Smokeless Tobacco Use

For all regions of India, 2.4% of women smoke and 12% chew tobacco. In Goa, 19% of women smoke, mostly bidis (4-13% in various districts) cigarette smoking was negligible. In many areas smokeless tobacco use was more common for women (27% in Goa, 35% in Kerala virtually no women smoked in Pune district in Mahrashtra, half of the women used smokeless tobacco and 39% used mishri. 

Krischnamurty, S., and S. Joshi. Gender differences and low birth weight with maternal smokeless tobacco use in pregnancy. J Trop Pediatr 1993 39(4) 253-254. 

The West Discovers Tobacco Tobacco as Panacea From Panacea to Panned Prevalence of Tobacco Use Smoking in the United States Initiation of Smoking Smokeless Tobacco Use Pharmacology of Nicotine Sites of Action Pharmacokinetics Tolerance and Dependence Tolerance... 

Prevalence of Smokeless Tobacco Use in the Past Month by Age and Gender, 2003... 

Subgroup data on smokeless tobacco use in the past month also are available from the 2004 national survey (SAMHSA, 2005) and arc presented in Table 7.3. As we have seen for other drugs, smokeless tobacco use is most popular among 18-25-year-olds. An even more striking difference is between men and women—men s usage rates exceed those of women more than 19-fold. 

The prevalence of smokeless tobacco use among men is about three times that among women. 

Sheiner, L., Jacob, P. (1988). Nicotine absorption and cardiovascular effects with smokeless tobacco use Companion with cigarettes and nicotine gum. Clinical Pharmacology and Therapeutics, 44, 23-28. 

W. J. (1985). Smokeless tobacco use in the United States Present and future trends. Annals of Behavioral Medicine, 7, 24—27. 

Ricer, R..E. 1987. Smokeless tobacco use A dangerous nicotine habit Postgraduate Medicine 81(4) 89-94. 

Winn, D.M., Surveillance of knowledge about cancer associated with smokeless tobacco use, in Smokeless Tobacco on Health an International Perspective, U.S. Department of Health and Human Services, National Institutes of Health, Bethesda, MD, 1992, pp. 11-17. 

Emster, V.L. et al.. Smokeless tobacco use and health effects among baseball players, JAMA, 264,218,1990. 

A new approach to the analysis of the carcinogenic TSNA in moist snuff tobacco is based on SFE with methanol-modified carbon dioxide. Extracted TSNA are trapped across a glass cartridge filled with Tenax GR, from which they are subsequently released by thermal desorption and analyzed by capillary GC-TEA LOD was <2 ng/g. The technique is fast, reproducible, highly selective and sensitive617. SFE with carbon dioxide was also used in the analysis of TSNA in smokeless tobacco. It revealed the presence of higher levels of 4-(methylnitrosamino)-l-(3-pyridyl)-l-butanone (300) than had been determined earlier by conventional methods618. 

Those in which tobacco is not heated or combusted, i.e., smokeless tobacco, e.g., snuff, snus, betel quid these are used orally predominantly, but some are used nasally. 

The predominant form of smokeless tobacco in Uzbekistan is nasway, which is a mixture of dried tobacco leaves, slaked lime, ash from tree bark, and flavoring and coloring agents water is added and the mixture is rolled into balls. In 2002,41% of Uzbek men said they used cigarettes and 38% said they had used nasway less than 1% of the women used nasway. 

In South Africa traditional or home-made products are more commonly used in rural areas while products manufactured by small cottage industries are dominant in urban areas. One of the small smokeless industries was bought by Swedish Match in 1999 and they ve continued to manufacture the same products used for both oral and nasal application. Unlike many other countries, nasal use predominates among the 13.2% of black women in South Africa who use smokeless tobacco, 80% nasally and 20% orally. Overall usage is approximately 10%, but reaches 18.6% among black children (Ayo-Yusuf et al. 2004). Only about 1% of South African men use snuff (Ayo-Yusuf et al. 2008). 

While gender roles and norms in some parts of the world have discouraged women from smoking, smokeless tobacco is more acceptable in some regions (e.g., Africa, India), and waterpipes in others (Middle East). Smokeless tobacco is responsible for four million deaths per year worldwide half of these are among women this is predicted to increase to 10 million deaths per year by 2030 (Christotides 2003). In contrast to India, women in the United States are much more likely to smoke cigarettes than to use smokeless tobacco. 

Similarly, in Mumbai only 0.4% of women smoked, but 57% of women 35 and older used smokeless tobacco). The use of chewing tobacco by women varied greatly by region, with less than 1% in several northern states, 5-10% in Andhra Pradesh and Goa, 20-30% Meghalay and Assam, 30 0% in Orissa and Arunachal Pradesh, and 61% in Mizoram. 

The primary alkaloid in tobacco is nicotine, but tobacco also contains small amounts of minor alkaloids such as anabasine, anatabine, myosmine, and others. The minor alkaloids are absorbed systemically and can be measured in the urine of smokers and users of smokeless tobacco (Jacob et al. 1999). The measurement of minor alkaloids is a way to quantitate tobacco use when a person is also taking in pure nicotine from a nicotine medication or a nontobacco nicotine delivery system. This method has been used to assess tobacco abstinence in clinical trials of smoking cessation with treatment by nicotine medications (Jacob et al. 2002). 

