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Är det farligt att snusa vad vet vi idag? Mats Wallström Avd för käkkirurgi.

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En presentation över ämnet: "Är det farligt att snusa vad vet vi idag? Mats Wallström Avd för käkkirurgi."— Presentationens avskrift:

1 Är det farligt att snusa vad vet vi idag? Mats Wallström Avd för käkkirurgi

2 3000 kemiska produkter Tobak 40-45% Vatten 45-60% Na-karbonate-Högt pH % Salt % Fuktämnen % Smakämnen < 1% Nikotin

3 Nikotin-alkaloid CNS-belöning Skelett- Muskelaturen. Stim Blockad Skelett- Muskelaturen. Stim Blockad Autonoma Ganglier Adremalin Parasymp Autonoma Ganglier Adremalin Parasymp Vasomotorisk- Center Puls,O2, Arrth, Vasocon Vasomotorisk- Center Puls,O2, Arrth, Vasocon Baroreceptorer Binjurebarken Adrenalin Ökad metabol effekt Bolinder-1997

4 Tobaksspecifika nitrosaminer 23 st i snus TSNA Tobacco-specific N-nitrosamine NNN N-nitrosonornicotine NNK 4 (metylnitrosamino)-1-(3pyridyl)- 1-butanone Cancerframkallande

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6 pH är den avgörande faktor hur mycket nikotin sommabsorberas genom slemhinnan och med vilken hastighet Tomar SL. Tob Control (3):

7 Snuskonsumption Sverige: 194 Norge:112 USA15?2 män %kvinnor %

8 Snuff-induced lesions - A Clinical and Experimental Study - Hirsch1983 Lip canal filled with snuff 10 h per day Rat incisors Surgically created canal in the lip Djurexperiment

9 Johansson Sl et al. Snuff-induced carcinogenisis: Effect of snuff initiated with 4-nitrouinoline N-Oxide Cancer research-1989 Larsson PA et al. Snuff tumorigenisis: effects of long- term snuff administrat after initiation with 4NQO and Herpes simplex virus type 1. J Oral Pathol Med Park NH et al. Role of Virus in Oral Cancinogenesis- NIH publication-1993 Grasso. Smokeless Tobacco and Oral Cancer: An Assessment of Evidence Derived from Laboratory Animals. Food and Chem Toxicol

10 Effekter på kroppen Lokala effekterSlemhinnan Parodontala Karies Allmänna Vanebildande Hjärta-kärl Graviditet Spädbarnsdöd Diabetes Cancer

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12 Snus läsioner 1963 – Pindborg undersökte 12 kroniska snusare. Inga dysplasier – Axéll delade in snusläsionen i 4 olika kliniska grader – Hirsch redogjorde för 50 kroniska snusare. Lätt dysplasi i alla kliniska grader 1991 – Andersson biopserade 250 snusare. Några dysplasier i materialet 2011 – Wallström undersökte reversibiliteten efter 6 månaders snusstopp att läsionen inte läkte ut.

13 Tandlossning Gingivala retraktioner: van Wyk noterad att angränsande tänder hade gingival retraktioner Modeér en ökad gingivit trots plackkontroll 1989 – Andersson fann att 23% vs 3% hade gingiva retraktioner beroende på förpacknings form

14 Tandlossning 2004, 2006, svenska studier fann ingen signifikant ökad bennedbrytning hos snusare jmf med icke tobaksnyttjare Bland snusare I en amerikansk studie var det dubbelt så vanligt med avancerad tandlossning jmf med icke tobaksnyttjare

15 Karies USA 4 studier hos unga individer. En studie visade på positiv korrelation mellan snusning-karies och gingivit. Skandinavien Hirsch-91Snusare hade ett significant högre DMFT

16 Cancer

17 The working group stated that “there is sufficient evidence in humans to establish smokeless tobacco as carcinogenic, i.e. smokeless tobacco causes cancer of the oral cavity and pancreas.” Cancer

