Characteristics of new tobacco products emerging on the tobacco market: implications for tobacco control policies Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden Annual 8th Conference of ISPTID, Boston, USA, 29 Septemner to 1 October 2010

New tobacco/nicotine products ”Ultra-light” cigarettes Electronic cigarettes Water pipe Nicotine water Nicotine disolvables - strips - sticks - pellets Swedish snus

Electronic cigarettes

Nicotine concentrations and craving relief by E-Cigarettes Eissenberg et al 2010

Reasons for using E-Cigarette N=81 In total 225 comments. To quit smoking 53 For health reasons 49 E-cigarettes less expensive 26 E-cigs can be smoked everywhere 21 To avoid disturbing other people 20 For the pleasure of smoking 19 To reduce consumption of cigs 14 By curiosity 10 Does/did e-cigarette help you quit smoking Yes a lot 79% Somewhat 16% Not at all 5% Etter 2010

Waterpipe (Hookah, Hubble-Bubble)

(Am J Prev Med 2009;37(6):518–523) Eissenberg T, Shihadeh A

Khabour et al. Assessment of Genotoxicity of Waterpipe and Cigarette Smoking in Lymphocytes Using the Sister-Chromatid Exchange Assay: A Comparative Study. Environmental and molecular mutagenesis 2010 The results show that waterpipe smoking and cigarette smoking significantly increase the frequencies of SCEs (P < 0.01) compared with those of nonsmokers, indicating the genotoxic effect of tobacco smoking. In addition, frequencies of SCEs were significantly higher among waterpipe smokers compared with CS (P < 0.01), indicating that waterpipe smoking is more genotoxic than cigarette smoking. Moreover, the frequency of SCEs increased with the extent of waterpipe use.

Swedish snus Fine ground tobacco leaves predominantly from air-cured dark tobacco Manufactured by a pasteurizing-like heating process (without fermentation as in manufacturing of American snuff), which results in v ery low levels of tobacco-specific nitrosamines and benzo(a)pyrene

Mean nitrosamine content of moist snuff products from various sources based on dry weight

Gartner et al. Lancet 2007

“Our argument is that nicotine products should all be regulated rationally in relation to each other, in proportion to their level of hazard, in a system designed to reduce the overall harm caused by nicotine dependence and use.” John Britton, Richard Edwards. Tobacco smoking, harm reduction, and nicotine product Regulation. Lancet 2008; 371: 441–45.

HARM 100% 10 0% Nicotine replacement products Snus Traditional cigarettes, Waterpipes Modified cigarettes E-cig ? THE CONTINUUM OF HARM FROM NICOTINE-DELIVERING PRODUCTS Snokless tobacco, e.g. India No tobacco use

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.

”Although nearly half of the smokers surveyed were willing to purchase an LNSLT product, most were interested in using these products for cessation rather than as a long-term substitute or for dual use with cigarettes.”

Summary Waterpipe smoking appears to be even more harmful than smoking traditional cigarettes. Toxicants in E-cigarette vapour are not well known. Nicotine delivery is low, but smoking cessation might be faciltated to some extent. Mortality risk in users of Swedish snus is modestly higher than in never tobacco users. The potential public health benefits of Swedish snus as a non-medical aid for large scale smoking cessation have now been demonstrated also outside Sweden. Product regulation of all smokeless tobaccos so as recommended by the WHO Study Group on Tobacco Product Regulation is an important public health issue.