Smokeless tobacco

Last updated
A historical depiction of a man taking snuff using his thumb and forefinger Schnupfer corrected.jpg
A historical depiction of a man taking snuff using his thumb and forefinger

Smokeless tobacco is a tobacco product that is used by means other than smoking. [1] Their use involves chewing, sniffing, or placing the product between gum and the cheek or lip. [1] Smokeless tobacco products are produced in various forms, such as chewing tobacco, snuff, snus, and dissolvable tobacco products. [2] Smokeless tobacco is widely used in South Asia and this accounts for about 80% of global consumption. [3] All smokeless tobacco products contain nicotine [4] and are therefore highly addictive. [5] Quitting smokeless tobacco use is as challenging as smoking cessation. [6]

Contents

Using smokeless tobacco can cause various harmful effects such as dental disease, oral cancer, oesophagus cancer, and pancreas cancer, coronary heart disease, as well as negative reproductive effects including stillbirth, premature birth and low birth weight. [5] [7] Smokeless tobacco poses a lower health risk than traditional combusted products. [8] However it is not a healthy alternative to cigarette smoking. [6] The level of risk varies between different types of products (e.g., low nitrosamine Swedish-type snus versus other smokeless tobacco with high nitrosamine levels) and producing regions. [9] [8] There is no safe level of smokeless tobacco use. [6] Globally it contributes to 650 000 deaths each year. [10]

Smokeless tobacco products typically contain over 3000 constituents, [11] which includes multiple cancer-causing chemicals. [6] Approximately 28 chemical constituents present in smokeless tobacco can cause cancer, among which nitrosamine is the most prominent. [12]

Smokeless tobacco consumption is widespread throughout the world. [12] Once addicted to nicotine from smokeless tobacco use, many people, particularly young people, expand their tobacco use by smoking cigarettes. [6] Males are more likely than females to use smokeless tobacco. [6]

Types

1894 Kinetoscope of Fred Ott taking a snuff and then sneezing, taken by Thomas Edison's laboratory
Dipping tobacco is placed between the lip and the gum (sublabial administration). Dipping tobacco in mouth.jpg
Dipping tobacco is placed between the lip and the gum (sublabial administration).

Most smokeless tobacco use involves placing the product between the gum and the cheek or lip. [1] Smokeless tobacco is a noncombustible tobacco product. [1]

Types of smokeless tobacco include:

Since there are varied manufacturing methods, products can differ greatly in chemical arrangement and nicotine level. [17] Smokeless tobacco products typically contain over 3000 constituents which play a part in their taste as well as scent. [11]

Nicotine levels

Smokeless tobacco differs depending on the type of product, the types of tobacco used, and the amount of each tobacco type used within a product. Each variable results in different level of nicotine. Furthermore, nicotine is absorbed by the body to different degrees depending on the pH level of the product, which is known as the free nicotine or unionized nicotine level.[ citation needed ]

Below are some measured nicotine levels of various smokeless tobacco products from 2006 and 2007 and their corresponding free nicotine levels as calculated by the Henderson–Hasselbalch equation. [18]

