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Health Issues

Emerging & Alternative Forms of Tobacco

In a world where the tobacco industry is constantly adjusting their strategies to get new users hooked, it can be hard for parents to keep up with all the dangerous forms of tobacco available. Tobacco companies market their products in several forms, and while some may look harmless, all have the potential to cause health problems.

In addition to cigarettes, there are many other forms of tobacco that parents should be aware of.

Note: Because the tobacco industry is always coming up with new products, this page is a constant work in progress.

Other forms of smoking

  • E-cigarettes: E-cigarettes are a type of electronic smoking device. Some people do not view using an e-cigarette as smoking, and instead call it "vaping." E-cigarettes are available in a wide variety of youth-friendly flavors, and can be refilled with liquid. This liquid often contains nicotine—a highly addictive chemical. Young children have been poisoned and killed from these liquid nicotine containers. E-cigarettes are very popular with youth. A recent Centers for Disease Control and Prevention (CDC) survey showed that e-cigarettes are the tobacco product teens use the most—even more than cigarettes.

  • Heat-Not-Burn Tobacco Products: Heat not burn products, such as IQOS, are marketed by tobacco companies as a better alternative to smoking because the tobacco is heated, not burned. However, these products still contain nicotine, which is highly addictive, in addition to chemicals, additives, and flavorings that are unsafe to inhale or breathe secondhand.

  • Cigars: A cigar is a large, tightly rolled bundle of tobacco wrapped in leaf tobacco (or another substance containing tobacco) that is smoked. Cigars contain the same carcinogens as cigarettes, so that even if cigar smoke is not inhaled, cigar smokers are still at risk from the carcinogens in the smoke they produce. Cigars are sold in a variety of flavors, and can be purchased in low numbers, which make them both cheap and popular with youth. The U.S. Food and Drug Administration (FDA) does not yet regulate cigars.

  • Little cigars and cigarillos: Little cigars are sold in larger packs, and typically come with filtered tips, indicating that they are meant to be inhaled like cigarettes. Little cigars usually contain 1 gram of tobacco, whereas cigarillos are a little larger than little cigars, and typically contain 3 grams of tobacco. The FDA does not yet regulate little cigars or cigarillos.

  • Hookah: Hookahs, or waterpipes, are a more socially-oriented form of tobacco use. Groups of people sit around a hookah, and tobacco—usually flavored—is heated, filtered by water, and passed through a hose to a mouthpiece, where it is inhaled, then passed to the next person in the group. Hookah use can lead to several types of cancers, as well as heart and lung diseases. In addition, because multiple people are sharing a mouthpiece, there is also a risk of hepatitis, herpes, and tuberculosis. Hookah bars and lounges are gaining popularity as a way for people to socialize and embrace multiculturalism while smoking. These lounges are especially popular with younger populations like college students and teens.

  • Bidis: A bidi is a hand rolled, leaf-wrapped cigarette. Bidis can be tied with a string at one or both ends. A bidi can be flavored with child-friendly flavors like chocolate or cherry. The amount of nicotine in bidi smoke is 3-5 times higher than the amount of nicotine in cigarette smoke. Several research studies have found that many of the same health problems associated with cigarettes can be common with bidi use.

  • Kreteks: Known as cloves or clove cigarettes, kreteks contain a rolled mixture of tobacco, cloves, and other additives. As with bidis, kretek use can cause some of the same health problems that cigarette smoking causes such as difficulty breathing, coughing up blood, and other lung problems.

  • Menthol cigarettes: Providing a cool, minty sensation, menthol cigarettes mask the harshness of smoking. Menthol's cooling, numbing properties may permit larger puffs, deeper inhalation or allow smoke to stay in the lungs for a longer period of time, and is used as a local anesthetic to relieve throat irritation. Menthol cigarettes are popular with African American smokers—83% of African American smokers smoke mentholated cigarettes, compared to only 24% of White smokers. The FDA's Tobacco Products Scientific Advisory Committee has concluded that removing menthol cigarettes from the market will improve the public health of the U.S., and the FDA is determining whether regulatory actions should be taken.

Forms of smokeless tobacco

Many people falsely believe that because there is no smoke, there is no danger. This is not true. Smokeless tobacco still contains many dangerous chemicals and ingredients that can cause harm to the body. In addition, some forms are easier to disguise use, as there is no tell-tale smoke. This may make it easier for children to use tobacco products.

  • Chewing tobacco: Known as spit tobacco, or chew, chewing tobacco can come in loose-leaf strips of shredded tobacco leaves, or in the form of a plug, where the tobacco is pressed together, wrapped in a tobacco leaf, then twisted to resemble a rope. The most common form is loose-leaf, which means the strips of tobacco are sweetened and packaged in a foil pouch. In each form, the user takes a piece from the package, and places it in their mouth, between their gums and cheek. Chewing tobacco users are at risk for gum loss, cancers, stained teeth, and oral sores.

  • Snuff: Snuff is also referred to as pinch, or dip, and is a finely-ground form of tobacco that can be either dry or moist. Dry snuff is often a powder-like consistency, and can be inhaled through the nostrils, taken orally, or placed between the gums and cheek, as is common to do with moist snuff.

  • Snus: Snus is moist snuff that originated in Sweden. Snus is dispensed in packets, or sachets (like miniature tea bags), and placed between the gums and cheek. Snus contains between 3-10mg of nicotine (compared to about 1.5mg in cigarettes), depending on the portion size, and is marketed as a safer alternative to smoking for scenarios when smoking is prohibited. Snus is also designed so that there is no need to spit the product juices out, as is the case with other forms of smokeless tobacco, and this may make the product more attractive to teens. Snus contains many of the same dangers as other smokeless forms of tobacco, despite intense marketing as a safer alternative to cigarettes.

  • Pellets and other candy-like forms of tobacco: Tobacco that is meant to dissolve in the user's mouth is given the broad term "dissolvable tobacco." Several tobacco companies have created dissolvable tobacco in the form of sticks, strips, or orbs. This can incorporate the orbs (which resemble tic tac candies), strips (resembling breath strips that you place on your tongue to freshen your breath), and sticks (resembling slightly larger toothpicks) that are currently in some markets around the U.S. These items resemble candy or mints, and are easy to mistake for candy or mint packaging, making it a danger to children. These dissolvable forms of tobacco typically dissolve in anywhere from three minutes (for a strip) to 30 minutes (for a stick), and the nicotine content in each differs—some contain more nicotine than a typical cigarette, some contain less. There is a significant concern for accidental overdose by youth that may not recognize these products as tobacco. A child putting several orbs in their mouth at the same time, thinking they are candy, could consume a dangerous amount of nicotine at once.

Many of these forms of tobacco are available in flavors and are easier to get than cigarettes. The American Academy of Pediatrics (AAP) recommends that flavors be banned from all tobacco products, , and that tobacco product prices be increased so that it is harder for teens to get these products.

Some of these forms are commonly found in social settings, and it is important to have conversations with your children about abstaining from tobacco use, and resisting peer pressure.

More information

Last Updated
American Academy of Pediatrics (Copyright © 2017)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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