1. FORMS of TOBACCO
This module focuses on different forms of tobacco that are available in the U.S.

2. FORMS of TOBACCO Cigarettes Spit tobacco (chewing tobacco, oral snuff)
Pipes
Cigars
Clove cigarettes
Bidis
Waterpipes (e.g., hookah)
Many forms of tobacco are available in the U.S.:
Cigarettes
Spit tobacco (chewing tobacco and oral snuff)
Pipes
Cigars
Clove cigarettes
Bidis
Waterpipes (e.g., hookah, shisha, narghile, goza, hubble bubble)
Several of these forms, such as clove cigarettes, bidis, and hookah, have attained increased popularity in recent years.
Image courtesy of the Centers for Disease Control and Prevention / Rick Ward

3. CIGARETTES Most common form of tobacco used in U.S.
376 billion cigarettes consumed in 2005
Per-capita consumption was 1,716 in 2005
U.S. smokers consumed an estimated 376 billion cigarettes in Although this value is approximately 3% less than the previous year, cigarettes are, by far, the most common form of tobacco used in the U.S. (USDA, 2006). Per-capita consumption in 2005 for adults aged 18 years or older was estimated at 1,716 cigarettes (USDA, 2006).
U.S. Department of Agriculture (USDA), Economic Research Service. (2006, April 28). Tobacco Outlook. Report TBS-260. Retrieved December 31, 2006, from

4. AMERICAN CIGARETTES Sold in packs (20 cigarettes/pack)
Total nicotine content (per cigarette)
Average 10.2 mg (range 7.2 to 13.4 mg)
Average machine yield (per cigarette)
Nicotine 0.88 mg (range <0.05 to 2.0 mg)
Tar 12 mg (range <0.5 to 27 mg)
Low tar/nicotine cigarettes
Actual exposure may be higher
Not safer
In the U.S., cigarettes are generally sold in packs containing 20 cigarettes, and a carton of cigarettes generally contains 10 packs.
In a study analyzing 32 of the top-selling American brands of cigarettes, the total nicotine content per cigarette averaged 10.2 mg with a range of 7.2 to 13.4 mg (Kozlowski et al., 1998). Notably, this study analyzed regular, light, and ultra-light cigarettes. Thus cigarettes labeled as “light” or “ultra-light” are not necessarily low nicotine content cigarettes.
Cigarette ratings for tar and nicotine are determined by a standardized U.S. Federal Trade Commission machine testing procedure that involves inhalation of 35 mL of smoke over 2 seconds every 60 seconds. Under these conditions, in 1998 the average machine yield of nicotine per American cigarette was 0.88 mg (range <0.05 to 2.0 mg); tar yields per cigarette averaged 12 mg (range <0.5 to 27 mg) (FTC, 2000). Full-flavor brands have higher nicotine and tar yields compared to light or ultra-light brands. For example, based on the FTC method, the tar and nicotine yields for Marlboro Full Flavor are 15 mg and 1.1 mg per cigarette, respectively. The corresponding tar and nicotine yields for Marlboro Light are 10 mg and 0.8 mg per cigarette, respectively (FTC, 2000).
♪ Note to instructor(s): A report issued by the Massachusetts Tobacco Control Program in 2006 has revealed that American tobacco manufacturers (Lorillard, Philip Morris, and RJ Reynolds) have increased the total nicotine content of cigarettes over a 6-year time period by nearly 17% (from an average of 12.9 mg per cigarette in 1998 to 14.3 mg per cigarette in 2004). This significant increase in tobacco content has lead to a nearly 10% increase in nicotine yield per cigarette during the same time period (from 1.72 mg in 1998 to 1.89 mg in 2004) (Keithly et al., 2006).
Federal Trade Commission (FTC). (2000). “Tar,” Nicotine and Carbon Monoxide of the Smoke of 1294 Varieties of Domestic Cigarettes for the Year Retrieved December 31, 2006, from
Keithly L, Cullen D, Land T. Changes in Nicotine Yield: 1998– Report produced by the Massachusetts Tobacco Control Program, Massachusetts Department of Public Health. Retrieved December 31, 2006, from
Kozlowski LT, Mehta NY, Sweeney CT, Schwartz SS, Vogler GP, Jarvis MJ, West RJ. (1998). Filter ventilation and nicotine content of tobacco in cigarettes from Canada, the United Kingdom, and the U.S. Tob Control 7:369–375.
Marlboro and Marlboro Light are registered trademarks of Philip Morris, Inc.

