Transcript Bild 1

Cutting tobacco’s death toll − an
overview of different options
Lars M. Ramström
Institute for Tobacco Studies
Stockholm, Sweden
5th Annual Conference of ISPTID, Hong Kong, 24th – 26th November 2006
OVERALL GOAL
Reducing tobacco-related
death and disease
Major strategies:
with regard to ”passive smoking”
● Smokefree environment programs
with regard to active tobacco use
● Decreased initiation of tobacco use
● Increased cessation of tobacco use
● Minimized exposure to tobacco toxins
Possibilities and limitations of the strategies
● Decreased
initiation ● Theoretically ideal, but
success rates are modest
and payoff in reduction of
death and disease comes late.
● Increased cessation ● Payoff in reduction of death
and disease comes quite soon,
but many users are unable or
unwilling to quit.
● Minimized exposure ● Possible means of additional
to tobacco toxins
reduction of tobacco-related
(”Risk reduction”)
death and disease.
Major toxins in cigarette smoke
● Nicotine
● Producing dependence
but only minor disease
risks.
● Carbon monoxide ● Major contributor to CVD.
● Irritant and
oxidizing gases
● Major contributors to
CVD and lung diseases.
● ”Tar”
● Aggregate of carcinogens
and other disease
producing substances.
Ni co ti n e i n take p er ci g arette (mg )
Pre dic te d a nd a c tua l nic otine inta k e s pe r c ig
s m ok e d by nom ina l nic otine y ie ld of us ua l br
Heal t h Survey f or Engl and 1998
1. 6
1. 4
1. 2
1. 0
0. 8
0. 6
0. 4
0. 2
0 -
.1
. 1-
. 2-
. 4-
. 5-
. 6-
. 7-
Ci garette ni coti ne yi el d (mg)
Act ual
Intake by
smoker
Pr edi ct ed
Delivery to
smoking machine
From: Jarvis et al 2001
. 8-
. 9-
1. 0 +
Intake of nicotine (summary)
An individual SMOKER’S intake of nicotine is NOT
determined by the cigarette (so as is the machine
yield of nicotine).
A SMOKER’S Intake of nicotine is determined by his
personal need for nicotine. He adjusts the way he
smokes each type of cigarette so that it gives him the
amount of nicotine he needs, irrespective of the
machine yield from the cigarette in question.
Intake of ”tar” , Example 1:
A smoker who needs
1.3 mg nicotine per cigarette (typical average)
smokes a cigarette with machine yields of
1.0 mg nicotine and 9 mg tar.
Since 1.0 mg nicotine is accompanied by 9 mg tar,
1.3 mg nicotine (intake by this smoker)
will be accompanied by 1.3  9 mg = 11.7 mg tar,
so, the smoker’s intake of tar is around 12 mg.
Intake of ”tar” , Example 2:
A smoker who needs
1.3 mg nicotine per cigarette, smokes
Bond Street International (”high tar” brand), and
Camel Lights (”low tar” brand).
M a c h i n e y i e l d s:
T a r/N i c o t i n e r a t i o s
BSI:13 mg tar,1.4 mg nicotine,(13/1.4 ≈ 9 mg tar/mg nicotine)
CL : 8 mg tar,0.6 mg nicotine,(8/0.6 ≈ 13 mg tar/mg nicotine)
Intake of ”tar” from Bond St Intnl: 1.3  9 ≈ 11 mg.
Intake of ”tar” from Camel Lights: 1.3  13 ≈ 17 mg.
Comparing brands for toxicity
• Nicotine
- No major differences according to brands (since
intake is mainly regulated by the smoker).
• Other substances
- Intake can differ between brands according to the
brand-related ratio to nicotine for the substance.
- The way the cigarette is smoked does not very
much influence the ratios to nicotine.They can
therefore serve as approximate
comparative indicators of brand-specific toxicity.
Can switching from one to another type of
cigarette result in any substantial risk reduction?
NO, since brand differences are small.
Smokers’ intake of different substances is unrelated to
the machine yield figures that are currently prescribed
as package labelling in some countries.
Such labelling practices are misleading and should
therefore be avoided when implementing the FCTC.
Labelling rules should rather prescribe information on
the true conditions that determine smokers’ intake.
Possible model for meaningful and
truthful ”consumer information” on
cigarette packages:
Your intake of nicotine from one cigarette:
0.5 – 2.5 mg, depending (mainly) on HOW you smoke.
One mg of nicotine from this cigarette is accompanied by:
Tar: 7-9 mg Carbon monoxide: 6-8 mg Benzene: 0.04-0.06 mg
Hydrogen Cyanide: 0.06-0.08 mg Formaldehyde: 0.05-0.07 mg
Can switching from burned to unburned tobacco
result in any substantial risk reduction?
