Article-Journal Extended Abstract 1)
A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.
BACKGROUND Tobacco use is projected to kill 1 billion people during the 21st century. While the majority will likely be killed by their use of cigarettes, tobacco use in other forms also contributes to worldwide morbidity and mortality.1 Table 1 lists a selection of different classes of non-cigarette forms of tobacco use, including smoked products, smokeless products and also non-tobacco delivery of nicotine.2 Such products have historically been treated differently from cigarettes for tax and regulatory purposes, and often have longer histories of use than manufactured cigarettes. All forms of tobacco use have negative health consequences, though the severity of those consequences can vary substantially among products.1 There is evidence that some tobacco and nicotine products may pose less of a health hazard than cigarette smoking and so could potentially play a role in reducing morbidity and mortality due to smoking.3 However, there is evidence that the public broadly misperceives the relative risks of smoking, tobacco use and nicotine, erroneously thinking smoked tobacco products (eg, waterpipes, cigars, pipes) are less hazardous than cigarettes while believing smokeless forms to be as or more hazardous, and overestimating the health effects due to nicotine.4-8 The current paper attempts to describe non-cigarette forms of tobacco as threats to and potential opportunities for public health and tobacco control. This paper is not intended to thoroughly review all tobacco product characteristics, their health effects, or usage patterns. Rather, it aims to use recent history to inform where opportunities and challenges for tobacco control and public health may arise.
|Table 1 Examples of non-cigarette forms of tobacco and nicotine use|
|Cigars||Chewing tobacco||Nicotine replacement therapy|
|Pipes||Moist snuff||Electronic nicotine delivery devices|
|Kreteks||Betel quid (with tobacco)|
Non-tobacco nicotine delivery
Of course, use of tobacco products is not the only way humans can self-administer nicotine. Around the world, nicotine-containing medications have been approved in several forms:
transdermal patches, gum, lozenges, sublingual tablets, inhalers and nasal sprays. (The nicotine in such medications is ultimately derived from tobacco, rather than synthesised in the laboratory.)
All of these products have undergone numerous randomised controlled trials and have demonstrated safety and efficacy in increasing the likelihood of cessation. In most countries, nicotine replacement therapies (NRTs) are approved for brief use (12 weeks) for cessation of smoking, though the UK has recently expanded its indications to assist smokers in reducing their cigarette consumption. The WHO in 2009 added NRT (patches and gum) to its Essential Medicines list, a testament to its safety and efficacy track record and in recognition of the public health need for efficacious smoking cessation treatments in the context of the Framework Convention on Tobacco Control (FCTC). A number of authors have made the case for NRTs as harm reduction products for smokers unable or unwilling to quit.139 147-150 There is emerging evidence that a substantial minority of NRT use is for reasons other than cessation151 152 with little evidence of abuse by non-tobacco users.
A broad class of products has also emerged over the last two decades that claim to provide nicotine apart from traditional tobacco or pharmaceutical sources. In the 2000s, for example, several websites began offering nicotine lollipops and lip balms, which were rejected by US regulators as unapproved drugs and abuses of the compounding privilege afforded to pharmacists. A related product concept marketed several times in different forms is bottled water containing nicotine.
Other products have included ‘tobacco gel’ substitutes for cigarettes, made from tobacco extracts and delivering nicotine transdermally. However, these ‘underground’ products have tended not to attract much market share.
Electronic nicotine delivery systems (ENDS) Electronic nicotine delivery systems (ENDS), however, upset this trend. Emerging in 2006 in China, they became more widely available throughout the world in 2008-2009.158-160 These devices, often constructed to resemble cigarettes, work by vapourising a solution containing nicotine dissolved with flavourants in a carrier medium (usually propylene glycol).
The products have typically been promoted as having reduced health risk compared to tobacco use and able to be used in situations where smoking is prohibited. The product occupies an interesting place with respect to harm reduction; unlike the case of medicinal nicotine products or even Swedish snus, where data on relative harms are plentiful, data on ENDS are lacking.161 On the one hand, nicotine delivered by vapour with few known toxicants should theoretically carry relatively low risks, particularly when compared to cigarettes.162 The limited data available suggest that the products are not likely to approach the health hazards of cigarettes. However, on the other hand, significant concerns exist with the purity of ingredients employed, device functionality and quality control, the ease with which devices can be modified by users, and the general lack of oversight in manufacturing or marketing. Additionally, the nicotine deliveries of ENDS tested thus far have been significantly lower than that of cigarettes, raising questions of whether they can substitute effectively over the long term. Survey studies with self-selected users indicate that ENDS users have used them to quit smoking cigarettes, but thus far no randomised controlled trials have been published.161 167 168 ENDS availability and promotion has prompted vociferous debate within the tobacco control community of a level commensurate with that surrounding LNST.160 169 …
Could non-cigarette tobacco or nicotine products attract new markets? The dominance of the cigarette may be wavering in certain markets, even as cigarette manufacturers enter new markets.