5. SPIT TOBACCO Chewing tobacco Snuff Looseleaf Plug Twist Moist Dry
The use of spit tobacco products in the U.S. was widespread until the end of the 19th century. With the advent of antispitting laws, loss of social acceptability, and increased popularity of cigarette smoking, its use declined rapidly in the 20th century. However, national data indicate a resurgence in spit tobacco use, particularly among young males (Ebbert et al., 2004). Spit tobacco is classified as either chewing tobacco or snuff (USDHHS, 1986).
Chewing tobacco is chewed or held in the cheek or lower lip. The following types of chewing tobacco are marketed in the U.S.:
Looseleaf: consists of stripped and processed tobacco leaves that are stemmed, cut, and loosely packed to form small strips of shredded tobacco (depicted in slide). Most brands are sweetened and flavored with licorice. Generally available in a 3-ounce pouch. Users tuck a piece of tobacco ¾ to 1 inch in diameter in the back of the mouth between the gum and jaw and chew intermittently.
Plug: made from tobacco leaves or fragments wrapped in fine tobacco and pressed into bricks (depicted in slide). Most plug tobacco is sweetened and flavored with licorice. Generally available in compressed bricks or blocks. Users chew or hold a piece inside cheek or lower lip.
Twist: handmade from leaf tobacco treated with a tar-like tobacco leaf extract and twisted into strands (depicted in slide) that are dried. Usually contains no sweeteners or flavoring agents. Generally sold by the piece. Used in a manner similar to plug tobacco.
Snuff has a much finer consistency than chewing tobacco and is held in place in the mouth without chewing. The following types of snuff are marketed in the U.S.:
Moist snuff: consists of tobacco stems and leaves that are processed into fine particles, strips, or mini-sachets resembling tea bags (depicted in slide). Some products are flavored. Has moisture content of up to 50%. Available in cans and plastic containers. Users place a small amount (a “pinch”) between the lip or cheek and gum (also known as dipping) and suck on the moist mass of tobacco for 30 minutes or longer. Because of increased surface area, finer cuts of tobacco result in more rapid absorption of nicotine.
Dry snuff: consists of tobacco that is fermented and processed into a dry powdered form. Generally has a moisture content of less than 10%. Available in cans and glass containers. Used in a manner similar to moist snuff but also may be sniffed.
Ebbert JO, Carr AB, Dale LC. (2004). Smokeless tobacco: An emerging addiction. Med Clin N Am 88:1593–1605.
U.S. Department of Health and Human Services (USDHHS). (1986). The Health Consequences of Using Smokeless Tobacco. A Report of the Advisory Committee to the Surgeon General (NIH Publication No ). Retrieved December 31, 2006, from
The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.

6. SPIT TOBACCO: U.S. OUTPUT, 1950–2005
This graph depicts the output (in millions of pounds) of spit tobacco products in the U.S. from 1950 to 2005.
Consumption of chewing tobacco (looseleaf, plug, and twist) has been on the decline since the mid-1980s (USDA, 2006). In contrast, snuff production has been increasing steadily since the late 1980s. In 2005, snuff consumption increased by an estimated 2% from the previous year (USDA, 2006). Snuff usage might be increasing as consumers substitute spit tobacco for cigarettes in situations where smoking is restricted or prohibited.
U.S. Department of Agriculture (USDA), Market and Trade Economics Division, Economic Research Service. (2004, December). Tobacco Situation and Outlook Yearbook. Report TBS Retrieved December 31, 2006, from
U.S. Department of Agriculture (USDA), Economic Research Service. (2006, April 28). Tobacco Outlook. Report TBS-260. Retrieved December 31, 2006, from
Graph based on data from U.S. Department of Agriculture. Tobacco Situation and Outlook Yearbook TBS-2004 (2004) and Tobacco Outlook TBS-260 (2006).

