Tobacco harm reduction in : population-level level proof of effectiveness Karyn Heavner, Carl V. Phillips, Patrik Hildingsson, Lisa Cockburn TobaccoHarmReduction.org
Tobacco Harm Reduction (THR) Switching from smoking to low risk nicotine products. These products are low risk because the user does not inhale smoke! The risk from smoking tobacco is caused by the smoking not the tobacco.
What are low risk nicotine products? Smokeless tobacco 99% less harmful than cigarettes Chewing tobacco Moist loose snuff Tobacco lozenges Snus (Swedish word for moist snuff in pouches) Pharmaceutical nicotine Long term use is probably as low risk as smokeless tobacco use Nicotine gum, patches, lozenges or inhaler Electronic cigarettes Less research, probably similar, definitely safer than cigarettes
What is going on in? There is a long tradition of snus use in. Snus is legal in, though the sale of it is unfortunately banned elsewhere in the European Union (EU). Over time many people in switched Over time, many people in switched from smoking to using snus.
The percentage of adults who smoke in is lower than elsewhere in the EU Source: World Health Organization, Regional Office for Europe, European health for all database (HFA-DB)
Smoking prevalence in is now lower among males (who more likely to have switched) than females In 2005: 13.9% of males in were regular daily smokers. 18.0% of females in were regular daily smokers. Elsewhere in the EU, more males than females smoke. Source: World Health Organization, Regional Office for Europe, European health for all database (HFA-DB)
Prevalence of tobacco use in northern (25 25 64 years old) In northern more men now use snus than smoke. The switch from smoking to snus has not been as dramatic in women. Source: Stegmayr B, Eliasson M, Rodu B. The decline of smoking in northern. Scand J Public Health. 2005;33(4):321-4;
Differences in THR between Swedish men and women The difference in adoption of tobacco harm reduction between Swedish men and women creates a natural experiment. As you will see in our results, Swedish men s health has improved dramatically, while women s health is more typical for Europe.
Objective of this study To describe and compare the death rates for smoking related diseases between and other countries in the European Union.
European Mortality Database Data Source (http://www.euro.who.int/informa tionsources/data/20011017_1) Included all countries that were EU members before May 2004
Methodology: Variables Sex-specific age-standardized death rates (per 100,000 000) Outcomes Cancer All neoplasms (i.e., cancers) Malignant neoplasm of lip/oral cavity/pharynx 1, 2 Malignant neoplasm of esophagus 1, 2 Malignant neoplasm of stomach Malignant neoplasm of colon, rectum & anus Malignant neoplasm of pancreas 1, 2 Malignant neoplasm of trachea, bronchus & lung 2 Non-cancer outcomes Ischaemic heart disease 1, 2 Cerebrovascular diseases (stroke, etc.) 1, 2 All diseases of the respiratory system 2 Chronic lower respiratory diseases 2 1 - Blamed on ST (largely incorrectly) 2 - Clearly caused by smoking
Methodology: Analysis All analyses stratified by sex Limited to people between 25 and 64 years old Most analyses limited it to 2006 data Most recent year for which Swedish data is available 2006 data not available for Belgium, Luxembourg, Portugal and Spain.
Results: Age-standardized death rates for cancer
All neoplasms (25-64) Th ll d th t i S d i f th l t i E b t th i The overall cancer death rate in is one of the lowest in Europe but there is nothing dramatic here. but if we separate males (who are more likely to use snus) and females
All neoplasms (25-64) The cancer rate for males is lower in than elsewhere in EU. The cancer rate for females is similar to the average rate in the EU. Now we will focus on 2006 data, the last year for which Swedish data were available.
