1. The Role of Harm Reduction in Tobacco control – An Update of Pros and Cons Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden 53rd International ICAA Conference on dependencies Cancún, Mexico, 3 – 6 November 2010

2. Basic strategies for tobacco control Prevention of onset Limitations: Does not pay off before second half of the century Cessation of all tobacco use Limitations: Many users are unable or unwilling to quit So, we need more strategies

4.  People smoke because they are addicted to nicotine, but nicotine itself is not especially hazardous; it is the other constituents of tobacco smoke that cause most of the harm.  Use of smoke-free nicotine would benefit smokers directly by reducing the personal harm caused by nicotine addiction. What is harm reduction, and how would it work for smoking? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.

6. 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.

9. Gartner et al. Lancet 2007

10. HARM 100% 10% 0% Medicinal nicotine products LN-SLT, e.g. Swedish Snus Traditional cigarettes, Waterpipes Modified cigarettes E-cig ? THE CONTINUUM OF HARM FROM NICOTINE-DELIVERING PRODUCTS Snokless tobacco, e.g. India No tobacco use Chewing tobacco, snuff, e.g. USA

11. Opponents of Tobacco Harm Reduction generally agree that switching to Low Nitrosamine Smokeless Tobacco (LN-SLT) e.g. Swedish 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 could incur negative effects on PUBLIC HEALTH.

12. For example, there are concerns that…  snus may lead to dual use rather than replace cigarettes.  nicotine addiction may be strengthened by snus use.  snus use may lead to fewer attempts to quit smoking.  snus may serve as a gateway to smoking and thereby increase smoking.

13. What can we learn about these matters by the evidence from Swedish population studies? FSI / ITS survey 2003-2006

14. Among Swedish male daily smokers who take up snus use… 55% end up as daily users of snus only 32% end up as free of any daily tobacco use 3% end up as continuing daily smokers 10% end up as dual daily users These figures demonstrate that… - Only a small proportion develops dual use. - A substantial proportion eventually escapes nicotine dependence. The idea that snus use were strengthening dependence is not consistent with these findings.

15. Further, there is evidence from basic research on drug dependence that… 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 could therefore be expected to be less addictive than cigarette smoking so as also suggested by the Swedish findings.

16. Does snus lead to fewer attempts to quit smoking?

17. In the FSI / ITS survey 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

18. Smokers who have started subsequent snus use appear to make more efforts to quit smoking than those who have not.

20. “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.

22. Is snus a gateway to smoking? How have initiation patterns in Sweden changed during the last 50 years?

24. SUMMARY There is a need for Tobacco Harm Reduction in addition to prevention and cessation. 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.

25. Thank you for your attention!