ProductNicotine (mg/g)Free Nicotine (mg/g)Free Nicotine (% of total nicotine)pHTypeFormYear
Ariva3.900.7017.957.36dissolvable, drypieces2007
Stonewall Natural8.191.1714.237.24dissolvable, drypieces2007
Beech-nut Chewing Tobacco7.070.020.355.56loose leafloose2006
Hawken Wintergreen2.920.010.225.37loose leafcut2007
Lancaster Premium Chewing Tobacco8.010.010.115.05loose leafloose2007
Levi Garrett Chewing Tobacco5.340.061.196.10loose leafloose2006
Red Man Chewing Tobacco8.580.080.885.97loose leafloose2006
Red Man Golden Chewing Tobacco7.700.060.725.88loose leafloose2006
Stoker Chew Apple Chewing Tobacco3.770.010.225.37loose leafloose2007
Taylor's Pride6.430.060.905.98plugone cut2006
Catch Dry Eucalyptus15.931.398.727.00snuff, drypouch2006
Catch Dry Licorice16.700.684.096.65snuff, drypouch2006
Skoal Dry11.912.3920.087.42snuff, drypouch2007
Taboka16.730.362.146.36snuff, drypouch2007
Taboka Green13.010.483.666.60snuff, drypouch2007
Bruton Scotch Snuff17.490.492.806.48snuff, drypowder2006
Dental Sweet Snuff11.140.131.196.10snuff, drypowder2006
Levi Garrett Snuff16.600.070.425.65snuff, drypowder2007
Railroad Mills Plain Scotch Snuff23.130.482.096.35snuff, drypowder2007
Red Seal Sweet Snuff15.080.402.626.45snuff, drypowder2007
Camel Frost13.254.7035.467.76snuff, moistpouch2006
Camel Frost14.104.7133.397.72snuff, moistpouch2007
Camel Original13.874.7033.907.73snuff, moistpouch2006
Camel Original13.496.2045.987.95snuff, moistpouch2007
Camel Spice13.166.6550.588.03snuff, moistpouch2006
Camel Spice13.166.6550.588.03snuff, moistpouch2007
Cooper Long Cut Wintergreen7.971.0913.687.22snuff, moistlong cut2007
Copenhagen12.683.2125.317.55snuff, moistfine cut2006
Copenhagen Long Cut13.915.3838.697.82snuff, moistlong cut2006
Copenhagen Pouches11.216.8160.778.21snuff, moistfine cut2006
General Loose7.151.8726.197.57snuff, moistcoarse2006
General Original Portion8.465.1060.228.20snuff, moistpouch2006
General White Portion7.924.8160.778.21snuff, moistpouch2006
Grizzly Long Cut Wintergreen10.296.5964.018.27snuff, moistlong cut2006
Grizzly Long Cut Wintergreen11.205.8652.308.06snuff, moistlong cut2007
Husky Fine Cut Natural12.864.7737.067.79snuff, moistfine cut2007
Kayak Long Cut Wintergreen11.882.2618.997.39snuff, moistlong cut2007
Kodiak Premium Wintergreen10.936.5259.668.19snuff, moistlong cut2006
Kodiak Premium Wintergreen10.708.1876.398.53snuff, moistlong cut2007
Longhorn Long Cut Wintergreen13.795.7241.457.87snuff, moistlong cut2007
Red Seal Fine Cut Natural13.173.1123.617.51snuff, moistfine cut2007
Renegades Wintergreen13.362.4017.957.36snuff, moistpouch2007
Skoal Fine Cut Original13.313.8528.957.63snuff, moistfine cut2006
Skoal Long Cut Cherry12.701.6713.157.20snuff, moistlong cut2006
Skoal Long Cut Mint12.933.6828.477.62snuff, moistlong cut2006
Skoal Long Cut Straight13.373.9429.427.64snuff, moistlong cut2006
Skoal Long Cut Wintergreen12.842.8722.387.48snuff, moistlong cut2006
Timberwolf Long Cut Wintergreen14.135.1636.537.78snuff, moistlong cut2007

Health effects

Various national and international health organizations, including the World Health Organization, the US National Cancer Institute, the UK Royal College of Physicians, stated that, even if it is less dangerous than smoking, using smokeless tobacco is addictive, represents a major health risk, has no safe level use and is not a safe substitute for smoking. [19] [20] [21] [22]

Using smokeless tobacco can cause a number of adverse health effects such as dental disease, oral cancer, oesophagus cancer, and pancreatic cancer, cardiovascular disease, asthma, and deformities in the female reproductive system. [12] It also raises the risk of fatal coronary artery disease, fatal stroke and non-fatal ischaemic heart disease [5] [7]

Globally it contributes to 650 000 deaths each year with a significant proportion of them in Southeast Asia. [10]

Smoking cessation and harm reduction

Quitting smokeless tobacco use is as challenging as smoking cessation. [6] There is no scientific evidence that using smokeless tobacco can help a person quit smoking. [21] [23]

It is not recommended to use any smokeless tobacco product as part of a harm reduction strategy. [19] [23] Tobacco companies that sell smokeless tobacco products promote them as harm reduction products and a less harmful substitute to cigarettes. [24] This creates a false perception of safety while real risk reduction can be achieved by smoking less. [19]

Safety

A can of Copenhagen with a warning label Theo Cope 121610.jpg
A can of Copenhagen with a warning label

Smokeless tobacco products vary extensively worldwide in both form and health hazards. The level of health risk varies between different types of products (e.g., low nitrosamine Swedish-type snus versus other smokeless tobacco with high nitrosamine levels from South Asia). [9] [8]

Even though smokeless tobacco poses a lower health risk than traditional combusted products, contrary to common belief it is not a "safe" alternative to conventional tobacco. [25] [6] There is no safe level of smokeless tobacco use. [6]

The declines in smokeless tobacco initiation among adolescents and young adults is particularly relevant to improving their health because smokeless tobacco use is often linked to subsequent cigarette initiation. [6] Smokeless tobacco users can experience negative health consequences at any age. [6] Youth use of tobacco in any form is unsafe. [26]

