An International Overview of Use of Smokeless Tobacco (ST) &    Other Tobacco Products           Elizabeth E. Brait, MSS  ...
Gender Differences2002, Global Youth Tobacco Survey  • Global data on gender differences are limited  • Western society tr...
General Info: Smokeless TobaccoGlobally, smokeless tobacco use is a significanttobacco use problem   • Variability in prod...
General Info: Other Tobacco Products• Nicotine and tar content are different   – Bidis: less tobacco, higher tar, more tox...
Health Risks & Consequences Oral Cavity Lesions and Cancer• Leukoplakia to invasive Squamous Cell Carcinoma  (SCC)• 75% of...
Oral Health Effects Bad breathTooth stains  Spitting  DroolingGum recession
Other Health Effects• Increased health risk factors for cardiovascular  disease and high blood pressure• Irritation of the...
Global Toxicity Differences•   28 carcinogens, including Nitrosamine•   Nitrosamines are a group of chemical compounds in ...
Addiction• Sodium carbonate and ammonium carbonate• Increasing the free nicotine and pH levels• Novices start low then gra...
General Prevalence of Smokeless  Tobacco & Other Tobacco Products• ST products exist in all regions throughout the world• ...
Smokeless Tobacco in North America              2 Forms of Smokeless Tobacco:              Chew: loose leaf, plug, twist, ...
SAMHSA, National Survey onDrug Use and Health in USA, 2003-04• 12 years and older• Past month use was 3%• Males used ST si...
Smokeless Tobacco & Baseball in the US
Central & South America:Chimó & Other Tobacco Products               • Chimó               • What it contains?            ...
United Kingdom: ST and Other Tobacco Products                 Ethnic Groups     • No national studies for ST     • Prelimi...
United Kingdom:Smokeless Tobacco & The Bangladesh Community     • 2004 Prevalence: Some form of ST tobacco     • Males (19...
Smokeless Tobacco in Sweden                 Swedish Snus•   Moist grounded oral tobacco product•   Loose or in teabag-like...
Smokeless Tobacco in Sweden4035302520                                                 197615                              ...
Swedish Snus Use:Harm reduction or harm increasing? • Advocating snus use to reduce smoking • Why this approach may be fla...
Tobacco in Sub-Saharian Africa• Limited data available on ST and other tobacco products• Difficult to attain true estimati...
Toombak in Sub-Saharian Africa               Toombak:               – Sudanese 18yr+:                  • 34% men          ...
Challenges in Sub-Saharian Africa?• Africa struggles with control of infectious diseases  and premature mortality due to H...
Tobacco Consumption  in the Middle East      Waterpipes and maassel tobacco        – Commonplace in Arab society        – ...
SE Asia: Tobacco Products–90% of worlds population who consume tobacco products thatare not cigarettes live in this region...
India• National prevalence data are scarce• Highest oral cancer rate in the world, partly  attributed to high prevalence o...
SE Asia: Smoking Tobacco Products •   Bidis •   Kreteks •   Cheroots •   Chuttas & Reverse Chutta Smoking •   Pipes, Chilu...
SE Asia: Smokeless Tobacco Products•   Preparations vary in different regions•   A mixture of similar ingredients•   Areca...
Challenges in SE Asia• Tobacco control and advertising restrictions are  not uniform in different countries• Smuggling• Go...
Tobacco and Poverty: Bangladesh• One of the poorest nations• Tobacco expenditures exacerbate poverty• Most families unable...
Conclusion:     ST and Other Tobacco Products• High prevalence, morbidity, and mortality rates in  developing countries• R...
International Use of Smokeless Tobacco and Other Tobacco Products (2006)
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International Use of Smokeless Tobacco and Other Tobacco Products (2006)

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Researcher and Presenter, SEDET, V Jornadas de Actualización en el Control del Tabaquismo, Badajoz, Spain (2006)

• Conducted a literature review, prepared and gave a PowerPoint presentation for an international conference (May 6, 2006) titled An International Overview of Use of Smokeless Tobacco and Other Tobacco Products

