Tobacco substitutes

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Health Topics
Tobacco substitutes

1
Overview
When quitting smoking many people feel the need
for help in the form of a tobacco substitute. There
are a wide variety of
different products billed as alternatives to smoking
that are supposedly healthier.

2
Overview
The main additive in cigarettes that makes them
so addictive is
nicotine. Hence most of the products that aim to
replace smoking are nicotine
replacements such as nicotine gum, inhalers,
patches and medications.

3
Overview
Other products are sold as smokeless tobacco such
as snuff and hookah or as better because they are
low yield cigarettes. Not all of these smoking
substitutes are
healthy or even better than cigarettes.

4
Chewing tobacco and Snuff
The two main types of smokeless tobacco in the
United States are chewing tobacco and snuff.
Smokeless tobacco is not a safe alternative to
smoking cigarettes.
Smokeless tobacco use can cause cancer, oral
health problems, and nicotine addiction.

5
Chewing TobaccoChewing tobacco comes in the
form of loose leaf, plug, or twist.

6
FormDescriptionUseMarket Share
(2009)**Percentage of U.S. market for smokeless
tobacco productsLoose leafCured tobacco strips
typically sweetened and packaged in foil
pouchesPiece taken from pouch and placed
between cheek and gums22.2%PlugCured tobacco
leaves pressed together into a cake or "plug" form
and wrapped in a tobacco leafPiece taken from
pouch and placed between cheek and
gums0.6%Twist (or roll)Cured tobacco leaves
(often flavored) twisted together to resemble

7
FormDescriptionUseMarket Share
(2009)**Percentage of U.S. market for smokeless
tobacco productsMoistCured and fermented
tobacco processed into fine particles and often
packaged in round cansPinch or "dip" is placed
between cheek or lip and gums75.3%DryFire-cured
tobacco processed into a powderPinch of powder
is taken orally or inhaled through the
nostrils1.4%SachetsMoist snuff packaged in ready-
to-use pouches that resemble small tea bagsSachet
is placed between cheek or teeth and gumsData

8
Health EffectsCancerSmokeless tobacco contains
28 cancer-causing agents (carcinogens).
Smokeless tobacco is a known cause of human
cancer; it increases the risk of developing cancer of
the oral cavity.

9
Oral HealthSmokeless tobacco is also strongly
associated with leukoplakia—a precancerous
lesion of the soft tissue in the mouth that consists
of a white patch or plaque that cannot be scraped
off.
Smokeless tobacco is associated with recession of
the gums, gum disease, and tooth decay.

10
Reproductive HealthSmokeless tobacco use during
pregnancy increases the risks for preeclampsia
(i.e., a condition that may include high blood
pressure, fluid retention, and swelling), premature
birth, and low birth weight.
Smokeless tobacco use by men causes reduced
sperm count and abnormal sperm cells.

11
Nicotine AddictionSmokeless tobacco use can lead
to nicotine addiction and dependence.
Adolescents who use smokeless tobacco are more
likely to become cigarette smokers.
Smokeless tobacco is not a safe substitute for
smoking cigarettes.

12
Smokeless Tobacco Use in the United
StatesPercentage of Adults Who Were Current
Smokeless Tobacco Users in 20098
3.5% all adults (aged 18 years and older)
7.0% men
0.3% women
1.0% African Americans

13
5.7% American Indian/Alaska Natives*
0.5% Asian Americans
1.1% Hispanics
4.5% whites
*2008 estimate; 2009 estimate not available

14
Percentage of High School Students who were
Current Smokeless Tobacco Users in 20099
6.1% all high school students
11.0% males
1.5% females

15
1.5% Asians
4.6% Hispanics
7.5% whites
Percentage of Middle Students who were Current
Smokeless Tobacco Users in 20099
2.6% all middle school students

16
4.1% males
1.2% females
2.0% Asians
3.4% Hispanics
2.8% whites

17
NOTE: "Current" user is defined as using smokeless
tobacco products on 1 or more of the 30 days
preceding the survey.
Tobacco Industry InformationThe five largest
tobacco manufacturers have spent record amounts
of money on smokeless tobacco advertising and
promotions:1
$547.9 million in 2008

18
The two leading smokeless tobacco brands for
users aged 12 years or older are—
Skoal® (with 25% of the market share) and

19
Copenhagen® (with 24% of the market share).

20
Hookah
-- Hookahs—sometimes called water pipes—are
used to smoke specially made tobacco that is
available in a variety of flavors (e.g., apple, mint,
cherry, chocolate, coconut, licorice, cappuccino,
and watermelon)
-- Hookah smoking is typically practiced in groups,
with the same mouthpiece passed from person to
person.

21
Hookah
-- Hookahs originated in ancient Persia and India
and have been used extensively for centuries.1,2,3
Today, hookah cafés are gaining popularity around
the globe, including Britain, France, Russia, the
Middle East, and the United States.1 An estimated
300 hookah cafés operated in the United States in
2006, and the numbers continue to grow.1 In
recent years, there has been a increase in hookah
use around the world, most notably among youth.

