Smokeless tobacco is a

tobacco product Tobacco is the agricultural product of the leaves of plants in the genus ''Nicotiana'', commonly termed ''tobacco plants''. All species of ''Nicotiana'' contain the addictive drug nicotine—a psychostimulant alkaloid found in all parts of the p ...

that is used by means other than smoking. Their use involves chewing, sniffing, or placing the product between gum and the cheek or lip. Smokeless tobacco products are produced in various forms, such as

chewing tobacco Chewing tobacco is a type of smokeless tobacco product that is placed between the cheek and lower gum to draw out its flavor. Some users chew it, others do not. It consists of coarsely chopped aged tobacco that is flavored and often sweetened; ...

snuff Snuff may refer to: Tobacco * Snuff (tobacco), fine-ground tobacco, sniffed into the nose ** Moist snuff or dipping tobacco ** Creamy snuff, an Indian tobacco paste Media and entertainment * Snuff film, a type of film that shows a murder Literat ...

snus Snus ( , ) is a tobacco product, originating from a variant of dry snuff in early 18th-century Sweden. It is placed between the upper lip and gum for extended periods, as a form of sublabial administration. Snus is not fermented. Although used ...

, and dissolvable tobacco products. Smokeless tobacco products typically contain over 3000 constituents. All smokeless tobacco products contain

nicotine Nicotine is a natural product, naturally produced alkaloid in the nightshade family of plants (most predominantly in tobacco and ''Duboisia hopwoodii'') and is widely used recreational drug use, recreationally as a stimulant and anxiolytic. As ...

and are therefore highly addictive. Quitting smokeless tobacco use is as challenging as

smoking cessation Smoking cessation, usually called quitting smoking or stopping smoking, is the process of discontinuing tobacco smoking. Tobacco smoke contains nicotine, which is addictive and can cause dependence. As a result, nicotine withdrawal often m ...

. Smokeless tobacco is much lower on the risk continuum than combusted products but varies in risk within that class of products (e.g., low nitrosamine Swedish-type snus versus other smokeless tobacco with high nitrosamine levels). It is estimated the safety risk of smokeless tobacco is similar to that of electronic cigarettes. There is no safe level of smokeless tobacco use. It is correlated with a number of

adverse effect An adverse effect is an undesired harmful effect resulting from a medication or other intervention, such as surgery. An adverse effect may be termed a " side effect", when judged to be secondary to a main or therapeutic effect. The term compl ...

s such as dental disease, oral cancer, oesophagus cancer, and pancreas cancer, as well as adverse reproductive effects including stillbirth,

premature birth Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 2 ...

and low birth weight. Smokeless tobacco products contain cancer-causing chemicals. Approximately 28 chemical constituents present in smokeless tobacco are carcinogenic in nature, among which nitrosamine is the most prominent. Smokeless tobacco accounts for an abundance of deaths globally with a significant proportion of them attributed to Southeast Asia. Smokeless tobacco consumption is widespread throughout the world. Once addicted to nicotine from smokeless tobacco use, many people, particularly young people, expand their tobacco use by smoking cigarettes. Males were more likely than females to have used smokeless tobacco in the past month.

Types

Most smokeless tobacco use involves placing the product between the gum and the cheek or lip. Smokeless tobacco is a noncombustible tobacco product. Types of smokeless tobacco include: *

Dipping tobacco Dipping tobacco is a type of finely ground or shredded, moistened smokeless tobacco product. It is commonly and idiomatically known as "dip". Dipping tobacco is used by placing a pinch, or "dip", of tobacco between the lip and the gum ( sublab ...

, a type of tobacco that is placed between the lower or upper lip and gums *

Chewing tobacco Chewing tobacco is a type of smokeless tobacco product that is placed between the cheek and lower gum to draw out its flavor. Some users chew it, others do not. It consists of coarsely chopped aged tobacco that is flavored and often sweetened; ...

, a type of tobacco that is chewed * Iqmik, an Alaskan tobacco product which also contains punk ash *

Snuff Snuff may refer to: Tobacco * Snuff (tobacco), fine-ground tobacco, sniffed into the nose ** Moist snuff or dipping tobacco ** Creamy snuff, an Indian tobacco paste Media and entertainment * Snuff film, a type of film that shows a murder Literat ...

, a type of tobacco that is inhaled or "snuffed" into the nasal cavity *

Snus Snus ( , ) is a tobacco product, originating from a variant of dry snuff in early 18th-century Sweden. It is placed between the upper lip and gum for extended periods, as a form of sublabial administration. Snus is not fermented. Although used ...

, similar to dipping tobacco although the tobacco is placed under the upper lip and there is no need for spitting * Creamy snuff, a fluid tobacco mixture marketed as a dental hygiene aid, albeit used for recreation *

Naswar Naswār ( ps, نسوار, Cyrillic script: насва́р), also called nās (ناس; на́с) or nasvay (نسوای; насвай), is a moist, powdered tobacco dip consumed mostly in Afghanistan and surrounding countries. Naswar is stuffed in ...