18 Case Age Location Snuff use (years) Smoking G.S. 75 Upper jaw 61No N.L. 91 Upper jaw 70 Not for 70 years F.A. 72 Upper jaw 42No K-G.B. 75Upper jaw71No S.W. 50Upper jaw 8 Prior to snuff use D.D. 85Upper jaw20No B.W. 79Lower jaw45 Not for 30 years F.N. 89Upper jaw69No S.E. 52Upper jaw20 Concomitant to snuff S.L. 67Upper jaw18 Not for 18 years H.G. 78 Lower jaw - No S-Å.G. 81Upper jaw66No X.X. 74Upper jaw40No R.F. 84Upper jaw30No X.X. 67Upper jaw49Not for 48 years Clinical data of the 15 patients with snuff induced oral cancer ORAL CANCER IN SWEDISH SNUFF-DIPPERS Hirsch et al Submitted

19 Mean age at time of diagnosis: 74, Median age at time of diagnosis: 75 Mean duration with the snuff habit: 43, Median duration with the snuff habit: 47 Mean age at start of snuff use: 30, Median age at start of snuff use: 31 Years Range Cancer

20 Schildt EB: Int J Cancer. 1998: Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. 410p/410c OR 0.7 CI 95% Rosenqvist K: Use of Swedish moist snuff, smoking and alcohol consumption in the aetiology of oral and oropharyngeal squamous cell carcinoma. A population-based case-control study in southern Sweden. 135p/320c OR 1.1 CI 95% Lewin F: Cancer. 1998: Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in Sweden. 605p/756cRR 4.7 for ever users CI 95% Cancer 3 svenska studier

21 Roosaar A et al Int J Cancer Cancer and mortality among users and nonusers of snus. Cohort 9976p Ökad cancerrisk oral och orofaryngeal RR 3.1 CI 95% Ökad dödlighet: HR 1.10 CI 95% Luo J et al Lancet: Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study p Pancreascancer RR 2.0 CI 95% norsk studie Boffetta P In J Cancer. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Cohort 10136p Pancreas cancer: RR 1.67 CI 95% Cancer 2 svenska studier

22 Long-term use of smokeless of smokeless tobacco Målsättning: Öka kunskapen om snusningens hälsoeffekter, Främst avseende risken för hjärt- och kärlsjukdom Bolinder G, Avhandling -97

23 Long-term use of smokeless of smokeless tobacco Material och metod: hälsoundersöktes totalt byggnadsarbetare av bygghälsan hade aldrig nyttjat tobak rökte > 15cig/dag var enbart snusare Bolinder G, Avhandling -97

24 Long-term use of smokeless of smokeless tobacco 1.Symptom, sjukfrånvaro och förtidspensionering hos snusare jämfört med rökare och tobaksfria I byggbranschen. 2.Ökad risk för död I hjärt-och kärl sjukdom hos snusare. 3.Fysisk arbetsförmåga vid långvarigt snusbruk. 4.Metabola riskfaktorer för hjärt-kärlsjukdom vid snusning. 5.Snusning och åderförkalkning-ultraljudsundersökning av intima-media-tjocklek I arteria carotis timmars blodtrycksmätning hos snusare, rökare och icke-tobaksbrukare. Bolinder G, Avhandling -97

25 Long-term use of smokeless of smokeless tobacco En av slutsatserna: 50% av alla dödsfall beror på hjärtkärl –sjukdommar. Vid en måttlig riskökning med en relativ risk på 1.4 och då 20% av svenska män snusar betyder det att ca 1300 dödsfall om året kan tillskrivas snusningen. Bolinder G, Avhandling -97

26 Hjärt-kärlsjukdomar Scandinavien Cohort studieOR CI Bolinder år Angina-typ Stroke H-K död år Angina Stroke H-K död Fall-kontroll studier MONICA 2 studier som inte visade på någon ökad risk för snusare att få hjärtinfarkt jmf med icke-snusare

27 Hjärt-kärlsjukdomar Kliniska epidemiologiska studier fokuserar på hjärt-kärlsjukdommar, Hjärtinfarkt, aterioskleros, stroke, högt blodtryck och metabola syndrom. Boffetta P, Straif K 2009 Lancet. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis. Dödlig hjärtinfarkt RR % CI Dödlig stroke Hergens 2007 J I Medicin Long-term use of Swedish moist snuff and the risk of myocardial infarction amongst men. Dödlig myocard RR % CI Henley 2005 Cancer Causes Contro. lTwo large prospective studies of mortality among men who use snuff or chewing tobacco. Ökad dödlighet HR , HR