7. SPIT TOBACCO Estimated 7.2 million users in the U.S. in 2004
Males (6.2%) more likely than females (0.5%) to be current users
Prevalence highest among
Young adults aged years
American Indians and Alaskan Natives
Residents of the southern U.S. and rural areas
Significant health risks
Numerous carcinogens
Nicotine exposure comparable to that of smokers, leading to
Physical dependence
Withdrawal symptoms after abstinence
According to the U.S. Department of Health and Human Services, in 2004 an estimated 7.2 million Americans aged 12 years or older (3.0%) had used spit tobacco in the past month. Males (5.8%) were more likely than females (0.3%) to be current users (USDHHS, 2005). The prevalence of spit tobacco use is highest among individuals aged 18–25 years and is substantially higher among American Indians, Alaskan Natives, and residents of the southern U.S. and rural areas (Ebbert et al., 2004; USDHHS, 2005).
Users of spit tobacco often believe this is a safe alternative to smoking cigarettes, because it is not inhaled. This is not true. Spit tobacco has high concentrations of numerous carcinogens, including nitrosamines, polycyclic aromatic hydrocarbons, and radioactive polonium-210, which are in direct contact with mucosal tissues for prolonged periods (USDHHS, 1986). Furthermore, regular spit tobacco users experience comparable exposure to nicotine and are as likely to develop physical dependence as are regular smokers (Ebbert, 2004).
♪ Note to instructor(s): Additional data, provided by the Centers for Disease Control and Prevention (CDC, 2006), indicate that in 2005, 2.3% of the adult population (ages 18 and older) had used chewing tobacco or snuff at least 20 times during their lifetimes and reported using chewing tobacco or snuff every day or some days. The prevalence is higher among men (4.5%) than among women (0.2%).
Centers for Disease Control and Prevention. (2006). Tobacco use among adults—United States, MMWR 55:1145–1147.
Ebbert JO, Carr AB, Dale LC. (2004). Smokeless tobacco: An emerging addiction. Med Clin N Am 88:1593–1605.
U.S. Department of Health and Human Services (USDHHS) The Health Consequences of Using Smokeless Tobacco. A Report of the Advisory Committee to the Surgeon General (NIH Publication No ). Retrieved December 31, 2006, from
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2005). Results from the 2004 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NHSDA Series H-28, DHHS Publication No. SMA 05–4062). Retrieved December 31, 2006 from

8. NICOTINE CONTENT in SPIT TOBACCO PRODUCTS
Dose
Product pH
Total free nicotine (mg/g)
Low
Skoal Bandits Wintergreen
6.9
0.5
Medium
Skoal Long Cut Wintergreen
7.4
2.0
Medium-High
Original Fine Cut Skoal Wintergreen
7.6
2.9
High
Copenhagen Snuff
8.6
9.0
This slide presents the nicotine content of some commonly used spit tobacco products (Henningfield et al., 1995).
Absorption of nicotine from chewing tobacco and snuff is pH dependent. With increasing pH, the fraction of free (un-ionized) nicotine increases, leading to increased absorption of nicotine across the buccal mucosa. Spit tobacco manufacturers manipulate the nicotine content and pH of their products by adding alkaline buffering agents and changing the tobacco processing methods to control the delivery of nicotine (Ebbert et al., 2004). For example, a “starter” formulation, such as Skoal Bandits, is more acidic (pH=6.9) and has a lower percentage of free nicotine to increase tolerability. Once dependence has been established, users generally advance to more alkaline, higher free nicotine content products such as Skoal Fine Cut (pH=7.6) and Copenhagen (pH=8.6), which are capable of delivering higher levels of nicotine. Under standardized laboratory conditions, the observed peak plasma levels of nicotine were 4.6 times higher with Copenhagen than with Skoal Bandits (Fant et al., 1999).
Ebbert JO, Carr AB, Dale LC. (2004). Smokeless tobacco: An emerging addiction. Med Clin N Am 88:1593–1605.
Fant RV, Henningfield JE, Nelson RA, Pickworth WB. (1999). Pharmacokinetics and pharmacodynamics of moist snuff in humans. Tob Control 8:387–392. Henningfield JE, Radzius A, Cone EJ. (1995). Estimation of available nicotine content of six smokeless tobacco products. Tob Control 4:57–61.
Dose
Product pH
Total Free Nicotine (mg/g)
Free
Nicotine
(%)
Low
Skoal Bandits Wintergreen
6.9
0.5
7.1
Medium
Skoal Long Cut Wintergreen
7.4
2.0
19.4
Medium-High
Original Fine Cut Skoal Wintergreen
7.6
2.9
27.6
High
Copenhagen Snuff
8.6
9.0
79.2
Data from Henningfield et al. (1995). Tob Control 4:57–61.