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  • The WHO African region is comprised of 46 countries. 36 (78%) of which are classified as low income, 5 (11%) are low-middle, 5 (11%) are upper middle income countries according to the World Bank. Nearly 50% of Africans are under the age 15. Information about tobacco use in Africa is sparse. Data comes from scattered surveys on smoking behavior, often with limited data to select regions, populations, or urban areas. Statistics on production and trade in manufactured cigarettes are readily available. However, because of illegal trade, they can not provide a true estimation on consumption. The full extent of tobacco use is grossly under estimated if only manufactured cigarettes are used to measure consumption. What we know is: That tobacco smoking consumption is more common among men than women. In Sudan, Toombak is a smokeless tobacco product used. Toombak is used by 34% of Sudanese men and 2.5% of women aged 18 years and older. Toombak is made with include and sodium bicarbonate It is rolled into a ball, weighing about 10g, called a saffa . The saffa is held between the gum and the lip or cheek, or under the tongue on the floor of the mouth. It is sucked slowly for 10 to 15 minutes. Male users periodically spit, while female users typically swallow the saliva generated. The user generally rinses his/her mouth with water after the saffa is removed. PROCESSING / MANUFACTURING of Toombak: After the tobacco leaves are harvested and they are left in a field for uniform drying. The leaves are then tied into bundles, sprinkled with water, and stored for a couple of weeks at 30 to 45ºC to allow fermentation. The leaves are then ground up and aged for up to a year. After aging, toombak vendors (in toombak shops) place the product in bowls and gradually add sodium bicarbonate until the mixture is approximately 4 parts tobacco to 1 part sodium bicarbonate. The mixture is blended by hand and constantly tested with the tips of the fingers until it becomes moist and hardened. The toombak is then placed in an airtight container for about 2 hours prior to sale. Other African regions and smokeless tobacco: The use of snuff, pipes, and hand-rolled cigarettes are common and popular in other parts of Africa In Algeria 24% of tobacco consumption is in the form of snuff. In Senegal,, about 90% of men and 11% of women use some form of tobacco. In Kenya, it is about 67% men and 32% women use some form of tobacco product. In S. Africa as many black women use snuff as smoke cigarettes, around 10% according to WHO. During the 1990’s a study reported that in S. Africa: There was a 30% increase in the consumption of snuff, whereas cigarette tobacco began to decline after 1993, after the introduction of the 1st tobacco legislation. On average, Africans smoke less than do smokers in other regions and cigarette consumption is not growing particularly fast, and in some states it is shrinking. Smokeless tobacco consumption is commonly used through the nose and less commonly used orally and is particularly popular among black African Women with a 13.2% prevalence rate. In 1999, a study suggested that the prevalence rate among South African black children was 18.6 A local study in 2000 reported a prevalence rate among pregnant African Women who used smokeless tobacco was approximately 10%. Tobacco related mortality data: Detailed annual statistics on causes of deaths are available from less than half the countries in the world. Often in low income countries, deaths are not certified and causes are not established. There are no recent country specific estimates for smoking-related mortality data in the sub-Saharan Africa. However, using cancer registry data studies have found that tobacco is a significant cause of death in Africa. Contrary to previous beliefs. A recent unpublished case-controlled study in South Africa: Found that smoking doubled the probability of dying from tuberculosis. In 1990, tuberculosis killed over a half a million people in the sub-Saharan Africa and the toll has been rising. Therefore, the risk for lung cancer is almost as high as that in the UK. Another study in 2003, looked at differences in worldwide tobacco use by gender. The results of this study found that in 12 of 25 locations studied in Africa students ages 13 -15 had were no significant consumption differences in either cigarette smoking or use other tobacco products. Use of other tobacco products was 11% for boys and 9.2% for girls between the ages 13-15. The boy to girl ratio was 1.1 to 1.0.
  • So what are these products? Bidis: most common in Bangeldesh, Nepal, and Sri-Lanka. And are a popular form of tobacco consumption accounting for 34% of tobacco produced in India They are 8 times greater than the number of cigarettes produced in India. Bedis are made by rolling a dried, rectangular piece of temburni leaf with sun-dried flakey tobacco into a conical shape that is secured with some thread. Although, bidis contains a smaller amount of tobacco than a cigarette, they delvers 45-50 mg of tar compared to an indian manufactured cigarette that delivers about 18-28 mg of tar. They also contain higher concentration of toxic agents and delivers more nicotine than an Indian cigarette. Cheroots: are used in Myanmar and Thailand. They are small cigars made with tobacco A variant of the cheroot is known as a keeyo A study done in Thailand including 1866 individuals found that 20% were keeyo smokers. In Chaing Mai area of N. Thailand, cheroots are smoked maily by women and this form of smoking was practiced by 4.5% of the population. Kreteks: Kretek smoking originated in Indonesia in 1824. are indigenous cheroots containing tobacco, cloves, and cocoa, also known as clove cigarettes. Kretek smoking has been popular in rural areas. The tar and nicotine of kreteks are estimated to be 2 to 5 times higher than Austrailian cigarettes. In Indonesia, 3 times more kreteks are produced than cigarettes. Chuttas: Similar to cheroots. They contain tobacco rolled into a cylindrical shape and one end is tied with a string. Chuttas smoking is widespread in coastal areas of India in Andhra Pradesh, Tamil Nadu, and Orissa. These products are generally small scale or made at home, and nearly 9% of tobacco products in India are used for making these products. Reverse Chutta Smoking: is smoking the Chutta in reverse. The prevalence rate of this in Srikakulam district, Andhra Pradesh is around 46%. Resulting in high incidence of palatal cancer and specific palatal changes. Palatal changes are precancerous. Indian women who practice reverse chutta smoking, with the lighted end of the cigar inside the mouth, have particularly high rates of oral cancer of the palatal mucosa. Dhumti: is a conical cigar made by rolling leaf tobacco in a leaf of a jack-fruit tree, occasionally in a banana leaf or other plants. Unlike, bidis and chuttas, Dhumti’s are not available through vendors, but are prepared by smokers themselves. In a random sample 5400 individuals 4% were Dhumti smokers in Goa. Reverse Dhumti Smoking: Occasionally Dhumti’s are smoked with the lighted end inside the mouth. The overall prevalence of this form of smoking is 0.5% in Goa. Pipes: have a long tradition in this region. Hooklis are clay pipes commonly used in western India, it is estimated that 11% of men in Bhavagar district of Gujrat use Hookli pipes. Chilums: are a straight, conical pipes made of clay. This pipe smoking method is exclusively used by males in the northern states of India, and predominately in rural areas. A survey of 35,000 individuals in Mainpuri district, Uttar Ppradesh found that 28% of the villagers were chilum smokers. Chilum smoking requires deep pulmonary effort. These pipes are often shared and used for other substances as well such as smoking opium and other narcotics. Waterpipes and hookahs: use a receptacle to pass the smoke and both require strong pulmonary effort. Waterpipes are generally used by karen tribesmen and come in a variety of sizes. Hookahs are an indian water pipe predominately used in northern and eastern India. In a study of 622 individuals in rural Bihar India, 18% of the individuals used the hookah and 95% of them were women. This predominence was explained because women mostly stayed at home and the hookah was inconvenient to carry by men who often left the house. However, since this study, there has been some decrease in hookah smoking.
  • International Use of Smokeless Tobacco and Other Tobacco Products (2006)

