Transcript Reducing the toll of smoking-related disease and death

6th July 2010
Reducing the toll of smoking-related disease and death:
The case for tobacco harm reduction
The rationale for establishing low-toxicity
smokeless nicotine product policies:
Why are the pros stronger than the cons?
Lars Ramstrom
Institute for Tobacco Studies, Sweden
Reduction of harm from tobacco use
is a top priority in public health.
But,
”Tobacco Harm Reduction”
is a controversial issue.
Tobacco Harm Reduction
is mainly a matter of replacing cigarettes
by a less harmful tobacco product.
”Low-tar” cigarettes are no candidates for
harm reduction,
but some ”low-toxicity” smokeless tobacco
products are.
One such product, Swedish SNUS, is
dominating the debate on Tobacco Harm
Reduction.
Opponents of Tobacco Harm Reduction

generally agree that switching to Snus
can yield substantial reduction of
tobacco-induced diseases for those
INDIVIDUALS who do thereby abstain
from cigarettes,
• but, there are concerns that unintended
effects can incur negative effects on
PUBLIC HEALTH.
Some concerns:
Is there a risk that
 snus serves as a gateway to smoking
and thereby increases smoking?
 snus becomes an additional use
rather than a replacement?
 nicotine addiction is strengthened by
snus use?
 snus is ineffektive as cessation aid?
 snus use will weaken smokers’ effort
to quit smoking?
What can we learn by the
evidence from Swedish
population studies?
PATHWAYS OF TOBACCO USE IN SWEDEN. MEN AGES 18-79.
Source: FSI / ITS surveys 2003-2006
Initiation
Current tobacco use
DUAL DAILY USE
SNUS  SMO
a
n=100 3.2%
18%
6%
DAILY SMOKING, NO DAILY SNUS USE
DAILY SNUS USE, NO DAILY SMOKING NO DAILY TOBACCO USE
27%
49%
SNUS
(NEVER SMO)
75%
25%
SMO  SNUS
10% 3%
55%
SMO
(NEVER SNUS)
43%
57%
32%
IS ONSET OF SNUS A GATEWAY TO SMOKING?
Initiation 5.4% of all cases Current tobacco use
of onset of daily
tobacco use
DUAL DAILY USE
SNUS  SMO
a
n=100 3.2%
18%
DAILY SMOKING, NO DAILY SNUS USE
Remaining ”secondary” smokers:
0.7% of all men
6%
DAILY SNUS USE, NO DAILY SMOKING NO DAILY TOBACCO USE
27%
49%
SNUS
(NEVER SMO)
75%
25%
SMO  SNUS
10% 3%
55%
SMO
(NEVER SNUS)
32%
43%
57%
Starting to smoke after onset of snus use is a
very rare option − and most of those cases, 76%,
end up by quitting smoking.
SNUS - ADDITIONAL USE OR REPLACEMENT?
Initiation
Current tobacco use
DUAL DAILY USE
SNUS  SMO
a
n=100 3.2%
18%
6% DAILY SMOKING, NO DAILY SNUS USE
DAILY SNUS USE, NO DAILY SMOKING NO DAILY TOBACCO USE
27%
49%
SNUS
(NEVER SMO)
75%
25%
SMO  SNUS
10% 3%
55%
SMO
(NEVER SNUS)
32%
43%
57%
Continuing daily dual users are a minority (12%)
of all dual initiators and constitute just 1.8% of all
men.
Is nicotine addiction strengthened
by switching to snus?
• Nicotine addictiveness is mainly
determined by the speed of delivery to
the brain.
• Nicotine delivery from snus is
substantially slower than from cigarettes.
• Snus use would therefore be deemed as
less addictive than cigarette smoking.
IS NICOTINE ADDICTION STRENGTHENED BY SNUS USE?
Initiation
Current tobacco use
DUAL DAILY USE
SNUS  SMO
a
n=100 3.2%
18%
6%
DAILY SMOKING, NO DAILY SNUS USE
DAILY SNUS USE, NO DAILY SMOKING
27%
49%
SNUS
(NEVER SMO)
NO DAILY TOBACCO USE
75%
25%
SMO  SNUS
10% 3%
55%
SMO
(NEVER SNUS)
32%
43%
57%
About a third of smokers who start snus use
do subsequently quit all daily use of nicotine.
This is not compatible with the idea that snus
use were strengthening nicotine addiction.
IS SNUS INEFFECTIVE AS SMOKING CESSATION AID?
Initiation
Current tobacco use
DUAL DAILY USE
SNUS  SMO
18%
6%
DAILY SMOKING, NO DAILY SNUS USE
DAILY SNUS USE, NO DAILY SMOKING
n=100 3.2%
SNUS
(NEVER SMO)
NO DAILY TOBACCO USE
27%
49%
75%
25%
SMO  SNUS
10% 3%
55%
SMO
(NEVER SNUS)
43%
57%
Rate of quitting daily smoking:
- never snus: 57%
- secondary snus use: 87%
- secondary smoking: 76%
32%
Will snus use weaken
smokers’ efforts to quit
smoking?
Efforts to quit smoking are
manifested in quit attempts.
• In the FSI / ITS study all Ever Daily Smokers
were asked: “Have you ever made a serious
attempt to quit smoking?”
• The odds of having made a quit attempt at
the time of the survey were significantly
higher for those primary daily smokers who
had subsequently started daily snus use as
compared to those who had not.
• OR for men 2.22, 95% CI 1.75 to 2.81
• OR for women 2.98, 95% CI 1.74 to 5.12
Smokers who have started subsequent
snus use appear to make more efforts to
quit smoking than those who have not.
SUMMARY
• There is little or no scientific
evidence to support arguments
against Tobacco Harm Reduction.
• There is a good deal of scientific
evidence to reject arguments against
Tobacco Harm Reduction.
• There is a good deal of scientific
evidence to support arguments for
Tobacco Harm Reduction.