1. Current challenges in tobacco prevention – do new products pose threats or opportunities? Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden 52nd International ICAA Conference on dependencies Estoril, Portugal, 11 to 16 October 2009

2. New nicotine delivery devices ”Ultra-light” cigarettes Electronic cigarettes Water pipe Nicotine water Nicotine disolvables - strips - sticks - pellets Swedish snus

3. New nicotine delivery devices ”Ultra-light” cigarettes Electronic cigarettes Water pipe Nicotine water Nicotine disolvables - strips - sticks - pellets Swedish snus

4. Electronic cigarettes

5. Waterpipe (Hookah, Hubble-Bubble)

6. Swedish snus Fine ground tobacco leaves predominantly from air-cured dark tobacco Manufactured by a pasteurizing-like heating process (without any fermentation so as used in most manufacturing procedures for American snuff) ∎ TSNA content: < 5 mg/kg ∎ BaP content: < 10  g/kg (TSNA content of American snuff: 16-130 mg/kg)

7. Loose snus Pouches of portion packed snus

8. Putting in a keeping it pouch of snus and under the lip

12. 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

13. ONSET RATE OF DAILY SMOKING By presence or absence of primary use of snus All males (n=2756) 40 % With primary snus use (n=397) 20 % Without primary snus use (n=2359) 43 % (Source: ITS/FSI study 2001/2002)

15. QUIT RATES IN SWEDEN (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% All WITHOUT a history of daily snus use 49% All WITH a history of daily snus use 72%

16. “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.

17. Summary E-cigarette smoking may be substantially less harmful to health than cigarette smoking, but more research is needed before definitve conclusions can be drawn. Water pipe smoking appears to be even more harmful to health than cigarette smoking. Snus use appears to - decrease juvenile onset of smoking - help smokers to quit all tobacco use - offer a substantially less harmful alternative for those who are unable or unwilling to quit completely.