Ma ales Female es * Data not available for Belgium, All neoplasm (death rate, 2006) 85.7 94.5 79.2 93.6 76.5 90.6 92.6 97.8 97.0 96.4 110.6 116.1 122.9 126.9 127.6 131.2 131.3 141.7 106.4 107.7 119.2 136.6 134.1 172.8 0 20 40 60 80 100 120 140 160 180 200 Luxembourg, Portugal and Spain. Age-standardized death rate per 100,000000 The countries are in the same order in each slide. The countries were sorted by the neoplasm death rate in males. is at the top since the neoplasm death rate in males is the lowest in the EU The EU total is at the bottom for comparison. The x-axis is different for different diseases.
Oral/pharyngeal cancer (death rate, 2006) Males Females * Data not available for Belgium, Luxembourg, Portugal and Spain. 1.0 1.2 10 1.0 1.4 1.7 0.8 1.2 1.3 1.9 1.9 1.5 2.0 2.4 2.8 2.9 36 3.6 4.2 4.2 5.5 71 7.1 7.4 8.9 9.1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Age-standardized death rate per 100,000 In the death rate from oral cancer: In, the death rate from oral cancer: is much lower than the EU average for males. is about the same as than the EU average for females. 12.3
Males Females * Data not available for Belgium, Luxembourg, Portugal and Spain. Pancreatic cancer (death rate, 2006) 5.5 5.0 47 4.2 4.7 4.1 4.3 4.4 4.5 5.5 52 5.2 5.4 7.5 6.4 7.0 9.0 70 7.0 7.4 8.1 8.5 8.7 7.7 8.4 10.2 0 1 2 3 4 5 6 7 8 9 10 11 6.3 Age-standardized death rate per 100,000 In the death rate from pancreatic cancer: In, the death rate from pancreatic cancer: is about the same as the EU average for males. is higher than the EU average for females.
Males Females Cancer of the lung, trachea, and bronchus (death rate, 2006) * Data not available for Belgium, Luxembourg, Portugal and Spain. 9.0 9.2 11.0 16.8 17.5 17.6 20.4 16.4 17.5 15.7 15.5 24.0 26.8 28.0 27.6 35.9 35.9 37.5 38.1 37.8 0 5 10 15 20 25 30 35 40 45 50 55 34.4 Age-standardized death rate per 100,000 In the death rate from lung cancer: In, the death rate from lung cancer: is much lower than the EU average for males. is slightly higher than the EU average for females. 40.1 53.0 54.6
Summary of cancer death rates less than EU average for males but not females: All cancers Oral/pharyngeal cancer Esophageal cancer* Cancer of the colon, rectum & anus* Cancer of the lung, trachea, bronchus Even for pancreatic c cancer, ce where e is similar to the EU average for males, they are still better off than Swedish females *data not shown
Results: Age-standardized death rates for other diseases
Males Females Ischaemic heart disease (death rate, 2006) * Data not available for Belgium, Luxembourg, Portugal and Spain. 12.1 11.2 12.8 16.1 9.6 17.4 7.3 11.5 10.6 12.7 4.7 10.4 27.5 34.0 34.5 37.2 43.8 46.3 49.6 52.1 0 10 20 30 40 50 60 70 80 90 55.2 Age-standardized death rate per 100,000 65.9 76.8 81.9 In the death rate from ischaemic heart disease: In, the death rate from ischaemic heart disease: is lower than the EU average for males. is higher than the EU average for females.
Males Females Cerebrovascular diseases (death rate, 2006) * Data not available for Belgium, Luxembourg, Portugal and Spain. 6.2 6.7 7.8 77 7.7 8.3 9.2 88 8.8 8.4 8.2 10.5 10.5 10.1 11.1 11.5 11.1 12.1 12.6 12.8 13.5 13.4 12.9 19.2 18.9 0 2 4 6 8 10 12 14 16 18 20 22 24 Age-standardized death rate per 100,000 22.9 In the death rate from cerebrovascular diseases: In, the death rate from cerebrovascular diseases: is relatively similar than the EU average for males and females.
