Swedish snus: Nicotine, Prevalence, Gateway,

Epidemiology of harm and Usefor smoking cessation

Karl Fagerstrom Ph.D.Smoker´s Information Centre

Helsingborg Sweden

That humanity at large will ever be able to dispense with Artificial Paradises seems very unlikely. Most men and women lead lives at the worst so painful, at the best so monotonous, poor and limited that the urge to escape, the longing to transcend themselves if only for a few moments, is and has always been one of the principal appetites of the soul.

Aldous Huxley

CULTURAL DRUGS

• ALCOHOL, BEER, WINE, HARD LIQUER

• CAFFEINE, SODA, TEA, COFFEE

• NICOTINE, CLEAN NIC. SMOKEFREE, CIGARETTES

Semi cultural• THC, marijuana etc

Nicotine/Tobacco is an ideal area for harm reduction.

Used largely because of nicotine.

Pure nicotine, and even unburnedtobacco, is not a big part of the problem: the health consequences.

Original Portion1 gram

Original White Portion0.8 gram

Original White Mini Portion0.4 gram

0

Denmark Finland Norway Sweden

EUROPE

SDR all causes, 0-64, per 100000, male 1995

L. Ramström, ITS. Adapted from WHO/EURO

Epidemiology of harm

Risk of first MI in Swedish males according to tobacco use

2.3* 2.6* 1.9*3.6*1.9*Smoking

1.4 .821.4* 0.90.9Snus

1.0 1.01.0 1.01.0Never used tobacco

OR OROR

Hergens Johans- Wen-Et al son et al. nberg et2005 2005 al 2007

Bolinderet al. 1994

Huhtasaariet al1999

Huhtasaariet al. 1992

1.0

1.0

OR OR OR

2.3*

1.70.7Rosenqvist et al 2006

2.81.1Schildt et al 1998

1.4Lewin et al 1998

Smoker/Neversnus

Snus/Neversmoker

Odds ratios for oral cancer

Lesions common but rarely develop to cancer Roosar et al 2006Anecdotal evidence for oral cancer Zetterstrom et al 2004

Cancer in pancreas

Bofetta et al RR 1.6 (1.1 – 2.5)

Luo et al RR 2.0 (1.2 – 3.3)

Diabetes

One study found and a slightly increasedrisk Persson et al 2002

While another found no increase Eliasson et al 1995

Prevalence

Prevalence of smoking among swedish men

1988-89 96-97 2006

10

20

30

16.7

20.0

SNUS28.4

19.1 SMOKING

Data Statistics Sweden 88-89 and 96-97, Public Health Institute 2007

Prevalence of smoking and snus use in Swedish men

22%

13%

Cessation

-10 -5 0 5 10 15 20 25 30 35 40 45 50 55 600

2

4

6

8

10

12

14

16

18

20

Plas

ma

nico

tine

(ng/

ml)

NICOTINE UPTAKE IN SWEDISH SNUFF TAKERS

Mean ± SEM

TIME (minutes)Snuff in mouth

Lunell and Lunell 2005

Kotlyar et al. 2007

36

55

2

42

55

1513

24

0

10

20

30

40

50

60

Males Females

Perc

ent

Nicotine gumNicotine patchSnusAll other

CESSATION AID AT THE LATEST QUIT SMOKING ATTEMPT

Ramstrom 2003

98Bupropion (Zyban)66254Snus (Smokeless)

489 282 Nicotine total3114inhaler64spray3012lozenges

18290patch240162Nicotine gum

WomenMen

Ramström & Foulds 2006

Use of different aids in latest quit attempt. 895 triersfrom a population sample.

13%61%Snus

5%36%NRT total

3%30%Patch

8%42%Gum

Ramström & Foulds 2006

Quit Reduced to occational

Outcome of latest quit attempt

Snus and Smoking Cessation in Swedish Twins N=7537

From existing data. Looking correlates of cessation among

Sex Social classMarried Level of educationAge onset DependenceDepression Ever used snusHealth status Alcohol dep/abuse

Highest Hazards Ratio found for snus 2.30 (1.9 – 2.7)

H Furberg personal communication

100%

85%

15%

Started as dailysnus users

Others

All males12%

3%Started daily smoking

Never started daily smoking

48%

37%Started daily smoking

Never started daily smoking

3/15=20%

Ever daily smokersamong those who

started as snus user

37/85=43%

Ever daily smokersamong all others

IS SNUS A GATEWAY TO SMOKING?Initiation of smoking in relation to previous snus habits

Foulds et al 2003

THE PRODUCT

PRODUCT TYPES

Snus exists in two forms:

• Loose snus, which is sold in 50 g cardboard or plastic cans.

