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Smokeless Tobacco Products Chemistry and Constituents
Dr. Mirjana Djordjevic, National Cancer Institute, U.S., and Dr. Ali Idris, Toombak Smoking and Research Center, Sudan, highlighted that there are more than 3000 identified compounds in cured tobacco. Several of these compounds have been assessed for their carcinogenicity; for example tobacco-specific chemicals called N-nitrosamines (TSNA). The range of TSNAs vary widely from trace levels reported in Swedish snus to almost 8000 parts per million (ppm) in Sudanese Toombak. The pH of snuff is important in that the higher the pH, the higher the level of nicotine available to be absorbed in the mouth. Several factors including the type of tobacco, climate in which it's grown, manufacturing, and storage, can change the chemical composition of the product. Dr. Idris added that the unusually high levels of TSNAs in Toombak are thought to play a major role in the initiation of cancer in Toombak users.
Dr. Gregory Connolly, Massachusetts Department of Public Health, U.S., provided examples of new smokeless tobacco products that are diverse and some appear similar in packaging and design to nicotine medications than to traditional tobacco products. These include products that are packaged in medicinal appearing forms, such as a nicotine lozenge that is made in part of compressed tobacco powder, Ariva, manufactured by Star Scientific, U.S. An increasing marketing ploy implemented by U.S. manufacturers of these products is positioning them for use by continuing smokers to use in situations when smoking is prohibited or inconvenient, such as on airline flights or in the workplace. Dr. Connolly stated "such promotion of dual product use could increase the health risks of tobacco use by delaying smoking cessation."
Dr, Guttenplan, New York University Dental and Medical Schools, U.S., reported on the carcinogenicity of smokeless tobacco. Chemical analyses revealed that snuff contains toxins that impair genetic material in addition to TSNAs. He stated that there is a great need for experimental model for induction of oral carcinogenesis by smokeless tobacco. Published studies on this model are scarce
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Reducing Risk/Harm? Science, Ethics, and Public Health
Dr. Scott Tomar, University of Florida, College of Dentistry, U.S., reviewed the published scientific literature about oral health effects of Swedish snus and U.S. moist snuff. Epidemiological studies generally revealed a high prevalence of oral lesions, often called leukoplakia, in users of both snus and U.S. moist snuff. Most studies reported dose response relationships between the duration of snuff use and the appearance of lesions. Swedish and U.S. studies were consistent in suggesting an increased risk of developing gingival recession (receding gums) where the tobacco is held in the mouth.
Dr. Deborah Winn, National Cancer Institute, U.S., conducted a review of the published scientific literature about the relationship to cancer of Swedish snus and U.S. Tobacco product use. Findings suggest that in the U.S., smokeless tobacco use increases the risk 4 to 6 times of developing oral cancer, where potential confounding of smoking can be ruled out. In Sweden, there is no overall association between smokeless tobacco and oral cancer. Risks were not increased with greater levels of use, but there is a risk among non-smokers based on one of two recent studies. Dr. Winn stated that, "more information about levels of carcinogens in smokeless tobacco and snus is needed to help clarify potential oral cancer risks."
Clive Bates, Action on Smoking and Health, England, provided a rationale for the use of smokeless tobacco as a strategy to reduce the prevalence of smoking. He stated that smokeless tobacco reduces the hazards associated with cigarette smoking by one or two orders of magnitude. Mr. Bates remarked that when one considers the health effects from cigarette smoking including cancer, respiratory health effects, cardiovascular disease, and passive smoke exposure, the cancer rate incurred from smokeless tobacco use is less harmful. Consequently, Mr. Bates argued for open-mindedness about the inclusion of smokeless tobacco in harm reduction strategies for individuals and explores implications at individual and population levels.
Dr. Gregory Connolly, Massachusetts Department of Public Health, U.S., reported that there are little data to support the premise that snus use contributed to the reduction in smoking prevalence in Sweden. In the U.S., 20% of snuff users are also daily cigarette smokers and adult male cigarette smokers are 2.5 times more likely to have switched from snuff to cigarette smoking than vice versa. Dr. Connolly stated, "the marketing of oral snuff in Sweden and the U.S. may undermine proven measures to curb smoking and promote youth initiation into smoking as well as adults, combining use of snuff and cigarettes, resulting in a negative impact on the public health."
