An International Overview of Use of Smokeless Tobacco (ST) &

Other Tobacco Products

Elizabeth E. Brait, MSSUniversity of Cantabria, Santander Spain

V Jornadas SEDET, Badajoz, May 4-6, 2006

Gender Differences 2002, Global Youth Tobacco Survey

• Global data on gender differences are limited

• Western society trends shows female smoking is increasing

• Tobacco companies recognize this untapped market

General Info: Smokeless Tobacco

Globally, smokeless tobacco use is a significant tobacco use problem

• Variability in products & use patterns• High prevalence in some countries • Oral use more common• Health hazards (oral lesions, cancers, dental

diseases, cardiovascular, diabetes, reproductive health effects, and mortality)

• Lack of research and evaluation• Youth more vulnerable• Leads to nicotine addiction and dependence

General Info: Other Tobacco Products

• Nicotine and tar content are different– Bidis: less tobacco, higher tar, more toxic, more nicotine

– Kreteks: tar and nicotine are 2-5 times more than an Australian cigarette

• Less control of product toxicity

• Health Hazards– Bidi and kreteks use is associated with cancer causing effects

– Pipes, chillums and hookah smoking require deep pulmonary effort, increases risk cancers

– Spread of tuberculosis and viruses (herpes, hepatitis)

• Products also lead to nicotine addiction and dependence

Health Risks & Consequences Oral Cavity Lesions and Cancer

• Leukoplakia to invasive Squamous Cell Carcinoma (SCC)

• 75% of daily uses get Leukoplakia in their mouth

• Most dangerous prognosis

• Survival rates (30-100%)

• Oral cancer is 4 times more likely to occur in ST users

• More men more than women

• Long-term ST users, 65-years or older

Oral Health Effects

Bad breath

Tooth stains

Spitting

Drooling

Gum recession

Other Health Effects

• Increased health risk factors for cardiovascular disease and high blood pressure

• Irritation of the stomach• Can cause adverse reproductive outcomes

– 2004, a study done in India, pregnant women using ST gave birth to newborns with low birth weight

• 28 carcinogens, including Nitrosamine

• Nitrosamines are a group of chemical compounds in ST

• NNK, most toxic tobacco specific nitrosamine

• High levels can cause cancer and tobacco related mortality

• Nitrosamine levels in ST products vary significantly throughout the world

Global Toxicity Differences

NNK

(g/g)

NNN

(g/g)

Total TSNA

(g/g)

Sweden 0.5 - 2.1 1.1 - 5.7 2.8 - 11.2

Sudan 188 – 7870 241 - 3808

USA 0.2 – 17.0 3 - 41 4 - 128

Addiction

• Sodium carbonate and ammonium carbonate

• Increasing the free nicotine and pH levels

• Novices start low then graduate to brands with higher levels of free nicotine

• Increasing the pH level can increase the snuff users nicotine absorption rate

• Absorption rate is the key determinant of the addiction potential

• Flavors are added to make ST products more palatable

General Prevalence of Smokeless Tobacco & Other Tobacco Products

• ST products exist in all regions throughout the world• Variations in prevalence rates worldwide

Smokeless Tobacco in North America

2 Forms of Smokeless Tobacco:

Chew: loose leaf, plug, twist, or brick

Snuff: fine grained tobacco, often in teabag-like pouches

Users pinch or dip and place in cheek or between lower lip and gum, and suck on tobacco juice

SAMHSA, National Survey on Drug Use and Health in USA, 2003-04

• 12 years and older• Past month use was 3%• Males used ST significantly more than females • Native American/Native Alaskan had highest

prevalence rate• Other high risk groups• Education and employment status were clear

predictors for use

Smokeless Tobacco & Baseball in the US

Central & South America: Chimó & Other Tobacco Products

• Chimó• What it contains?• How it is used?• Who uses it?• Other parts of Latin

America• Reverse smoking

United Kingdom: ST and Other Tobacco ProductsEthnic Groups

• No national studies for ST• Preliminary data only on ethnic groups in the

UK• Smoking rates vary between ethnic groups • Lack of understanding and perception about the

toxicity of tobacco • An on-going concern

United Kingdom:Smokeless Tobacco & The Bangladesh Community

• 2004 Prevalence: Some form of ST tobacco• Males (19%), Females (26%)• 80% of adults chewed betel quid regularly• Majority of females and half males incorporated

tobacco into the quid• 20% of women use burnt tobacco leaves as a

dentrifice• Limited data on ethnic recording with cancer registry• High rates of oral cancer among S. Asian

populations in UK

Smokeless Tobacco in SwedenSwedish Snus

• Moist grounded oral tobacco product

• Loose or in teabag-like pouches

• Product is placed behind the upper lip and sucked on

• Made from a different selection of tobacco product

• Different curing method than in the USA

• Swedish snus has lower levels of tobacco specific cancer causing nitrosamines and lower pH levels

Smokeless Tobacco in Sweden

0

5

10

15

20

25

30

35

40

MaleSmoking

Male Snus FemaleSmoking

Female Snus

19762002

Swedish Snus Use: Harm reduction or harm increasing?

