1. Smoking cessation aided by low-toxicity smokeless tobacco can save many lives Lars M. Ramström Institute for Tobacco Studies Täby, Sweden UKNSCC 2014 Thursday 12th June - Friday 13th June 2014

2. 100% 0% Medicinal nicotine products LN-SLT, e.g. Swedish Snus, E-cig Traditional cigarettes, Waterpipes Modified cigarettes HEALTH RISKs OF NICOTINE-DELIVERY PRODUCTS Asian/African smokless tobacco No tobacco Chewing tobacco, US snuff

4. Recommendations for regulation of smokeless tobacco ● The combined concentration of NNN plus NNK in smokeless tobacco should be limited to 2 μg/g dry weight of tobacco. ●The concentration of benzo[a]pyrene in smokeless tobacco should be limited to 5 ng/g dry weight of tobacco.

7. Reduction of life expectancy: Tobacco users, age 40, in comparison with ”Never tobacco users” Estimated number of years lost Men Women Current smokers who continue to smoke5.044.09 Current smokers who quit all tobacco use0.530.34 Current smokers who switch to snus0.770.52 Current snus users who never smoked0.280.19 Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014

8. Gartner et al. Lancet 2007

10. Among boys WITHOUT primary daily snus use: - 46% start daily smoking Among boys WITH primary daily snus use: - 18% start daily smoking Source: FSI / ITS surveys 2003 - 2011

11. Among all boys who have started daily smoking… - 92% come from the group of never daily snus users - 8% come from the group of primary daily snus-users Source: FSI / ITS surveys 2003 - 2011

14. QUIT RATES IN SWEDEN (Proportion of ” Ever daily smokers ” having quit completely) All men 63% All women 54% Men WITHOUT a history of daily snus use 55% Women WITHOUT a history of daily snus use 54% Men WITH a history of daily snus use 74% Women WITH a history of daily snus use 71%

15. Snus use and cessation of smoking The numbers in green sectors indicate aid-specific quit ratios (successfulness) Source: FSI /ITS surveys 2003-2006

16. Part of the primary daily smokers do eventually take up daily snus use, others do not. What do the endpoints look like in each category?

17. ENDPOINTS (MEN) Primary daily smokers who have NOT taken up daily snus use 53% no smoking 4% occasional smoking 43% continued daily smoking Primary daily smokers who HAVE taken up daily snus use 78% no smoking 9% occasional smoking 4% daily smoking, no daily snus use 9% daily smoking and snus use

19. “In Sweden, the availability and use by men of an oral tobacco product called snus, one of the less hazardous smokeless tobacco products, is widely recognised to have contributed to the low prevalence of smoking in Swedish men and consequent low rates of lung cancer.” Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.

21. DEATH RATES (PER 100,000) ATTRIBUTABLE TO TOBACCO 2004. Men and women age 60-69 Sweden European Union Member States other than Sweden MinMedianMax MEN Lung cancer8791220399 Other cancer3641105217 All cardiovascular72107170618 All causes2223785501388 WOMEN Lung cancer61539127 Other cancer1711039 All cardiovascular63550222 All causes17314115690

22. Statement from specialists in nicotine science and public health policy Dr Margaret Chan Director General World Health Organisation Geneva CC: FCTC Secretariat, Parties to the FCTC, WHO Regional Offices 26 May 2014 Dear Dr Chan Reducing the toll of death and disease from tobacco – tobacco harm reduction and the Framework Convention on Tobacco Control (FCTC) We are writing in advance of important negotiations on tobacco policy later in the year at the FCTC Sixth Conference of the Parties. … Letter from 53 scientists in 18 countries all over the world available at http://nicotinepolicy.net/documents/letters/MargaretChan.pdf

23. … There are now rapid developments in nicotine-based products that can effectively substitute for cigarettes but with very low risks. These include for example, e-cigarettes and other vapour products, low-nitrosamine smokeless tobacco such as snus, and other low-risk non-combustible nicotine or tobacco products that may become viable alternatives to smoking in the future. Taken together, these tobacco harm reduction products could play a significant role in meeting the 2025 UN non- communicable disease (NCD) objectives by driving down smoking prevalence and cigarette consumption. … …Indeed, similar arguments have been made about the use of smokeless tobacco in Scandinavia but the evidence is now clear that this product has made a significant contribution to reducing both smoking rates and tobacco-related disease, particularly among males. … …The potential for tobacco harm reduction products to reduce the burden of smoking related disease is very large, and these products could be among the most significant health innovations of the 21st Century – perhaps saving hundreds of millions of lives.

24. SUMMARY Some kinds of smokeless tobacco can be a ”quiet killer” but Low-toxicity smokeless tobacco can save many lives