Dr. Lynn Kozlowski, Pennsylvania State University, U.S. addressed the issue of ethical standards in providing honest health relevant information to the public taking into account human rights. He emphasized that arena of public health communications should be held to the same ethical standards as are applied in scientific research.
Dr. Lars Ramström, Institute for Tobacco Studies, Sweden, presented data about the Swedish experience of snus as a substitute for smoking. The prevalence of daily smoking among Swedish men is 15% and among women, 19%, while the prevalence of daily snus use is 20% among men and only 2% among women. The combined use of cigarettes and snus occurs in 2% of men. Among men who smoke and have made a quit attempt, snus was the most common cessation aid used by 55%, while 36% used nicotine gum. However, among women who smoke and have made a quit attempt, nicotine replacement therapy was the most popular form of smoking cessation aid, with 55% using nicotine gum, 42% using nicotine patch and only 15% using snus. Dr. Ramström concluded his talk by saying that men who used snus as cessation aid had the greatest success rate in quitting smoking, 65 %, compared to 50% for nicotine gum users. He also stated that the use of snus as a substitute for smoking seems to have been one of the factors contributing to Sweden's low smoking prevalence and accordingly low rates of tobacco-related diseases.
Dr. Dorothy Hatsukami, University of Minnesota, U.S., reported that smokeless tobacco could be used in several ways as a potential harm reduction tool for cigarette smokers. This includes ST use as a method of cessation, as a means to reduce the number of cigarettes smoked, and as a product to be used in situations where smoking is not allowed. The impact of using ST in these ways is relatively unknown. The toxicity of ST products varies by brand and across countries. To date, limited research data are available in addressing the feasibility and impact of this approach. Dr. Hatsukami stated, "Further examination is needed to determine the feasibility of using smokeless tobacco as a means of quitting cigarette smoking."
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Discussant Responses
Dr. Gunilla Bolinder, Clinical Proficiency Centre, Karolinska Institutet, Sweden, commented that the reduction in smoking prevalence in Sweden may not be largely attributed to use of snus, as evidenced by the data demonstrating that women have experienced similar reductions in smoking prevalence as men but without increased snus use. However, it is most likely that the concerted efforts of Swedish government and public health organizations have contributed greatly to this reduction. Dr. Bolinder emphasized that conclusive scientific evidence does not exist to support the notion of the use of smokeless tobacco products for smoking cessation. She stated that since smokeless tobacco products are intended for pleasurable use, nicotine replacement products should be the first choice for a person trying to quit tobacco.
Dr. Prakash Gupta, Tata Institute of Fundamental Research, India, synthesized the evidence presented in the sessions about risk and harm reduction. He commented on the weakness of the evidence supporting the claim that snus contributed significantly to the reduction in smoking prevalence in Sweden and emphasized the efficacy of the vigorous smoking prevention and cessation efforts enacted by the Swedish Ministry of Health. In addition, he remarked that advocating for smokeless tobacco use as a safer alternative to smoking may undermine tobacco use cessation efforts in that it provides an excuse to continue tobacco use, a scientifically proven unhealthy behavior. Dr. Gupta identified the lack of scientific trials and data that indicate to what extent smokeless tobacco users could benefit from using current nicotine replacement therapy to quit smokeless tobacco. He emphasized that steps taken by the tobacco control and public health communities should not be dictated by the tobacco industry. He also stressed the importance of considering the implications of claiming that one kind of smokeless tobacco is a safer than another, which may be the case with Sweden and India.
Dr. David Sweanor, Non-Smokers' Rights Association, Canada, defined risk and harm reduction as strategies "to reduce the adverse physical, social, and mental health consequences of a behavior without abstinence to reduce the impact in a humanistic way while encouraging abstinence." He stated that the harm incurred by cigarette smoking is so horrendous and use is so persistent as to warrant additional methods of reducing harm, supplementary to advising cessation. This includes, long-term use of nicotine replacement therapy or, potentially, oral tobacco products to minimize the risk incurred by people around tobacco users.