9. HEALTH CONSEQUENCES of SPIT TOBACCO USE
Periodontal effects
Gingival recession
Bone attachment loss
Dental caries
Oral leukoplakia
Cancer
Oral cancer
Pharyngeal cancer
♪ Note to instructor(s): Please delete this slide if you are also teaching the Epidemiology of Tobacco Use module.
Like smoking, chewing and dipping have serious health effects (Ebbert et al., 2004; Taybos, 2003), including the following:
Periodontal effects: Regular users of spit tobacco are at significant risk for the development of gingival recession (complete or partial loss of the tissue covering the root of the tooth) and periodontal degeneration. The loss of gingival tissue generally occurs at sites constantly exposed to tobacco. The high sugar content found in many spit tobacco products might account for the increased incidence of dental caries in spit tobacco users.
Soft tissue alterations/leukoplakia: Oral leukoplakia is the main precancerous effect of spit tobacco for which the health care provider should screen. These light-colored lesions are formed in the mouth through contact between tobacco and the soft tissues of the inner mouth. Continued use can transform these lesions into carcinomas. When users quit, the oral leukoplakia tends to disappear.
Cancer: The most serious consequence of spit tobacco use is an increased risk for the development of oral and pharyngeal cancers. The nitrosamine levels of moist snuff are very high; most oral cancers are caused by the use of moist snuff. Use of alcohol further increases risk of oral cancer.
Counseling can be used successfully for spit tobacco cessation; pharmacotherapy might be helpful in some cases, although the effects with spit tobacco users are not well established.
Ebbert JO, Carr AB, Dale LC. (2004). Smokeless tobacco: An emerging addiction. Med Clin N Am 88:1593–1605.
Taybos G. (2003). Oral changes associated with tobacco use. Am J Med Sci 326:179–182.
Oral Leukoplakia
Image courtesy of Dr. Sol Silverman -
University of California San Francisco

10. PIPE TOBACCO Prevalence of pipe smoking in the U.S. is less than 1%
Pipe smokers have an increased risk of death due to:
Cancer (lung, oral cavity, esophagus, larynx)
Chronic obstructive pulmonary disease
Risk of smoking tobacco-related death:
cigarettes > pipes ≈ cigars
The consumption of loose tobacco (smoking tobacco) for pipes has been in steady decline over the past fifty years (USDA, 2004). Data from the National Survey on Drug Use and Health in 2003 suggest the prevalence of pipe smoking among Americans is less than 1% (USDHHS, 2004).
Compared to never-smokers, pipe smokers have an increased risk of death from lung, oral, esophageal, and laryngeal cancer and chronic obstructive pulmonary disease (Henley et al., 2004). The risk of tobacco-related mortality among pipe smokers is lower than that observed in cigarette smokers and comparable to that found among cigar smokers (Henley et al., 2004). These differences might result from the tendency of pipe and cigar smokers to smoke less and generally to inhale less deeply than do cigarette smokers.
Henley SJ, Thun MJ, Chao A, Calle EE. (2004). Association between exclusive pipe smoking and mortality from cancer and other diseases. J Natl Cancer Inst 96:853–861.
U.S. Department of Agriculture (USDA), Market and Trade Economics Division, Economic Research Service. (2004, December). Tobacco Situation and Outlook Yearbook. Report TBS Retrieved December 31, 2006, from
U.S. Department of Health and Human Services (USDHHS), Substance Abuse and Mental Health Services Administration. (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NHSDA Series H-25, DHHS Publication No. SMA 04–3964). Retrieved December 31, 2006, from

11. HERMAN ® is reprinted with permission from
Since the early 1990s, sales of cigars in the U.S. have increased markedly due to the perception that cigar smoking is a symbol of wealth and success and the mistaken impression that they are a safe alternative to cigarettes (Nyman et al., 2002).
Nyman AL, Taylor TM, Biener L. (2002). Trends in cigar smoking and perceptions of health risks among Massachusetts adults. Tob Control 11(Suppl 2):ii25–ii28.
HERMAN ® is reprinted with permission from
LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.