, an Afghan tobacco product similar to dipping tobacco * Tobacco gum, a kind of chewing gum containing tobacco *

Gutka Gutka, ghutka, guṭkha or betel quid is a chewing tobacco preparation made of crushed areca nut (also called betel nut), tobacco, catechu, paraffin wax, slaked lime (Calcium hydroxide) and sweet or savory flavourings, in India, Pakistan, other ...

, a mixture of tobacco, areca nut, and various flavoring sold in South Asia * Dissolvable tobacco, a variation on chewing tobacco that completely dissolves in the mouth * Toombak and shammah, preparations found in North Africa, East Africa, and the Arabian peninsula *

Topical tobacco paste Topical tobacco paste is a home remedy sometimes recommended as a treatment for wasp, hornet, fire ant, scorpion or bee stings,Henderson–Hasselbalch equation.

Prevalence

More than 300 million people are using smokeless tobacco worldwide. People of many regions, including India, Pakistan, other Asian countries, and North America, have a long history of smokeless tobacco use. Once addicted to nicotine from smokeless tobacco use, many people, particularly young people, expand their tobacco use by smoking cigarettes. Because young people who use smokeless tobacco can become addicted to nicotine, they may be more likely to also become cigarette smokers. Youth are particularly susceptible to starting smokeless tobacco use. Males were more likely than females to have used smokeless tobacco in the past month. In 2014, 3.3 percent of people aged 12 or older (an estimated 8.7 million people) used smokeless tobacco in the past month. Past month smokeless tobacco use remained relatively stable between 2002 and 2014. Past month smokeless tobacco use between 2002 and 2014 was mostly consistent among adults aged 26 or older. There was more variability in the percentages of young adults aged 18 to 25 and adolescents aged 12 to 17 who used smokeless tobacco between 2002 and 2014. Smokeless tobacco use for adolescents aged 12 to 17 was higher during the mid-2000s, but the 2014 estimates were closer to the lower levels seen in the early 2000s. In 2014, an estimated 1.0 million people aged 12 or older used smokeless tobacco for the first time in the past year; this represents 0.5 percent of people who had not previously used smokeless tobacco. In 2016 about 2 of every 100 middle school students in the US (2.2%) reported current use of smokeless tobacco. In 2016 nearly 6 of every 100 high school students in the US (5.8%) reported current use of smokeless tobacco.

Health effects

Positions of medical organizations

, the

World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...

states that "Smokeless tobacco use is a significant part of the overall world tobacco problem." , the American Cancer Society states that "Using any kind of spit or smokeless tobacco is a major health risk. It's less lethal than smoking tobacco, but less lethal is a far cry from safe." , the

National Cancer Institute The National Cancer Institute (NCI) coordinates the United States National Cancer Program and is part of the National Institutes of Health (NIH), which is one of eleven agencies that are part of the U.S. Department of Health and Human Services. ...

states that "because all tobacco products are harmful and cause cancer, the use of all of these products should be strongly discouraged. There is no safe level of tobacco use. People who use any type of tobacco product should be urged to quit". A panel of experts convened by the

National Institutes of Health The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late ...

(NIH) in 2006 stated that the "range of risks, including nicotine addiction, from smokeless tobacco products may vary extensively because of differing levels of nicotine, carcinogens, and other toxins in different products". According to a 2002 report by the

Royal College of Physicians The Royal College of Physicians (RCP) is a British professional membership body dedicated to improving the practice of medicine, chiefly through the accreditation of physicians by examination. Founded by royal charter from King Henry VIII in 1 ...

, "As a way of using nicotine, the consumption of non-combustible tobacco is of the order of 10–1,000 times less hazardous than smoking, depending on the product". As long ago as 1986, the advisory committee to the Surgeon General concluded that the use of smokeless tobacco "is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous oral conditions and can lead to nicotine addiction and dependence".

Smoking cessation

Quitting smokeless tobacco use is as challenging as

. There is no scientific evidence that using smokeless tobacco can help a person quit smoking.

Harm reduction

, the

states that "There is no evidence to recommend that any smokeless tobacco product should be used as part of a harm reduction strategy." Tobacco companies that sell smokeless tobacco products promote them as harm reduction products and a less harmful substitute to cigarettes.

