Swedish snus: Nicotine, Prevalence, Gateway, Epidemiology of harm and Use for smoking cessation

Transcription

1 Swedish snus: Nicotine, Prevalence, Gateway, Epidemiology of harm and Use for smoking cessation Karl Fagerstrom Ph.D. Smoker s Information Centre Helsingborg Sweden

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 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 consequences.

5 Original Portion 1 gram Original White Portion 0.8 gram Original White Mini Portion 0.4 gram

6 1995 SDR all causes, 0-64, per , male 0 EUROPE Finland Denmark L. Ramström, ITS. Adapted from WHO/EURO Norway Sweden

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8 Epidemiology of harm

9 Risk of first MI in Swedish males according to tobacco use Huhtasaari et al Huhtasaari et al 1999 Bolinder et al Hergens Johans- Wen- Et al son et al. nberg et al 2007 OR OR OR OR OR OR Never used tobacco Snus * Smoking 1.9* 3.6* 1.9* 2.3* 2.3* 2.6*

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11 Odds ratios for oral cancer Snus/Never smoker Smoker/Never snus Lewin et al 1998 Schildt et al 1998 Rosenqvist et al Lesions common but rarely develop to cancer Roosar et al 2006 Anecdotal evidence for oral cancer Zetterstrom et al 2004

12 Cancer in pancreas Bofetta et al RR 1.6 ( ) Luo et al RR 2.0 ( )

13 Diabetes One study found and a slightly increased risk Persson et al 2002 While another found no increase Eliasson et al 1995

14 Prevalence

15 Prevalence of smoking among swedish men

16 Prevalence of smoking and snus use in Swedish men SNUS 22% SMOKING 13% Data Statistics Sweden and 96-97, Public Health Institute 2007

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18 Cessation

19 NICOTINE UPTAKE IN SWEDISH SNUFF TAKERS Plasma nicotine (ng/ml) Mean ± SEM Snuff in mouth TIME (minutes)

20 Lunell and Lunell 2005

21 Kotlyar et al. 2007

22 CESSATION AID AT THE LATEST QUIT SMOKING ATTEMPT Nicotine gum Nicotine patch Snus All other Percent Males Females Ramstrom 2003

23 Use of different aids in latest quit attempt. 895 triers from a population sample. Nicotine gum patch lozenges spray inhaler Nicotine total Snus (Smokeless) Bupropion (Zyban) Men Women Ramström & Foulds 2006

24 Outcome of latest quit attempt Gum Quit 42% Reduced to occational 8% Patch 30% 3% NRT total 36% 5% Snus 61% 13% Ramström & Foulds 2006

25 Snus and Smoking Cessation in Swedish Twins N=7537 From existing data. Looking correlates of cessation among Sex Social class Married Level of education Age onset Dependence Depression Ever used snus Health status Alcohol dep/abuse Highest Hazards Ratio found for snus 2.30 ( ) H Furberg personal communication

26 IS SNUS A GATEWAY TO SMOKING? Initiation of smoking in relation to previous snus habits Started as daily snus users 15% Started daily smoking 3% Never started daily smoking Ever daily smokers among those who started as snus user 3/15=20% All males 12% 100% Others Started daily smoking 37% Ever daily smokers among all others 85% Never started daily smoking 37/85=43% 48% Foulds et al 2003

27 THE PRODUCT

28 PRODUCT TYPES Snus exists in two forms: Loose snus, which is sold in 50 g cardboard or plastic cans. Portion-packed snus which is sold in three packaging varieties, plastic cans with 24 x 1 g portions and plastic cans with 20 x 0.5 g portions or 20 x 0.3 g portions. Different flavor varieties exist in all forms.

29 Important steps in manufacturing Selection of tobacco Curing Production in closed process Heating/pasteurisation Storage

30 SHELF LIFE Shelf Life Characteristics: Swedish snus is moist and therefore limited in shelf life. The shelf life depends on storage conditions Swedish snus should be stored cool. Typical shelf life is 3 months, of which approx. 1 month at ambient temperature.

31 GOTHIATEK limits for undesired components (based on 50% water content in the finished product) Component Limit Component Limit Nitrite < 5 mg/kg Cadmium < 0.5 mg/kg TSNA < 5 mg/kg Lead < 1.0 mg/kg NDMA < 5 µg/kg Arsenic < 0.25 mg/kg BaP < 10 µg/kg Nickel < 2.25 mg/kg Pesticides According to the Swedish Match Pesticide Policy Chromium < 1.5 mg/kg

32 GOTHIATEK Raw material requirements Additives All additives in Swedish Snus by GOTHIATEK shall satisfy the requirements of the Swedish Match Ingredients Policy. This policy requires that all additives in Swedish Snus by GOTHIATEK shall be approved as food additives, or approved as tobacco additives, according to the specific regulations in each country where the products are actively marketed. In addition, stricter internal limits are applied.

33 GOTHIATEK Raw material requirements Tobacco Leaf tobacco for Swedish Snus by the GOTHIATEK standard shall be selected so that the limits for undesired components in each specific product are met. Leaf tobacco for Swedish Snus by GOTHIATEK must not contain gene modified tobacco (GMO).

34 GOTHIATEK Process requirements The tobacco shall be comminuted in a controlled process satisfying the requirements for specified particle size distributions. Any foreign object must be identified and separated. Swedish Snus by GOTHIATEK shall be heat-treated, using parameters that are effective enough to kill the natural microbial flora of the tobacco to specified residual bacteria limits ("snus pasteurisation"). From the point of charge to discharge of the batch the manufacturing process shall be performed in a closed system to prevent the product from being contaminated by external microflora or foreign objects.

35 MODELLING OF HARM

36 Table 1: Relative risk of tobacco-attributable mortality in snus users compared with current smokers by cause All cardiovascular diseases (including coronary heart disease, stroke, and arterial disease) 0 10 ( ) 0 10 ( ) Upper aerodigestive, pancreatic, bladder, and renal cancer 0 15 ( ) 0 30 ( ) Lung cancer 0 02 ( ) ( ) COPD and other respiratory diseases 0 00 Gartner et al 2007

37 Table 3: Years of healthy life lost compared with people who have never used tobacco, men. Age Current smokers Smokers who Smokers who Current snus users continue smoking switch to snus quit smoking who never smoked ( ) 0 63 ( ) 0 37 ( ) 0 28 ( ) ( ) 0 99 ( ) 0 77 ( ) 0 28 ( ) ( ) 1 71 ( ) 1 40 ( ) 0 48 ( ) ( ) 2 01 ( ) 1 81 ( ) 0 39 ( ) ( ) 1 55 ( ) 1 47 ( ) 0 22 ( ) Gartner et al 2007

38 Conclusions. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking. Gartner et al 2007

39 Pillars of Tobacco Control Prevention of initiation Assistance with cessation Protection from environmental tobacco smoke Harm reduction? Ken Warner

40 Pillars of Tobacco Control Effect of snus Prevention of initiation Positive? Assistance with cessation Positive Protection from environmental tobacco smoke Positive Harm reduction? Positive

41 Thank you