Males Females Chronic lower respiratory diseases (death rate, 2006) * Data not available for Belgium, Luxembourg, Portugal and Spain. 1.1 1.3 1.4 2.4 2.9 2.6 3.6 3.8 3.7 3.6 4.6 4.3 5.1 53 5.3 5.8 6.6 6.5 6.3 7.6 7.7 10.00 10.5 10.2 0 1 2 3 4 5 6 7 8 9 10 11 12 Age-standardized death rate per 100,000 In the death rate from chronic lower respiratory diseases: In, the death rate from chronic lower respiratory diseases: is much lower than the EU average for males. is about the same as the EU average for females. 11.3
Summary of non-cancer death rates Swedish rate is less than the EU average for males but not females: Ischaemic heart disease Chronic lower respiratory diseases All diseases of the respiratory system* has relatively similar rates for males & females: Cerebrovascular disease *data not shown
Features of data from national statistics (ecological data) Cannot directly compare exposed and unexposed individuals. Cannot control for individual confounders But, given the natural experiment, the very large contrast in exposure prevalences, and completeness of the reporting, in this case it is the best available data.
Conclusion In (compared to the rest of the EU), the death rate from most smoking caused diseases is: Lower for males. About the same or higher for females. Any risk from snus is so small that it is not apparent. Swedish men s heavy use of snus does not appear to cause a measurable risk for anything.
Conclusion If other countries had s tobacco use pattern, we would expect similar reductions in risk. Millions of deaths could potentially be averted if the ban on snus elsewhere in the EU was lifted. Non-EU countries (including developing nations) would likely l see similar il benefits if THR were promoted.
Thank you! This research was conducted at the University of Alberta School of Public Health, inspired by research originally conducted at Swedish Match. This and other research by Drs. Phillips and Heavner and Ms. Cockburn are supported by an unrestricted (completely hands-off) grant from U.S. Smokeless Tobacco Company to the University of Alberta. Mr. Hildingsson is employed by Swedish Match.
For more information: Dr. Carl V. Phillips: cvphilo@gmail.com Dr. Karyn Heavner: karynkh@aol.com For more information on tobacco harm reduction: TobaccoHarmReduction.org
Supplemental Slides
has among the lowest per capita consumption of cigarettes in the EU Source: World Health Organization, Regional Office for Europe, European health for all database (HFA-DB)
Alcohol consumption in the EU Source: World Health Organization, Regional Office for Europe, European health for all database (HFA-DB)
Esophageal cancer (death rate, 2006) Males Fe emales * Data not available for Belgium, Luxembourg, Portugal and Spain. 0.8 09 0.9 0.1 0.5 09 0.9 1.3 1.2 1.3 1.8 2.6 2.3 2.3 2.8 2.5 2.9 3.1 6.0 6.2 6.5 6.8 0 1 2 3 4 5 6 7 8 9 10 6.4 Age-standardized death rate per 100,000 8.0 89 8.9 8.9
