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Current challenges in tobacco
prevention – do new products pose
threats or opportunities?
Lars M. Ramström
Institute for Tobacco Studies
Stockholm, Sweden
52nd International ICAA Conference on dependencies
Estoril, 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 snus
Fine 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 snusPouches of
portion 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
EstoniaEstoniaEstoniaEstoniaEstonia
LithuaniaLithuaniaLithuaniaLithuaniaLithuania
LatviaLatviaLatviaLatviaLatvia
FranceFranceFranceFranceFrance
Austr ia Austr ia Austr ia Austr ia Austr ia
DenmarkDenmarkDenmarkDenmarkDenmark
GermanyGermanyGermanyGermanyGermany
IrelandIrelandIrelandIrelandIreland
Belgium Belgium Belgium Belgium Belgium
LuxembourgLuxembourgLuxembourgLuxembourgLuxembourg
Switzer landSwitzer landSwitzer landSwitzer landSwitzer land
IcelandIcelandIcelandIcelandIceland
NorwayNorwayNorwayNorwayNorway
United KingdomUnited KingdomUnited KingdomUnited KingdomUnited Kingdom
CanadaCanadaCanadaCanadaCanada
The Nether landsThe Nether landsThe Nether landsThe Nether landsThe Nether lands
United StatesUnited StatesUnited StatesUnited StatesUnited States
SwedenSwedenSwedenSwedenSweden
0 1 2 3 4 5 6
Cancer of the oral cav ityAge adj usted mortality rates per 100 000Men in North America, Northern and W estern 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 r isk of death for male tobacco users (whole bar)
Green sector : Never-smokers' death r isk (reference) Red sector : Excess r isk (above Never-smokers)
Less than 9% of
Data derived from:B jartveit 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 B iomarkers 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 WomenCurrent 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)
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 alternativefor those who are unable or unwilling to quitcompletely.