Page 24 Complete Your CE Test Online - Click Here inhale, there was a much higher death risk from oral, laryngeal, and esophageal cancer [72]. Pipes: Even though smoking tobacco in pipes may be enjoying a resurgence with people using “natural” tobacco, pipes still have about the same risks as cigars. Pipe smokers have an increased risk of death from cancer of the lung, oropharynx, esophagus, colorectum, pancreas, and larynx as well as risks for COPD and cerebrovascular disease. Pipe smoke, even when not deliberately inhaled, is concentrated around and breathed in by the smoker with all of the particulates, toxic gases, and carcinogens from burning tobacco. Although the risks are generally less than with smoking cigarettes, this is mainly due to less time smoking and less inhalation. Risk increases with years of pipe smoking, number of pipes smoked per day, and depth of inhalation [98]. Smokeless tobacco: Smokeless tobacco is tobacco that is not burned; the two best-known forms are chewing tobacco and snuff. It may be called oral tobacco, spit or spitting tobacco, dip, or chew. Most people chew or suck (dip) the tobacco in their mouth and spit out the tobacco juices that build up, although “spitless” smokeless tobacco has also been developed [193]. There are also newer forms of oral tobacco, such as dissolvable tobacco (flavored lozenges, meltaway strips, pellets, orbs, and sticks that look like toothpicks) and snus (moist snuff in small dose packs that may contain flavorings). Unfortunately, smokeless tobacco is another way for people (especially teens and youth) to try tobacco products. Some will become addicted, and it is unclear how many teens graduate to even more dangerous combustible forms of tobacco. Many of these smokeless tobacco products are easy to ingest and can pose unexpected dangers. Large doses of nicotine are toxic; overdoses can happen to teens and adults as well as kids (or pets) who unexpectedly find these products and ingest them [3]. Even though oral tobacco kills fewer people than smoking, it is still not a safe option. Smokeless tobacco causes oral cancer, esophageal cancer, and pancreatic cancer [109]. At least 28 chemicals in smokeless tobacco are carcinogens [109]. The most harmful chemicals in smokeless tobacco are the TSNAs, which are formed during the growing, curing, fermenting, and aging of tobacco. The level of TSNAs varies by product. Scientists have found that the nitrosamine level is directly related to the risk of cancer. In addition to nitrosamines, other cancer-causing substances in smokeless tobacco include polynuclear aromatic hydrocarbons (also known as polycyclic aromatic hydrocarbons, or PAHs), polonium-210, and lead-210 [109]. Radioactive elements are introduced via fertilizers that farmers use to increase the size of their tobacco crops; tobacco also contains the naturally occurring radionuclide, radium. Radium radioactively decays to release radon, which rises from the soil around the plants. The radon and its decay products cling to the sticky hairs (trichomes) on the bottom of tobacco leaves as the plant grows. The decay products include radioactive elements lead-210 and polonium-210. Rain does not wash them away, and they remain in all forms of commercial tobacco [280]. Some companies make certain smokeless products sound safe, for example, snus, at least those from Sweden, are reputed to have less TSNAs. But, U.S. tobacco companies are not required to label their products with their ingredients, and certainly not with their carcinogen levels. American snus are not processed the same way as Swedish types, and have variable TSNA levels, as do most of the new smokeless tobacco products [263]. Using smokeless tobacco may also cause heart disease, gum disease, and oral lesions other than cancer, such as leukoplakia (a white precancerous lesion) [109]. Like all forms of tobacco, smokeless is addictive because it contains nicotine, which in this case is absorbed directly through the oral mucosa [193]. Smokeless tobacco is just as difficult to quit as smoking. E-cigarettes and other electronic nicotine delivery devices: Devices such as electronic cigarettes, e-cigars, e-hookahs, and vape pens are very similar to one another but very different in composition and design from traditional cigarettes (although some are designed to look like cigars or cigarettes). They come in many shapes and sizes, but are typically comprised of a battery, a heating element, and a reservoir for a liquid solution that most often contains nicotine. Although the use of these devices is often referred to as “vaping,” the term is inaccurate. Electronic nicotine delivery devices produce an aerosol of liquid droplets, not actually a vapor. Dr. Michele Bloch, chief of the NCI’s Tobacco Control Research Branch, explains that very small particles in the aerosol can penetrate deep into the lungs, making the presence of any toxic chemicals in the aerosol potentially hazardous [159]. Electronic nicotine delivery devices are often marketed as a safer alternative to cigarettes, or as a way to cut down or quit smoking. Proponents and distributors like to point out that the main ingredients are “generally recognized as safe” by the FDA. However, most health care workers know that the FDA’s “safe” list refers to food ingredients, not components to be inhaled, which is quite different. Oils, for example, are safe to eat, but not generally safe to inhale. In addition, manufacturers do not usually list all of the ingredients in the liquids, which vary greatly by maker and flavor. Finally, while the companies typically list the amount of nicotine the product is supposed to deliver, surveys have found that this labeled amount is not always accurate: some labeled no nicotine contained fairly large amounts, and others had much less than labeled. The refill liquids are made in a number of countries, including the U.S. and China as well as European countries [303]. There are serious concerns that the flavors in the liquids – more than 7,000 have been catalogued, ranging from bacon to peanut butter chocolate – are attractive to teens, making the products a potential gateway to traditional tobacco products. There are data that suggest this is occurring. A 2013 study from the U.S. Centers for Disease Control and Prevention (CDC) found that youths who have used e-cigarettes are twice as likely to say that they might or would probably smoke conventional cigarettes than those who have never used e-cigarettes [67]. There is also a wide degree of quality in the manufacture of electronic vapor devices, a majority of which are made in China. Many Chinese manufacturing companies are not as closely regulated as their counterparts in the U.S., and brands are sometimes counterfeited [47]. There are anecdotal reports of people who have used the devices to quit smoking. However, there are much purer forms of nicotine in carefully controlled doses and safer delivery systems that can be used by people who want to quit smoking. There is even an inhalable form of nicotine available by prescription for those who want to quit smoking safely. Given all this, and the fact that they have only been around a few years, research on anything beyond short-term effects is still pending. This will be the case until these products have been in use long enough for longitudinal studies. Again, as it is known that nicotine is addictive, these are another route for people to become chronic users of nicotine. Helping your patient quit People who use tobacco should be urged to quit; even those who already have cancer can benefit from quitting. There are many forms of nicotine replacement and other drugs that have been proven to help with the physical part of quitting tobacco [194]. Individual or group counseling, telephone “quitlines” like the CDC’s 1-800-QUIT- NOW, and groups such as Nicotine Anonymous (NicA) are some of the methods that can be used to help with the emotional and mental components of quitting. There is even an online group dedicated to quitting smokeless, at Many of these methods are cost-free or partly covered by insurance.