Last updated: June 2021
Suggested citation: Bellew, B, Winnall, W, Hanley-Jones, S, Greenhalgh, EM, & Winstanley, MH. 3.27 Health effects of smoking tobacco in other forms. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from http://www.tobaccoinaustralia.org.au/3-27-health-effects-of-smoking-tobacco-in-other-fo
Data from the 2019 National Drug Strategy Household Survey1 show that while the vast majority of Australian smokers (84%) use manufactured cigarettes, a variety of other tobacco products are also used. Use of loose cigarette tobacco (commonly known as roll-your-own (RYO)) tobacco is common in Australia. Forty-five percent of Australian smokers over the age of 14 reported any use of roll-your-own tobacco in 2019, up from 26% in 2001. Some cigarette smokers use RYO tobacco exclusively (13.9% of smokers 14 years and over in 2019) and some use it in combination with manufactured (factory-made) cigarettes (32.7% in 2019). Some smokers report using unbranded roughly processed tobacco for rolling into cigarettes (also known as chop-chop). This tobacco is sold on the black market, without taxes and is illegal both to possess or supply—see Section 13.7 for further discussion. The proportion of smokers currently using unbranded loose tobacco has not changed significantly over six years to 2019. It was reported at 3.6% in 2013 and 4.9% in 2019.2
Other manufactured tobacco products smoked either regularly or occasionally in Australia (either exclusively or in addition to cigarettes) include cigars, traditional pipe tobacco and shisha tobacco used in waterpipes. In 2019, 5.4% of smokers use cigars, 2.2% reported using pipe tobacco, and 4.2% of current smokers used waterpipe tobacco.1
Kreteks and bidis are also used by small numbers of people in Australia, the former being a type of clove cigarette originating in Indonesia, and the later a small, thin, hand-rolled cigarette consisting of sun-dried and cured tobacco flakes rolled in tendu or temburni leaves, native to Asia. The proportion of smokers in Australia aged 14 years and over who had used bidis in the last 12 months was 1.1%.1 Consumption patterns for kreteks are unknown in Australia.
For more information on the extent to which tobacco products other than manufactured cigarettes are used in Australia, see Chapter 1, Section 1.12.
3.27.1 Manufactured loose tobacco
Manufactured loose tobacco, hand-rolled in cigarette paper and smoked with or without a filter, causes the same range of diseases as smoking manufactured cigarettes, contrary to some smokers’ misperception of roll-your-own (RYO) tobacco as less harmful than factory-made.3 Comparison of exposure to carcinogens among roll-your-own and factory-made cigarette smokers shows RYO to be no less harmful than factory-made cigarettes.4 Variations in the quantity of tobacco used per cigarette and filtration make measurements of individual exposure 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 do 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, the incidence of lung cancer has not varied between the tobacco products used, nor have other health benefits become apparent.5
3.27.2 Unbranded loose tobacco (‘chop-chop’)
Chop-chop is used by some as an alternative to manufactured cigarette tobaccos (either factory-made cigarettes or manufactured RYO tobacco) 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.6-8 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 aflatoxin, 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.9 Australian chop-chop users report significantly worse health than smokers of licit tobacco. In a comparison with licit-only tobacco smokers, current users of chop-chop had significantly greater odds of reporting below-average social functioning (OR 1.61; 95% CI, 1.06–2.44), measurable disability (OR 1.95; 95% CI, 1.08–3.51), below-average mental health (OR 1.61; 95% CI, 1.22–2.13) and above-average bodily pain (OR 1.40; 95% CI, 1.06–1.85).10
3.27.3 Cigar smoking
A cigar is a roll of tobacco wrapped in tobacco leaf. Most cigars are made from a single type of tobacco that is air-cured and fermented.11 There are three main types available in Australia; large cigars, cigarillos and little cigars. Large cigars usually contain more than 5 g of tobacco with some containing as much as 20 g.12 Cigarillos are a smaller type of cigar that usually contain about 3 g of tobacco.12 Little cigars are the same size and shape as cigarettes and are often packaged like cigarettes, sometimes with a filter. Unlike for cigarettes, most cigar smokers only allow the smoke into their mouth and throat. However, some smokers do inhale cigar smoke into their lungs.12
Cigar smoke is at least as harmful and as 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.13 In laboratory assays, particulate matter from cigarillos has a stronger cellular toxicity and genotoxicity (causing of mutations in DNA) than that from cigarettes.14 A 2016 symposium on cigar use, health effects and policy implications, noted that quantification of toxicant exposure from cigar smoke can be challenging as consumption behaviour varies. Some people inhale cigar smoke, others do not; some smoke only a portion of a cigar, returning to re-light the product later; while some people like to chew on their cigar, all of which have unique consequences on toxicant exposure.15
Cigar smoking carries many of the same health risks as cigarette smoking, with research showing an increased risk of all-cause mortality.16, 17 Cigar smoking increases the risk of oral, oesophageal, laryngeal, bladder, pancreatic and lung cancer,16-23 as well as the risk of coronary heart disease, aortic aneurysm and stroke.17, 19
