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Carmarthenshire. NHS TRUST. YMDDIRIEDOLAETH GIG. Sir Gaerfyrddin. Do harm reduction techniques make an impact on smokers health?. Keir Lewis First National Conference Manchester 29 th September 2007. Bryan Curtis aged 34 St Petersburg Times 1999. www.whyquit.com.

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do harm reduction techniques make an impact on smokers health

Carmarthenshire

NHS TRUST

YMDDIRIEDOLAETH GIG

Sir Gaerfyrddin

Do harm reduction techniques make an impact on smokers health?

Keir Lewis

First National Conference

Manchester 29th September 2007

slide2

Bryan Curtis aged 34

St Petersburg Times 1999

www.whyquit.com

slide3
Concept of harm reduction means supplying the addictive molecule in a ‘safer’ form
  • Basis of most of our smoking cessation medications
introduction
Introduction
  • Lack of proof for ST in harm reduction
  • Dangers of nicotine and smokeless tobacco
  • Dangers of smokeless tobacco manufacturers
does st reduce smoking
Does ST reduce smoking?
  • 13,865 US men
  • Daily snus vs. never snus, OR 4.2 of quitting smoking in preceding 1yr –GOOD!
  • Many smokers who take up the use of snus in an effort to quit instead end up asking for both products
  • “Men were more than 2.5 times as likely to have switched from snus to cigarettes than to have switched from cigarettes to snus”
  • Non-smokers who use snus are more likely than those who don’t to eventually begin smoking

Prev Med 2004; 38 (3): 309-17

Am J Prev Med 2002; 23 (3): 143-9

slide6

Smokers who switch to SNUS virtually same benefit as complete quitters

To cause harm:

17-21 non-smokers start SNUS to offset 1 smoker switching to SNUS

Problems:

Theoretical modelling on Australian data as old as 1998

Expert panels decided risk of cancer etc

Assumed each switch was final

No pregnant users etc

does st reduce smoking1
Does ST reduce smoking?
  • ‘Light’ cigarettes – same idea!!
  • Most people quit without using SNUS

“At best a mere five percent of all adult men in Sweden have quit smoking with the use of SNUS”

    • Dr. Goran Boethius, Chairman of Public Health Carolinska Institute
  • Young people use SNUS but older people are quitting
  • Cross-sectional, underpowered i.e. not RCTs vs. best practice
the evidence of st reducing smoking is flawed is it corrupt
The evidence of ST reducing smoking is flawed – is it corrupt?
  • Much of the research on the relative health impact of ST has been funded by the tobacco industry (Smokeless Tobacco Poses Challenge for Stop-Smoking Advocates, Join Together, 2006).

First holder of the endowed chair in Tobacco Harm Reduction Research.

Created by

U.S. Smokeless Tobacco Co.

and Swedish Match AB,

who committed nearly ($3.4 m)

slide9

Twins!

Retrospective!

Self-reported!

does st really reduce smoking
Does ST really reduce smoking?
  • “We simply do not have enough quality scientific evidence to conclude that anytobacco product, including ST, is a means of reducing the risks of cigarette smoking. At this time, any public health recommendation that positions ST as a safer substitute for cigarettes or as a quitting aid would be premature and dangerous. With the memory of our experience with low-tar cigarettes fresh in our minds, we must move extremely cautiously before making any statement or endorsement about the potential reduced risk of any tobacco product."
    • 17th U.S. Surgeon General Richard Carmona, M.D., MPH.
introduction1
Introduction
  • Lack of proof for ST in harm reduction
  • Dangers of nicotine and smokeless tobacco
  • Dangers of smokeless tobacco manufacturers
dangers of nicotine
Dangers of nicotine
  • 1drop iv causes immediate death.
  • Promotes cell proliferation and the progression of tumours1
  • Delays wound healing (vasoconstrictor)2
  • Interferes with the healing of bone fractures and also inhibits bone fusion processes3
  • Delays tendon and ligament healing3

1. Ann J Med 1992; 93(1A):225-245 2. Glassman 2001 3. Andersen 2000

tobacco pharmacology
Tobacco pharmacology

snuffing

Considerable variation in absorption (7-79%!)