Cancer

Graphic from the 2016 Centers for Disease Control and Prevention report entitled Smokeless Tobacco: Health Effects Tobacco cancer.png
Graphic from the 2016 Centers for Disease Control and Prevention report entitled Smokeless Tobacco: Health Effects

Smokeless tobacco (including products where tobacco is chewed) is a cause of oral cancer, oesophagus cancer, and pancreas cancer. [5] Increased risk of oral cancer caused by smokeless tobacco is present in countries such as the United States but particularly prevalent in Southeast Asian countries where the use of smokeless tobacco is common. [28] [29]

Smokeless tobacco can cause white or gray patches inside the mouth (leukoplakia) that can develop into oral cancer. [27] [12]

Carcinogens

All tobacco products, including smokeless, contain cancer-causing chemicals. [6] [12] These carcinogenic compounds occurring in smokeless tobacco vary widely, and depend upon the kind of product and how it was manufactured. [4] There are 28 known cancer-causing substances in smokeless tobacco products. [4]

Carcinogenic compounds in smokeless tobacco belong primarily to three groups of compounds: tobacco-specific nitrosamines (TSNA), N-nitrosoamino acids and N-nitrosamines. Among these TSNAs are the most abundant in smokeless tobacco and the most carcinogenic. [4] [12] N-nitrosonornicotine and ketone are group 1 carcinogens to humans. [24] These two nitrosamines found in smokeless tobacco products are the main agents for the majority of cancers in smokeless tobacco users. [24]

Products such as 3-(methylnitrosamino)-proprionitrile, nitrosamines, and nicotine initiate the production of reactive oxygen species in smokeless tobacco, eventually leading to fibroblast, DNA, and RNA damage with carcinogenic effects in the mouth of tobacco consumers. [12] The metabolic activation of nitrosamine in tobacco by cytochrome P450 enzymes may lead to the formation of N-nitrosonornicotine, a major carcinogen, and micronuclei, which are an indicator of genotoxicity. These effects lead to further DNA damage and, eventually, oral cancer. [12]

Other chemicals found in tobacco can also cause cancer. [27] These include the radioactive element polonium-210 found in tobacco fertilizer. [27] Harmful chemicals are also formed when tobacco is cured with heat (polycyclic aromatic hydrocarbons). [27] Furthermore tobacco contains harmful metals such as arsenic, beryllium, cadmium, chromium, cobalt, lead, nickel, and mercury. [27]

The amounts of nicotine in saliva from using smokeless tobacco could be at amounts that can be toxic to cells in the oral cavity. [30]

Cardiovascular disease

Using smokeless tobacco increases the risk of fatal coronary heart disease and stroke. [5] [7] Use of smokeless tobacco also seems to greatly raise the risk of non-fatal ischaemic heart disease among users in Asia, although not in Europe. [5]

Effects during pregnancy

Smokeless tobacco can cause adverse reproductive effects including stillbirth, premature birth, low birth weight. [5] [27] Nicotine in smokeless tobacco products that are used during pregnancy can affect how a baby's brain develops before birth. [27]

Management

Due to the harm caused by smokeless tobacco, it use might lead to the need for management or treatment. Some medications that show some benefits are varenicline and nicotine lozenges. Some behavioural interventions may also help. [31]

Prevalence

More than 300 million people are using smokeless tobacco worldwide. [32] People of many regions, including India, Pakistan, other Asian countries, and North America, have a long history of smokeless tobacco use. [12] Once addicted to nicotine from smokeless tobacco use, many people, particularly young people, expand their tobacco use by smoking cigarettes. [6] Because young people who use smokeless tobacco can become addicted to nicotine, they may be more likely to also become cigarette smokers. [27] Youth are particularly susceptible to starting smokeless tobacco use. [19]

United States

Males were more likely than females to have used smokeless tobacco in the past month. [6] In 2014, 3.3 percent of people aged 12 or older (an estimated 8.7 million people) used smokeless tobacco in the past month. Past month smokeless tobacco use remained relatively stable between 2002 and 2014. [6] Past month smokeless tobacco use between 2002 and 2014 was mostly consistent among adults aged 26 or older. [6] There was more variability in the percentages of young adults aged 18 to 25 and adolescents aged 12 to 17 who used smokeless tobacco between 2002 and 2014. [6] Smokeless tobacco use for adolescents aged 12 to 17 was higher during the mid-2000s, but the 2014 estimates were closer to the lower levels seen in the early 2000s. [6] In 2014, an estimated 1.0 million people aged 12 or older used smokeless tobacco for the first time in the past year; this represents 0.5 percent of people who had not previously used smokeless tobacco. [6] Prevalence of smokeless tobacco types that contain areca nut is increasing in the Western Pacific. [11]