• Advocating snus use to reduce smoking• Why this approach may be flawed?• Encouraging ST use can have some harmful

effects– Promotes and encourages adoption of ST use– Can increase smoking initiation– People who quit tobacco, may not do so– Health effects from ST remain unclear– All ST products are addictive

Tobacco in Sub-Saharian Africa

• Limited data available on ST and other tobacco products

• Difficult to attain true estimation because of illegal trade

• Cigarette production and manufacturing data offers an estimation of tobacco consumption

• Overall consumption is grossly under estimated

According to World Health Organization:

• Tobacco smoking is more common among men

• African’s smoke less than in other regions

• Nasally use by Black African Women

Toombak in Sub-Saharian Africa

Toombak: – Sudanese 18yr+:

• 34% men• 2.5% women

– How it is used

Other African regions– Other tobacco products– Little difference between

male and female use rates

Challenges in Sub-Saharian Africa?

• Africa struggles with control of infectious diseases and premature mortality due to HIV/AIDS

• No tobacco laws or industry regulations in many countries in Africa

• Perceived as a safe alternative to smoking cigarettes

• Not mandated to disclose nicotine content or delivery capability of ST products

Tobacco Consumption in the Middle East

Waterpipes and maassel tobacco

– Commonplace in Arab society

– Prevalence data is scarce

– Increasing use

– Perceived as less harmful

– More socially acceptable for females

Shammah

– Chew tobacco

– Limited research

– Leukoplakia and oral cancer

SE Asia: Tobacco Products

Smoking tobacco products: – bidis, cheroots, kreteks,chuttas, reverse chutta smoking, Dhumti, reverse

dhumti smoking, pipe, hookli, chilum, waterpipe, and hookah.

Non-smoking tobacco products:– pan (betel quid) with tobacco, pan masala, tobacco with areca nut and

slated lime in various mixtures

Products used for teeth cleaning:– mirhri, gudhaka, bajjar, and creamy snuff

–90% of worlds population who consume tobacco products that are not cigarettes live in this region–Integrated in traditional practices and cultural values for centuries

–Most products are made at home–Global concerns

India

• National prevalence data are scarce• Highest oral cancer rate in the world, partly

attributed to high prevalence of ST use• 30 - 40% tobacco consumption is ST• Most of which is Nicotiana Rustica• Higher concentrates of tobacco specific

nitrosamines

SE Asia: Smoking Tobacco Products

• Bidis• Kreteks • Cheroots• Chuttas & Reverse Chutta Smoking• Pipes, Chilums, Waterpipes & Hookahs

SE Asia: Smokeless Tobacco Products

• Preparations vary in different regions

• A mixture of similar ingredients

• Areca nut increases salivation, red saliva, a stimulant

• Smokeless products (Pattiwala, Khaini, Mainpuri, Mawa, Gutkha, Dry snuff, Naswar or Niswar)

• Preparations used for teeth cleaning, breath freshening, oral antiseptic (Mishri, gudhaku, bajjar, and gul)

• Prepared at home and used by women more

• Higher level of oral cancer, highly addictive, high carcinogenicity

• Increases mouth ulcers, rotting teeth and gums, can lead to total removal of teeth

Challenges in SE Asia

• Tobacco control and advertising restrictions are not uniform in different countries

• Smuggling • Governmental role in tobacco production and

exportation

Tobacco and Poverty: Bangladesh

• One of the poorest nations• Tobacco expenditures exacerbate poverty• Most families unable to provide basic needs• Tobacco spending often out weights basic need

spending• Co-existing with a thriving tobacco industry• Prevalence is high, especially among the

poorest people• Tobacco control and poverty reduction

Conclusion: ST and Other Tobacco Products

• High prevalence, morbidity, and mortality rates in developing countries

• Research and tobacco regulations are limited• Real menace is the tobacco industry• Targeting already smokers

– Switch from Other Products to cigarettes

• Increase female smoking– Extensive research conducted on female smoking patterns, needs,

and product preferences– Products designs and advertising promotions with female style

characteristics– Using themes important to women

• Association between tobacco and poverty