A pilot study of the acceptability of and pouch (Zonnic) in cessation • NZ background • Why consider snus ? • Pilot amongst hospitalised smokers of their CHOICE of product

Smokefree New Zealand 2025 • Smokefree environments act – All work places smokefree – Bars restaurants – All government facilities – But little impact on smoking prevalence

• 2011 Māori party enquiry into industry – NZ Government policy: – Large regular tax increases – No tobacco sales after 2025 – < 5% smokers – Plain packaging – Increase quit service and research into novel approaches both policy and cessation • 600,000 smokers need to quit over next 13 years – New approaches • Is snus of any value in this effort?? • Is snus acceptable to NZ smokers? – No history oral tobacco use • Less harmful than smoking • More harmful than NRT • Addictive

Chewing tobacco and NRT developed in Sweden 1741 Government regulated smoking Tax on smoking – Nobility and Priests – 1 taler Farm workers maids 16 ore Soldiers, boatmen and miners - exempt -snuff, – no tax

Zonnic 4 mg nicotine bound to cellulose

1 gram nitrosamine depleted tobacco (Used Sweden v low rates of cancer mouth and lung)

Summary results

Satisfying: Zonnic > snus p>0.05

Craving reduction: Zonnic > snus >> gum p>0.05 Smoking reduction: all products cf. baseline p<0.01 Zonnic 42%; snus 37%; 33% gum Gastro side-effects: gum > Zonnic + snus p<0.05 Preference: Zonnic = snus > gum 40%,40%,20% p>0.05

Smoking Cessation • 100 in hospital smokers with a smoking related condition – wanted to quit – FTND >3 – >9 /day – Enrolled tried both at visit. – Given both snus and zonnic to use ad lib for 1 week – 91 seen again after 1 week – 82 made choice • Subjects (100). 45% male – 21% Smoked during current in-patient stay – 99 tried to quit previously – 99 used NRT previously – 88 advice to quit from a professional – 56 live with a smoker – Desire to quit • No desire = 0 • Slight = 13 • Moderate = 48 • A lot = 38

Smoking Cessation • 82 subjects chose either snus or zonnic to use for 3 months

– 30% snus (25) 70% Zonnic (57) [p=0.006] – Males 40% chose snus – Females 23% chose snus N= 91 Use during 7 day trial of both products

Snus Zonnic p Median (IQ) How often Used 3.0 4.0 0.009 1= Never 5= Every Day (2-4) (3-5)

Liked product 3.0 4.0 0.006 1=Strongly dislike 5= Strongly like (2-4) (2-5)

N= 91 CES ( evaluation Scale)

Snus Zonnic p Median (IQ) Satisfaction 9.0 13.0 0.0002 3 questions (7 point Likert) (3-13) (7-17)

Aversion 2.0 2.0 0.009 Dizzy, nauseous (7 point Likert) (2-4) (2-2)

Snus (median, mean IQR) Zonnic (median, mean p-value IQR) Indigestion. 0: ‘Not at all’; 1: 0, 0.03 0, 0.02 n.s. ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a (0 to 0) (0 to 0) bit’; 4: ‘Extreme’ Heart-burn. 0: ‘Not at all’; 1: 0, 0.05 0, 0.09 n.s. ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a (0 to 0) (0 to 0) bit’; 4: ‘Extreme’ Acid reflux. 0: ‘Not at all’; 1: 0, 0.14 0, 0.08 n.s. ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a (0 to 0) (0 to 0) bit’; 4: ‘Extreme’ Burp. 0: ‘Not at all’; 1: ‘Slight’; 0, 0.21 0, 0.14 n.s. 2: ‘Moderate’; 3: ‘Quite a bit’; 4: (0 to 0) (0 to 0) ‘Extreme’ Salty. 0: ‘Not at all’; 1: ‘Slight’; 1.00, 1.14 0, 0.18 <0.001 2: ‘Moderate’; 3: ‘Quite a bit’; 4: (0 to 2.00) (0 to 0) ‘Extreme’ Diarrhoea. 0: ‘Not at all’; 1: 0, 0.02 0, 0.01 n.s. ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a (0 to 0) (0 to 0) bit’; 4: ‘Extreme’ Hiccough. 0: ‘Not at all’; 1: 0, 0.09 0, 0.13 n.s. ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a (0 to 0) (0 to 0) bit’; 4: ‘Extreme’ Cough. 0: ‘Not at all’; 1: 0, 0.11 0, 0.17 n.s. ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a (0 to 0) (0 to 0) bit’; 4: ‘Extreme’ Excess saliva. 0: ‘Not at 1.00, 0.99 0, 0.57 =0.005 all’; 1: ‘Slight’; 2: ‘Moderate’; 3: (0 to 2.00) (0 to 1.00) ‘Quite a bit’; 4: ‘Extreme’ Hurt mouth. 0: ‘Not at all’; 0, 0.33 0, 0.44 n.s. 1: ‘Slight’; 2: ‘Moderate’; 3: ‘Quite (0 to 0) (0 to 1.00) a bit’; 4: ‘Extreme’ Hurt throat. 0: ‘Not at all’; 1: 0, 0.44 0, 0.31 n.s. ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a (0 to 1.00) (0 to 0) bit’; 4: ‘Extreme’ Severity of “other” 1.00, 1.14 0.00, 0.80 n.s. side-effects. 0: ‘Not at all’; 1: (0 to 2.00) (0 to 1.00) ‘Slight’; 2: ‘Moderate’; 3: ‘Quite a bit’; 4: ‘Extreme’

% not% smoked 7 day consecutive on 7 consecutive abstinence days % abstinent 60 Snus Zonnic 50

40

30

20

10

0 0 2 4 6 8 10 months 12

Conclusions • Small pilot – cautious • Confirmed previous results • Zonnic: – more often chosen than snus – Used more per day during 7 day trial than snus – More satisfying and less aversive. – Similar side effect profile to snus

• No difference in quit rates • Pilot study funded by NZ Ministry of Health

• Vicki Ward • Angela Thie • Brent Caldwell Thank You