In 2016 about 2 of every 100 middle school students in the US (2.2%) reported current use of smokeless tobacco. [26] In 2016 nearly 6 of every 100 high school students in the US (5.8%) reported current use of smokeless tobacco. [26]

Public policy

WHO FCTC policies

The WHO Framework Convention on Tobacco Control (FCTC) contains a set of common goals, minimum standards for tobacco control policy in the 168 countries which signed it. The FCTC policies are also applicable for smokeless tobacco however they are less implemented in regards to these products. Only 57 countries have policies regulating smokeless tobacco use. 13 countries and the European Union apply a ban for advertising and promoting smokeless tobacco. The sale of smokeless tobacco to minors (Article 16 of FCTC) is restricted only in 13 countries and the WHO-defined Eastern Mediterranean region. 11 countries use taxation and pricing measures (Article 6) to reduce use in the general population. [33]

In countries where they are applied to smokeless tobacco, FCTC policies had a positive impact on reducing their use. If multiple policies, including large taxes, are implemented, premature deaths can be prevented. However if taxation is higher for smoking products only people might switch to cheaper alternatives like smokeless tobacco. [33]

Banning

The manufacture, distribution and sale of smokeless tobacco is banned completely in Bhutan, Singapore, and Sri Lanka. Partial bans on import and sales on some products are in effect in Australia, Bahrain, Brazil, India, Iran, Tanzania, Thailand, New Zealand, the UK and the European Union. [33]

History

Smokeless tobacco was first discussed in the English language in 1683 as a powdered tobacco for breathing into the nose. [34] People have used it for over a thousand years. [34] Cigarette manufacturers have penetrated the smokeless tobacco market. [35]

Positions of medical organizations

As long ago as 1986, the advisory committee to the Surgeon General concluded that the use of smokeless tobacco "is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous oral conditions and can lead to nicotine addiction and dependence". [21] According to a 2002 report by the Royal College of Physicians, "As a way of using nicotine, the consumption of non-combustible tobacco is of the order of 10–1,000 times less hazardous than smoking, depending on the product". [22] A panel of experts convened by the National Institutes of Health (NIH) in 2006 stated that the "range of risks, including nicotine addiction, from smokeless tobacco products may vary extensively because of differing levels of nicotine, carcinogens, and other toxins in different products". [21] In 2010 the National Cancer Institute stated that "because all tobacco products are harmful and cause cancer, the use of all of these products should be strongly discouraged. There is no safe level of tobacco use. People who use any type of tobacco product should be urged to quit". [21] In 2015 the American Cancer Society stated that "Using any kind of spit or smokeless tobacco is a major health risk. It's less lethal than smoking tobacco, but less lethal is a far cry from safe." [20] In 2017 the World Health Organization states that "Smokeless tobacco use is a significant part of the overall world tobacco problem." [19]

Public perceptions

Many people who use smokeless tobacco may think it is safer than smoking, but all tobacco products contain toxicants, and use of smokeless tobacco poses its own significant health risks. [6] In South and South-East Asia these products are considered part of the cultural heritage and there is little enthusiasm for regulation. Around 80% of users live in these regions. [36]

See also

Related Research Articles

<span class="mw-page-title-main">Nicotine</span> Chemical stimulant produced by some plants

Nicotine is a naturally produced alkaloid in the nightshade family of plants and is widely used recreationally as a stimulant and anxiolytic. As a pharmaceutical drug, it is used for smoking cessation to relieve withdrawal symptoms. Nicotine acts as a receptor agonist at most nicotinic acetylcholine receptors (nAChRs), except at two nicotinic receptor subunits where it acts as a receptor antagonist.

<span class="mw-page-title-main">Gutka</span> Tobacco preparation chewed in South Asia

Gutka, ghutka, guṭkha is a type of betel quid and chewing tobacco preparation made of crushed areca nut, tobacco, catechu, paraffin wax, slaked lime and sweet or savory flavourings, in India, Pakistan, other Asian countries, and North America.

<span class="mw-page-title-main">Snus</span> Moist tobacco product placed under the upper lip

Snus is a Swedish tobacco product and non-tobacco nicotine product consumed by placing a pouch of powdered tobacco leaves or powdered non-tobacco plant fibers under the lip for nicotine to be absorbed through the oral mucosa. Whereas the nicotine in tobacco-based snus derives from tobacco leaves, the nicotine in non-tobacco snus can be either naturally or synthetically synthesized.