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Media Advisory
Tuesday, September 24, 2002
Worldwide Marketing of Smokeless Tobacco
Dr. Paul Nordgren, National Institute of Public Health, Stockholm, Sweden provided an overview of the history and current state of snus use in Sweden and the evolution of the marketing strategies of the Swedish Tobacco Company, now known as Swedish Match. Dr. Nordgren reported that snus (moist oral snuff) was traditionally used by rural elderly men in Sweden. However, as use declined in the post World War II period, the tobacco company shifted its marketing campaign to target young, urban men and male athletes. During the 1980s, new marketing strategies emphasized the use of snus as an alternative for times when smoking is prohibited. During the last few years, the main focus of marketing was snus as a means for smoking cessation or smoking reduction.
Dr. Surendra Shastri, Tata Memorial Center, Mumbai, India, reported that in India smokeless tobacco companies market their products in a similar manner as in the United States. For example, products are glamorized through the use of sports figures and social events in commercials and print advertising. A large smokeless tobacco company sponsors the Indian equivalent of the Academy Awards called the Bollywood Awards in an effort to promote its product as glamorous. Although an advertising ban was enacted in 2001 for Gutkha (in the state of Mabarashtra), the tobacco companies continue to display product banners at religious festivals.
Dr. Alan Blum, University of Alabama Center for the Study of Tobacco Society, presented information about U.S Smokeless Tobacco company's marketing strategies. These strategies include marketing its brands as a safer alternative to smoking and the use of female college students to promote its products to use at sporting events and concerts.
Regional and Policy Interventions
The history of the Irish experience is unique is that portion smokeless tobacco products were banned in 1985 by the Minister of Health. This ban was in reaction to the U.S. Smokeless Tobacco Company's (USST) attempt to introduce its products on the Irish market. Following a challenge by USST, in 1988 the ban was extended to include all smokeless tobacco products, including loose snuff and chewing tobacco and remains in effect to this day. In 1994, the European Union (EU) enacted a directive, which prohibited the sale of snuff but not chewing tobacco. In addition, it was reported that there is no intention to consider lifting the EU ban.
Judith Wilkenfeld, Campaign for Tobacco Free Kids, USA reported on the case of USST and the Federal Trade Commission (FTC). In February 2002, USST asked FTC to issue and advisory opinion that the company be allowed to make advertising claims based on the fact that smokeless tobacco products are considered to be a significantly reduced risk alternative to cigarette smoking. Ms. Wilkenfeld expressed her opinion that FTC lacks the regulatory authority and scientific expertise needed to evaluate these claims. Mitch Zeller, USA, expounded on key principles recommended for guiding policy development. This includes submitting all data to a regulatory agency if a smokeless tobacco company seeks to make health claims and that it should be the company's responsibility to conduct research to support the claims. The research should address not only exposure, but also health risks associated with use.
Smokeless Tobacco Cessation
Dr. E.D. Glover, West Virginia University School of Medicine, USA, reviewed the pharmacological smokeless tobacco cessation studies and reported that; overall, nicotine replacement therapy has shown a lack of an effect to date. However, use of buproprion with smokeless tobacco users shows has shown promise in a few studies, which warrants further research. Dr. Herbert Severson provided detailed descriptions of several behavioral interventions with smokeless tobacco users. He highlighted the effectiveness of the use of an oral exam to motivate users to quit. This has broad implications for interventions worldwide, in that it can be a cost-effective, easily implemented strategy. Dr. Asgeir Helgason, Stockholm Center of Public Health, Sweden, found that snus was not a significant contributor to abstinence from smoking with quitline callers in Sweden. Moreover, he reported similar levels of effectiveness for telephone interventions with smokers and snus users in Sweden.
