dependnece in comparison with Karl Fagerstrom Ph.D. Fagerstrom Consulting

Transcription

1 Snus: Degree of harm and dependnece in comparison with other tobacco/nicotine ti products. Karl Fagerstrom Ph.D. Fagerstrom Consulting

2 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

3 CULTURAL DRUGS ALCOHOL, BEER, WINE, HARD LIQUER CAFFEINE, SODA, TEA, COFFEE NICOTINE, CLEAN NIC. SMOKEFREE, CIGARETTES Semi cultural THC, marijuana etc

4 Summary of evidence comparing risk of CID in current and never snus users Whole based on population studies conducted in Sweden a Never smokers Disease Source Study type b N c RR/OR (95% CI) N c RR/OR (95% CI) Whole population IHD/AMI e Bolinder et al. (1994) PC ( ) f Hergens et al. (2007) PC ( ) Haglund et al. (2007) PC ( ) f,g ( ) g,h Wennberg et al. (2007) NCC ( ) f,g ( ) Huhtasaari et al. (1992) CC ( ) f,g ( ) g,h Huhtasaari et al. (1999) CC ( ( ) fg ( ( ) h Hergens et al. (2005) CC ( ) f ( ) Janzon and Hedblad (2009) PC ( ) g ( ) g Hansson et al. (2009) PC ( ) ( ) Total i 9 101( ( ) 12) 9 099( ( ) 14) Stroke Bolinder et al. (1994) PC ( ) f Hergens et al. (2008a) PC ( ) Haglund et al. (2007) PC ( ) f,g ( ) g,h Asplund et al. (2003) NCC ( ) g Janzon and Hedblad (2009) PC ( ) g ( ) g Hansson et al. (2009) PC ( ) ( ) Total i ( ) ( ) Any CID l Bolinder et al. (1994) PC ( ) Haglund et al. (2007) PC ( ) f,g ( ) f,g,h Roosaar et al. (2008) PC NA 1.11 ( ) l NA 1.15 ( ) l Janzon and Hedblad (2009) PC ( ) f,g ( ) f,g Hansson et al. (2009) PC ( ) ( ) Total i ( ) j ( ) j Lee 2011

5 Lee, 2011

6 Gartner et al. 2010

7 CONTINUUM OF HARM Traditional cigarettes Modified cigarettes, no burning Snokless tobacco, e.g. India Snus NRT HIGH LOW

8 Do we also have a continuum of dependnece?

9 Success in Stopping Using Different Tobacco/Nicotine Products in Percent When Treated Different Placebo Products Cigarette cessation Success rate (%) (Cochrane, 2011) with placebo SLT Cessation (Cochrane, 2011) Nicotine gum 11.2 Nicotine patch 9.8 Varenicline 10.0 Bupropion 10.2 Nicotine gum 26.6 Nicotine patch Nicotine lozenge 21.1 Varenicline 33.0 Bupropion 19.1 M=10% M=25% Cessation of long-term use of nicotine replacement therapy (Tonnesen & Mikkelsen, 2012) Vareneicline 36.0 M=36% Fagerstrom & Eissenberg 2012

10 CONTINUUM OF DEPENDENCE HIGH Traditional cigarettes Smokeless tobacco NRT LOW Gum Patch

11 Cigarette smoking must come to an end. Direct and complete ban Reduction in nicotine content Through current regulatory framework given to FDA

12 Another proposal: INCREASING THE LEGAL AGE Make legal age to buy the same for alcohol and tobacco. No one is forced to stop Protects people from starting Easy to get accepted by the public To phase out cigarettes is easier when there are alternative products available When cigarettes are gone the next steps with less addictive products should be easier

13 Survey in a representative sample of (N=500) Singaporeans on support for a smoking ban. Khoo et al 2010 Tob Con

14 Thank you for your attention

15 Nicotine/Tobacco is an ideal area for harm reduction. Used largely because of nicotine. Pure nicotine, and even unburned tobacco, is not a big part of the problem: the health h consequences.

16 Plasma nicotine concentrations for nicotine and tobacco products 14 tion concentrat l ) n nicotine c ( ng/ml Increase in Source: Balfour DJ & Fagerström KO. Pharmacol Ther : Minutes Smokeless tobacco Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch

17 Current smokers continuing Smokers who switch to snus Smokers who quit tobacco Current snus use who never smoked Projected years lost Age at baseline year

18 Table 2- Age-standardized mortality rates a from smoking-related diseases in men in selected countries relative to Sweden (=100) b Sweden USA UK Hungary France Japan Ischaemic heart disease Stroke COPD Oral cancer Oesophageal cancer Stomach cancer Liver cancer Pancreatic cancer Larynx cancer Lung cancer Bladder cancer Kidney cancer a Rates for men aged 35+ in 2004 standardized to the European Standard Population (Waterhouse et al., 1976). b Estimated from WHO mortality database ( Lee 2011

19 Smoking cessation during follow-up by initial snus use based on cohort studies of Swedish adults a No snus Snu Followup s e Study/start date b Source (yrs) Sex N c n d N c n d RR (95% CI) VIP cohort Lundqvist et al. (2009) 10 M F ( ) ( ) SSLC cohort Tillgren et al. (1996) 8 M ( ) SSLC cohort Stenbeck et al. (2009) 8 M f ( ( ) 8 M f ( ) MONICA cohorts 1986,90,94 Rodu et al. (2003) 5,9,13 M ( ) MSNS cohort Lindström et al. (2002) 1 M+F M+F ( ) 388 g g 1.82 ( ) Telephone helpline cohort 1999 Helgason et al. (2004) 1 M+F ( ) h ) Lee 2011

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