22
Hookah
-- Hookah is known by a number of different
names, including narghile, argileh, shisha, hubble-
bubble, and goza.
-- Hookahs vary in size, shape, and composition.
-- A typical modern hookah comprises a head (with
holes in the bottom), a metal body, a water bowl,
and a flexible hose with a mouthpiece.

23
Hookah
**Compared with Cigarettes**
While many hookah smokers may consider this
practice less harmful than smoking cigarettes,
hookah smoking carries many of the same health
risks as cigarettes.
-- Water pipe smoking delivers the addictive drug
nicotine and is at least as toxic as cigarette smoke.

24
Hookah
-- Due to the mode of smoking—including
frequency of puffing, depth of inhalation, and
length of the smoking session—hookah smokers
may absorb higher concentrations of the toxins
found in cigarette smoke.
-- A typical 1-hour-long hookah smoking session
involves inhaling 100–200 times the volume of
smoke inhaled from a single cigarette.

25
Hookah
-- Hookah smokers are at risk for the same kinds of
diseases as are caused by cigarette smoking,
including oral cancer, lung cancer, stomach cancer,
cancer of the esophagus, reduced lung function,
and decreased fertility.
**Hookah smoking is NOT a safe alternative to
smoking cigarettes.**

26
Hookah
**Health Effects Hookah Smoke and Cancer**
-- The charcoal used to heat tobacco in the hookah
increases the health risks by producing high levels
of carbon monoxide, metals, and cancer-causing
chemicals.

27
Hookah
-- Even after it has passed through water, the
smoke produced by a hookah contains high levels
of toxic compounds, including carbon monoxide,
heavy metals, and cancer-causing chemicals.
-- Hookah tobacco and smoke contain numerous
toxic substances known to cause lung, bladder, and
oral cancers.

28
Hookah
-- Irritation from exposure to tobacco juices
increases the risk of developing oral cancers. The
irritation by tobacco juice products is likely to be
greater among hookah smokers than among pipe
or cigar smokers because hookah smoking is
typically practiced (with or without inhalation)
more often and for longer periods of time.
**Other Health Effects of Hookah Smoke**

29
Hookah
-- Hookah tobacco and smoke contain numerous
toxic substances known to cause clogged arteries
and heart disease.
-- Infectious diseases may be transmitted by
sharing a hookah.

30
Hookah
-- Babies born to women who smoked one or more
water pipes a day during pregnancy have lower
birth weights (were at least 3½ ounces less) than
babies born to nonsmokers and are at an increased
risk for respiratory diseases.
**Hookahs and Secondhand Smoke**

31
Hookah
-- Secondhand smoke from hookahs poses a
serious risk for nonsmokers, particularly because it
contains smoke not only from the tobacco but also
from the heat source (e.g., charcoal) used in the
hookah.

32
Low yield cigarettes
After the landmark 1964 Surgeon General's Report
on the health consequences of smoking, cigarette
manufacturers began heavily marketing cigarettes
labeled "light," "low," and "mild" (or similar
descriptors). Cigarettes with "light/low/mild"
labels delivered less tar or nicotine in standardized
machine measurements. They were often referred
to as "potentially reduced-exposure products," and
advertisements implied that they were safer than
regular or "full-flavor" cigarettes.

33
However, due to passage of the Family Smoking
Prevention and Tobacco Control Act,
manufacturers are now prohibited from
manufacturing for sale or distribution any tobacco
products for which the label, labeling, or
advertising contains the descriptors "light," "low,"
or "mild" or any similar descriptors.

34
There is no strong scientific evidence that low-yield
cigarettes are less harmful than regular
cigarettes. Smoking cessation is the only way
smokers can avoid the health risks of smoking (see
CDC's Smoking Cessation fact sheet for more
information).
Cigarette DesignLow-yield cigarettes were defined
by measuring tar on standardized smoking
machines.

35
Cigarette brands that yield approximately 1–6 mg
of tar were historically called "ultra light."
Those with approximately 6–15 mg of tar were
called "light."
Brands yielding more than 15 mg of tar were called
"regular" or "full flavor."

36
The following cigarette design changes over the
past decades affected the tar and nicotine
measurements:
Addition of different size and density filters
Ventilation holes in the cigarettes to bring in air
and dilute the smoke measured

37
Chemical additives in the paper and/or tobacco
Tobacco (i.e., using different types, blends, and
curing methods)
Changes in cigarette design have not made
cigarettes safe.

38
No strong scientific evidence exists indicating that
changes in cigarette design have resulted in a
decrease in the diseases caused by smoking
cigarettes.
Compensatory SmokingMost smokers are addicted
to nicotine, and, consequently, compensate when
smoking low-yield cigarettes in order to take in
more nicotine than estimated by a smoking
machine.