<span class="mw-page-title-main">Nicotine replacement therapy</span> Treatment for tobacco use disorder

Nicotine replacement therapy (NRT) is a medically approved way to treat people with tobacco use disorder by taking nicotine through means other than tobacco. It is used to help with quitting smoking or stopping chewing tobacco. It increases the chance of quitting tobacco smoking by about 55%. Often it is used along with other behavioral techniques. NRT has also been used to treat ulcerative colitis. Types of NRT include the adhesive patch, chewing gum, lozenges, nose spray, and inhaler. The use of multiple types of NRT at a time may increase effectiveness.

<span class="mw-page-title-main">Nitrosamine</span> Organic compounds of the form >N–N=O

In organic chemistry, nitrosamines are organic compounds with the chemical structure R2N−N=O, where R is usually an alkyl group. They feature a nitroso group bonded to a deprotonated amine. Most nitrosamines are carcinogenic in nonhuman animals. A 2006 systematic review supports a "positive association between nitrite and nitrosamine intake and gastric cancer, between meat and processed meat intake and gastric cancer and oesophageal cancer, and between preserved fish, vegetable and smoked food intake and gastric cancer, but is not conclusive".

<span class="mw-page-title-main">Chewing tobacco</span> Type of smokeless tobacco product

Chewing tobacco is a type of smokeless tobacco product that is placed between the cheek and lower gum to draw out its flavor. It consists of coarsely chopped aged tobacco that is flavored and often sweetened; it is not ground fine like dipping tobacco. Unwanted juices are spat while chewing.

Nicotine gum is a chewing gum containing the active ingredient nicotine polacrilex. It is a type of nicotine replacement therapy (NRT) used alone or in combination with other pharmacotherapy for smoking cessation and for quitting smokeless tobacco.

<span class="mw-page-title-main">Dipping tobacco</span> Finely ground smokeless tobacco product

Dipping tobacco is a type of finely ground or shredded, moistened smokeless tobacco product. It is commonly and idiomatically known as dip. Dipping tobacco is used by placing a pinch, or "dip", of tobacco between the lip and the gum. The act of using it is called dipping. Dipping tobacco is colloquially called chaw, snuff, rub, or fresh leaf among other terms; because of this, it is sometimes confused with other tobacco products—namely dry snuff.

<i>N</i>-Nitrosonornicotine Chemical compound

N-Nitrosonornicotine (NNN) is a tobacco-specific nitrosamine produced during the curing and processing of tobacco.

<span class="mw-page-title-main">Health effects of tobacco</span> Circumstances, mechanisms, and factors of tobacco consumption on human health

Tobacco products, especially when smoked or used orally, have serious negative effects on human health. Smoking and smokeless tobacco use is the single greatest cause of preventable death globally. As many as half of people who smoke tobacco or use it orally die from complications related to such use. It has been estimated that each year, in total about 6 million people die from tobacco-related causes, with 600,000 of these occurring in non-smokers due to secondhand smoke. It is further estimated to have caused 100 million deaths in the 20th century.

<span class="mw-page-title-main">Snuff (tobacco)</span> Smokeless tobacco type

Snuff is a type of smokeless tobacco product made from finely ground or pulverized tobacco leaves. It is snorted or "sniffed" into the nasal cavity, delivering nicotine and a flavored scent to the user. Traditionally, it is sniffed or inhaled lightly after a pinch of snuff is either placed onto the back surface of the hand, held pinched between thumb and index finger, or held by a specially made "snuffing" device.

Tobacco harm reduction (THR) is a public health strategy to lower the health risks to individuals and wider society associated with using tobacco products. It is an example of the concept of harm reduction, a strategy for dealing with the use of drugs. Tobacco smoking is widely acknowledged as a leading cause of illness and death, and reducing smoking is vital to public health.

<span class="mw-page-title-main">Flavored tobacco</span> Tobacco product with added flavorings

Flavored tobacco products — tobacco products with added flavorings — include types of cigarettes, cigarillos and cigars, hookahs and hookah tobacco, various types of smokeless tobacco, and more recently electronic cigarettes. Flavored tobacco products are especially popular with youth and have therefore become targets of regulation in several countries.

Tobacco-specific nitrosamines (TSNAs) comprise one of the most important groups of carcinogens in tobacco products, particularly cigarettes and fermented dipping snuff.