12. CIGARS Estimated 13.7 million cigar smokers in the U.S. in 2004
Tobacco content of cigars varies greatly
One cigar can deliver enough nicotine to establish and maintain dependence
Cigar smoking is not a safe alternative to cigarette smoking
Cigars are conventionally defined as “any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco” (Baker et al., 2000). Cigar tobacco is generally air cured and produces smoke with a more alkaline pH, which allows for buccal absorption of nicotine.
According to the U.S. Department of Health and Human Services, in 2004 an estimated 13.7 million Americans aged 12 years or older (5.7%) had smoked one or more cigars in the past month (USDHHS, 2005). The prevalence of cigar use was highest among individuals aged years (12.7%); males (9.8%) were more likely than females (1.9%) to be current cigar smokers (USDHHS, 2005).
Exactly how much nicotine an individual might obtain from a single cigar is difficult to determine or generalize, because cigar weight and nicotine content vary widely from brand to brand and from cigar to cigar. Most cigars range in weight from about 1 to 22 g; a typical cigarette weighs less than 1 g. The nicotine content in 10 commercially available cigars studied in 1996 ranged from 10 to 444 mg (Henningfield et al., 1999). In comparison, standard U.S. cigarettes have a relatively narrow total nicotine content, ranging between 7.2 and 13.4 mg of nicotine per cigarette (Kozlowski et al., 1998). Relating these data, Henningfield and colleagues concluded that it is possible for one large cigar to contain as much tobacco as an entire pack of cigarettes and deliver enough nicotine to establish and maintain dependence (Henningfield et al., 1999).
Cigar smoking is not a safe alternative to cigarette smoking. The adverse health effects of cigar smoking have been well described and include an increased risk of cancer of the lung, oral cavity, larynx, esophagus, and pancreas. In addition, cigar smokers who inhale deeply are at increased risk for developing cardiovascular disease and chronic obstructive pulmonary disease (Baker et. al., 2000; NCI, 1998). On average, cigarette smokers who switch to smoking only cigars will decrease their risk of developing lung cancer, but their risk remains markedly higher than if they were to quit smoking altogether (NCI, 1998).
♪ Note to instructor(s): Additional data, provided by the Centers for Disease Control and Prevention (CDC, 2006), indicate that in 2005, 2.2% of the adult population (ages 18 and older) had smoked at least 50 cigars in their lifetime and reported smoking cigars every day or some days. The prevalence is higher among men (4.3%) than among women (0.3%).
Baker F, Ainsworth SR, Dye JT, Crammer C, Thun MJ, et al. (2000). Health risks associated with cigar smoking. JAMA 284:735–740.
Centers for Disease Control and Prevention. (2006). Tobacco use among adults—United States, MMWR 55:1145–1147.
Henningfield JE, Fant RV, Radzius A, Frost S. (1999). Nicotine concentration, smoke pH, and whole tobacco aqueous pH of some cigar brands and types popular in the U.S. Nicotine Tob Res 1:163–168.
Kozlowski LT, Mehta NY, Sweeney CT, Schwartz SS, Vogler GP, Jarvis MJ, West RJ. (1998). Filter ventilation and nicotine content of tobacco in cigarettes from Canada, the United Kingdom, and the U.S.. Tob Control 7:369–375.
National Cancer Institute (NCI). (1998). Cigars: Health Effects and Trends (Smoking and Tobacco Control Monograph No. 9; NIH Publication No ). Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, p. 67.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2005). Results from the 2004 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NHSDA Series H-28, DHHS Publication No. SMA 05–4062). Retrieved December 31, 2006 from

13. CIGARS: U.S. CONSUMPTION, 1950–2005
As depicted in this graph, cigar consumption in the U.S. has increased significantly over the past decade. (USDA, 2004, 2006). According to the U.S. Department of Agriculture Economic Research Service, cigar consumption reached an estimated 5.1 billion in 2005 (USDA, 2006).
Some data suggest the increased consumption is due to a greater prevalence of occasional cigar smoking by previous nonsmokers, particularly among those of higher socioeconomic status (NCI, 1998). This trend is likely the result of enhanced marketing and promotional efforts by the tobacco industry. For example, cigar advertisements often depict celebrities or athletes, associating cigar smoking with glamour, affluence, and success. Similarly, popular magazines including Cigar Aficionado and Smoke overtly promote cigar use and repeatedly reinforce the concept that cigar smoking is synonymous with a successful lifestyle (Wenger et al., 2001). Increasing numbers of former cigarette smokers switching to cigars and experimentation among adolescents with cigar smoking might also play a role in the increased prevalence of cigar use (NCI, 1998).
National Cancer Institute (NCI). (1998). Cigars: Health Effects and Trends (Smoking and Tobacco Control Monograph No. 9; NIH Publication No ). Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute.
U.S. Department of Agriculture (USDA), Market and Trade Economics Division, Economic Research Service. (2004, December). Tobacco Situation and Outlook Yearbook. Report TBS Retrieved December 31, 2006, from
U.S. Department of Agriculture (USDA), Economic Research Service. (2006, April 28). Tobacco Outlook. Report TBS-260. Retrieved December 31, 2006, from
Wenger LD, Malone RE, George A, Bero LA. (2001). Cigar magazines: Using tobacco to sell a lifestyle. Tob Control 10:279–284.
Graph based on data from U.S. Department of Agriculture. Tobacco Situation and Outlook Yearbook TBS-2004 (2004) and Tobacco Outlook TBS-260 (2006).