Stomach cancer (death rate, 2006) Males Fe emales * Data not available for Belgium, Luxembourg, Portugal and Spain. 1.9 35 1.7 2.1 3.5 1.9 3.0 3.0 2.9 3.1 3.7 3.8 38 4.2 3.7 3.8 4.6 5.0 5.2 59 5.9 6.2 0 1 2 3 4 5 6 7 8 Age-standardized death rate per 100,000 5.9 6.4 6.7 67 6.7 7.7
Cancer of the colon, rectum & anus (death rate, 2006) Males Fem males * Data not available for Belgium, Luxembourg, Portugal and Spain. 5.0 5.5 5.9 6.3 7.1 7.7 8.4 81 8.1 7.9 7.2 7.9 9.1 9.3 10.5 11.5 11.6 12.2 11.8 12.5 11.7 13.1 13.5 13.9 14.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Age-standardized death rate per 100,000
Difference in death rates (male-female) All Cancer site Lip, oral Esopha Stomach Colon, Pancreas Trachea, cavity & gus rectum & bronchus Pharynx anus &l lung -7.9 1.6 2.3 1.8 2.1 1.9-0.6 15.4 19 1.9 21 2.1 27 2.7 36 3.6 40 4.0 15.0 4.2 3.2 4.0 3.7 8.2 2.3 9.2 UK 8.4 2.2 6.1 2.1 3.8 2.3 7.6 3.7 2.5 6.6 1.5 3.8 1.5 8.3 50.4 1.6 1.7 3.7 0.9 3.3 43.8 37.1 4.3 2.2 3.6 4.1 3.8 25.0 38.6 78 7.8 51 5.1 21 2.1 45 4.5 34 3.4 21.11 33.5 7.1 5.3 3.1 5.6 3.4 20.6 7.6 5.2 4.3 2.1 2.2 3.8 3.5 75.8 10.3 6.8 3.4 4.6 4.0 38.8 40.2 5.9 5.1 3.4 4.6 3.3 24.7
Ratio of death rates (male:female) All Cancer site Lip, oral Esopha Stomach Colon, Pancreas Trachea, cavity & gus rectum & bronchus Pharynx anus &l lung 0.9 2.3 3.7 2.0 1.3 1.4 1.0 12 1.2 30 3.0 34 3.4 18 1.8 16 1.6 18 1.8 27 2.7 1.0 4.1 2.7 2.7 2.3 1.5 1.5 UK 1.1 2.6 3.2 2.2 1.5 1.5 1.4 1.0 2.5 3.9 1.5 1.4 1.3 1.3 1.7 3.0 29.8 2.2 1.2 1.8 5.7 1.4 4.5 5.5 1.9 1.5 1.9 3.3 14 1.4 68 6.8 65 6.5 15 1.5 16 1.6 16 1.6 23 2.3 1.3 4.8 5.1 1.8 1.7 1.7 2.2 1.1 3.7 2.8 1.7 1.2 1.6 1.1 1.8 6.3 6.7 2.8 1.6 1.9 3.5 1.4 4.8 5.0 2.1 1.6 1.7 2.6
All diseases of the respiratory system (death rate, 2006) Males Fem males * Data not available for Belgium, Luxembourg, Portugal and Spain. 32 3.2 55 4.3 5.5 4.1 4.9 5.8 7.3 7.3 7.4 8.0 9.9 10.4 11.5 11.0 14.0 13.2 13.9 13.2 14.7 0 2 4 6 8 10 12 14 16 18 20 22 14.4 14.1 Age-standardized death rate per 100,000 14.8 16.8 21.3
Difference in death rates (male-female) Disease Ischaemic heart disease Cerebrovascular disease Diseases of the respiratory Chronic lower respiratory diseases system 31.7 4.3 2.5-0.1 65.6 6.5 7.2 4.0 42.4 1.6 1.5 0.5 UK 49.9 3.4 6.5 2.3 24.4 2.1 1.1-1.2 64.5 11.9 91 9.1 14 1.4 27.2 4.4 4.1 1.6 38.2 0.9 7.4 5.9 39.4 4.9 6.6 3.4 26.6 6.0 2.7-1.1 22.9 5.3 6.3 2.4 36.0 5.2 7.1 2.9
Ratio of death rates (male:female) Disease Ischaemic heart disease Cerebrovascular disease Diseases of the respiratory Chronic lower respiratory diseases system 3.6 1.5 1.5 1.0 6.9 1.5 2.7 2.6 4.3 1.2 1.1 1.1 UK 4.1 1.3 1.4 1.3 3.6 1.2 1.1 0.8 47 4.7 21 2.1 29 2.9 23 2.3 4.7 1.7 2.3 2.3 4.3 1.1 2.3 2.3 4.1 1.6 1.9 1.8 3.5 1.5 1.2 0.9 5.9 1.8 2.5 2.7 4.5 1.6 2.0 1.8