Jacob P, 3rd, Yu L, Shulgin AT, Benowitz NL (1999) Minor tobacco alkaloids as biomarkers for tobacco use comparison of users of cigarettes, smokeless tobacco, cigars, and pipes. Am J Public Health 89(5) 731-736... 

While cigarette sales in the USA declined 18%, from 21 billion packs in 2000 to 17.4 billion packs in 2007, during the same time period sales of other products, such as moist snuff, increased by 1.10 billion cigarette pack equivalents (Connolly and Alpert 2008). In the USA, the most common smokeless tobacco (ST) products are chewing tobacco (loose leaf, plug, and twist), moist snuff, and dry snuff. Many other forms of smokeless tobacco that are used globally were described in an lARC monograph (lARC 2007). All ST products contain nicotine and other tobacco alkaloids that are inherent to tobacco leaf. 

Abstract Delivery of nicotine in the most desirable form is critical in maintaining people s use of tobacco products. Interpretation of results by tobacco industry scientists, studies that measure free-base nicotine directly in tobacco smoke, and the variability of free-base nicotine in smokeless tobacco products all indicate that the form of nicotine delivered to the tobacco user, in addition to the total amount, is an important factor in whether people continue to use the product following their initial exposure. The physiological impact of nicotine varies with the fraction that is in the free-base form and this leads to continued exposure to other toxic tobacco contents... 

The acid-base chemistry of nicotine is now well known and investigations have shown that nicotine in tobacco smoke or in smokeless tobacco prodncts can exist in pH-dependent protonated or nnprotonated free-base forms. In tobacco smoke, only the free-base form can volatilize readily from the smoke particnlate matter to the gas phase, with rapid deposition in the respiratory tract. Using volatility-based analytical measurements, the fraction of nicotine present as the free-base form can be quantitatively determined. For smokeless tobacco products, the situation differs because the tobacco is placed directly in the oral cavity. Hence, the pH of smokeless tobacco prodncts can be measured directly to yield information on the fraction of nicotine available in the nnprotonated free-base form. It is important to characterize the fraction of total nicotine in its conjugate acid-base states as this dramatically affects nicotine bioavailability, because the protonated form is hydrophilic while the nnprotonated free-base form is lipophilic and thus readily diffuses across membranes (Armitage and Turner 1970 Schievelbein et al. 1973). As drug delivery rate and addiction potential are linked (Henningfield and Keenan 1993), increases in delivery rate due to increased free-base levels affect the addiction potential. 

Evidence from the tobacco industry documents, from research studies that measure free-base directly in tobacco smoke particulate, and from examination of smokeless tobacco products, all show that the level of free-base nicotine as delivered to the tobacco user is a critical variable in the acceptance of tobacco products and their continued use. The physiological impact of the rapid delivery of nicotine in the free-base form is a critical determinant of continued nicotine-seeking behavior, with the unintended consequences of exposure to the other toxic components of tobacco smoke and smokeless tobacco. Evaluating total delivered nicotine alone is not sufficient to characterize product differences. To fully understand the influence nicotine has on the allure of these products, both total and free-nicotine levels must be measured. A comprehensive understanding of nicotine delivery is needed to help find effective means for breaking its addictive nature and, ultimately, in reducing the morbidity and mortality associated with tobacco use. The levels of free-base nicotine must be included as part of any effort to achieve a better understanding of how tobacco products themselves influence their continued use. 

As shown in Fig. 1, the speed of nicotine uptake in venous blood following several forms of nicotine delivery varies widely, from that of the very slow pattern of nicotine appearance in the blood (several hours to peak level) produced by current transdermal nicotine medications to the explosive rise produced by tobacco smoke inhalation. Nicotine gum, lozenge, tablet, and vapor inhaler can provide more rapid delivery of nicotine than the patch, but the speed and amount obtained are constrained by use patterns. Smokeless tobacco products deliver their nicotine more rapidly than nicotine gum and with less physical effort, but are still slower than cigarettes in their nicotine dehvery. 

The long-term use patterns of various nicotine-containing products differ by dose and form. Clearly, dependent users of cigarettes and smokeless tobacco often use these products for years prior to making a quit attempt, and often take years to successfully quit. In contrast, users of medicinal nicotine tend to use the products for a much shorter duration. For example, one study found that among 805 households that purchased lucotine gum, 2.3% of new purchase incidents led to continuous monthly purchase of gum for >6 months. For nicotine patches (2050 households). 

In the past decade. Ecstasy use has exploded. In fact, although overall illicit drug use by teens markedly decreased in the past several years — including use of marijuana, inhalants, hallucinogens, LSD, cocaine, crack, heroin, tranquilizers, alcohol, cigarettes, and smokeless tobacco — Ecstasy use continued to rise, unabated (Figure 5.1). 

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