14. CLOVE CIGARETTES (also known as KRETEKS)
Mixture of tobacco and cloves
Imported from Indonesia
Use is more prevalent among young smokers
Two times the tar and nicotine content of standard cigarettes
Clove cigarettes or “kreteks” have been imported into the U.S. from Indonesia since the late 1960s. Clove cigarettes contain approximately 60–70% tobacco and 30–40% minced cloves (AMA, 1988).
In Indonesia, where these products originate, smokers typically do not inhale. In contrast, the typical clove cigarette smoker in the U.S. (aged 17–30 years) inhales deeply and retains the smoke in the lungs, subsequently increasing the risk for potentially harmful effects. In smoking machine tests, clove cigarettes deliver nearly twice as much nicotine and carbon monoxide and nearly three times as much tar as conventional filtered U.S. cigarettes (Malson et al., 2003).
♪ Note to instructor(s): Clove cigarettes are tobacco products, and smoking them carries all the hazards associated with smoking all-tobacco cigarettes. In addition, the smoking of clove cigarettes has been associated with rare but serious cases of hemorrhagic pulmonary edema, pneumonia, bronchitis, and hemoptysis (AMA, 1988; CDC, 1985; Guidotti et al., 1989). It has been speculated that eugenol, a compound possessing local anesthetic properties and present in large quantities in clove cigarette smoke, might be toxic to pulmonary tissue. The anesthetic effects of eugenol also might increase the risk of pulmonary aspiration resulting from an impaired gag reflex (Guidotti et al., 1989). Clove cigarettes also contain flavoring compounds that exceed those present in standard cigarettes. The health impact of these flavoring compounds currently is not known (Stanfill et al., 2006).
American Medical Association (AMA) Council on Scientific Affairs. (1988). Council report: Evaluation of the health hazard of clove cigarettes. JAMA 260:3641–3644.
Centers for Disease Control and Prevention (CDC). (1985). Epidemiologic notes and reports illnesses possibly associated with smoking clove cigarettes. MMWR 34:297–299.
Guidotti TL, Laing L, Prakash U. (1989). Clove cigarettes: The basis for concern regarding health effects. West J Med 151:220–228.
Malson JL, Lee EM, Murty R, Moolchan ET, Pickworth WB. (2003). Clove cigarette smoking: Biochemical, physiological, and subjective effects. Pharmacol Biochem Behav 74:739–745.
Stanfill SB, Brown CR, Yan X, Watson CH, Ashley DL. (2006). Quantification of flavor-related compounds in the unburned contents of bidi and clove cigarettes. J Agric Food Chem 54:8580–8588.