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Media Advisory
Monday, September 23, 2002
Global Perspectives
On the first day of the 3rd International Conference on Smokeless Tobacco, scientists from Africa, India, Europe, the Americas, and the Middle East presented summaries of the issue of smokeless tobacco use in their region of the world. The presentations provided overviews of over 20 smokeless, or non-combustible, tobacco products in use around the world and highlighted the variability of their prevalence in many countries, from 46% of the West Nile region population in Sudan to 3.4% of U.S. population. Presentations by Dr. Ahmed Ogwell, Oral and Craniofacial Research Associates, Kenya, and Dr. Ali Idris, Toombak Smoking and Research Centre, Sudan, demonstrated the dearth of data about the scope and determinants of smokeless tobacco products in Africa and other under-developed parts of the Middle East. An emerging concern is the presence of immigrant populations who are retaining their smokeless tobacco use as they temporarily or permanently migrate to the new host country. In the Americas, smokeless tobacco use, which dates back to the indiginous populations of North and South America, has traditionally been associated with rural elderly populations, but the 2000 Global Youth Tobacco Survey results revealed that a much larger proportion of youth are using non-combustible tobacco products.
Smokeless Tobacco Addiction
The addictive nature of the nicotine in smokeless tobacco products is a key consideration when addressing the issues surrounding their use. Dr. Jack Henningfield, Pinney Associates, U.S., emphasized that the pH of smokeless tobacco products is manipulated to the speed and amount of nicotine delivered to the user. They are primarily altered in this manner in order to promote the use of these products as starter products as the altered pH makes then milder and helps the new user tolerate the product. Dr. Torgny Svensson, Karolinska Institutet, Sweden, presented data about the potential effectiveness of a nicotine vacccine that would allow the formation of antibodies, which would disable the ability of nicotine delivered to produce its pleasurable effects in the brain. This is being further explored and validated in research being conducted in Sweden. New research suggests that nicotine and tobacco do not only involve the reward systrem in the brain, but those regions of the brain involved in decision making and controlling behavior. Data suggest that co-abuse with alcohol may be the result of genetic predispositions to ethanol and nicotine reward response systems of the brain.
Health Effects
Smokeless tobacco use has long contributed to high rates of oral (mouth) cancer in many cultures throughout the world from the Pacific Islands to India and neighboring countries, to republics formed from the former Soviet Union, to Africa, Sweden and the United States. These products can include many other ingredients, but all include tobacco and are almost always used by mouth. Smokeless tobaccos used in the developed world include about 30 carcinogens, but one of the most important chemical classes are nitrosamines. In the Sudaan for example, nitrosamine levels are extremely high and cause high rates of oral cancer there. By contrast, in Sweden, nitrosamine levels are quite low and recent studies suggest little or no excess oral cancer risks. Conference attendees discussed the relationship of smokeless tobacco to cancer risks, but also data was presented on other health problems. Studies in Sweden have implicated smokeless tobacco use in the development of cardiovascular, but this has not been studied in other cultures. One presentation found that smokeless tobacco use used as a dentifrice by pregnant women was associated with having low-weight babies. Another study was among the first to suggest a link between smokeless tobacco and type 2 diabetes.
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Press Information
22 September 2002
Comparison of smoking habits and health hazards in Sweden and Norway
Significant differences in smoking habits and lung cancer incidence are evident in Sweden and Norway during the time period 1960-1997. Brian Wicklin, Senior Statistician at the Swedish Statistical Bureau VECA presents the results [1] at a poster session at the 3rd International Conference on Smokeless Tobacco in Stockholm, Monday September 22nd .
The figures are compiled from official statistical sources. The report refers to the time period 1960-1997. The figures for 1997-2000 are updates presented in the poster session.
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1. Higher lung cancer incidence in Norway
Age standardised rates per 100,000 inhabitants, based on census population in each country and not on a European or world standardised population data.
Figure 1 Lung cancer incidence in Sweden 1960-2000 and Norway 1960-1999
Age standardised rates per 100,000 inhabitants
The lung cancer incidence for males in Norway 1995-97 was 66 per 100 000 inhabitants (age standardised and mean value for the years 1995-1997) compared to 38 in Sweden. The comparative figures for women were 27 and 21, respectively.
The lung cancer incidence for females in Sweden and Norway increased at about the same rate 1960-1990 and thereafter the difference has widened.
