Smokeless tobacco

A historical depiction of a man taking snuff using his thumb and forefinger.

Dipping tobacco is placed directly in the mouth.

1894 Kinetoscope of Fred Ott taking a snuff and then sneezing, taken by Thomas Edison's laboratory.

Smokeless tobacco is tobacco or a tobacco product that is used by means other than smoking. These uses include chewing, sniffing, placing the product between the teeth and gum, or application to the skin. Smokeless tobacco products are produced in various forms, such as chewing tobacco, snuff, snus, and dissolvable tobacco products. All smokeless tobacco products contain nicotine. It is highly addictive. Quitting smokeless tobacco use is as challenging as smoking cessation.

According to a 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". It is correlated with a number of adverse effects such as dental disease, oral cancer, oesophagus cancer, and pancreas cancer, as well as adverse reproductive effects including stillbirth, premature birth and low birth weight. There is no safe level of smokeless tobacco use. Smokeless tobacco products contain cancer-causing chemicals. Approximately 28 chemical constituents present in smokeless tobacco are carcinogenic in nature, among which nitrosamine is the most prominent. Smokeless tobacco accounts for an abundance of deaths globally with a significant proportion of them attributed to Southeast Asia.

Smokeless tobacco consumption is widespread throughout the world. Once addicted to nicotine from smokeless tobacco use, many people, particularly young people, expand their tobacco use by smoking cigarettes. Males were more likely than females to have used smokeless tobacco in the past month.

Types

Types of smokeless tobacco include:

• Dipping tobacco, a type of tobacco that is placed between the lower or upper lip and gums
• Chewing tobacco, a type of tobacco that is chewed
• Iqmik, an Alaskan tobacco product which also contains punk ash
• Snuff, a type of tobacco that is inhaled or "snuffed" into the nasal cavity
• Snus, similar to dipping tobacco although the tobacco is placed under the upper lip and there is no need for spitting
• Creamy snuff, a fluid tobacco mixture marketed as a dental hygiene aid, albeit used for recreation
• Naswar, an Afghan tobacco product similar to dipping tobacco
• Tobacco gum, a kind of chewing gum containing tobacco
• Gutka, a mixture of tobacco, areca nut, and various flavoring sold in South Asia
• Dissolvable tobacco, a variation on chewing tobacco that completely dissolves in the mouth
• Toombak and shammah, preparations found in North Africa, East Africa, and the Arabian peninsula
• Topical tobacco paste, a paste applied to the skin and absorbed through the dermis

Since there are varied manufacturing methods, products can differ greatly in chemical arrangement and nicotine level.

Prevalence

More than 300 million people are using smokeless tobacco worldwide. People of many regions, including India, Pakistan, other Asian countries, and North America, have a long history of smokeless tobacco use. Once addicted to nicotine from smokeless tobacco use, many people, particularly young people, expand their tobacco use by smoking cigarettes. Quitting smokeless tobacco use is as challenging as smoking cessation.

Males were more likely than females to have used smokeless tobacco in the past month. 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. Past month smokeless tobacco use between 2002 and 2014 was mostly consistent among adults aged 26 or older. 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. 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. 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.

Safety

Smokeless tobacco products vary extensively worldwide in both form and health hazards, with some evidently toxic forms such as from South Asia, and some forms with less hazards such as snus from Sweden. It is correlated with a number of adverse effects such as dental disease, oral cancer, oesophagus cancer, and pancreatic cancer, as well as adverse reproductive effects including stillbirth, premature birth, low birth weight, cardiovascular disease, asthma, and deformities in the women reproductive system. A correlation was identified between smokeless tobacco and risk of fatal coronary artery disease and fatal stroke. 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.

According to a 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". Smokeless tobacco is not a healthy alternative to cigarette smoking. There is no safe level of smokeless tobacco use. The declines in smokeless tobacco initiation among adolescents and young adults is particularly relevant to improving the health of the nation because smokeless tobacco use is often linked to subsequent cigarette initiation. Smokeless tobacco users can experience these negative health consequences at any age. Smokeless tobacco accounts for an abundance of deaths globally with a significant proportion of them attributed to Southeast Asia.

Cancer

All tobacco products contain toxicants, and smokeless tobacco products contain cancer-causing chemicals. The carcinogenic compounds occurring in smokeless tobacco vary widely, which rely upon the kind of product and how it was manufactured. A 2017 review found "Overall, 28 carcinogens have been rigorously identified across a range of major smokeless tobacco products, primarily from 3 groups of compounds: nonvolatile, alkaloid-derived TSNAs; N-nitrosoamino acids; and volatile N-nitrosamines. Among these carcinogens, researchers identify TSNAs as the most abundant in smokeless tobacco and the most carcinogenic." 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. 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. The World Health Organization has classified smokeless tobacco products as human carcinogenic compounds, in particular tobacco-specific nitrosamines, which account for 76 to 91% of the total N-nitroso compound (NOC) burden.

See also

• Herbal smokeless tobacco
• Tobacco
• Electronic cigarette, a cigarette-shaped product that vaporizes nicotine
• Herbal cigarette
• Tobacco usage in sport