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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 snus Pouches of portion packed snus Putting in a pouch of snus and keeping it under the lip Prevalence of daily moking and daily snus use Men and women (age 18-70) in Sweden 1976-2002 Observations (bars) and least square regression lines 50 % % 50 45 45 40 40 35 35 30 30 25 25 20 20 15 15 10 10 5 5 0 0 1976 1980 1985 1988 Daily smoking, men Daily smoking, women 1996 Daily snus use, men Daily snus use, women 1976-1988 NTS-surveys, 1996-2002 ITS/FSI-surveys Ramström 2003 2000 2002 Cancer of the oral cav ity Age adj ust ed mort alit y rat es per 100 000 Men in Nort h America, Nort hern and W est ern Europe Estonia Lithuania Latvia Fr ance Austr ia Denm ar k Ger m any Ir eland Belgium Luxem bour g Switzer land Iceland Nor way United Kingdom Canada The Nether lands United States Sweden 0 1 2 3 4 Source: GLOBOCAN 2002 database: http://www.-dep.iarc.fr 5 6 Relative risk of death for male tobacco users(whole bar) Green sector: Never-smokers' death risk (reference) Red sector: Excess risk (above Never-smokers) Cigarette smokers L ess t h an 9% o f Snus users Never-smokers 0,0 0,5 1,0 1,5 2,0 2,5 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 S mokeless Tobacco P roduct Compared with S moking Cigarettes: E stimats of a P anel of E xperts. Cancer E pidemiol B iomarkers P rev 2004; 13(12):2035-2041. Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014 Reduction of life expectancy: Tobacco users, age 40, in comparison with ”Never tobacco users” Current smokers who continue to smoke Estimated number of years lost Men Women 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 ONSET RATE OF DAILY SMOKING By presence or absence of primary use of snus All males (n=2756) 40 % With primary snus use (n=397) Without primary snus use (n=2359) 20 % 43 % (Source: ITS/FSI study 2001/2002) QUIT RATES IN SWEDEN (Proportion of ”Ever daily smokers” having quit completely) • All men All women 59% 49% • Men WITHOUT a history of daily snus use Women WITHOUT a history of daily snus use • Men WITH a history of daily snus use Women WITH a history of daily snus use 51% 48% 72% 71% • All WITHOUT a history of daily snus use All WITH a history of daily snus use 49% 72% Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008. “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.” 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.