The lung cancer incidence for males in Sweden and Norway increased at about the same rate 1960-75 and thereafter the difference has widened significantly. The data for 1960-1997 shows a significant difference between the sexes (decrease for men and increase for women).
In Norway, the lung cancer incidence has increased for both males and females during 1960-1997.
Table 1 Lung cancer incidence in Sweden and Norway.
Moving average 1960-1962, 1980-1982 and 1995-1997.
| |
Men |
Women |
| |
Sweden |
Norway |
Sweden |
Norway |
| 1960-1962 |
26 |
21 |
6 |
5 |
| 1980-1982 |
46 |
54 |
13 |
12 |
| 1995-1997 |
38 |
66 |
21 |
27 |
Sweden 1997-2000: Decrease in lung cancer incidence for males in Sweden from 37.4 per 100 000 inhabitants 1997 to 36.4 in 2000 and for females increase from 20.2 and 24.1.
Norway 1997-1999: Almost unchanged lung cancer incidence for males in Norway 64.6 in 1997 and 65.0 in 2000 and an increase from 27.7 to 30.6 for females.
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2. Tobacco habits
Sweden
In Sweden, daily smoking prevalence among adult males declined from 36 to 17 percent during the 17-year period from 1980 to 1997. The corresponding figures for women were 29 and 22, respectively. During the same period the use of ”Swedish snus” (Swedish moist snuff) among men increased from 17 to 19 percent (latest figures).
The figures for 2000 suggest that smoking prevalence among Swedish males reached 17.1 per cent and females 21.1
Sweden was the first country in the World to reduce adult smoking prevalence below the World health organisation (WHO) goal of reducing overall smoking prevalence below 20 percent in 1997. The overall smoking prevalence rate was 31 in 1980 and 19 in 1997.
Norway
In Norway, smoking prevalence is declining more slowly compared to Sweden. The daily smoking rate among adult males in Norway was reduced from 42 per cent in 1980 to 35 in 1997 whilst for females the corresponding figures showed an increase from 30 and 33. The smoking prevalence among Norwegians is significantly higher than in Sweden.
The figures for 2000 suggest that smoking prevalence among males in Norway reached 31 per cent and females 32. The daily intake of “Swedish snus” among men in Norway has remained at 5 percent during 1998-2000.
Table 2 Smoking prevalence in Sweden and Norway
Moving average 1980-1982 and 1995-1997
(Sweden 16-84 year and Norway 16-74 years.)
| |
Men |
Women |
| |
Sweden |
Norway |
Sweden |
Norway |
| 1980-1982 |
35 |
41 |
28 |
32 |
| 1995-1997 |
20 |
34 |
23 |
33 |
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3. Tobacco intake
The statistical data for 1960-2000 indicates that consumption of smoking tobacco in per capita terms has continued on its downward direction in Sweden and Norway. The daily intake of “Swedish snus” has increased in Sweden whilst in Norway it has both decreased and increased.
Table 3 Per capita consumption of tobacco in Sweden and Norway, 1960 –2000
Sales figures converted to grams per person 15 +.
Moving average 19600-1962, 1970-1972, 1980-1982, 1990-1992 and 1998-2000
| |
1960-1962 |
1970-1972 |
1980-1982 |
1990-1992 |
1998-2000 |
| SWEDEN |
| Smoking tobacco of all kinds |
1131 |
1383 |
1337 |
1209 |
740 |
| "Swedish snus" |
444 |
405 |
562 |
683 |
796 |
| |
| NORWAY |
| Smoking tobacco of all kinds |
1631 |
1853 |
1808 |
1608 |
1191 |
| "Swedish snus" |
171 |
105 |
82 |
80 |
99 |
Smoking tobacco of all kinds: Cigarettes, pipe and roll tobacco, cigars/cigarillos.
Figure 2 Sweden: Tobacco consumption 1960-2000
Intake, grams tobacco per person 15+
Figure 3 Norway: Tobacco consumption 1960-2000
Intake, grams tobacco per person 15+
|
Annex 1
Lung cancer incidence, Sweden 1960-2000 and Norway, 1960-1999.
