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Karen W. Geletko, MPHFlorida State University

College of Medicine

Identify various forms, prevalence and trendsof smoking and smokeless tobacco products

Recognize and explain why these alternateforms are not a safe substitute to cigarettes

Identify health problems associated with theuse of smoking tobacco and smokelesstobacco use

While rates of cigarette smoking havedeclined, rates of usage of other tobaccoproducts have remained unchanged or evenincreased in some instances

Smoking bans and Clean Indoor Air policieshave unintentionally effected the use ofsmokeless tobacco products

Tobacco use of any kind is likely to posehealth risks

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Source: Saunders C and Geletko, KW. Adolescent use of multiple tobacco products. Nicotine Tob Res (Accepted for publication).

Smoking Tobacco:◦ Cigarettes◦ Cigars◦ Pipes◦ Bidis◦ Kreteks◦ Hookahs

Smokeless Tobacco:◦ Chewing Tobacco◦ Snuff◦ Snus◦ Dissolvable Tobacco

Products

Other Products◦ Electronic Cigarettes

TOBACCO PRODUCTS

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Cigars: Types include large cigars,cigarillos, and little cigars

Pipes: Tobacco in chamber is smoked bymouthpiece

PIPES

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Perceived as a safe alternative to cigarettesbecause they are more “natural”

Also perceived as safe if not inhaled 15% of adolescents (grades 6-12) and 15%

of adults are current cigar smokers 6% of adolescents and 2% of adults are

current pipe smokers

Addiction to nicotine Increased risk for lung and

oral cancer Gum disease and tooth

loss Those who inhale deeply –

a higher risk of coronaryheart disease and lungdiseases

Bidis are thin unfiltered hand-rolledcigarettes consisting of tobacco rolled in atendu leaf and secured with a colorful string

Kreteks also known as clove cigarettescontain a mixture of tobacco, cloves, andother additives

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BIDIS

KRETEKS

Not perceived as a “real” cigarette and thusnot harmful

Thought to be tobacco-free and/or herbalcigarettes

Gaining popularity among teens Approximately 4% of adolescents and 1.4%

of adults are current bidis or kretek users

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Nicotine addiction Increased risk for abnormal lung function

and coronary heart disease Bidis increase the risk for cancer (oral, lung,

stomach, esophageal) Kreteks can also lead to bronchitis,

pneumonia, respiratory infections, difficultybreathing

Hookahs are water pipes used to smoketobacco

Also called shisha, nargeela, kaylan, hubblebubble, or water pipe

Traditionally found in middle easterncountries, and gaining popularity in the U.S.

HOOKAH

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HOOKAH

Usually practiced in groups,with “rites” associated withpreparation of the instrumentand with the smoking itself

The hookah is the center of asocial activity of conversationand passing time

The hose is passed fromperson to person, and thesame mouthpiece is usuallyused by all of the participants

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Believed to be less harmful due to waterfiltration

More pleasant due to various flavors Marketed as less expensive than smoking

cigarettes Little data on U.S. prevalence of use◦ Rates range from 5-8% current and 11-21% ever

tried among adolescents◦ 10% current and 41% ever tired among young adults

Addiction to nicotine Increased risk for cancer and heart disease Secondhand smoke exposure Increased risk for infectious diseases such

as herpes, hepatitis, TB Hookah smoking can be a potential

predictor of cigarette smoking

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Tobacco Products

Includes chewing tobacco (chew, dip, spit),snuff, snus, and gutka

Snuff is finely ground or shredded tobaccothat can be dry or moist

Snus is finely-ground tobacco, or moistsnuff, in a sachet

Gutka is Betel quid with tobacco

MOIST SNUFF(chewing tobacco)

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DRIED SNUFF

SNUS

SNUS

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GUTKA

Common perception that smokelesstobacco is less risky than regular smoking

No published evidence that smokelesstobacco is an effective method of quittingsmoking

3% of adults and 8% of adolescents arecurrent smokeless tobacco users

Addiction to nicotine Increased risk for oral, nasal,

liver, mucosa, andpancreatic cancers

Other oral conditions such asleukoplakia, gingivalrecession and dental caries

Increased risk forhypertension

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Dissolvable tobaccoconsists of smallpieces ofcompressed, finelyground tobaccopowder, binders andflavorings that areshaped into pellets,sticks or strips

