3.27 Health effects of smoking tobacco in other forms

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3.0 Background

3.1 Tobacco—a leading preventable cause of death and disease

3.2 Cardiovascular diseases

3.3 Lung cancer

3.4 Respiratory diseases

3.5 Other cancers caused by or associated with smoking

3.6 Reproductive health and smoking

3.7 Pregnancy and smoking

3.8 Infant health and smoking

3.9 Increased susceptibility to infection in smokers

3.10 Eye diseases

3.11 Dental diseases

3.12 Gastrointestinal diseases

3.13 Bone density and risk of fractures

3.14 Effects of smoking on the skin

3.15 Smoking and complications in medical treatment

3.16 Smoking and diabetes

3.17 Poorer levels of general health

3.18 Smoking, motor vehicle crashes and other injuries

3.19 Burns and fires caused by tobacco use

3.20 Tobacco poisoning

3.21 Health effects for younger smokers

3.22 Genetic influences on tobacco-caused disease

3.23 Smoking, dementia and cognitive decline

3.24 Lung disease, smoking and occupational exposures

3.25 Air pollution, cigarette smoking and ill health

3.26 Health effects of smoking brands that claim to deliver lower levels of tar, nicotine and carbon monoxide

3.27 Health effects of smoking tobacco in other forms

3.28 Health 'benefits' of smoking?

3.29 Morbidity (ill health) attributable to tobacco-caused disease

3.30 Deaths attributable to tobacco by disease category

3.31 Morbidity and mortality due to tobacco-caused disease and socioeconomic disadvantage

3.32 Health effects of smoking other substances

3.33 Health effects of chewing tobacco, and of other smokeless tobacco products

3.34 Public perceptions of tobacco as a drug, and knowledge and beliefs about the health consequences of smoking

3.35 Health benefits of cessation

3.36 The global tobacco pandemic

Acknowledgments

References

Most Australians consume tobacco in the form of manufactured cigarettes. According to national survey data, loose tobacco, or 'roll-your-own', was used by 25% of smokers in 2004, and exclusively by only 5% of smokers. Just more than 1% of smokers reported that they smoked only cigars or pipes, with 8% of smokers reporting that they used these products sometimes. A small proportion of Australian smokers use unbranded loose tobacco, also known as 'chop-chop.' One in 10 Australians aged 14 and over have smoked chop-chop, its popularity being greater among males.148 Smoking tobacco by means of a waterpipe (using a system by which smoke passes through water prior to inhalation) is widespread in other parts of the world149 and may be practised to a minor extent in Australia. For more information on the extent to which tobacco products other than manufactured cigarettes are used in Australia, see Chapter 1, Section 1.11.

3.27.1 Manufactured loose tobacco

Manufactured loose tobacco, hand-rolled into cigarette paper and smoked with or without a filter, causes the same range of diseases as smoking manufactured cigarettes. Variations in quantity of tobacco used per cigarette and filtration make measurements of individual exposure more difficult to assess, but the directly comparable exposure to harmful constituents and method of consumption means that smokers of these products have at least an equivalent risk of developing disease as smokers of conventional cigarettes. Several decades of research on the health effects of tobacco use have enabled comparisons between products with and without filters, and with high and low nicotine and tar yields. Overall, incidence of lung cancer has not varied with tobacco product used, and nor have other health benefits become apparent.5

3.27.2 Unbranded loose tobacco ('chop-chop')

Chop-chop is finely cut, unprocessed loose tobacco that has been grown, distributed and sold without government intervention or taxation.150 It has become a popular alternative to other manufactured tobaccos due to its comparative affordability, and common misapprehensions that it is less harmful to health since it is apparently more 'natural' and 'unadulterated,' not having been processed in the usual way.151, 152 Research has shown that some batches of chop-chop contain bulking agents such as twigs, raw cotton and grass clippings. Fungal (mould) spores have also been detected. Fungal spores are of particular health concern since they give rise to mycotoxins, including aflotoxin, a known carcinogen. Inhalation of and contact with fungi and their mycotoxins can cause a range of adverse responses in the liver, kidneys and skin, and cause illnesses including allergic reactions, chronic bronchitis, asthma and lung diseases.153

Since there is no specific research on the health effects of smoking chop-chop, and there is no reason to believe otherwise, it is inferred that smoking chop-chop damages health in the same ways as do other manufactured tobacco products, and that there may be additional risks due to contaminants described above.

3.27.3 Cigar smoking

Cigar smoke is at least as toxic and carcinogenic as cigarette smoke; and possibly more so. Cigars contain more tobacco per stick than cigarettes, take longer to smoke, and produce higher concentrations of a number of noxious compounds including carbon monoxide, nitrogen oxides, carcinogenic N-nitrosamines and ammonia. However cigar smokers do not exhibit the same disease patterns as cigarette smokers, which is most probably due to different typical patterns of use and inhalation. Cigar smokers have higher levels of mortality from all causes than people who have never smoked, but generally have lower mortality rates than cigarette smokers. Risk of developing smoking-related disease due to cigar use increases with age, the depth of smoke inhalation, and the number of cigars smoked.154

Most people who smoke cigars, do so on an occasional rather than a regular or daily basis, and tend not to inhale the smoke deep into the lungs. The alkaline pH of cigar smoke means that the nicotine it contains is readily absorbed through the oral mucosa. Cigar smokers therefore receive a high smoke exposure to the mouth and tongue, and constituents of smoke in their saliva are swallowed, resulting in higher risks of oral and oesophageal cancers. In regular cigar smokers, this risk is similar to that of cigarette smokers.154