Age standardised rates per 100 000 inhabitants, based on census population in each country and not on a European or world standardised population data.
|
| |
Men |
Women |
| |
Sweden |
Norway |
Sweden |
Norway |
| |
| 1960 |
23,70 |
19,80 |
5,42 |
4,40 |
| 1961 |
25,51 |
20,90 |
5,37 |
4,90 |
| 1962 |
28,66 |
23,30 |
7,16 |
5,10 |
| 1963 |
30,98 |
22,90 |
6,59 |
4,30 |
| 1964 |
31,98 |
24,00 |
6,98 |
5,70 |
| 1965 |
32,50 |
24,10 |
7,81 |
4,30 |
| 1966 |
31,49 |
37,00 |
6,70 |
5,20 |
| 1967 |
32,52 |
29,30 |
7,29 |
7,20 |
| 1968 |
38,23 |
34,30 |
8,07 |
6,10 |
| 1969 |
36,33 |
31,00 |
8,78 |
7,80 |
| 1970 |
38,00 |
36,30 |
9,14 |
8,60 |
| 1971 |
39,98 |
37,60 |
8,46 |
7,80 |
| 1972 |
41,42 |
38,10 |
9,04 |
8,00 |
| 1973 |
42,78 |
33,00 |
9,72 |
7,60 |
| 1974 |
43,96 |
39,40 |
10,79 |
7,60 |
| 1975 |
43,63 |
43,40 |
10,28 |
9,40 |
| 1976 |
46,63 |
45,00 |
10,18 |
9,00 |
| 1977 |
44,79 |
47,80 |
10,28 |
8,70 |
| 1978 |
43,89 |
48,40 |
10,66 |
9,90 |
| 1979 |
41,54 |
47,90 |
11,261 |
0,00 |
| 1980 |
45,05 |
51,70 |
12,911 |
1,00 |
| 1981 |
46,41 |
54,90 |
13,151 |
2,10 |
| 1982 |
47,38 |
54,80 |
14,181 |
2,50 |
| 1983 |
45,80 |
54,00 |
14,621 |
3,30 |
| 1984 |
46,95 |
60,00 |
14,581 |
4,10 |
| 1985 |
44,97 |
57,80 |
15,321 |
5,00 |
| 1986 |
44,41 |
64,10 |
15,741 |
5,70 |
| 1987 |
44,02 |
59,10 |
17,421 |
6,90 |
| 1988 |
43,19 |
60,80 |
16,401 |
6,90 |
| 1989 |
42,89 |
60,70 |
16,672 |
0,00 |
| 1990 |
42,80 |
62,90 |
17,382 |
0,70 |
| 1991 |
42,91 |
61,60 |
19,362 |
1,90 |
| 1992 |
40,87 |
63,90 |
18,862 |
1,70 |
| 1993 |
40,04 |
66,10 |
19,772 |
3,70 |
| 1994 |
41,88 |
65,90 |
21,372 |
4,60 |
| 1995 |
38,02 |
65,40 |
21,572 |
4,80 |
| 1996 |
37,28 |
67,90 |
21,672 |
8,80 |
| 1997 |
37,38 |
64,60 |
20,182 |
7,70 |
| 1998 |
37,90 |
64,40 |
21,402 |
6,50 |
| 1999 |
36,90 |
65,00 |
22,803 |
0,60 |
| 2000 |
36,40 |
|
24,10 |
|
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Annex 2 Sweden and Norway in a global perspective
Source: IARC Cancer data base
The male population of Sweden had the lowest lung cancer incidence among the industrialised countries in 2000. In Norway, the male population the incidence was higher than in Sweden but relatively lower in comparison with most of the industrialised countries of Europe.
