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Smokeless Tobacco . an Overview

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Smokeless Tobacco . an Overview Beiträge zur Tabakforschung International/Contributions to Tobacco Research Volume 23 @ No. 5 @ September 2009 Smokeless Tobacco – An Overview* by Hubert Klus1, Michael Kunze2, Steffen König3 and Ernst Pöschl3 1 Oriongasse 9, 3100 St. Pölten, Austria 2 Institut für Sozialmedizin der Medizinischen Universität Wien, Rooseveltplatz 4, 1090 Wien, Austria 3 Pöschl Tabak GmbH & Co. KG, Dieselstraße 1, 84144 Geisenhausen, Germany CONTENTS combustion and pyrolysis products of tobacco generated during smoking are considered to be responsible for the Summary 248 harmful effects. Smokeless tobacco, another wide-spread Introduction 249 form of tobacco use, is not subjected to burning and produces 1. Description of smokeless tobaccos – no combustion or pyrolysis products. Therefore, there is an Smokeless tobaccos in Europe and the USA 250 increasingly intense debate about the potential role of smoke- 1.1 Tobacco products for sniffing 250 less tobacco in reducing the harm of tobacco use. 1.2 Tobaccos products for sucking 251 An overview is presented on the different types of smoke- 1.3 Chewing tobaccos 251 less tobaccos consumed around the world. Commercial 2 Description of smokeless tobaccos – products differ widely in composition and patterns of use. Smokeless tobaccos outside Europe The smokeless tobaccos of the Western world (Europe and and the USA 251 North America) need to be clearly distinguished from those 3 Regulations for smokeless tobaccos popular in Asia, Africa and South America. The modern in Europe 252 smokeless tobaccos used in Europe and North America are 4 Toxicological and epidemiological reviewed regarding their chemical composition and toxi- assessment 253 cological properties. Agents of concern found in smokeless 4.1 Chemical composition and toxicological tobacco, especially the tobacco specific N-nitrosamines, are considerations 253 dealt with in particular. 4.1.1 Tobacco specific N-nitrosamines (TSNAs) 253 The epidemiological evidence is summarized concerning a 4.1.2 Other constituents and contaminants 255 wide range of health outcomes. Published reviews and 4.1.3 Summary of analytical data for studies are presented and interpreted regarding non-neo- contemporary products 256 plastic oral diseases, various forms of cancer, circulatory 4.1.4 In vitro toxicological assessment 257 diseases, several other diseases and pregnancy outcome. 4.2 Epidemiological assessment 257 While many of the epidemiological studies have weak- 4.2.1 Reviews across several health outcomes 257 nesses and data are often inconsistent it is quite obvious 4.2.2 Reviews and studies on specific health that smokeless tobacco use is much less risky for con- outcomes 259 sumers than smoking. In fact, for modern forms of Euro- Discussion 265 pean moist snuff such as Swedish snus, which is subject to Acknowledgment 269 strict quality standards, there is evidence for – if any – only References 269 very limited serious health risk. The ongoing public discussion centers around the influence smokeless tobacco may have on smoking rates (initiation or SUMMARY cessation) and the occurrence of tobacco specific diseases - with Sweden being a revealing example. There is an inter- Smoking, especially cigarette smoking, is the most common esting controversy regarding product and marketing regu- form of tobacco consumption world-wide. It is generally lations for smokeless tobaccos in the European Union. accepted that smoking carries health risks for smokers. The [Beitr. Tabakforsch. Int. 223 (2009) 248–276] *Received: 23rd February 2008 – accepted: 6th August 2009 ZUSAMMENFASSUNG rôle potentiel que jouent des produits de tabac sans fumée pour la réduction des effets nuisibles de la consommation Rauchen – vor allem von Zigaretten – ist weltweit die du tabac. üblichste Form, Tabak zu konsumieren. Es ist allgemein Un bref aperçu est donné sur les différents types de tabacs anerkannt, dass Rauchen gesundheitsschädlich ist. Die Ver- sans fumée consommés dans le monde entier. Les produits brennungs- und Pyrolyseprodukte, die beim Rauchen des disponibles sur le marché sont fortement différents dans la Tabaks entstehen, werden für die schädlichen Wirkungen composition et les modes d’utilisation. Les produits sans verantwortlich gemacht. „Smokeless tobacco”, eine andere fumée disponibles en Europe et l’Amérique du Nord sont weit verbreitete Form des Tabakgenusses, wird dagegen nicht clairement à distingués des produits vendus en Asie, en verbrannt und bildet keine Verbrennungs- oder Pyrolyse- Afrique et en Amérique du sud. Les tabacs sans fumée produkte. Daraus hat sich eine Debatte steigender Intensität consommés en Europe et en Amérique du Nord sont ergeben über die Rolle, die „smokeless tobacco” bei