Safety

Smokeless tobacco products vary extensively worldwide in both form and health hazards, with some evidently toxic forms such as from South Asia, and some forms with less hazards such as snus from Sweden. It is correlated with a number of

s such as dental disease, oral cancer, oesophagus cancer, and pancreatic cancer, cardiovascular disease, asthma, and deformities in the female reproductive system. A correlation was identified between smokeless tobacco and risk of fatal coronary artery disease and fatal stroke. Use of smokeless tobacco also seems to greatly raise the risk of non-fatal ischaemic heart disease among users in Asia, although not in Europe. It is estimated the safety risk of smokeless tobacco is similar to that of electronic cigarettes, which has about 1% of the mortality risk of traditional cigarettes. Smokeless tobacco is not a healthy alternative to cigarette smoking. There is no safe level of smokeless tobacco use. The declines in smokeless tobacco initiation among adolescents and young adults is particularly relevant to improving the health of the nation because smokeless tobacco use is often linked to subsequent cigarette initiation. Smokeless tobacco users can experience these negative health consequences at any age. Smokeless tobacco accounts for an abundance of deaths globally with a significant proportion of them attributed to Southeast Asia. Youth use of tobacco in any form is unsafe.

Carcinogenicity

All tobacco products contain

toxicant A toxicant is any toxic substance, whether man-made or naturally occurring. By contrast, a toxin is a poison produced naturally by an organism (e.g. plant, animal, insect). The different types of toxicants can be found in the air, soil, water, or ...

s, and smokeless tobacco products contain cancer-causing chemicals. The carcinogenic compounds occurring in smokeless tobacco vary widely, which rely upon the kind of product and how it was manufactured. A 2017 review found "Overall, 28 carcinogens have been rigorously identified across a range of major smokeless tobacco products, primarily from 3 groups of compounds: nonvolatile, alkaloid-derived TSNAs; N-nitrosoamino acids; and volatile N-nitrosamines. Among these carcinogens, researchers identify TSNAs as the most abundant in smokeless tobacco and the most carcinogenic." The amounts of nicotine in saliva from using smokeless tobacco could be at amounts that can cause cytotoxicity, according to ''

in vitro ''In vitro'' (meaning in glass, or ''in the glass'') studies are performed with microorganisms, cells, or biological molecules outside their normal biological context. Colloquially called " test-tube experiments", these studies in biology ...

'' studies. Other chemicals found in tobacco can also cause cancer. These include: A radioactive element (polonium-210) found in tobacco fertilizer. Chemicals formed when tobacco is cured with heat (polynuclear aromatic hydrocarbons—also known as

polycyclic aromatic hydrocarbon A polycyclic aromatic hydrocarbon (PAH) is a class of organic compounds that is composed of multiple aromatic rings. The simplest representative is naphthalene, having two aromatic rings and the three-ring compounds anthracene and phenanthrene. ...

s). Harmful metals (arsenic, beryllium, cadmium, chromium, cobalt, lead, nickel, mercury). Products such as 3-(methylnitrosamino)-proprionitrile, nitrosamines, and nicotine initiate the production of reactive oxygen species in smokeless tobacco, eventually leading to fibroblast, DNA, and RNA damage with carcinogenic effects in the mouth of tobacco consumers. The metabolic activation of nitrosamine in tobacco by cytochrome P450 enzymes may lead to the formation of N-nitrosonornicotine, a major carcinogen, and micronuclei, which are an indicator of genotoxicity. These effects lead to further DNA damage and, eventually, oral cancer. Smokeless tobacco can cause white or gray patches inside the mouth (leukoplakia) that can lead to cancer. The

has classified smokeless tobacco products as human carcinogenic compounds, in particular tobacco-specific nitrosamines, which account for 76 to 91% of the total N-nitroso compound (NOC) burden. A 2014 review found there is "a number of ethnically linked smokeless tobacco types that contain areca nut, a Group 1 carcinogen. Use of areca nut-containing smokeless tobacco is known to cause oral cancer, yet despite this, prevalence is increasing in the Western Pacific." N-nitrosonornicotine and ketone are group 1 carcinogens to humans. These two nitrosamines found in smokeless tobacco products are the main agents for the majority of cancers in smokeless tobacco users.

Effects during pregnancy

It is correlated with adverse reproductive effects including stillbirth, premature birth, low birth weight. Using smokeless tobacco during pregnancy can increase the risk for early delivery and stillbirth. Nicotine in smokeless tobacco products that are used during pregnancy can affect how a baby's brain develops before birth.

Management

Due to smokeless tobacco harms, it should be treated. some medications shows some benefits are varenicline, nicotine lozenges. some behavioural interventions may help, however a cochrane review mentioned that there components need to be clearer.

History

Smokeless tobacco was first discussed in the English language in 1683 as a powdered tobacco for breathing into the nose. People have used it for over a thousand years. Cigarette manufacturers have penetrated the smokeless tobacco market.

Public perceptions

Many people who use smokeless tobacco may think it is safer than smoking, but all tobacco products contain toxicants, and use of smokeless tobacco poses its own significant health risks. In South and South-East Asia these products are considered part of the cultural heritage and there is little enthusiasm for regulation. Around 80% of users live in these regions.

References

{{Drug use Tobacco products Carcinogens IARC Group 1 carcinogens Articles containing video clips