39
Many smokers block the ventilation holes, thus
inhaling more tar and nicotine than measured by
machines.
Many smokers inhale longer, harder, and more
frequently when smoking low-yield cigarettes to
get more nicotine.

40
Smokers may get as much or more tar and nicotine
from cigarettes with low-yield ratings as from
regular cigarettes because of the ways they
compensate when smoking them.
Smokers Who Use Low-Yield CigarettesUse of low-
tar products increases dramatically as age,
education level, and income level increase.

41
Use of low-yield cigarettes is higher among women
than men.
Many smokers consider smoking low-yield
cigarettes, menthol cigarettes, or additive-free
cigarettes to be safer than smoking regular
cigarettes, even though no strong scientific
evidence exists to substantiate these beliefs.

42
Many smokers may have switched to low-yield
brands instead of quitting; smokers may be misled
by the implied promise of reduced toxicity
underlying the marketing of such brands.
Health Risks of SmokingExisting research does not
support recommending that smokers switch to
low-yield cigarettes.

43
No strong scientific evidence exists indicating that
changes in cigarette design have resulted in a
decrease in the diseases caused by cigarettes.

44
Nicotine Replacement
This medication guide was created to provide you
with a general understanding of the current
medications used by smokers who are trying to
quit. Please note that this guide may not include
every medication available. All of these
medications have been shown to be useful for
helping smokers quit. There is no one medication
that works best for all smokers. Always read the
instructions on the package carefully and talk with
your doctor or pharmacist if you have questions.
The dosing information bel

45
**First-Line Medications: Nicotine Replacement
Therapy (NRT)**These medications are called "first-line" because
many smokers use these when they first try to
quit. If the first-line medications don’t work, they
might try a "second-line" medication instead.

46
Therapy (NRT)**Nicotine replacement therapy (NRT) helps smokers
quit by reducing their craving sensations. These
craving sensations happen when the body goes
through withdrawal from the nicotine in tobacco.
NRT products provide controlled amounts of
nicotine. Individuals reduce their use of NRT
products over time, allowing their bodies to
gradually adjust to increasingly lower nicotine
levels.
Nicotine Patches-Over-the-Counter

47
Therapy (NRT)**The nicotine patch is placed on the skin and
supplies a small and steady amount of nicotine to
the body. Nicotine patches contain varied amounts
of nicotine (21 mg, 14 mg, or 7 mg, for example)
and the user reduces the dose over time.
Nicotine Gum- Over-the-Counter

48
Therapy (NRT)**Nicotine gum is chewed to release nicotine that is
absorbed through tissue inside the mouth. The
user chews the gum until it produces a tingling
feeling, then places (parks) it between the cheek
and gum tissue. Nicotine gums have varied
amounts of nicotine (typically 2 mg or 4 mg) to
allow users to reduce the amount of nicotine in
their bodies.
Nicotine Lozenges- Over-the-Counter

49
Therapy (NRT)**Nicotine lozenges look like hard candy and are
placed in the mouth to dissolve slowly. The
nicotine lozenge (typically a 2 mg or 4 mg dose of
nicotine) releases nicotine as it slowly dissolves in
the mouth.
Nicotine Inhaler- Prescription

50
Therapy (NRT)**A nicotine inhaler is a cartridge attached to a
mouthpiece. Inhaling through the mouthpiece
delivers a specific amount of nicotine to the user.
Nicotine Nasal Spray- Prescription

51
Therapy (NRT)**Nicotine nasal spray is a pump bottle containing
nicotine, which is inserted into the nose and
sprayed. Nicotine nasal spray can be used for fast
craving control, especially for heavy smokers.
**First-Line Medications: Other**
Bupropion- Prescription

52
Therapy (NRT)**Bupropion, also known as Zyban®, helps to reduce
nicotine withdrawal symptoms and the urge to
smoke. Bupropion can be used safely with nicotine
replacement products.
Varenicline Prescription

53
Therapy (NRT)**Varenicline, also known as Chantix®, is a
prescription medication that eases nicotine
withdrawal symptoms and blocks the effects of
nicotine from cigarettes if the user starts smoking
again.
**Second-Line Medications**
Nortriptyline- Prescription

54
Therapy (NRT)**Nortriptyline, also known as Aventyl®, is generally
prescribed to treat depression; however
nortriptyline has been prescribed to assist with
smoking cessation when the first-line medications
do not work. The use of nortriptyline for smoking
cessation has not been approved by the Food and
Drug Administration (FDA).
Clonidine- Prescription

55
Therapy (NRT)**Clonidine, also known as Catapres®, is generally
prescribed to treat high blood pressure; however
clonidine may reduce tobacco withdrawal
symptoms when first-line medications do not
work. The use of clonidine for smoking cessation
has not been approved by the FDA.

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