1. Policies for helping smokers who cannot quit: a prerequisite for maximum prevention of tobacco induced diseases Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden 7th Annual Conference of ISPTID, Kyoto, Japan, 26-28 September, 2008

2. Overall goal for tobacco control: Maximum prevention of tobacco induced diseases This goal includes intermediate objectives concerning measures to help specific target groups such as:  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. 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.

11.  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.  Use of smoke-free nicotine would benefit smokers directly by reducing the personal harm caused by nicotine addiction What is harm reduction, and how would it work for smoking? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.

12.  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.  However, although helpful, few smokers find NRT to be a satisfying alternative to smoking What is the safest way to provide nicotine without smoke? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.

13.  Nicotine can also be obtained without smoke from a range of tobacco products, usually referred to as ‘smokeless’ tobacco.  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.  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. What are the alternatives to medicinal nicotine? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.

15. #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

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

17. Summary and conclusions (2) In order to prevent largest possible number of potentially preventable cases of tobacco induced diseases there is a need for policies helping those smokers who cannot quit to find less harmful alternatives, such as medicinal nicotine or low risk types of smokeless tobacco.