<span class="mw-page-title-main">Naswar</span> Dipping tobacco

Naswār, also called nās, nāsor or nasvay, is a moist, powdered tobacco dip consumed mostly in Afghanistan, and surrounding countries, including Pakistan, India and neighboring Central Asian republics. Naswar is stuffed in the floor of the mouth under the lower lip, or inside the cheek, known as butt style stuffing, for extended periods of time, usually for 15 to 30 minutes. It is similar to dipping tobacco and snus. Swabi, Bannu, Dera Ismail Khan, Charsadda, Mohmand and Herat are renowned for their production of some of the highest quality Naswar.

Dissolvable tobacco is a smokeless tobacco product that dissolves in the mouth. Major tobacco manufacturers that sell dissolvable tobacco products include R. J. Reynolds Tobacco Company. Research into health effects of dissolvable and other new tobacco products was among the reasons of the establishment of the Tobacco Products Scientific Advisory Committee of the Food and Drug Administration in 2009.

The health effects of electronic cigarettes (e-cigarettes) include a range of potential risks such as exposure to toxic chemicals, the possibility of increased likelihood of respiratory and cardiovascular diseases, and concerns about their possible role in cancer development. Upon their introduction, there were marketing claims that they were a safer alternative to traditional tobacco products.

A heated tobacco product (HTP) is a tobacco product that heats the tobacco at a lower temperature than conventional cigarettes. These products contain nicotine, which is a highly addictive chemical. The heat generates an aerosol or smoke to be inhaled from the tobacco, which contains nicotine and other chemicals. HTPs may also contain additives not found in tobacco, including flavoring chemicals. HTPs generally heat tobacco to temperatures under 600 °C (1100 °F), a lower temperature than conventional cigarettes.

The chemical constituents of different types of snus vary, and population-level studies suggest that the disease risks vary as well. Using snus is harmful to health, although much less than smoking tobacco.

