CONCLUSIONS:

The use of Swedish snuff was associated with increased risks of very and moderately preterm birth with both spontaneous and induced onsets. Swedish snuff is not a safe alternative to cigarette smoking during pregnancy.

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.

Effect of Swedish snuff on preterm birth

BACKGROUND: Swedish snuff has been discussed internationally as a safer alternative to tobacco smoking. International cigarette manufacturers are promoting new snuff products, and the use of Swedish snuff is increasing, especially among women of childbearing age. The effect of Swedish snuff on pregnancy complications is unknown.

Maternal use of Swedish snuff (snus) and risk of stillbirth.

METHODS: In this population-based cohort study, we estimated the risk of stillbirth in snuff users (n = 7629),light smokers (1-9 cigarettes/day; n = 41,488), and heavy smokers (≥10 cigarettes/day; n = 17,014), using nontobacco users (n = 504,531) as reference.

Maternal use of Swedish snuff and risk of stillbirth.

RESULTS: Compared with nontobacco users, snuff users had an increased risk of stillbirth (adjusted OR= 1.6 [95% CI= 1.1-2.3]);the risk was higher for preterm (<37 weeks) stillbirth (2.1 [1.3-3.4]).

For light smokers, the adjusted odds ratio of stillbirth was 1.4 (1.2-1.7) and the corresponding risk for heavy smokers was 2.4 (2.0-3.0).

Wikstrom AK Epidermiology 2010 Nov;21(6):772-8.

Maternal use of Swedish snuff and risk of stillbirth.

CONCLUSIONS: Use of Swedish snuff during pregnancy was associated with a higher risk of stillbirth. The mechanism behind this increased risk seems to differ from the underlying mechanism in smokers. Swedish snuff does not appear to be a safe alternative to cigarette smoking during pregnancy.

Maternal use of Swedish snuff and risk of stillbirth.

Wikstrom AK Epidermiology 2010 Nov;21(6):772-8.

Harm reduction

Definition:

A product is harm reducing if it lowers total

tobacco – related mortality and morbidity

Even though use of that product may involve

Continued exposure to tobacco toxicants

Clearing the Smoke., Assessing the Scienece Base for Tobacco Harm Reduction

Interventionsstudier

Farmakologiska studier: CI 95%

Buprion - 1 studie OR 1.0 0.23-4.37 NRT - 2 studie (tuggimmi) OR 0.98 0.59-1.63NRT – 3 studier (plåster) OR 1.16 0.88-1.54

Betendevetenskapliga studier: Ind/grupp – 8 studier OR 2.42 1.79-3.24

Cochrane 2007