Cutting tobacco’s death toll − an overview of different options Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden 5th Annual Conference of ISPTID, Hong Kong, 24th – 26th November 2006

OVERALL GOAL Reducing tobacco-related death and disease Major strategies: with regard to ”passive smoking” ● Smokefree environment programs with regard to active tobacco use ● Decreased initiation of tobacco use ● Increased cessation of tobacco use ● Minimized exposure to tobacco toxins

Possibilities and limitations of the strategies ● Decreased initiation ● Theoretically ideal, but success rates are modest and payoff in reduction of death and disease comes late. ● Increased cessation ● Payoff in reduction of death and disease comes quite soon, but many users are unable or unwilling to quit. ● Minimized exposure ● Possible means of additional to tobacco toxins reduction of tobacco-related (”Risk reduction”) death and disease.

Major toxins in cigarette smoke ●Nicotine ●Producing dependence but only minor disease risks. ● Carbon monoxide ● Major contributor to CVD. ●Irritant and ● Major contributors to oxidizing gases CVD and lung diseases. ●”Tar” ●Aggregate of carcinogens and other disease producing substances.

Intake of nicotine (summary) An individual SMOKER’S intake of nicotine is NOT determined by the cigarette (so as is the machine yield of nicotine). A SMOKER’S Intake of nicotine is determined by his personal need for nicotine. He adjusts the way he smokes each type of cigarette so that it gives him the amount of nicotine he needs, irrespective of the machine yield from the cigarette in question.

Intake of ”tar”, Example 1: A smoker who needs 1.3 mg nicotine per cigarette (typical average) smokes a cigarette with machine yields of 1.0 mg nicotine and 9 mg tar. Since 1.0 mg nicotine is accompanied by 9 mg tar, 1.3 mg nicotine (intake by this smoker) will be accompanied by 1.3  9 mg = 11.7 mg tar, so, the smoker’s intake of tar is around 12 mg.

Intake of ”tar”, Example 2: A smoker who needs 1.3 mg nicotine per cigarette, smokes Bond Street International (”high tar” brand), and Camel Lights (”low tar” brand). M a c h i n e y i e l d s: T a r/N i c o t i n e r a t i o s BSI:13 mg tar,1.4 mg nicotine,(13/1.4 ≈ 9 mg tar/mg nicotine) CL : 8 mg tar,0.6 mg nicotine,(8/0.6 ≈ 13 mg tar/mg nicotine) Intake of ”tar” from Bond St Intnl: 1.3  9 ≈ 11 mg. Intake of ”tar” from Camel Lights: 1.3  13 ≈ 17 mg.

Comparing brands for toxicity Nicotine - No major differences according to brands (since intake is mainly regulated by the smoker). Other substances - Intake can differ between brands according to the brand-related ratio to nicotine for the substance. - The way the cigarette is smoked does not very much influence the ratios to nicotine.They can therefore serve as approximate comparative indicators of brand-specific toxicity.

Can switching from one to another type of cigarette result in any substantial risk reduction? NO, since brand differences are small. Smokers’ intake of different substances is unrelated to the machine yield figures that are currently prescribed as package labelling in some countries. Such labelling practices are misleading and should therefore be avoided when implementing the FCTC. Labelling rules should rather prescribe information on the true conditions that determine smokers’ intake.

Possible model for meaningful and truthful ”consumer information” on cigarette packages: Your intake of nicotine from one cigarette: 0.5 – 2.5 mg, depending (mainly) on HOW you smoke. One mg of nicotine from this cigarette is accompanied by: Tar: 7-9 mg Carbon monoxide: 6-8 mg Benzene: mg Hydrogen Cyanide: mg Formaldehyde: mg

Can switching from burned to unburned tobacco result in any substantial risk reduction? Probably: YES, because the major harmful toxins in cigarette smoke are formed during the combustion and consequently absent in smokeless tobacco products. Still, some smokeless tobacco products are very harmful, but there is a very wide variation between products at the lower and the upper end of the scale.

Excerpt from: Gray N, Henningfield J. Lancet Sep 9;368(9539):

How hazardous is Sweden’s smokeless tobacco, ”snus” ?

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

Does primary snus use make young people more or less likely to start smoking???

ALLMENALLMEN PDSNU Primary Daily SNus Users, 16 % of total, (started daily snus use without previous daily smoking) NON-PDNSU SNUS AND SMOKING, SWEDISH MEN AGES % of PDSNU initiated daily smoking becoming “Secondary Daily SMOkers”, SDSMO 47 % of NON-PDSNU initiated daily smoking becoming “Primary Daily SMOkers”, PDSMO INITIATION OF SMOKING Derived from: Ramström L M, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006: 15:

CHANGES OF INITATION PATTERNS Swedish men born in: RATE OF INITIATION of Primary daily snus use 8 %16 %30 %29 % Primary daily smoking56 %45 %26 %20 % SUM64 %45 %26 %20%

Does snus use make smokers more or less likely to stop smoking ???

ALLMENALLMEN PDSNU Primary Daily SNus Users, 16 % of total, (started daily snus use without previous daily smoking) NON-PDNSU ALLPDSMOALLPDSMO SDSNU Secondary Daily SNus Users, i.e. PDSMO who initiated daily snus use NON-SDSNU SNUS AND SMOKING, SWEDISH MEN AGES % of PDSNU initiated daily smoking becoming “Secondary Daily SMOkers”, SDSMO 47 % of NON-PDSNU initiated daily smoking becoming “Primary Daily SMOkers”, PDSMO 77 % of SDSNU quit smoking completely 52 % of NON-SDSNU quit smoking completely INITIATION CESSATION OF SMOKING OF SMOKING 62 % of SDSMO quit smoking completely SDSMO (These smokers have a history of daily snus use) Derived from: Ramström L M, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006: 15: (Prevalence of remaining daily smokers from this category = 1 %) (Prevalence of remaining daily smokers from this category = 13 %) ( Prevalence of remaining daily smokers from this category = 1 %)

QUIT RATE (Proportion of ”Ever daily smokers” having quit completely) All men 59% All women 49% Men WITHOUT a history of daily snus use 51% Women WITHOUT a history of daily snus use 48% Men WITH a history of daily snus use 72% Women WITH a history of daily snus use 71%

Risk reduction by products like snus: some policy considerations (1) Snus use entails nicotine dependence and some health risks, but risk levels are closer to those of no-tobacco-use than to those of cigarette smoking. Primary snus use is associated with reduced likelyhood for onset of smoking. Increase of initiation of snus use is associated with an even greater decrease of initiation of smoking. Secondary snus use is associated with increased likelyhood of stopping smoking. When used as smoking cessation aid, snus is more effective than nicotine gum or patch. Switching from cigarettes to snus may be a first step towards no-tobacco-use. In Sweden snus appears to be a contributing factor behind the low level of tobacco-related mortality.

Risk reduction by products like snus: some policy considerations (2) Regulations are needed to safeguard product quality. Strict legislation is needed to prevent sales to minors and restrain manufacturers from using misleading claims or other undue marketing practices. Labelling of packages should give consumer information regarding product content and characteristics including additives. Public education campaigns should point out actual risks while avoiding the kind of scaremongering that has sometimes been seen in the past. It should be kept in mind that experience from Sweden may not be immediately applicable in other countires.