Appealing toadolescents andyounger adults

Types:◦ Ariva◦ Stonewall◦ Camel Orbs◦ Camel Sticks◦ Camel Strips◦ Marlboro Sticks◦ Skoal Sticks

DISSOLVABLE TOBACCO

DISSOLVABLE TOBACCO

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DISSOLVABLE TOBACCO

Few studies have looked specifically atdissolvable products

Some types deliver more nicotine thancigarettes

Thought to have health effects similar toother smokeless products:◦ Addiction to nicotine◦ Oral, esophageal and pancreatic cancers◦ Other oral conditions such as leukoplakia, gingival

recession and dental caries◦ Heart disease and hypertension

PRODUCTS

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Battery-operated devices that containcartridges filled with nicotine, flavor andother chemicals and turns them into a vaporthat is inhaled by the user

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http://esmoking101.com/images/verticle_ecigstyles.jpg

From http://www.e-cigarettepedia.com/wp-content/uploads/2009/02/e-cigarette-mechanics-copy-1024x627.jpg

Perceived to be less toxic than tobacco Often used as a cessation aid or used in

places where smoking is not allowed Limited data on current use General trends of users:◦ Majority male and former smokers◦ Median age of late 30’s and early 40’s◦ Majority have college degree and household income

above average

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Probably less harmful than cigarettes Contain carcinogens, including nitrosamines,

toxic chemicals Not manufactured according to the high

standards imposed on pharmaceuticalcompanies, some do not disclose ingredients

Have potential to be as effective as NRT butcurrently no data to support manufacturers’claims that e-cigarettes help smokers quit

RECOMMENDATIONS

The same cessation efforts used to helpsmokers quit cigarettes can also be appliedto other forms of tobacco◦ Especially true for smoking tobacco◦ Smokeless tobacco cessation may present more of a

challenge… Behavioral interventions can increase

abstinence rates for non-cigarette tobaccousers

As always, a combination of counseling andpharmacotherapy are most effective

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NRT may decrease cravings and short-termabstinence rates, but does not improve long-term abstinence

Bupropion may not significantly increase tobaccoabstinence rates, but has shown to be effectivein decreasing cravings and weight gain

Recent studies indicate Varenicline may beeffective in helping smokeless tobacco users quit

Behavioral interventions increase abstinencerates

Thank you!

Bidis and Kreteks• Padmavathi, P., et al., Bidis--hand-rolled, Indian cigarettes: induced biochemical changes in

plasma and red cell membranes of human male volunteers. Clin Biochem, 2009. 42(10-11): p.1041-5.

• Soldz, S. and E. Dorsey, Youth attitudes and beliefs toward alternative tobacco products: cigars,bidis, and kreteks. Health Educ Behav, 2005. 32(4): p. 549-66.

• Soldz, S., D.J. Huyser, and E. Dorsey, Characteristics of users of cigars, bidis, and kreteks andthe relationship to cigarette use. Prev Med, 2003. 37(3): p. 250-8.

• Malson, J.L., et al., Nicotine delivery from smoking bidis and an additive-free cigarette.Nicotine Tob Res, 2002. 4(4): p. 485-90.

• Robbins, L.T., Flavored cigarettes (bidis) popular among youth. NCSL Legisbrief, 2001. 9(45): p.1-2.

Dissolvable Tobacco Products• Connolly, Gregory N. et al. “Unintentional Child Poisonings Through Ingestion of Conventional

and Novel Tobacco Products”. Pediatrics. 19 April 2010.http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-2835v1

• Letter to Industry on Dissolvable Smokeless Tobacco Products (Star Scientific, Inc).http://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/ucm199711.htm

• Tobacco Products Scientific Advisory Committee.http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/default.htm

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Cigars and Pipes• Rodriguez, J., et al., The association of pipe and cigar use with cotinine levels, lung function,

and airflow obstruction: a cross-sectional study. Ann Intern Med, 2010. 152(4): p. 201-10.• McCormack, V., et al., Cigar and pipe smoking and cancer risk in the european prospective

investigation into cancer and nutrition. Int J Cancer, 2010.• Summaries for patients: Pipe and cigar smoking and lung function. Ann Intern Med, 2010.

152(4): p. I-28.• Streppel, M.T., et al., Mortality and life expectancy in relation to long-term cigarette, cigar and

pipe smoking: the Zutphen Study. Tob Control, 2007. 16(2): p. 107-13.• Wannamethee, S.G., et al., Associations between cigarette smoking, pipe/cigar smoking, and

smoking cessation, and haemostatic and inflammatory markers for cardiovascular disease. EurHeart J, 2005. 26(17): p. 1765-73.

• Shaper, A.G., S.G. Wannamethee, and M. Walker, Pipe and cigar smoking and majorcardiovascular events, cancer incidence and all-cause mortality in middle-aged British men. IntJ Epidemiol, 2003. 32(5): p. 802-8.

Electronic Cigarettes• Bullen, C., et al., Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke

and withdrawal, user preferences and nicotine delivery: randomized cross-over trial. TobControl, 2010. 19(2): p. 98-103.

• FDA Warns of Health Risks Posed by E-Cigarettes.http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM173430.pdf

Hookah• American Lung Association. An Emerging Deadly Trend: Waterpipe Tobacco Use Exit

Notification/Disclaimer Policy. Washington: American Lung Association, 2007.• Knishkowy, B., Amitai, Y. Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior

Exit Notification/Disclaimer Policy. Pediatrics. 2005;116:113–119.• World Health Organization. Tobacco Regulation Advisory Note. Water Pipe Tobacco

Smoking: Health Effects, Research Needs and Recommended Actions by Regulators ExitNotification/Disclaimer Policy. (PDF–550 KB) Geneva: World Health Organization, TobaccoFree Initiative, 2005.

• El-Hakim Ibrahim E., Uthman Mirghani AE. Squamous cell carcinoma and keratoacanthomaof the lower lips associated with "Goza" and "Shisha" smoking. International Journal ofDermatology 1999;38:108-110.

• Rastam, S., et al., Water pipe smoking and human oral cancers. Med Hypotheses, 2010.74(3): p. 457-9.

• Fouad, F.M., S. Rastam, and A.E. Al Moustafa, Involvement of water pipe smoking in thedevelopment of human pancreatic cancer. Int J Cancer, 2010. 127(2): p. 497-8.

• Dugas, E., et al., Water-pipe smoking among North American youths. Pediatrics, 2010.125(6): p. 1184-9.

• Barnett, T.E., et al., Water pipe tobacco smoking among middle and high school students.Am J Public Health, 2009. 99(11): p. 2014-9.

• Sajid, K.M., K. Chaouachi, and R. Mahmood, Hookah smoking and cancer: carcinoembryonicantigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J, 2008. 5: p. 19.

Traditional Smokeless Tobacco• Wiium, N. and L.E. Aaro, Outcome expectations and use of smokeless tobacco (snus): A

cross-sectional study among young Norwegian snus users. Scand J Psychol, 2010.• Tomar, S.L., H.R. Alpert, and G.N. Connolly, Patterns of dual use of cigarettes and

smokeless tobacco among US males: findings from national surveys. Tob Control, 2010.19(2): p. 104-9.

• Mejia, A.B., P.M. Ling, and S.A. Glantz, Quantifying the effects of promoting smokelesstobacco as a harm reduction strategy in the USA. Tob Control, 2010.

• Mejia, A.B. and P.M. Ling, Tobacco industry consumer research on smokeless tobaccousers and product development. Am J Public Health, 2010. 100(1): p. 78-87.

• Gartner, C.E. and W.D. Hall, Smokeless tobacco products: Unrecognised regulatory andpolicy opportunities. Drug Alcohol Rev, 2010. 29(2): p. 119-20.

• Ebbert, J.O., et al., Smokeless tobacco reduction with the nicotine lozenge andbehavioral intervention. Nicotine Tob Res, 2010.

• Dale LC, Ebbert JO, Schroeder DR, Croghan IT, Rasmussen DF, Trautman JA, et al.Bupropion for the treatment of nicotine dependence in spit tobacco users: A pilot study.Nicotine and Tobacco Research 2002;4(3):267-74.

• Glover E, Glover P, Sullivan C, Cerullo C, Hobbs G. A comparison of sustained-releasebupropion and placebo for smokeless tobacco cessation. American Journal of HealthBehavior 2002;26(5):386-93.