• Portion-packed snus which is sold in three packaging varieties, plastic cans with 24 x 1 g portions and plastic cans with 20 x 0.5 g portions or 20 x 0.3 g portions. Different flavor varieties exist in all forms.

Important steps in manufacturing

• Selection of tobacco• Curing• Production in closed process• Heating/pasteurisation• Storage

SHELF LIFE

Shelf Life Characteristics:• Swedish snus is moist and therefore

limited in shelf life.• The shelf life depends on storage

conditions• Swedish snus should be stored cool.• Typical shelf life is 3 months, of which

approx. 1 month at ambient temperature.

Component Limit Component Limit

Nitrite < 5 mg/kg Cadmium < 0.5 mg/kg

TSNA < 5 mg/kg Lead < 1.0 mg/kg

NDMA < 5 µg/kg Arsenic < 0.25 mg/kg

BaP < 10 µg/kg Nickel < 2.25 mg/kg

Pesticides According tothe SwedishMatch PesticidePolicy

Chromium < 1.5 mg/kg

GOTHIATEK® limits for undesired components(based on 50% water content in the finished product)

Raw material requirements

Additives

All additives in Swedish Snus by GOTHIATEK® shall satisfy the requirements of the Swedish Match Ingredients Policy. This policy requires that all additives in Swedish Snus by GOTHIATEK® shall be approved as food additives, or approved as tobacco additives, according to the specific regulations in each country where the products are actively marketed. In addition, stricter internal limits are applied.

GOTHIATEK®

Raw material requirements

Tobacco

• Leaf tobacco for Swedish Snus by the GOTHIATEK® standard shall be selected so that the limits for undesired components in each specific product are met.

• Leaf tobacco for Swedish Snus by GOTHIATEK® must not contain gene modified tobacco (GMO).

GOTHIATEK®

Process requirements•The tobacco shall be comminuted in a controlled process satisfying the requirements for specified particle size distributions. Any foreign object must be identified and separated.

•Swedish Snus by GOTHIATEK® shall be heat-treated, using parameters that are effective enough to kill the natural microbial flora of the tobacco to specified residual bacteria limits ("snus pasteurisation").

•From the point of charge to discharge of the batch the manufacturing process shall be performed in a closed system to prevent the product from being contaminated by external microflora or foreign objects.

GOTHIATEK®

MODELLING OF HARM

Table 1: Relative risk of tobacco-attributable mortality in snus users compared with current smokers by cause

All cardiovascular diseases (including coronary heart disease, stroke, and arterial disease) 0·10 (0·075–0·125) 0·10 (0·075–0·125)

Upper aerodigestive, pancreatic, bladder, and renal cancer

0·15 (0·1125–0·1875) 0·30 (0·225–0·375)

Lung cancer 0·02 (0·015–0·025) 0·034 (0·0255–0·0425)

COPD and other respiratory diseases 0·00

Gartner et al 2007

Age Current smokers Smokers who Smokers who Current snus userscontinue smoking switch to snus quit smoking who never smoked

35 5·02 (4·72–5·35) 0·63 (0·56–0·69) 0·37 (0·34–0·40) 0·28 (0·23–0·34)

45 5·03 (4·72–5·36) 0·99 (0·91–1·08) 0·77 (0·71–0·83) 0·28 (0·23–0·34)

55 4·80 (4·49–5·13) 1·71 (1·56–1·87) 1·40 (1·29–1·52) 0·48 (0·39–0·58)

65 3·95 (3·65–4·26) 2·01 (1·83–2·21) 1·81 (1·65–1·99) 0·39 (0·32–0·48)

75 2·36 (2·11–2·62) 1·55 (1·35–1·75) 1·47 (1·29–1·68) 0·22 (0·17–0·27)

Table 3: Years of healthy life lost compared with people who havenever used tobacco, men.

Gartner et al 2007

Conclusions.

Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbersby inveterate smokers.

14–25 people who have never smoked would need to start using snus to offset the health gain from everynew tobacco user who used snus rather thansmoking.

Gartner et al 2007

Pillars of Tobacco Control

• Prevention of initiation• Assistance with cessation• Protection from environmental

tobacco smoke

• Harm reduction?

Ken Warner

Pillars of Tobacco Control

• Prevention of initiation Positive?• Assistance with cessation Positive• Protection from environmental tobacco

smoke Positive

• Harm reduction? Positive

Effect of snus

Thank you