Lung cancer incidence – Male 2000
Age standardized rate, ASR. World standard population (W)
IARC CancerBase No5. http://www-dep.iarc.fr/
| |
ASR (W) |
|
|
| World |
34.92 |
Central America |
|
| More developed countries |
55.62 |
Mexico |
24.48 |
| Less developed countries |
24.79 |
Cuba |
47.18 |
| |
| Europe |
|
South America |
|
| Sweden |
21.41 |
Brazil |
24.97 |
| Iceland |
31.52 |
Argentina |
40.78 |
| Portugal |
33.91 |
|
|
| Norway |
35.07 |
Africa |
|
| Finland |
36.83 |
Nigeria |
00.65 |
| Ireland |
39.54 |
Sudan |
01.18 |
| Austria |
42.09 |
Namibia |
07.46 |
| Denmark |
46.82 |
Egypt |
10.63 |
| United Kingdom |
47.61 |
South Africa |
25.49 |
| Switzerland |
48.52 |
|
|
| Germany |
50.25 |
Australia/New Zealand |
|
| Spain |
53.22 |
New Zealand |
41.37 |
| France |
53.52 |
Australia |
42.24 |
| Greece |
55.79 |
|
|
| Lithuania |
57.66 |
Asia |
|
| Italy |
59.41 |
Sri Lanka |
01.94 |
| Luxembourg |
60.49 |
India |
09.04 |
| Latvia |
61.52 |
Saudi Arabia |
10.30 |
| The Netherlands |
62.04 |
Indonesia |
19.99 |
| Estonia |
69.86 |
Pakistan |
20.07 |
| Russian Federation |
74.86 |
Bangladesh |
22.42 |
| Belgium |
76.43 |
China |
38.46 |
| Poland |
78.22 |
Turkey |
40.10 |
| Yugoslavia |
80.89 |
Japan |
40.26 |
| |
|
Philippines |
51.33 |
| North America |
|
China, Hong Kong |
74.72 |
| Canada |
55.08 |
|
|
| United States of America |
58.56 |
|
|
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Annex 3 Some data about Oral cancer risk
Source: IARC Cancer data base
Around 20 percent of the male population in Sweden used “Swedish snus” on a daily basis. The comparative figure for Norway was 5. Therefore, it is interesting to study the oral cancer incidence in these two countries and to compare the figures with countries that have different tobacco habits.
Oral cancer incidence – Male 2000
Age standard rate, ASR. World standard population (W)
IARC CancerBase No5. http://www-dep.iarc.fr/
| World |
6.42 |
Central America |
|
| More developed countries |
7.55 |
Mexico |
3.55 |
| Less developed countries |
5.98 |
Cuba |
8.88 |
| |
| Europe |
|
South America |
|
| Greece |
3.02 |
Argentina |
6.53 |
| United Kingdom |
4.40 |
Brazil |
10.52 |
| Sweden |
4.52 |
|
|
| Iceland |
4.81 |
Africa |
|
| Poland |
5.33 |
Egypt |
0.64 |
| Norway |
5.77 |
Nigeria |
2.30 |
| The Netherlands |
5.79 |
South Africa |
11.33 |
| Switzerland |
5.81 |
Sudan |
13.07 |
| Ireland |
5.90 |
Namibia |
26.94 |
| Finland |
6.47 |
|
|
| Latvia |
6.58 |
Australia/New Zealand |
|
| Italy |
6.74 |
New Zealand |
4.63 |
| Lithuania |
7.56 |
Australia |
13.58 |
| Denmark |
7.66 |
|
|
| Russian Federation |
7.73 |
Asia |
|
| Yugoslavia |
9.17 |
China |
1.24 |
| Estonia |
9.50 |
Indonesia |
1.45 |
| Austria |
10.39 |
Turkey |
3.53 |
| Luxembourg |
10.43 |
Saudi Arabia |
3.71 |
| Belgium |
10.78 |
Japan |
4.00 |
| Portugal |
11.01 |
China, Hong Kong |
4.79 |
| Germany |
13.19 |
Philippines |
5.80 |
| Spain |
13.77 |
India |
12.84 |
| France |
14.94 |
Bangladesh |
13.36 |
| |
|
Pakistan |
14.69 |
| North America |
|
Sri Lanka |
36.07 |
| United States of America |
6.25 |
|
|
| Canada |
7.3 |
|
|
[1] The report was commissioned by ESTOC (European branch organisation for smoke free tobacco, Brussels).
Please contact Rachel Grana at granar@mail.nih.gov with any questions or comments about the conference.
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