der examinés ici concernant leur composition chimique et leurs Verminderung tabakbedingter Schäden spielen könnte. effets toxicologiques. Les composants d’intérêt particulier, In einem Überblick werden die verschiedenen weltweit présent dans le tabac sans fumée, particulièrement les N- konsumierten Formen von „smokeless tobacco” vorgestellt. nitrosamines spécifiques du tabac (TSNA) sont examinés Die Handelsprodukte unterscheiden sich erheblich in ihrer plus en détail. Zusammensetzung und ihrem Gebrauch. „Smokeless Un résumé sur l’évidence épidémiologique des effets tobacco” in der westlichen Welt (Europa und Nordamerika) sanitaires allégués du tabac sans fumée est présenté. Un ist klar von dem zu unterscheiden, der in Asien, Afrika und aperçu de la littérature est donné et examiné concernant les Südamerika verbreitet ist. Die chemische Zusammen- maladies de la bouche non néoplastiques, les différentes setzung und die toxikologischen Eigenschaften von moder- formes du cancer, les maladies du système circulatoire, nem „smokeless tobacco” in Europa und Nordamerika plusieurs autres maladies et la grossesse. Alors que werden besprochen. Die Betonung liegt dabei auf den beaucoup des études épidémiologiques souffrent de fai- problematischen Bestandteilen in „smokeless tobacco”, blesses et de données contradictoires, il semble être évident besonders auf den tabakspezifischen N-Nitrosaminen. que la consommation du tabac sans fumée est moins nui- Die epidemiologischen Befunde für ein weites Feldes sible à la santé que le fumage. En effet, pour les marques gesundheitlicher Auswirkungen werden zusammengefasst. commerciales modernes européennes de tabac à sucer, Publizierte Übersichtsartikel und Studien werden vorge- comme le tabac à sucer suédois, soumis à des normes stellt und interpretiert betreffend nicht-neoplastische orale strictes de qualité, des données suggèrent que les risques Krankheiten, verschiedene Formen von Krebs, Krankheiten sanitaires soient, s’il y en a, très réduits. des Kreislaufs, bestimmte andere Krankheiten und Schwan- Les discussions en cours traitent de l’influence potentielle gerschaften. Obwohl zahlreiche epidemiologische Studien du tabac sans fumée sur le comportement de fumage Schwächen aufweisen und die Daten oft widersprüchlich (commencement ou cessation) et des maladies spécifiques sind, ist es ziemlich offensichtlich, dass der Genuss von du tabac, la Suède servant comme un exemple. Une „smokeless tobacco” für den Konsumenten viel weniger controverse intéressante est en cours dans l’Union Risiko birgt als das Rauchen. Für die heutigen Formen von européenne concernant la législation commerciale relative europäischem „moist snuff” wie dem schwedischem au tabac sans fumée. [Beitr. Tabakforsch. Int. 23 (2009) „snus”, der strengen Qualitätsstandards unterworfen ist, hat 248–276] sich in der Tat – wenn überhaupt – nur ein sehr begrenztes Risiko ernster gesundheitlicher Folgen gezeigt. Die öffentliche Diskussion betrifft den Einfluss von INTRODUCTION „smokeless tobacco” auf den Anstoß zu rauchen oder es aufzugeben und auf das Auftreten tabakbedingter Krank- Smoking, especially cigarette smoking, is the most com- heiten, wobei Schweden als aufschlussreiches Beispiel mon form of tobacco consumption world-wide. It is dient. Eine interessante Kontroverse betrifft die Produkt- generally accepted that tobacco smoking carries health risks und Marktregulierungen für smokeless tobacco in der for smokers, such as different forms of cancer and diseases Europäischen Union. [Beitr. Tabakforsch. Int. 23 (2009) of the heart and circulatory system (1). Certain combustion 248–276] and pyrolysis products of tobacco generated primarily during puffing, such as polycyclic aromatic hydrocarbons, phenols, carbon monoxide, nitric oxide, acetaldehyde, RESUME isoprene and butadiene, are considered to play a key role in increasing the health risks for smokers. In addition, several Le fumage – particulièrement le fumage de cigarettes – biologically active endogenous tobacco constituents are constitue le moyen le plus courant de consommation du directly transferred from tobacco into smoke, such as tabac dans le monde entier. Il est généralement admis que nicotine, the tobacco specific N-nitrosamines and aroma le fumage entraîne des risques pour la santé. Les produits substances (2). de combustions et de pyrolyse du tabac générés au cours du Besides smoking, tobacco may also be consumed without fumage sont considérés comme être responsables des effets burning in form of the different kinds of “smokeless nuisibles. Les produits de tabac sans fumée (à macher ou à tobacco”. Smokeless tobaccos do not give rise to sub- priser), ce qui constitue un autre moyen très répandu de la stances usually generated by tobacco burning. Therefore, consommation du tabac, ne sont ni brûles ni pyrolysés. Par
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