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Är det farligt att snusa vad vet vi idag?. Mats Wallström Avd för käkkirurgi. 3000 kemiska produkter. Tobak 40-45% Vatten 45-60% Na-karbonate-Högt pH 1.5-3.5% Salt 1.5-3.5% Fuktämnen 1.5-3.5% Smakämnen < 1% Nikotin. Nikotin -alkaloid.

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Är det farligt att snusa

vad vet vi idag?

Mats Wallström

Avd för käkkirurgi


3000 kemiskaprodukter

  • Tobak 40-45%

  • Vatten 45-60%

  • Na-karbonate-Högt pH 1.5-3.5%

  • Salt 1.5-3.5%

  • Fuktämnen 1.5-3.5%

  • Smakämnen < 1%

  • Nikotin


Nikotin-alkaloid

CNS-belöning

Autonoma

Ganglier

Adremalin Parasymp

Vasomotorisk-

Center

Puls,O2, Arrth, Vasocon

Binjurebarken

Adrenalin Ökad metabol effekt

Baroreceptorer

Skelett-

Muskelaturen.

Stim Blockad

Bolinder-1997


Tobaksspecifikanitrosaminer

23 stisnus

  • TSNA Tobacco-specific N-nitrosamine

  • NNN N-nitrosonornicotine

  • NNK 4 (metylnitrosamino)-1-(3pyridyl)-

    • 1-butanone

Cancerframkallande


pH är den avgörande faktor hur mycket

nikotin sommabsorberas genom slemhinnan

och med vilken hastighet

Tomar SL. Tob Control 1997 6(3):219-25.


Snuskonsumption

män % kvinnor %

Sverige: 19 4

Norge: 11 2

USA 15? 2


Djurexperiment
Djurexperiment

Rat incisors

Lip canal filled

with snuff 10 h

per day

Surgically

created canal

in the lip

Snuff-induced lesions - A Clinical

and Experimental Study - Hirsch1983


Djurexperiment1
Djurexperiment

Johansson Sl et al. Snuff-induced carcinogenisis:

Effect of snuff initiated with 4-nitrouinoline N-Oxide

Cancer research-1989

Larsson PA et al. Snuff tumorigenisis: effects of long-

term snuff administrat after initiation with 4NQO and

Herpes simplex virus type 1. J Oral Pathol Med -1989

Park NH et al. Role of Virus in Oral Cancinogenesis-

NIH publication-1993

Grasso. Smokeless Tobacco and Oral Cancer:

An Assessment of Evidence Derived from Laboratory

Animals. Food and Chem Toxicol - 1998


Effekter p kroppen
Effekter på kroppen

Lokala effekter Slemhinnan

Parodontala

Karies

Allmänna Vanebildande

Hjärta-kärl

Graviditet

Spädbarnsdöd

Diabetes

Cancer


Snus l sioner
Snus läsioner

1963 – Pindborg undersökte 12 kroniska

snusare. Inga dysplasier.

1976 – Axéll delade in snusläsionen i 4

olika kliniska grader.

1982 – Hirsch redogjorde för 50 kroniska

snusare. Lätt dysplasi i alla kliniska grader

1991 – Andersson biopserade 250 snusare.

Några dysplasier i materialet

2011 – Wallström undersökte reversibiliteten

efter 6 månaders snusstopp att läsionen

inte läkte ut.


Tandlossning
Tandlossning

Gingivala retraktioner:

1965 - van Wyk noterad att angränsande

tänder hade gingival retraktioner.

1980 - Modeér en ökad gingivit trots

plackkontroll

1989 – Andersson fann att 23% vs 3% hade

gingiva retraktioner beroende på förpacknings

form


Tandlossning1
Tandlossning

2004, 2006, 2006. 3 svenska studier fann ingen

signifikant ökad bennedbrytning hos snusare

jmf med icke tobaksnyttjare

2005. Bland 12 000 snusare I en amerikansk studie

var det dubbelt så vanligt med avancerad tandlossning

jmf med icke tobaksnyttjare


Karies

USA

4 studier hos unga individer. En studie visade på positiv

korrelation mellan snusning-karies och gingivit.

Skandinavien

Hirsch-91 Snusare hade ett significant högre DMFT



Cancer

The working group stated that

“there is sufficient evidence in humans to establish smokeless tobacco as carcinogenic, i.e. smokeless tobacco causes cancer of the oral cavity and pancreas.”