15. BIDIS Imported from India Resemble marijuana joints
Available in candy flavors
Deliver higher levels of tar, carbon monoxide, and nicotine than cigarettes
“Cigarettes with training wheels”
Bidis are small, brown, hand-rolled cigarettes imported primarily from India and other Southeast Asian countries; they consist of tobacco wrapped in a tendu or temburni leaf (CDC, 1999). Bidis resemble marijuana joints, which may impart a counterculture attraction.
Bidis, which are available in chocolate, vanilla, strawberry, cherry, mango, orange, and other flavors, tend to be popular among younger smokers. In a recent survey of 63,728 adults in 15 U.S. states, young adults (18-24 years) reported the highest rates of ever (16.5%) and current (1.4%) bidi use. Among young adults, males, blacks and current cigarette smokers were more likely to have ever tried or be current bidi users (Delnevo et al., 2004). In a previous survey in Massachusetts, reasons cited by urban adolescents for smoking bidis were that they were better tasting, less expensive, safer, and easier to buy than traditional cigarettes (CDC, 1999).
Although bidis contain less tobacco than standard cigarettes, studies have shown they produce substantial amounts of tar, nicotine, and carbon monoxide (CDC 1999; Rickert, 1999; Watson et al., 2003). A study using standardized smoking machine testing methods found that bidis deliver three times the amount of carbon monoxide and nicotine and nearly five times the amount of tar found in standard cigarettes (Rickert, 1999). Because of the low combustibility of the leaf wrapper, bidis must be puffed constantly to keep them lit. As a result, bidi smokers inhale more frequently and more deeply, thereby markedly increasing the delivery of tar and other toxins (CDC, 1999). Most bidis do not have a traditional filter tip, which further increases exposure to toxic constituents present in smoke. Like clove cigarettes, bidis also contain flavoring compounds that exceed those present in standard cigarettes. The health impact of these flavoring compounds currently is not known (Stanfill et al., 2006).
Spot checks in various retail outlets have shown that many of these products are not labeled with health warnings (Taylor & Biener, 2001). The absence of Surgeon General warning labels might lead to the false impression that these products are safer than other forms of tobacco. Experts have referred to these forms of tobacco as “cigarettes with training wheels,” because young smokers become addicted to the nicotine in these candy-flavored cigarettes, later transferring their addiction to more conventional tobacco formulations (clove cigarettes, cigarettes, spit tobacco).
Centers for Disease Control and Prevention (CDC). (1999). Bidi use among urban youth—Massachusetts, March–April MMWR 48:796–799.
Delnevo CD, Pevzner ES, Hrywna M, Lewis MJ. (2004). Bidi cigarette use among young adults in 15 states. Prev Med 39:207–211.
Rickert WS. (1999). Determination of Yields of “Tar", Nicotine and Carbon Monoxide from Bidi Cigarettes: Final Report. Ontario, Canada: Labstat International, Inc.
Stanfill SB, Brown CR, Yan X, Watson CH, Ashley DL. (2006). Quantification of flavor-related compounds in the unburned contents of bidi and clove cigarettes. J Agric Food Chem 54:8580–8588.
Taylor TM, Biener L. (2001). Bidi smoking among Massachusetts teenagers. Prev Med 32:89–92.
Watson CH, Polzin GM, Calafat AM, Ashley DL. (2003). Determination of tar, nicotine, and carbon monoxide yields in the smoke of bidi cigarettes. Nicotine Tob Res 5:747–753.
Image courtesy of the Centers for Disease Control and Prevention / Dr. Clifford H. Watson

16. BIDIS
This photo, provided by the Centers for Disease Control and Prevention, demonstrates differences in the tobacco within a bidi (top) and a cigarette (bottom).
Note that although bidis might contain less tobacco, because of their unique composition they deliver higher levels of tar, carbon monoxide, and nicotine than do standard U.S. cigarettes.
Image courtesy of the Centers for Disease Control and Prevention / Dr. Clifford H. Watson

17. WATERPIPES Also known as Hookah Shisha Narghile Goza Hubble bubble
Tobacco flavored with fruit pulp, honey, and molasses
Increasingly popular among young smokers in coffee houses, bars, and lounges
The waterpipe is an ancient smoking apparatus whereby users inhale smoke that is passed through water. Waterpipe nomenclature is region-specific and includes names such as “hookah” (Africa and Indian subcontinent), “narghile” [nar-gee-leh], “nargile” (Israel, Jordan, Lebanon, Syria), “shisha”, “boory” or “goza” (Egypt, Saudi Arabia) and “hubble bubble” (many regions) (Maziak et al., 2004).
The waterpipe consists of the following major components:
Head: located at the top of the waterpipe; generally constructed of clay. Tobacco is placed in the head and then covered with perforated aluminum foil. Small pieces of burning charcoal are placed on top of the foil. Heat emanating from the burning charcoal is drawn through the tobacco mixture, which then generates smoke.
Body: the section between the head and water bowl; generally constructed of metal with a tray designed to catch ash from the burning charcoal. A tube inside the body of the pipe connects the head with the water bowl.
Water bowl: located at the bottom of the waterpipe; generally constructed of glass and partially filled with water. Smoke enters the water through the tube extending from the body of the pipe.
Hose: flexible tube attached to the body of the waterpipe just above the water bowl. Waterpipes may have single or multiple hoses.
Mouthpiece: connection attached at the end of the hose. Disposable plastic mouthpieces are often used for infection control purposes.
After the user inhales through the mouthpiece, a vacuum created in the water bowl causes the smoke to “bubble” through the water and collect in the airspace above the water. The cooled smoke is then transported to the user through the hose and mouthpiece during inhalation.
Maassel, the tobacco most often used in waterpipes, contains a mixture of tobacco, dried fruit pulp, honey, and molasses. A variety of flavors are available, including banana, apple, cherry, melon, strawberry, apricot, kiwi, mint, and cappuccino. Other tobacco formulations such as Tumbak and Jurak are less highly sweetened (Maziak et al., 2004).
In the U.S., use of waterpipes is becoming increasingly popular among young adults. Hookah bars, lounges, cafes, and restaurants have been emerging in many urban areas of the country including Los Angeles, San Francisco, and New York City. Although many smokers assume the water pipe filters out harmful substances in smoke, there are no data to substantiate this belief. Hookah users inhale tobacco smoke and are at risk for developing dependence and other adverse health-related conditions associated with smoking.
Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. (2004). Tobacco smoking using a waterpipe: A re-emerging strain in a global epidemic. Tob Control 13:327–333.
Image courtesy of Mr. Sami Romman /