    1. 1. An International Overview of Use of Smokeless Tobacco (ST) & Other Tobacco Products Elizabeth E. Brait, MSS University of Cantabria, Santander Spain V Jornadas SEDET, Badajoz, May 4-6, 2006
    2. 2. Gender Differences2002, 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
    3. 3. General Info: Smokeless TobaccoGlobally, smokeless tobacco use is a significanttobacco 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
    4. 4. 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
    5. 5. 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
    6. 6. Oral Health Effects Bad breathTooth stains Spitting DroolingGum recession
    7. 7. 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
    8. 8. Global Toxicity Differences• 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 NNK NNN Total TSNA (µg/g) (µg/g) (µg/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
    9. 9. 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
    10. 10. General Prevalence of Smokeless Tobacco & Other Tobacco Products• ST products exist in all regions throughout the world• Variations in prevalence rates worldwide
    11. 11. 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
    12. 12. SAMHSA, National Survey onDrug 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
    13. 13. Smokeless Tobacco & Baseball in the US
    14. 14. 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
    15. 15. United Kingdom: ST and Other Tobacco Products Ethnic 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
    16. 16. 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
    17. 17. Smokeless Tobacco in Sweden Swedish 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
    18. 18. Smokeless Tobacco in Sweden4035302520 197615 20021050 Male Male Snus Female Female Snus Smoking Smoking
    19. 19. 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
    20. 20. 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 estimatedAccording 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
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. SE Asia: Tobacco Products–90% of worlds population who consume tobacco products thatare not cigarettes live in this region–Integrated in traditional practices and cultural values for centuriesSmoking 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 mixturesProducts used for teeth cleaning: – mirhri, gudhaka, bajjar, and creamy snuff–Most products are made at home–Global concerns
    25. 25. 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
    26. 26. SE Asia: Smoking Tobacco Products • Bidis • Kreteks • Cheroots • Chuttas & Reverse Chutta Smoking • Pipes, Chilums, Waterpipes & Hookahs
    27. 27. 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
    28. 28. Challenges in SE Asia• Tobacco control and advertising restrictions are not uniform in different countries• Smuggling• Governmental role in tobacco production and exportation
    29. 29. 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
    30. 30. 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

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