Population impacts of snus tobacco initiation and cessation

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1 Population impacts of snus tobacco initiation and cessation Karl Lund, Ph.d Research Director, Tobacco

2 Polarcircle Norway

3 Registered sales of tobacco products in Norway World war II Cigarettes Roll-your-own Chew Snus Pipe Snus- 40% of the market

4 Total ban on all indoor smoking in 2004 Brrr, brr brr..brr!!

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10 Use (daily + occasionally) of cigarettes and snus Norwegians aged years (Three yearly moving average) Smoke-free air policy Smoke-free air policy

11 Snus in Norway: peer-reviewed scientific articles Lund KE. Tobacco Harm Reduction in the Real World: has the availability of snus in Norway increased smoking cessation? Drugs and Alcohol Today, 2013; 13 (2): Lund KE, Vedoy TF, Bauld L. Do never smokers make up an increasing share of snus users as cigarette smoking declines? Changes in smoking status among snus users in Norway Resubmitted Addiction Health gains from smoking cessation, smoking reduction and smoking substitution produced by snus, has more than out-weighted the health loss in the fraction of neversmokers taking up snus Lund KE, McNeill A. Patterns of dual use of snus and cigarettes in a mature snus market. Nicotine & Tobacco Research, 2013; 15 (3): Lund KE. Association between willingness to use snus to quit smoking and perception of relative risk between snus and cigarettes. Nicotine & Tobacco Research 2012; 14: Lund KE, McNeill A, Scheffels J. The use of snus for quitting smoking compared with medicinal products. Nicotine & Tobacco Research 2010; 12 (8): Lund KE, Scheffels J, McNeill. The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction 2010; 106: Lund M, Lund KE, Halkjelsvik T. Contrasting smokers' and snus users' perceptions of personal tobacco behavior in Norway. Nicotine & Tobacco Research Dec;16(12): Lund KE. A tobacco-free society or tobacco harm reduction? Norwegian Institute for Alcohol and Drug Research. SIRUS-report 6/2009. Lund I, Lund KE. How has the availability of snus influenced cigarette smoking in Norway? Int J Environ Research and Public Health 2014; 11. Larsen E, Rise J, Lund KE. Risk characteristics of adolescent snus users compared to non-users of tobacco, smokers and dual users of snus and cigarettes. Addiction Research and Theory 2013; 38 (7): Larsen E, Rise J & Lund KE. The relationship between snus use and smoking cognitions. Addiction Research and Theory, 2012; 20 (6): Scheffels, J., Lund, K.E. & McNeill, A. Contrasting snus and NRT as methods to quit smoking. An observational study. Harm Reduction Journal, 2012; Feb 29; 9, 10

12 Regulations for snus and cigarettes Snus Tobacco cigarettes Plain Packaging Yes Yes Display ban Yes Yes Specific tax Yes Yes Blanket ban on indoor use No Yes Pre-market registration No No Flavour limitation Probably Yes Advertising ban Yes Yes Age limit 18 yrs Yes Yes

13 Norwegian government June 2016: Proposed regulations for e-cigarettes E-cigarettes Snus Tobacco cigarettes Plain Packaging No Yes Yes Display ban No Yes Yes Specific tax No Yes Yes Blanket ban on indoor use Yes No Yes Pre-market registration Yes No No Flavour limitation TPD Probably Yes Advertising ban Yes Yes Yes Age limit 18 yrs Yes Yes Yes

14 Comparative analysis of topics important to policy makers E-cigarettes Snus Health risk: Long term epidem. evidence available? No Yes Affect bystanders? (Annoyance) No Behaviour: Mimics smoking? Yes No Suppliers: Products from tobacco industry? Some Yes Consumers: Vocal advocacy groups? Yes No Concerns: Addictive potential? Yes Yes Normalize smoking-hypothesis? Yes No Most important to policy makers Gateway-hypothesis? Yes Yes Delay cessation-hypothesis? Yes Yes Intransient dual use-hypothesis? Yes Yes Hook never-smokers Yes Yes

15 Ever snus users Norwegian males aged 16-74

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17 Approx % «otherwise tobacco-free»?

18 Norway: Daily smoking, aged years Males Females

19 Is there a tipping point? A continuing decline in smoking - partly due to the availability to snus will eventually lead to a continued increase in the relative share of never smokers among snus users But to produce a net population level harm. 20 individuals who would never smoke, would need to start using snus to offset the health gain from each tobacco user who choose snus instead of cigarettes The ratio will probably never come to that The availability of snus will continue to produce a positive net effect for public health

20 Given the decline in smoking, the main effect of snus in tobacco harm reduction will increasingly be in reducing smoking initiation, while its effect on smoking cessation may eventually diminish. it is not so much the efficacy of new nicotine delivery systems as temporary aids to cessation, but their potential as long-term alternatives to tobacco that makes the virtual elimination of tobacco a realistic future target. (p 653)

21 In that case...in an imaginary situation where the prevalence of smoking has declined to a minimum, the public health effect from the availability of snus will depend on the ratio between.. snus users who in the absence of snus would have become smokers and..snus users who in the absence of snus would have remained completely tobacco-free «otherwise smoker» «otherwise tobacco-free»

22 Will the experience with snus in Scandinavia be repeated elsewhere for e-cigarettes?

23 Take-home-messages Don t visit Scandinavia (cold, wet, expensive, ugly Swedes ) Even if smoking has been declining rapidly, the majority of snus users still derive from the smoking population Due to the risk difference, only an unrealistic increase of snus use among neversmokers will tip the public health effect to negative The quit-smoking-effect from snus limited to a specific historical stage in phasing out of cigarette smoking The potential as a long-term alternative to cigarettes will be the most important contribution of snus in the cigarette endgame

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