1. Le rôle de la réduction de dommages dans la lutte antitabac The role of harm reduction in tobacco control Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden EMASH Portugal Seminar, Coimbra, 23-24 October, 2008

2. OVERALL GOAL for tobacco control: Reducing tobacco-related morbidity and mortality as far as possible INTERMEDIATE OBJECTIVES for practical measures in tobacco control These will be s pecific for measures to help different target groups, for example:  Never tobacco users  Current tobacco users

3. Objective of measures to help never-tobacco-users: Preventing onset of tobacco use Strength:  In individuals for whom these measures have been successful, tobacco induced diseases will not occur Weaknesses:  Measures to prevent onset of tobacco use have limited success rate  Even when successful: Virtually no reduction of disease in nearest 30–40 years

6. #1 objective of measures to help current tobacco users: Quitting all tobacco/nicotine use Strength:  Disease risks decreasing substantially, eventually approaching never-user levels Weaknesses:  Treatments in clinical settings reach a limited fraction of smokers and have limited success rate  Quit attempts made outside clinical settings (the majority of all) get no or inadequate support

7. Occurrence of quit attempts in Sweden (% of all ever daily smokers) Men Women  Not made any quit attempt 9% 8%  Made one or more quit attempts - but do still smoke 36%47% - and have quit completely55%45% Source: ITS/FSI surveys of the Swedish population

8. ”Do still smoke” after latest quit attempt by level of nicotine dependence Men Women  Low nicotine dependence 34% 36%  Medium nicotine dependence 40%56%  High nicotine dependence 56% 66% Source: ITS/FSI surveys of the Swedish population

9. #2 objective of measures to help current tobacco users Switching to a nicotine product that is markedly less harmful Strengths:  Realistic alternative even for highly nicotine dependent people  Disease risks potentially decreasing almost as much as when quitting Weaknesses:  Continued exposure to nicotine  Maintenence of nicotine dependence  Limited availability of appropriate products

10. What is “markedly less harmful”? Nicotine delivery products that do not require inhalation of combustion products and do not deliver concentrations of toxic chemicals likely to cause disease, e.g. nicotine replacement therapy products and potentially low-nitrosamine smokeless tobacco products (e.g. snus, Ariva, Stonewall).

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 Source: Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014

13. Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014. Excerpts from the Summary: For net harm to occur, 14–25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14–25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking.

14. Source: ITS/FSI surveys of the Swedish population 2004 and 2006

16. Slide from: Berzelius symposium 71 The Swedish Society of Medicine, 24–25 April, 2008 The Tobacco epidemic - controlling one of the greatest threats to human health this century

17. Slide from: Berzelius symposium 71 (John Hughes) The Swedish Society of Medicine, 24–25 April, 2008 The Tobacco epidemic - controlling one of the greatest threats to human health this century

19. Main area #4 Helping those who cannot quit: considering the potential of a harm reduction approach in tobacco control to help people whose addiction to nicotine makes it extremely difficult to quit altogether.

21. Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008. What is harm reduction, and how would it work for smoking?  People smoke because they are addicted to nicotine, but nicotine itself is not especially hazardous; it is the other constituents of tobacco smoke that cause most of the harm.  Harm reduction is therefore feasible in tobacco smoking by providing smokers with nicotine from a source that does not involve inhaling tobacco smoke.  Use of smoke-free nicotine would benefit smokers directly by reducing the personal harm caused by nicotine addiction.

22. Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008. What is the safest way to provide nicotine without smoke?  The safest form of nicotine is medicinal or ‘pure’ nicotine, such as that contained in nicotine replacement therapy (NRT) products including skin patches and chewing gum.  Medicinal nicotine is by far the safest alternative to smoking, other than quitting nicotine use altogether.  However, although helpful, few smokers find NRT to be a satisfying alternative to smoking.  This is partly because NRT products deliver lower doses of nicotine, and deliver them more slowly, than cigarettes.

23. Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008. What are the alternatives to medicinal nicotine?  Nicotine can also be obtained without smoke from a range of tobacco products, usually referred to as ‘smokeless’ tobacco.  All smokeless tobacco products are therefore more hazardous than medicinal nicotine, and in some cases especially so, but all are also substantially less hazardous than smoking.  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.  However, the Swedish data provide proof of concept that substitution of smokeless for smoked tobacco can be effective as a harm reduction strategy.

24. Summary and conclusions (1) Primary prevention policies are important - but not enough Smoking cessation policies are important - but not enough

25. Summary and conclusions (2) Smokers who are unable or unwilling to be without nicotine should be offered less harmful alternatives to cigarettes, such as medicinal nicotine or low risk types of smokeless tobacco.

26. Summary and conclusions (3) Alternative nicotine delivery products should be strictly regulated in order to safeguard that only products that are markedly less harmful than cigarettes are available.