18. POTENTIALLY REDUCED-EXPOSURE PRODUCTS (PREPs)
Tobacco formulations altered to minimize exposure to harmful chemicals in tobacco
Cigarette-like delivery devices
Eclipse, Accord
Modified tobacco products
Advance, Omni, Quest
Oral noncombustible tobacco products
Ariva, Revel, Stonewall, Snus
No evidence to prove that PREPs reduce the risk of developing tobacco-related disease
Potentially reduced-exposure products (PREPs) are tobacco formulations that have been altered to minimize exposure to harmful chemicals in tobacco. PREPs are marketed by the tobacco industry as a safer alternative to conventional cigarettes based on limited studies that show reductions in exposure to nicotine, nitrosamines, polycyclic aromatic hydrocarbons, and carbon monoxide. Most American cigarettes already employ methods of toxin reduction through filtration (use of cellulose acetate filters) or dilution (filter ventilation holes to dilute the smoke). PREPs use different methods to reduce toxin exposure. These methods are described below.
Cigarette-like delivery devices (Eclipse, RJ Reynolds; Accord, Philip Morris)
These products heat tobacco (without burning it), which reduces the formation of toxins generated during the combustion of tobacco. The Eclipse cigarette looks like a conventional cigarette but contains only a small amount of tobacco. When the user lights the carbon tip on the end of the cigarette, it heats up a column containing glycerin and tobacco, generating a smoke-like vapor that contains nicotine. Similarly, the Accord cigarette is inserted into a specially developed, battery-powered heating device that delivers a specific dose of smoke during each inhalation.
Modified tobacco products (Advance, developed by Star Scientific; Omni, Vector Tobacco; Quest, Vector Tobacco)
These formulations decrease toxin exposure through the following techniques:
Alterations in the tobacco curing process: Star Scientific, Inc., utilizes a proprietary tobacco curing process that reportedly reduces the levels of cancer-causing nitrosamines in tobacco (Advance).
Chemically modified tobacco: through the addition of additives such as palladium, Vector Tobacco has created a chemically modified cigarette (Omni) that allegedly reduces the levels of nitrosamines and polycyclic aromatic hydrocarbons.
Genetically modified tobacco: Vector tobacco markets a cigarette (Quest) that contains genetically engineered “reduced-nicotine” tobacco.
Oral noncombustible tobacco products (Ariva and Stonewall, Star Scientific; Revel, US Smokeless Tobacco; Camel Snus, RJ Reynolds Tobacco)
These oral formulations of tobacco are available as small sachets of flavored tobacco (Revel, Snus) or lozenges containing compressed low-nitrosamine tobacco powder (Ariva, Stonewall) that are marketed as cigarette substitutes for situations where smoking is prohibited. Smokeless tobacco products reduce exposure to the harmful products associated with combustion.
Although in theory these products reduce the risk of exposure to harmful constituents in tobacco smoke, it is important for clinicians to know that there is no evidence to prove that PREPs reduce the risk of developing tobacco-related disease.
Hatsukami D, Hecht S. (2005). Hope or Hazard? What Research Tells Us About “Potentially Reduced-Exposure” Tobacco Products. (Minneapolis: University of Minnesota Transdisciplinary Tobacco Use Research Center). Retrieved December 31, 2006, from
Accord image courtesy of Dr. Dorothy Hatsukami - University of Minnesota

19. FORMS of TOBACCO: SUMMARY
Cigarettes are, by far, the most common form of tobacco used in the U.S.
Other forms of tobacco exist and are increasing in popularity.
All forms of tobacco are harmful.
Attention to all forms of tobacco is needed.
To summarize, although cigarettes are by far the most commonly used form of tobacco in the U.S., other forms of tobacco exist. Many of these forms have increased in popularity in recent years, in part because of their social appeal and because of intensive marketing efforts by tobacco companies. However, all forms of tobacco carry significant health risks. As a result, it is important for clinicians to become familiar with the various types of tobacco and to routinely assess their patients’ use of tobacco, not just cigarettes.