-amount of nicotine,

-pH of product,

-size of tobacco cutting

Also variation in carcinogens

‘Low NNK snus’ sounds like

‘Low tar cigarette’?

slide14
An average dose of nicotine for snuff is 3.6mg, and 1.8mg for cigarettes (American Cancer Society)
  • x8-10 SNUS a day = 30-40 cigarettes (Does Smokeless Mean Harmless, 2001 Mayo Clinic report).
carcinogens are higher in st
Carcinogens are higher in ST
  • 420 smokers (25/day) vs. 182 ST (4 tins per week)
  • Adjusted for age, gender, renal function
  • Cotinine higher in urine (p<.001)
  • Biomarker for NNK 73% higher in the urine (p<.0001)
dangers of nicotine and smokeless tobacco
Dangers of nicotine and smokeless tobacco
  • "It's the smoke, stupid!“ David Sweanor, University of Ottawa
  • Mucosal iritation, gum recession, bone loss around the teeth, stained or teeth abrasions, bad breath and cancer of the mouth and pharynx have been reported in users of ST
slide17
ST associated with significant increase in the risk of pancreatic cancer.
  • SNUS use not associated with increases in risk of cancer of the oral cavity/pharynx, oesophagus, stomach, lung, kidney or bladder

Population?

SNUS habits?

Length of follow-up?

Boffetta, 2005

slide18

Problems:

1. ‘Non-current’ rather than ‘never’ users

Under-estimates risk

2. Combined end-point not deaths

3. Still significant increase in IHD/MI/CVA!

slide19

Why this paper and why now?

European Commission and Scientific Committee on Emerging and Newly Identified

Health Risks (SCENIHR), is now inviting stakeholders to comment on the scientific

opinion on "Health Effects of Smokeless Tobacco Products" which has just been

published:

http://ec.europa.eu/health/ph_risk/committees/04_scenihr/scenihr_cons_06_en.htm

The consultation will run until 28 September 2007.

is st safe
Is ST safe?

Risk estimate ‘difficult’

Oral cancer risk – everywhere except Sweden?

more dangers of smokeless tobacco
More dangers of smokeless tobacco
  • Increased likelihood of cataracts OR 1.67 (India)
  • Raised risk of preterm delivery, pre-eclampsia reduced foetal growth, probably still birth?

"Is it just the smoke, stupid?” Keir Lewis, BASSP

Br J Ophthalmol. 2006;90(11):1374-7 BMJ 2004;328(7455):1538

Am J Obst Gynecol. 2003;189(4):939-43 Epidemiology 2006;17(1):47-51

is st safe1
Is ST safe?

Reversible?

is st addictive yes
Is ST addictive? Yes
  • Can you give ST up? Difficult!
  • Meta-analysis

- 3 trials of patches(OR 1.16) - 2 trials gum(OR 0.98)- 1 trial Bupropion(OR 1.0)

  • Behavioural interventions -oral examination and feedback (OR 2.4)

Cochrane Database Syst Rev. 2004;(3):CD004306

introduction2
Introduction
  • Lack of proof for ST in harm reduction
  • Dangers of nicotine and smokeless tobacco
  • Dangers of smokeless tobacco manufacturers
dangers of st manufacturers1
Dangers of ST manufacturers

Sufficient?

Inveterate?

dangers of st manufacturers2
Dangers of ST manufacturers

“When you can’t smoke –SNUS”

dangers of st manufacturers3
Dangers of ST manufacturers
  • Multiple test-sites of ST across the world
  • Articles are appearing in newspapers extolling the benefits of ST as an aid to quitting smoking
  • In the past ten years, sales of ST have increased 30% in the USA (EU has 55% more people than the USA)
  • “Free Gear for Lids” campaign; tobacco tin lids were exchanged for free outdoor and recreational gear -a powerful incentive for youngsters or inveterate smokers?
dangers of st manufacturers4
Dangers of ST manufacturers

"I see it as a young adult marketing strategy.” -Cathryn Cushing, Oregon's Tobacco Prevention and Education Program, The Oregonian (1/7/07)

“The web site for Camel Snus seems aimed at young adult males to get them to start using products."

-Mitch Zeller, director Office of Tobacco Programs at the FDA during the1990s

dangers of st manufacturers5
Dangers of ST manufacturers
  • Will the tobacco industry use SNUS marketing as a "gateway" to promote cigarettes?
  • They now have a window of opportunity to bring about change
dangers of st manufacturers6
Dangers of ST manufacturers
  • "To sing the praises of SNUS is a deathblow to 20 years of hard tobacco preventive work . SNUS only saves the life of the tobacco industry"

Dr. Gunilla Bolinder, Director of Education at Stockholm's Karolinska University Hospital

my old adage
My old adage . . .
  • If a tobacco company comes out in favour of something – this signals that there must be something wrong!
slide34

LOTS!

LOTS!

NO!

?

NO!

summary
Summary
  • Lack of proof for ST in harm reduction
  • Dangers of nicotine and smokeless tobacco
  • Dangers of smokeless tobacco manufacturers

You ‘snoose’ you lose