28 Metabolt syndrom/ diabetes Norberg, 2006, Scand J Public Health. Contribution of Swedish moist snuff to the metabolic syndrome: a wolf in sheep's clothing? Longitudinell cohort 16492p efter 10 år. Metsy bland snusare OR 1.6 ( ) höga triglycerider OR 1.6 ( ), obesitas 1.7 ( ) Persson, 2000 J Intern Med.. Cigarette smoking, oral moist snuff use and glucose intolerance. J Intern Med Cross sectional study 3128 män där 52% hade en ärftlig belastning Mer än 3 dosor/vecka OR 2.7 ( ) Eliasson M, Rodu B J Intern Med. Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study. Snusare OR 1.34 ( )7 and Har snusat OR 1.18 ( )

29 OBJECTIVE: To compare the effects of Swedish snuff and cigarette smoking on risks of preterm birth. DESIGN: Population-based cohort study. All live, singleton births in Sweden MAIN OUTCOME MEASURES: Very (<32 weeks) and moderately (32-36 weeks) preterm birth. Effect of Swedish snuff on preterm birth Wikström AK et al BJOG 2010 Jul;117(8): Epub 2010 May 11.

30 METHODS: Odds ratios (OR) with 95% confidence intervals (CI) were used to estimate relative risks for preterm birth in snuff users (n = 7607), light smokers (1-9 cigarettes/day; n = ) heavy smokers (ten or more cigarettes/day; n = ) non-tobacco users (n = ) as reference. Effect of Swedish snuff on preterm birth Wikström AK et al BJOG 2010 Jul;117(8): Epub 2010 May 11.

31 RESULTS: Compared with non-tobacco users, snuff users had increased risks of both very (adjusted OR 1.38; 95% CI ) and moderately (adjusted OR 1.25; 95% CI ) preterm birth. Wikström AK et al BJOG 2010 Jul;117(8): Epub 2010 May 11. Effect of Swedish snuff on preterm birth

32 CONCLUSIONS: The use of Swedish snuff was associated with increased risks of very and moderately preterm birth with both spontaneous and induced onsets. Swedish snuff is not a safe alternative to cigarette smoking during pregnancy. Wikström AK et al BJOG 2010 Jul;117(8): Epub 2010 May 11. Effect of Swedish snuff on preterm birth

33 BACKGROUND: Swedish snuff has been discussed internationally as a safer alternative to tobacco smoking. International cigarette manufacturers are promoting new snuff products, and the use of Swedish snuff is increasing, especially among women of childbearing age. The effect of Swedish snuff on pregnancy complications is unknown. Maternal use of Swedish snuff (snus) and risk of stillbirth.

34 METHODS: In this population-based cohort study, we estimated the risk of stillbirth in snuff users (n = 7629), light smokers (1-9 cigarettes/day; n = 41,488), and heavy smokers (≥10 cigarettes/day; n = 17,014), using nontobacco users (n = 504,531) as reference. Maternal use of Swedish snuff and risk of stillbirth.

35 RESULTS: Compared with nontobacco users, snuff users had an increased risk of stillbirth (adjusted OR= 1.6 [95% CI= ]); the risk was higher for preterm (<37 weeks) stillbirth (2.1 [ ]). For light smokers, the adjusted odds ratio of stillbirth was 1.4 ( ) and the corresponding risk for heavy smokers was 2.4 ( ). Wikstrom AK Epidermiology 2010 Nov;21(6): Maternal use of Swedish snuff and risk of stillbirth.

36 CONCLUSIONS: Use of Swedish snuff during pregnancy was associated with a higher risk of stillbirth. The mechanism behind this increased risk seems to differ from the underlying mechanism in smokers. Swedish snuff does not appear to be a safe alternative to cigarette smoking during pregnancy. Maternal use of Swedish snuff and risk of stillbirth. Wikstrom AK Epidermiology 2010 Nov;21(6):772-8.

37 Harm reduction Definition: A product is harm reducing if it lowers total tobacco – related mortality and morbidity Even though use of that product may involve Continued exposure to tobacco toxicants Clearing the Smoke., Assessing the Scienece Base for Tobacco Harm Reduction

38 Interventionsstudier Farmakologiska studier: CI 95% Buprion - 1 studieOR NRT - 2 studie (tuggimmi)OR NRT – 3 studier (plåster)OR Betendevetenskapliga studier: Ind/grupp – 8 studierOR Cochrane 2007


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