Dr. Ramstrom, from the Institute for Tobacco studies in Boston, 2010.

1. Characteristics of new tobacco products
emerging on the tobacco market: implications
for tobacco control policies
Lars M. Ramström
Institute for Tobacco Studies
Stockholm, Sweden
Annual 8th Conference of ISPTID, Boston, USA, 29 Septemner to 1 October 2010

2. New tobacco/nicotine products
•
•
•
•
•
”Ultra-light” cigarettes
Electronic cigarettes
Water pipe
Nicotine water
Nicotine disolvables
- strips
- sticks
- pellets
• Swedish snus

3. Electronic cigarettes

4. Nicotine concentrations and craving relief by ECigarettes
Eissenberg et al 2010

5. Reasons for using E-Cigarette
N=81 In total 225 comments.
• To quit smoking
• For health reasons
• E-cigarettes less expensive
• E-cigs can be smoked everywhere
• To avoid disturbing other people
• For the pleasure of smoking
• To reduce consumption of cigs
• By curiosity
53
49
26
21
20
19
14
10
Does/did e-cigarette help you quit smoking
Yes a lot
79%
Somewhat
16%
Etter 2010
Not at all
5%

6. Waterpipe (Hookah, Hubble-Bubble)

7. Eissenberg T, Shihadeh A
(Am J Prev Med 2009;37(6):518–523)

8. Khabour et al. Assessment of Genotoxicity of Waterpipe
and Cigarette Smoking in Lymphocytes Using the
Sister-Chromatid Exchange Assay: A Comparative Study.
Environmental and molecular mutagenesis 2010
The results show that waterpipe smoking and cigarette
smoking significantly increase the frequencies
of SCEs (P < 0.01) compared with those of nonsmokers,
indicating the genotoxic effect of tobacco smoking.
In addition, frequencies of SCEs were significantly
higher among waterpipe smokers compared with
CS (P < 0.01), indicating that waterpipe smoking is more
genotoxic than cigarette smoking.
Moreover, the frequency of SCEs increased with the
extent of waterpipe use.

9. Swedish snus
Fine ground tobacco leaves
predominantly from air-cured dark tobacco
Manufactured by a pasteurizing-like heating
process (without fermentation as in
manufacturing of American snuff), which results
in very low levels of tobacco-specific
nitrosamines and benzo(a)pyrene

10. Mean nitrosamine content of moist snuff products
from various sources based on dry weight
Country
Brand (yr sampled)
NNK
µg/g
NNN
µg/g
Sweden
Ettan snus (2000)
0.5
1.1
188 - 362
241 - 369
4.3
3.4
20.8
14.3
Sudan (Toombak)
3 samples (1993)
United States
Skoal (2000)
Copenhagen (2000)

11. Cancer of the oral cavity
Age adjusted mortality rates per 100 000
Men in North America, Northern and Western Europe
Estonia
Lithuania
Latvia
France
Austria
Denmark
Germany
Ireland
Belgium
Luxembourg
Switzerland
Iceland
Norway
United Kingdom
Canada
The Netherlands
United States
Sweden
0
1
2
3
4
Source: GLOBOCAN 2002 database: http://www.-dep.iarc.fr
5
6

13. Gartner et al. Lancet 2007

14. “Our argument is that nicotine products should
all be regulated rationally in relation to each
other, in proportion to their level of hazard, in a
system designed to reduce the overall harm
caused by nicotine dependence and use.”
John Britton, Richard Edwards. Tobacco smoking, harm reduction, and nicotine
product Regulation. Lancet 2008; 371: 441–45.

15. E-cig ?
100%
0%
Snus
Nicotine replacement products
No tobacco use
Snokless tobacco, e.g. India
Modified cigarettes
Traditional cigarettes, Waterpipes
THE CONTINUUM OF HARM FROM
NICOTINE-DELIVERING PRODUCTS
HARM
10

17. Recommendations for regulation of smokeless tobacco
●The combined concentration of NNN plus NNK in smokeless tobacco
should be limited to 2 μg/g dry weight of tobacco.
●The concentration of benzo[a]pyrene in smokeless tobacco should be
limited to 5 ng/g dry weight of tobacco.

20. ”Although nearly half of the smokers
surveyed were willing to purchase an
LNSLT product, most were interested in
using these products for cessation rather
than as a long-term substitute or for dual
use with cigarettes.”

21. Summary
• Waterpipe smoking appears to be even more harmful than
smoking traditional cigarettes.
• Toxicants in E-cigarette vapour are not well known.
Nicotine delivery is low, but smoking cessation might be
faciltated to some extent.
• Mortality risk in users of Swedish snus is modestly higher
than in never tobacco users.
• The potential public health benefits of Swedish snus as a
non-medical aid for large scale smoking cessation have
now been demonstrated also outside Sweden.
• Product regulation of all smokeless tobaccos so as
recommended by the WHO Study Group on Tobacco
Product Regulation is an important public health issue.