Page 7 Complete Your CE Test Online - Click Here ● ● Bidis, small, flavored, hand-rolled cigarettes from southeast Asia, that are wrapped in a tendu or temburni leaf, and often secured with a colorful string at the end. ● ● Kreteks, or cigarettes made with tobacco, cloves, and other flavors. These were banned by the 2009 Family Smoking Prevention and Tobacco Control Act due to their clove flavoring but have recently been re-introduced into the U.S. as “little cigars.” ● ● Cigars, including little cigars and cigarillos. ● ● Smokeless tobacco. ● ● Electronic nicotine delivery systems, such as e-cigarettes, vape pens, and other vapor systems. These alternative products are increasingly being used by teens and young adults. Between 2000 and 2011, the consumption of other combustible tobacco products has increased 123% (that increase does not include smokeless and vapor products). Younger people adopt alternative tobacco products for a number of reasons [117]: ● ● The products are not well-regulated. ● ● There is the mistaken perception that the products are safer or more natural than cigarettes. ● ● The products are flavored to make them more palatable to nonsmokers. ● ● They often cost less than cigarettes. ● ● Many of these products are not even labeled as harmful to health. Given that most current adult smokers started when they were in their teens or youth, this does not bode well for the future of cancer prevention. Historically, out of every three young smokers, one will quit, and one will die of a tobacco-related illness. Electronic cigarettes and other vape products have not been well researched regarding their long-term health hazards [117]. Cigars, hookahs, bidis, and kreteks all carry the known health risks of combustible tobacco, very much like cigarettes. Smokeless tobacco has known cancer risks, but some of the other oral tobacco products (e.g. tobacco lozenges, orbs, strips, sticks, and meltaways) need more research on their health effects. The one thing all of these alternative products have in common is that they deliver nicotine and are addictive. Cigars: While cigarette consumption declined by one-third in the U.S. between 2000 and 2011, cigar consumption doubled. Cigar smoke has higher levels of tobacco-specific nitrosamines (TSNAs) than cigarettes and higher levels of carbon monoxide, and carries much the same risk as cigarettes and other combustible tobacco [72]. Most cigars are composed of air-cured and fermented tobacco, with a tobacco wrapper. They can vary in size and shape and contain between one and 20 grams of tobacco. Cigars sold in the U.S. are categorized by size [155]: ● ● Large cigars can measure more than seven inches in length, and they typically contain between five and 20 grams of tobacco. Some premium cigars contain the tobacco equivalent of an entire pack of cigarettes. Large cigars can take between one to two hours to smoke. ● ● Cigarillos are a type of smaller cigar. They are somewhat bigger than little cigars and cigarettes and contain about three grams of tobacco. ● ● Little cigars are about the same size and shape as cigarettes, are often packaged like cigarettes (20 little cigars in a package), and contain about one gram of tobacco. Also, unlike large cigars, some little cigars have a filter, which makes it seem they are designed to be smoked like cigarettes (that is, for the smoke to be inhaled) [155]. Many “little cigars” are smoked exactly like cigarettes and in most states they cost less due to tax loopholes. Chang et al. (2015) looked at 22 studies of cigar smokers and death. They confirmed a strong dose relationship between the number of cigars smoked per day and how deeply the smokers inhaled the smoke and the development of oral, laryngeal, lung, pancreatic, and esophageal cancers as well as coronary heart disease and aortic aneurysm. Even among cigar smokers who reported that they did not 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].