Probably: YES,
because the major harmful toxins in cigarette smoke
are formed during the combustion and consequently
absent in smokeless tobacco products.
Still, some smokeless tobacco products are very
harmful, but there is a very wide variation between
products at the lower and the upper end of the scale.
Excerpt from:
Gray N, Henningfield J.
Lancet. 2006 Sep 9;368(9539):899-901.
How hazardous is Sweden’s
smokeless tobacco, ”snus” ?
Mean nitrosamine content of moist snuff products
from various sources based on dry weight
Country
NNK
Brand (yr sampled) g/g
NNN
g/g
Total TSNA
g/g
2.8
Sweden
Ettan snus (2000)
0.5
1.1
Sudan (Toombak)
3 samples (1993)
188-362
241-369
4.3
3.4
20.8
14.3
United States
Skoal (2000)
Copenhagen (2000)
64.0
41.1
Whole bar: Relative risk of death for male tobacco users
Green sector: Never-smokers' death risk (reference)
Red sector: Excess risk (above Never-smokers)
Cigarette smokers
Less t han 9% of
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.
Does primary snus use
make young people
more or less likely to start
smoking???
SNUS AND SMOKING, SWEDISH MEN AGES 16-79
INITIATION
OF SMOKING
L (started daily snus
20 % of PDSNU
initiated daily
smoking becoming
“Secondary
Daily SMOkers”,
L
SDSMO
PDSNU
Primary Daily SNus
A Users, 16 % of total,
use without
previous daily
smoking)
M
E NON-PDNSU
N
47 % of NON-PDSNU
initiated daily
smoking becoming
“Primary Daily
SMOkers”, PDSMO
Derived from: Ramström L M, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006:15:210-214
CHANGES OF INITATION PATTERNS
Swedish men born in:
1940- 1950- 1960- 19701949 1959 1969 1979
RATE OF INITIATION of
Primary daily snus use
Primary daily smoking
8 % 16 % 30 % 29 %
56 % 45 % 26 % 20 %
SUM
64 % 45 % 26 % 20%
Does snus use make
smokers more or less
likely to stop smoking ???
SNUS AND SMOKING, SWEDISH MEN AGES 16-79
INITIATION
OF SMOKING
L (started daily snus
20 % of PDSNU
initiated daily
smoking becoming
“Secondary
Daily SMOkers”,
L
SDSMO
PDSNU
Primary Daily SNus
A Users, 16 % of total,
use without
previous daily
smoking)
M
E NON-PDNSU
N
47 % of NON-PDSNU
initiated daily
smoking becoming
“Primary Daily
SMOkers”, PDSMO
CESSATION
OF SMOKING
A
L
L
P
D
S
M
O
SDSMO
62 % of SDSMO quit smoking completely
(These smokers
have a history of
daily snus use)
(Prevalence of remaining daily
smokers from this category = 1 %)
SDSNU
77 % of SDSNU quit smoking completely
Secondary Daily
SNus Users, i.e.
PDSMO who
initiated daily
snus
use
(Prevalence of remaining daily
smokers from this category = 1 %)
NON-SDSNU
52 % of NON-SDSNU quit smoking
completely
(Prevalence of remaining daily
smokers from this category = 13 %)
Derived from: Ramström L M, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006:15:210-214
QUIT RATE
(Proportion of ”Ever daily smokers” having quit completely)
• All men
All women
59%
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
Women WITH a history of daily snus use
72%
71%
Risk reduction by products like snus:
some policy considerations (1)
• Snus use entails nicotine dependence and some
health risks, but risk levels are closer to those of
no-tobacco-use than to those of cigarette smoking.
• Primary snus use is associated with reduced
likelyhood for onset of smoking.
• Increase of initiation of snus use is associated with an
even greater decrease of initiation of smoking.
• Secondary snus use is associated with increased
likelyhood of stopping smoking.
• When used as smoking cessation aid, snus is more
effective than nicotine gum or patch.
• Switching from cigarettes to snus may be a first step
towards no-tobacco-use.
• In Sweden snus appears to be a contributing factor
behind the low level of tobacco-related mortality.
Risk reduction by products like snus:
some policy considerations (2)
• Regulations are needed to safeguard product quality.
• Strict legislation is needed to prevent sales to minors
and restrain manufacturers from using misleading
claims or other undue marketing practices.
• Labelling of packages should give consumer
information regarding product content and
characteristics including additives.
• Public education campaigns should point out actual
risks while avoiding the kind of scaremongering that
has sometimes been seen in the past.
• It should be kept in mind that experience from Sweden
may not be immediately applicable in other countires.