References

  1. 1 2 3 4 "Smokeless Tobacco Products, Including Dip, Snuff, Snus, and Chewing Tobacco". United States Food and Drug Administration. 7 May 2018.PD-icon.svg This article incorporates text from this source, which is in the public domain .
  2. Czoli, Christine D; Fong, Geoffrey T; Mays, Darren; Hammond, David (2016). "How do consumers perceive differences in risk across nicotine products? A review of relative risk perceptions across smokeless tobacco, e-cigarettes, nicotine replacement therapy and combustible cigarettes". Tobacco Control. 26 (e1): tobaccocontrol–2016–053060. doi:10.1136/tobaccocontrol-2016-053060. ISSN   0964-4563. PMID   27625408. S2CID   3367137.
  3. Smokeless tobacco, South Asia. "Smokeless tobacco use in South Asia" (PDF).
  4. 1 2 3 4 Drope, Jeffrey; Cahn, Zachary; Kennedy, Rosemary; Liber, Alex C.; Stoklosa, Michal; Henson, Rosemarie; Douglas, Clifford E.; Drope, Jacqui (2017). "Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine". CA: A Cancer Journal for Clinicians. 67 (6): 449–471. doi: 10.3322/caac.21413 . ISSN   0007-9235. PMID   28961314.
  5. 1 2 3 4 5 6 7 Vidyasagaran, A. L.; Siddiqi, K.; Kanaan, M. (2016). "Use of smokeless tobacco and risk of cardiovascular disease: A systematic review and meta-analysis" (PDF). European Journal of Preventive Cardiology. 23 (18): 1970–1981. doi:10.1177/2047487316654026. ISSN   2047-4873. PMID   27256827. S2CID   206820997.
  6. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Lipari, R. N; Van Horn, S. L (31 May 2017). "Trends in Smokeless Tobacco Use and Initiation: 2002 to 2014". Substance Abuse and Mental Health Services Administration. PMID   28636307.{{cite journal}}: Cite journal requires |journal= (help)PD-icon.svg This article incorporates text from this source, which is in the public domain .
  7. 1 2 3 Gupta, Ruchika; Gupta, Sanjay; Sharma, Shashi; Sinha, Dhirendra N; Mehrotra, Ravi (2019-01-01). "Risk of Coronary Heart Disease Among Smokeless Tobacco Users: Results of Systematic Review and Meta-Analysis of Global Data". Nicotine & Tobacco Research. 21 (1): 25–31. doi:10.1093/ntr/nty002. ISSN   1469-994X. PMC   6941711 . PMID   29325111.
  8. 1 2 3 Hajat, C.; Stein, E.; Ramstrom, L.; Shantikumar, S.; Polosa, R. (4 December 2021). "The health impact of smokeless tobacco products: a systematic review". Harm Reduction Journal. 18 (1): 123. doi: 10.1186/s12954-021-00557-6 . ISSN   1477-7517. PMC   8643012 . PMID   34863207.
  9. 1 2 Abrams, David B.; Glasser, Allison M.; Pearson, Jennifer L.; Villanti, Andrea C.; Collins, Lauren K.; Niaura, Raymond S. (2018). "Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives". Annual Review of Public Health. 39 (1): 193–213. doi: 10.1146/annurev-publhealth-040617-013849 . ISSN   0163-7525. PMC   6942997 . PMID   29323611. Creative Commons by small.svg  This article incorporates text by David B. Abrams, Allison M. Glasser, Jennifer L. Pearson, Andrea C. Villanti, Lauren K. Collins, and Raymond S. Niaura available under the CC BY 4.0 license.
  10. 1 2 Sinha, Dhirendra N; Suliankatchi, Rizwan A; Gupta, Prakash C; Thamarangsi, Thaksaphon; Agarwal, Naveen; Parascandola, Mark; Mehrotra, Ravi (2016). "Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: systematic review and meta-analysis". Tobacco Control. 27 (1): tobaccocontrol–2016–053302. doi:10.1136/tobaccocontrol-2016-053302. ISSN   0964-4563. PMID   27903956. S2CID   10968200.
  11. 1 2 3 Lauterstein, Dana; Hoshino, Risa; Gordon, Terry; Watkins, Beverly-Xaviera; Weitzman, Michael; Zelikoff, Judith (2014). "The Changing Face of Tobacco Use Among United States Youth". Current Drug Abuse Reviews. 7 (1): 29–43. doi:10.2174/1874473707666141015220110. ISSN   1874-4737. PMC   4469045 . PMID   25323124.
  12. 1 2 3 4 5 6 7 8 9 Niaz, Kamal; Maqbool, Faheem; Khan, Fazlullah; Bahadar, Haji; Ismail Hassan, Fatima; Abdollahi, Mohammad (2017). "Smokeless tobacco (paan and gutkha) consumption, prevalence, and contribution to oral cancer". Epidemiology and Health. 39: e2017009. doi:10.4178/epih.e2017009. ISSN   2092-7193. PMC   5543298 . PMID   28292008. Creative Commons by small.svg  This article incorporates text by Kamal Niaz, Faheem Maqbool, Fazlullah Khan, Haji Bahadar, Fatima Ismail Hassan, Mohammad Abdollahi available under the CC BY 4.0 license.
  13. Kinyanjui, Maureen (22 May 2023). "'Kuber is killing families!' Concerned Alai warns government". Mpasho. Retrieved 27 December 2023.
  14. "Smokeless tobacco (SLT) products". extranet.who.int. Retrieved 2024-02-23.
  15. Saddichha, Sahoo; Khess, Christoday Raja Jayant (January 2010). "Prevalence of tobacco use among young adult males in India: a community-based epidemiological study". The American Journal of Drug and Alcohol Abuse. 36 (1): 73–77. doi:10.3109/00952990903575814. ISSN   1097-9891. PMID   20141401.