Clearly, waterpipes are growing in popularity worldwide, fed by attractive flavours, imagery and perceptions of safety.67 BAT, Swedish Match, RJ Reynolds and Philip Morris believe at least some smokers may be attracted to smokeless tobacco.172 193 They have acquired smokeless tobacco manufacturers and/or introduced smokeless tobacco products, often linked to established cigarette brand names. Historical context also suggests that populations can shift with regard to their preferred delivery systems for nicotine.194 195 Use of chewing and snuffing tobacco products was impacted by anti-spitting laws enacted in the late 1800s and early 1900s to combat the spread of tuberculosis and other infectious diseases.194 Smoked products then became acceptable substitutes. A century later, the pendulum appears to be swinging in the opposite direction, particularly as the health hazards of passive smoking were established. Cigarette smoking is becoming a stigmatised behaviour as prevalence declines and restrictions proliferate.196-199 Since smokeless tobacco use, particularly in its spitless forms, is less visible to others, it may carry less social stigma than does smoking. Medicinal nicotine and ENDS may have similar advantages vis a vis social acceptability. So, social pressures being applied to cigarette use could contribute to making non-cigarette tobacco relatively more attractive to those addicted to nicotine. And as noted earlier, increasing cigarette taxes (and therefore prices) may make substitution of less taxed tobacco products evermore economically attractive so long as product differentials in tax treatment persist.
An interesting case study to watch is how ENDS have 159 160achieved notoriety. ENDS have spread via the internet and pressure groups and trade associations created to promote them.200 A community of users (‘vapers’) has emerged, facilitated by the internet and social networking, arguing forcefully for light regulation, if any, for the product (eg, Consumer Advocates for Smoke-free Alternatives Association). Message boards (eg, Vapor Talk Forum) allow users to exchange experiences, as well as to obtain information about modifying ENDS and sharing ‘how to’ instructions. The ease of peer-to-peer communication facilitated by the internet may allow novel product use to diffuse more widely than by traditional channels.201 Peer-to-peer communication can be an effective form of persuasion. If one considers a ‘diffusion of innovations’ framework, this makes perfect sense; early adopters are often highly influential in driving new product use and popularising niche products.202 The ENDS issue may reflect broader trends in social networking and the promotion of tobacco products. Internal documents indicate that R.J. Reynolds explored viral strategies to market its Eclipse reduced risk cigarette,203 and there is evidence that tobacco companies have been directly and indirectly marketing via social media.204-206 Message boards for Camel Snus showed that participants advised one another on product use, purchase locations and suggestions on improving the product.206 These developments may have implications for how research findings and regulatory actions regarding tobacco products are communicated and understood in the 21st century.
That is, scientists and public health advocates may increasingly have to rely on alternative strategies to disseminate informationinto the public sphere, complementing the traditional outlets ofjournal publications and government reports.207 Translating knowledge to regulators and the public, who will increasinglycommunicate among themselves, may require much more direct and ‘real-time’ engagement by tobacco control scientists.
CONCLUSIONS AND RESEARCH AGENDA
A wide variety of non-cigarette forms of tobacco and nicotine exist, ranging from smoked forms to smokeless forms to tobacco-free nicotine. Non-cigarette forms of tobacco are widely available, and their use varies regionally and globally. Smoked forms of tobacco such as bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and associtated health hazards, with some clearly toxic forms (eg, in South Asia), and some forms with far fewer hazards (eg, in Sweden). A market is also burgeoning for nicotine delivery systems not directly reliant on tobacco (eg, ENDS). Broadly, while there is a continuum of risk for tobacco products, public perceptions and indeed regulatory schemes do not often coincide with actual risk.1e3 Regulations under the FCTC and the US FDA may occasion a shift away from cigarettes towards other forms of tobacco use, and these regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by reducing attractiveness and/or toxicity. Research needs in tobacco control may shift if non-cigarette tobacco products grow in popularity around the world. It will be important to make sure that independent science is available to guide governments in making evidence based decisions, as it has for the past 20 years of tobacco control activity. Below is a list of priority areas where greater research effort could be directed: