Alternative Tobacco Products-Geltko [Read-On

3/8/2012
Karen W. Geletko, MPH
Florida State University
College of Medicine
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Identify various forms, prevalence and trends
of smoking and smokeless tobacco products
Recognize and explain why these alternate
forms are not a safe substitute to cigarettes
Identify health problems associated with the
use of smoking tobacco and smokeless
tobacco use
While rates of cigarette smoking have
declined, rates of usage of other tobacco
products have remained unchanged or even
increased in some instances
Smoking bans and Clean Indoor Air policies
have unintentionally effected the use of
smokeless tobacco products
Tobacco use of any kind is likely to pose
health risks
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Source: Saunders C and Geletko, KW. Adolescent use of multiple tobacco products. Nicotine Tob Res (Accepted for publication).
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Smoking Tobacco:
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Cigarettes
Cigars
Pipes
Bidis
Kreteks
Hookahs
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Smokeless Tobacco:
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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 by
mouthpiece
PIPES
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Perceived as a safe alternative to cigarettes
because 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 coronary
heart disease and lung
diseases
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Bidis are thin unfiltered hand-rolled
cigarettes consisting of tobacco rolled in a
tendu leaf and secured with a colorful string
Kreteks also known as clove cigarettes
contain a mixture of tobacco, cloves, and
other additives
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BIDIS
KRETEKS
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Not perceived as a “real” cigarette and thus
not harmful
Thought to be tobacco-free and/or herbal
cigarettes
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, difficulty
breathing
Hookahs are water pipes used to smoke
tobacco
Also called shisha, nargeela, kaylan, hubble
bubble, or water pipe
Traditionally found in middle eastern
countries, and gaining popularity in the U.S.
HOOKAH
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HOOKAH
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Usually practiced in groups,
with “rites” associated with
preparation of the instrument
and with the smoking itself
The hookah is the center of a
social activity of conversation
and passing time
The hose is passed from
person to person, and the
same mouthpiece is usually
used by all of the participants
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Believed to be less harmful due to water
filtration
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
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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 tobacco
that can be dry or moist
 Snus is finely-ground tobacco, or moist
snuff, 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
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Common perception that smokeless
tobacco is less risky than regular smoking
No published evidence that smokeless
tobacco is an effective method of quitting
smoking
3% of adults and 8% of adolescents are
current smokeless tobacco users
Addiction to nicotine
Increased risk for oral, nasal,
liver, mucosa, and
pancreatic cancers
Other oral conditions such as
leukoplakia, gingival
recession and dental caries
Increased risk for
hypertension
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Dissolvable tobacco
consists of small
pieces of
compressed, finely
ground tobacco
powder, binders and
flavorings that are
shaped into pellets,
sticks or strips
Appealing to
adolescents and
younger adults
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Types:
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Ariva
Stonewall
Camel Orbs
Camel Sticks
Camel Strips
Marlboro Sticks
Skoal Sticks
DISSOLVABLE TOBACCO
DISSOLVABLE TOBACCO
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DISSOLVABLE TOBACCO
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Few studies have looked specifically at
dissolvable products
Some types deliver more nicotine than
cigarettes
Thought to have health effects similar to
other 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 contain
cartridges filled with nicotine, flavor and
other chemicals and turns them into a vapor
that is inhaled by the user
http://esmoking101.com/images/verticle_ecigstyles.jpg
From http://www.e-cigarettepedia.com/wp-content/uploads/2009/02/e-cigarette-mechanics-copy-1024x627.jpg
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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 pharmaceutical
companies, some do not disclose ingredients
Have potential to be as effective as NRT but
currently no data to support manufacturers’
claims that e-cigarettes help smokers quit
RECOMMENDATIONS
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The same cessation efforts used to help
smokers quit cigarettes can also be applied
to 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 tobacco
users
 As always, a combination of counseling and
pharmacotherapy are most effective
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NRT may decrease cravings and short-term
abstinence rates, but does not improve longterm abstinence
Bupropion may not significantly increase tobacco
abstinence rates, but has shown to be effective
in decreasing cravings and weight gain
Recent studies indicate Varenicline may be
effective in helping smokeless tobacco users quit
Behavioral interventions increase abstinence
rates
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Thank you!
Bidis and Kreteks
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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 and
the 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
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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/TobaccoProductsScien
tificAdvisoryCommittee/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. Eur
Heart J, 2005. 26(17): p. 1765-73.
Shaper, A.G., S.G. Wannamethee, and M. Walker, Pipe and cigar smoking and major
cardiovascular events, cancer incidence and all-cause mortality in middle-aged British men. Int
J Epidemiol, 2003. 32(5): p. 802-8.
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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. Tob
Control, 2010. 19(2): p. 98-103.
FDA Warns of Health Risks Posed by E-Cigarettes.
http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM173430.pdf
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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 Exit
Notification/Disclaimer Policy. (PDF–550 KB) Geneva: World Health Organization, Tobacco
Free Initiative, 2005.
El-Hakim Ibrahim E., Uthman Mirghani AE. Squamous cell carcinoma and keratoacanthoma
of the lower lips associated with "Goza" and "Shisha" smoking. International Journal of
Dermatology 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 the
development 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: carcinoembryonic
antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J, 2008. 5: p. 19.
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Traditional Smokeless Tobacco
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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 smokeless
tobacco as a harm reduction strategy in the USA. Tob Control, 2010.
Mejia, A.B. and P.M. Ling, Tobacco industry consumer research on smokeless tobacco
users 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 and
policy opportunities. Drug Alcohol Rev, 2010. 29(2): p. 119-20.
Ebbert, J.O., et al., Smokeless tobacco reduction with the nicotine lozenge and
behavioral 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-release
bupropion and placebo for smokeless tobacco cessation. American Journal of Health
Behavior 2002;26(5):386-93.
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