  16. Ratsch, A; Steadman, KJ; Bogossian, F (2010). "The pituri story: a review of the historical literature surrounding traditional Australian Aboriginal use of nicotine in Central Australia". Journal of Ethnobiology and Ethnomedicine. 6: 26. doi: 10.1186/1746-4269-6-26 . PMC   2944156 . PMID   20831827.
  17. Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi, Giuseppe (2013). "E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism". Seminars in Thrombosis and Hemostasis. 40 (1): 060–065. doi: 10.1055/s-0033-1363468 . ISSN   0094-6176. PMID   24343348.
  18. Borgerding M F, Bodnar J A, Curtin , Swauger (2012). "The chemical composition of smokeless tobacco: A survey of products sold in the United States in 2006 and 2007". Regulatory Toxicology and Pharmacology. 64 (3): 367–387. doi:10.1016/j.yrtph.2012.09.003. PMID   23000415.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. 1 2 3 4 5 "Recommendation on smokeless tobacco products" (PDF). World Health Organization. 2017. pp. 1–9.
  20. 1 2 "Health Risks of Smokeless Tobacco". American Cancer Society. 13 November 2015.
  21. 1 2 3 4 5 "Smokeless Tobacco and Cancer". United States Department of Health and Human Services. National Cancer Institute at the National Institutes of Health. 25 October 2010.PD-icon.svg This article incorporates text from this source, which is in the public domain .
  22. 1 2 Royal College of Physicians of London. Tobacco Advisory Group (2002). Protecting Smokers, Saving Lives: The Case for a Tobacco and Nicotine Regulatory Authority. Royal College of Physicians. pp. 5–. ISBN   978-1-86016-177-3.
  23. 1 2 ERS (2019-05-29). "ERS Position Paper on Tobacco Harm Reduction". ERS - European Respiratory Society. Retrieved 2024-05-30.
  24. 1 2 3 Gupta, Alpana K.; Tulsyan, Sonam; Bharadwaj, Mausumi; Mehrotra, Ravi (2019). "Grass roots approach to control levels of carcinogenic nitrosamines, NNN and NNK in smokeless tobacco products". Food and Chemical Toxicology. 124: 359–366. doi:10.1016/j.fct.2018.12.011. ISSN   0278-6915. PMID   30543893. S2CID   56485210.
  25. Christen AG, McDonald JL, Olson BL, Christen JA (1989). "Smokeless tobacco addiction: a threat to the oral and systemic health of the child and adolescent". Pediatrician (Review). 16 (3–4): 170–7. PMID   2692003.
  26. 1 2 3 "Youth and Tobacco Use". Centers for Disease Control and Prevention. 20 September 2017.PD-icon.svg This article incorporates text from this source, which is in the public domain .
  27. 1 2 3 4 5 6 7 8 9 "Smokeless Tobacco: Health Effects". Centers for Disease Control and Prevention. 1 December 2016.PD-icon.svg This article incorporates text from this source, which is in the public domain .
  28. Aupérin A (May 2020). "Epidemiology of head and neck cancers: an update". Current Opinion in Oncology. 32 (3): 178–186. doi:10.1097/CCO.0000000000000629. PMID   32209823. S2CID   214644380.
  29. Wyss AB, Hashibe M, Lee YA, Chuang SC, Muscat J, Chen C, et al. (November 2016). "Smokeless Tobacco Use and the Risk of Head and Neck Cancer: Pooled Analysis of US Studies in the INHANCE Consortium". American Journal of Epidemiology. 184 (10): 703–716. doi:10.1093/aje/kww075. PMC   5141945 . PMID   27744388.
  30. Holliday, Richard S; Campbell, James; Preshaw, Philip M. (2019). "Effect of nicotine on human gingival, periodontal ligament and oral epithelial cells. A systematic review of the literature". Journal of Dentistry. 86: 81–88. doi:10.1016/j.jdent.2019.05.030. ISSN   0300-5712. PMID   31136818. S2CID   169035502.
  31. Ebbert, JO; Elrashidi, MY; Stead, LF (26 October 2015). "Interventions for smokeless tobacco use cessation". The Cochrane Database of Systematic Reviews. 2015 (10): CD004306. doi:10.1002/14651858.CD004306.pub5. PMC   6793613 . PMID   26501380.
  32. Rostron, Brian L; Chang, Joanne T; Anic, Gabriella M; Tanwar, Manju; Chang, Cindy M; Corey, Catherine G (2018). "Smokeless tobacco use and circulatory disease risk: a systematic review and meta-analysis". Open Heart. 5 (2): e000846. doi:10.1136/openhrt-2018-000846. ISSN   2053-3624. PMC   6196954 . PMID   30364426.
  33. 1 2 3 "WHO | Updated status of the WHO Framework Convention on Tobacco Control". 17 November 2004. Archived from the original on 17 November 2004. Retrieved 12 December 2021.{{cite web}}: CS1 maint: bot: original URL status unknown (link)
  34. 1 2 Schivo, Michael; Avdalovic, Mark V.; Murin, Susan (February 2014). "Non-Cigarette Tobacco and the Lung". Clinical Reviews in Allergy & Immunology. 46 (1): 34–53. doi:10.1007/s12016-013-8372-0. ISSN   1080-0549. PMID   23673789. S2CID   23626872.
  35. Levy, David T.; Cummings, K. Michael; Villanti, Andrea C.; Niaura, Ray; Abrams, David B.; Fong, Geoffrey T.; Borland, Ron (2017). "A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products". Addiction. 112 (1): 8–17. doi:10.1111/add.13394. ISSN   0965-2140. PMC   5079857 . PMID   27109256.
  36. Siddiqi, Kamran (5 April 2019). "Smokeless tobacco products flying under the radar of regulation in many countries". The Conversation. Retrieved 20 May 2019.