In cigar smokers who do not inhale the smoke deeply, the risk of laryngeal cancer is less than that of cigarette smokers, as are the risks of lung cancer, other lung disease and heart disease. However, the risk of developing disease increases with extent of exposure to cigar smoke. Daily smoking (with moderate inhalation) of five cigars provides a disease risk profile similar to that of a typical pack-a-day cigarette smoker.154

Cigarette smokers who switch to cigars may reduce their lifetime risk of developing lung cancer, ischaemic heart disease and COPD, compared with cigarette smokers who continue their usual smoking behaviour. However cigarette smokers who have switched have a higher risk of developing these three major disease entities than cigar smokers who have not previously smoked cigarettes. Cigarette smokers who switch to cigar smoking may not reduce their disease risk if they smoke cigars on a daily basis and inhale the smoke deeply.154

3.27.4 Pipe smoking

Regular pipe smoking is generally associated with a lower risk of death from smoking-caused diseases than cigarette smoking, and a similar to or greater risk of mortality than is associated with cigar use.155 Disease patterns differ from those observed in cigarette smokers because pipe smokers tend to inhale the smoke less deeply, taking up nicotine through the mucous membranes lining the mouth instead of predominantly via the lungs. Risk for developing cancers of the larynx, lung, oropharynx, oesophagus, colorectum and pancreas is significantly higher among pipe smokers than never smokers. As among cigarette smokers, alcohol use in pipe smokers greatly increases the risk of developing cancers of the upper aero-digestive tract.

Pipe smoking is also associated with a significantly higher risk of dying from COPD, cerebrovascular disease, and cardiovascular disease. As with cigarette smoking, the risk of developing tobacco-caused disease varies in a dose-response relationship, disease risk increasing with the amount smoked, the depth to which it is inhaled, and the duration of smoking. For most disease entities the relative risk of developing tobacco-related disease declines with quitting, increased length of time of cessation, and younger age at quitting.155

Cigarette smokers who switch to pipes may lower their lifetime risk of developing lung cancer, ischaemic heart disease and COPD, compared to continuing cigarette smokers. However, cigarette smokers who have changed still have a higher risk of developing these diseases than pipe smokers who have not previously smoked cigarettes. Reduced disease risk is for the most part due to reductions in quantities smoked and to a lesser extent, reduced inhalation.156

3.27.5 Waterpipe smoking

Tobacco smoking by waterpipe, also known as narghile, argileh, boory, goza, hookah, hubble-bubble or shisha smoking, is a practice dating back about four centuries and traditionally seen in the Eastern Mediterranean Region, India, Pakistan, Bangladesh and some parts of China.149, 157 Despite its extensive usage (it is estimated that about one billion people worldwide are waterpipe users158), the health effects of waterpipe smoking (WPS) have not been widely studied. This is an area requiring urgent research.159, 160

Waterpipe apparatus varies widely in design, but the method of use requires the heating with burning charcoal of moist tobacco (usually sweetened and flavoured) to produce smoke, which is passed through water before being inhaled via a mouthpiece on the end of a hose.149, 157 WPS usually occurs in a social setting with a number of participants seated around the waterpipe, taking it in turns to inhale. Waterpipe use had declined in popularity during the early 20th century, becoming the preserve of older men; but there has been a resurgence of use in younger people in the Eastern Mediterranean and Arab regions, where it is increasingly viewed as a fashionable and sociable behaviour, as well as an inexpensive way of using tobacco.157, 160 The availability of pre-moistened, shaped and flavoured tobacco made especially for waterpipe use ('Maassel') since the 1990s is likely to have contributed to a resurgence in WPS in the Eastern Mediterranean Region, and its increased popularity among younger users.149, 161 Whereas in some regions cigarette smoking is not socially acceptable for women, WPS may not carry the same stigma and female participation rates are high.149, 162 WPS among adolescents is also both socially acceptable and common in some parts of the world.149

Interest in WPS has spread through Western Europe and the United States of America, following patterns of migration, and the appearance of 'hookah bars or cafes' is increasing.163

Perceptions that WPS is a safer form of smoking because the smoke is 'purified' by passage through water are spurious. Although the moist smoke produced by WPS may be more palatable than cigarette smoke,157 many of the harmful gases and chemicals found in cigarette smoke are present in equal or even greater amounts in waterpipe smoke, including carbon monoxide, nicotine and heavy metals.149 Waterpipe smokers are typically exposed to smoke over a longer period than cigarette smokers, a session lasting somewhere from 45 minutes to an hour, but some sessions may continue for many hours.157 Although waterpipe smokers usually do not smoke on so frequent a basis as cigarette smokers,160, 162 it has been estimated that during a typical session, a waterpipe smoker can take ten times the number of puffs and each puff can be ten times the volume, compared to smoking a single cigarette.159

The lack of research on the constituents of waterpipe smoke, and the fact that many waterpipe smokers also smoke cigarettes, means that much of the evidence on its use and disease risk is preliminary. However, there is evidence that WPS is addictive,162, 164 as well as research that associates WPS with a number of adverse outcomes, including increased risk of cancers of the mouth, airways and lungs and bladder, the development of coronary heart disease, and decreased lung function.149 Shared waterpipe use (whether used as a means of administering tobacco or other substances such as marijuana165) is associated with increased risk of infection from contagious disease.157 Secondhand smoke from WPS is also potentially harmful.157