Clinical data of the 15 patients

with snuff induced oral cancer

Case Age Location Snuff use (years) Smoking

G.S. 75 Upper jaw 61 No

N.L. 91 Upper jaw 70 Not for 70 years

F.A. 72 Upper jaw 42 No

K-G.B. 75 Upper jaw 71 No

S.W. 50 Upper jaw 8 Prior to snuff use

D.D. 85 Upper jaw 20 No

B.W. 79 Lower jaw 45 Not for 30 years

F.N. 89 Upper jaw 69 No

S.E. 52 Upper jaw 20 Concomitant to snuff

S.L. 67 Upper jaw 18 Not for 18 years

H.G. 78 Lower jaw - No

S-Å.G. 81 Upper jaw 66 No

X.X. 74 Upper jaw 40 No

R.F. 84 Upper jaw 30 No

X.X. 67 Upper jaw 49 Not for 48 years

ORAL CANCER IN SWEDISH SNUFF-DIPPERS Hirsch et al Submitted


Cancer

Years Range

Mean age at time of diagnosis: 74,6 50-91  

Median age at time of diagnosis: 75

Mean duration with the snuff habit: 43,5 8-71

Median duration with the snuff habit: 47  

Mean age at start of snuff use: 30,8 4-65

Median age at start of snuff use: 31


Cancer

3 svenska studier

Schildt EB: Int J Cancer. 1998: Oral snuff, smoking habits and alcohol

consumption in relation to oral cancer in a Swedish case-control study.

410p/410c OR 0.7 CI 95% 0.4-1.1

Rosenqvist K: Use of Swedish moist snuff, smoking and alcohol consumption

in the aetiology of oral and oropharyngeal squamous cell carcinoma.

A population-based case-control study in southern Sweden.

135p/320c OR 1.1 CI 95% 0.5-25

Lewin F: Cancer. 1998: Smoking tobacco, oral snuff, and alcohol in

the etiology of squamous cell carcinoma of the head and neck:

a population-based case-referent study in Sweden.

605p/756c RR 4.7 for ever users CI 95% 1.6-13.8


Cancer

2 svenska studier

Roosaar A et al. 2008 Int J Cancer Cancer and mortality among users and nonusers of snus. Cohort 9976p 1973-2002.

Ökad cancerrisk oral och orofaryngeal RR 3.1 CI 95% 1.5-6.6

Ökad dödlighet: HR 1.10 CI 95% 1.01-1.21

Luo J et al. 2007 Lancet: Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a

retrospective cohort study. 279897p

Pancreascancer RR 2.0 CI 95% 1.2-3.3

1 norsk studie

Boffetta P. 2005- In J Cancer . Smokeless tobacco use and risk of cancer of the pancreas and other organs. Cohort 10136p

Pancreas cancer: RR 1.67 CI 95% 1.12-2.5


Long term use of smokeless of smokeless tobacco
Long-term use of smokeless of smokeless tobacco

Målsättning:

Öka kunskapen om snusningens hälsoeffekter,

Främst avseende risken för hjärt- och kärlsjukdom

BolinderG, Avhandling-97


Long term use of smokeless of smokeless tobacco1
Long-term use of smokeless of smokeless tobacco

  • Material och metod:

  • 1971-78 hälsoundersöktes totalt 135 036 byggnadsarbetare av bygghälsan.

  • 32 546 hade aldrig nyttjat tobak

  • 14 983 rökte > 15cig/dag

  • 6 297 var enbart snusare

BolinderG, Avhandling-97


Long term use of smokeless of smokeless tobacco2
Long-term use of smokeless of smokeless tobacco

  • Symptom, sjukfrånvaro och förtidspensionering hos snusare

  • jämfört med rökare och tobaksfria I byggbranschen.

  • Ökad risk för död I hjärt-och kärl sjukdom hos snusare.

  • Fysisk arbetsförmåga vid långvarigt snusbruk.

  • Metabola riskfaktorer för hjärt-kärlsjukdom vid snusning.

  • Snusning och åderförkalkning-ultraljudsundersökning av

  • intima-media-tjocklek I arteria carotis.

  • 24-timmars blodtrycksmätning hos snusare, rökare och

  • icke-tobaksbrukare.

BolinderG, Avhandling-97


Long term use of smokeless of smokeless tobacco3
Long-term use of smokeless of smokeless tobacco

En av slutsatserna:

50% av alla dödsfall beror på hjärtkärl –sjukdommar.

Vid en måttlig riskökning med en relativ risk på 1.4 och

då 20% av svenska män snusar betyder det att ca 1300

dödsfall om året kan tillskrivas snusningen.

BolinderG, Avhandling-97


Hjärt-kärlsjukdomar

Scandinavien

Cohort studieORCI

Bolinder-94 34-54år Angina-typ 2.0 1.49-2.9

Stroke 1.9 0.6-5.7

H-K död 2.1 1.5-2.9

55-64år Angina 1.2 1.0-1.5

Stroke 1.2 0.7-1.8

H-K död 1.0 1.0-1.4

Fall-kontroll studier

MONICA 2 studier som inte visade på någon ökad risk för snusare att få hjärtinfarkt jmf med icke-snusare


Hjärt-kärlsjukdomar

Kliniska epidemiologiska studier fokuserar påhjärt-kärlsjukdommar,

Hjärtinfarkt, aterioskleros, stroke, högt blodtryck och metabola syndrom.

Boffetta P, Straif K 2009 Lancet. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis.

Dödlig hjärtinfarkt RR 1.13 95% CI 1.06-1.21 Dödlig stroke 1.40 1.28-1.54

Hergens 2007 J I Medicin Long-term use of Swedish moist snuff and the risk of myocardial infarction amongst men.

Dödlig myocard RR 1.96 95% CI 1.08-3.58

Henley 2005 Cancer Causes Contro. lTwo large prospective studies of mortality among men who use snuff or chewing tobacco.

Ökad dödlighet HR 1.17 1.11-1.23, HR 1.18 1.08-1.29


Metaboltsyndrom/ diabetes

Norberg, 2006, Scand J Public Health. Contribution of Swedish moist

snuff to the metabolic syndrome: a wolf in sheep's clothing?

Longitudinell cohort 16492p efter 10 år.

Metsy bland snusare OR 1.6 (1.26-2.15)

höga triglycerider OR 1.6 (1.30-1.95), obesitas 1.7 (1.36-2.18)

Persson, 2000 J Intern Med.. Cigarette smoking, oral moist snuff use and glucose intolerance. J Intern Med. 2000

Cross sectional study 3128 män där 52% hade en ärftlig belastning

Mer än 3 dosor/vecka OR 2.7 (1.3-5.5)

Eliasson M, Rodu B. 2004 J Intern Med. Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study.

Snusare OR 1.34 (0.65-2.)7 and Har snusat OR 1.18 (0.48-2.9)


Effect of Swedish snuff on preterm birth

OBJECTIVE:

To compare the effects of Swedish snuff and cigarette smoking on risks of preterm birth.

DESIGN:

Population-based cohort study.

All live, singleton births in Sweden 1999-2006.

MAIN OUTCOME MEASURES:

Very (<32 weeks) and

moderately (32-36 weeks) preterm birth.

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.


Effect of Swedish snuff on preterm birth

METHODS:

Odds ratios (OR) with 95% confidence intervals (CI) were used to estimate relative risks for preterm birth in

snuff users (n = 7607),

light smokers (1-9 cigarettes/day; n = 41 436)

heavy smokers (ten or more cigarettes/day; n = 16 951)

non-tobacco users (n = 503 957) as reference.

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.


Effect of Swedish snuff on preterm birth

RESULTS:

Compared with non-tobacco users,

snuff users had increased risks of both

very (adjusted OR 1.38; 95% CI 1.04-1.83) and

moderately (adjusted OR 1.25; 95% CI 1.12-1.40) preterm birth.

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.


Effect of Swedish snuff on preterm birth

CONCLUSIONS:

The use of Swedish snuff was associated with increased risks of very and moderately preterm birth with both spontaneous and induced onsets. Swedish snuff is not a safe alternative to cigarette smoking during pregnancy.

Wikström AK et al 2010. BJOG 2010 Jul;117(8):1005-10. Epub 2010 May 11.


Maternal use of Swedish snuff (snus)

and risk of stillbirth.

BACKGROUND:

Swedish snuff has been discussed internationally as a safer alternative to tobacco smoking. International cigarette manufacturers are promoting new snuff products, and the use of Swedish snuff is increasing, especially among women of childbearing age. The effect of Swedish snuff on pregnancy complications is unknown.


Maternal use of Swedish snuff and risk of stillbirth.

METHODS:

In this population-based cohort study, we estimated the risk of stillbirth in

snuff users (n = 7629),

light smokers (1-9 cigarettes/day; n = 41,488), and

heavy smokers (≥10 cigarettes/day; n = 17,014),

using nontobacco users (n = 504,531) as reference.


Maternal use of Swedish snuff and risk of stillbirth.

RESULTS:

Compared with nontobacco users,

snuff users had an increased risk of stillbirth (adjusted OR= 1.6 [95% CI= 1.1-2.3]);

the risk was higher for preterm (<37 weeks) stillbirth (2.1 [1.3-3.4]).

For light smokers, the adjusted odds ratio of stillbirth was 1.4 (1.2-1.7) and the corresponding risk for heavy smokers was 2.4 (2.0-3.0).

Wikstrom AK Epidermiology 2010 Nov;21(6):772-8.


Maternal use of Swedish snuff and risk of stillbirth.

CONCLUSIONS:

Use of Swedish snuff during pregnancy was associated with a higher risk of stillbirth. The mechanism behind this increased risk seems to differ from the underlying mechanism in smokers. Swedish snuff does not appear to be a safe alternative to cigarette smoking during pregnancy.

Wikstrom AK Epidermiology 2010 Nov;21(6):772-8.


Harm reduction

Definition:

A product is harm reducing if it lowers total

tobacco – related mortality and morbidity

Even though use of that product may involve

Continued exposure to tobacco toxicants

Clearing the Smoke., Assessing the Scienece Base for Tobacco Harm Reduction


Interventionsstudier
Interventionsstudier

Farmakologiska studier: CI 95%

Buprion - 1 studie OR 1.0 0.23-4.37

NRT - 2 studie (tuggimmi) OR 0.98 0.59-1.63

NRT – 3 studier (plåster) OR 1.16 0.88-1.54

Betendevetenskapliga studier:

Ind/grupp – 8 studier OR 2.42 1.79-3.24

Cochrane 2007


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