A 2015 systematic review found mortality risks from cigar smoking vary by number of cigars per day and inhalation level, but can be as high as, or exceed those, of cigarette smoking. Specifically, primary cigar smoking (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) was associated with all cause-mortality, oral cancer, oesophageal cancer, pancreatic cancer, laryngeal cancer, lung cancer, coronary heart disease, and aortic aneurysm. Strong dose–response relationships were observed between the number of cigars smoked per day and inhalation level, and oral, oesophageal, laryngeal, and lung cancers. Among primary cigar smokers who reported that they did not inhale, relative mortality risk was still highly elevated for oral, oesophageal, and laryngeal cancers.17 These findings were later confirmed in a 2019 study, which also identified an increased prevalence of stroke, in addition to heart disease.19
A 2010 European longitudinal study involving more than 100,000 men found that, compared to never smokers, the risk of cancers of the lung, upper aerodigestive tract and bladder combined, was more than doubled (HR 2.2; 95% CI, 1.3–3.8) for exclusive cigar smokers. Effects were stronger in current than in ex-smokers and in inhalers than in non-inhalers. For ever smokers of both cigarettes and cigars there was more than a five-fold increase in the risk of these cancers (HR 5.7; 95% CI, 4.4–7.3) making the risk elevation as high as that among exclusive cigarette smokers.18
In 2018, a nationally representative US longitudinal study followed-up on 357,420 people who reported using cigars, pipes, or cigarettes from 1985 to the end of 2011. The results of this study showed that exclusive cigar smokers (HR, 1.20; 95% CI, 1.03-1.38) had higher all-cause mortality risks than never tobacco users, and had an elevated risk of dying from tobacco-related cancer (HR, 1.61; 95% CI, 1.11-2.32), including cancer of the bladder, oesophagus, larynx, lung, oral cavity, and pancreas.16
Smoke drifting from the burning tip of a lit cigar contains most of the same harmful and carcinogenic compounds as cigarette smoke. As they are larger, cigars generate smoke for a longer period of time—as long as 90 minutes for a single large cigar. This is a health concern for those constantly exposed to indoor cigar smoke;13 some researchers have concluded that high passive exposure to smoke from cigars and pipes may be associated with lung cancer risk.20
3.27.4 Pipe smoking
Longitudinal research conducted in Norway has reported that pipe smoking is not safer than cigarette smoking. The study followed a cohort of more than 16,000 men for up to 13 years. Between pipe and cigarette smokers, no or only minor differences were found in mortality from any cause and the specified smoking-related diseases.24 Pipe smoking is associated with decreased lung function and increased odds of airflow obstruction, even in participants who had never smoked cigarettes;25 it is associated with a significantly higher risk of dying from COPD, cerebrovascular disease and cardiovascular disease. Compared to never smokers, exclusive pipe smokers are estimated to have a three-fold increase in risk (HR 3.0; 95% CI, 2.1–4.5) for cancers of lung, upper aerodigestive tract and bladder combined,18 and an eight-fold risk (OR 8.7; 95% CI, 4.0–18.9) of all upper digestive tract cancers (including a 12-fold risk for oral and seven-fold risk for pharyngeal cancer).26 Pipe smokers who are also heavy alcohol drinkers have a massive 38-fold increased risk of these cancers (OR 38.8; 95% CI, 13.6–110.9) as compared to never smokers and light drinkers, strongly suggesting that pipe smoking and heavy alcohol drinking may interact in a way that greatly increases the risks.26
A 2018 nationally representative US longitudinal study following 357,420 participants who reported using cigar, pipe, or cigarettes from 1985 to the end of 2011 showed exclusive current pipe smokers (HR, 1.58; 95% CI, 1.05-2.38) had an elevated risk of dying from a tobacco-related cancer than never-smokers, including bladder, oesophagus, larynx, lung, oral cavity, and pancreas.16
As with cigarette smoking, the risk of tobacco-caused mortality from pipe-smoking varies in a dose–response relationship. Mortality risk increases with the amount smoked, the depth to which it is inhaled and the duration of smoking. For most disease entities, the relative risk of mortality declines with quitting, increased length of time of cessation and younger age at quitting.27
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 of the mouth instead of predominantly via the lungs. Some earlier studies suggested the possibility of some harm reduction benefits in switching from cigarette to pipe smoking.18 It was suggested that the magnitude of the extra risk was smaller if people had switched to cigars or pipes only (i.e. quit cigarettes) and had not compensated with greater smoking intensity. However, it should be noted that research has found men who switched from cigarettes-only to pipe-only had a risk that was not significantly different from the risk in sustained smokers of cigarettes only,24 so that the overall conclusion about pipe smoking is that it is hazardous and is certainly not a safe alternative to cigarette smoking.
3.27.5 Waterpipe smoking
Using a waterpipe to smoke tobacco is not a safe alternative to cigarette smoking.28 Names for waterpipes vary and include ‘narghile’, ‘arghile’, ‘shisha’, ‘goza’, ‘hubble bubble’ and ‘hookah’.29 Waterpipe use is common through the Middle East and Asia. Waterpipes were widely used in Turkey during the Ottoman Empire (15th century), Iran, Lebanon, Syria, Jordan, Greece, India, Pakistan, Palestine, Egypt and Saudi Arabia. As people immigrated to Europe from India, Pakistan, Northern Africa and the Middle East, hookahs and hookah cafes began appearing in European cities. Today, hookah bars and cafés are popular in many parts of Britain, France, Spain, Russia, India, Asia and throughout the Middle East, and are growing in popularity in the US.30 Epidemiological studies show an increase in the popularity of waterpipes since the year 1990s, particularly in younger people around the world. In countries that report data, prevalence was estimated at 6–34% of young people (13 to 15 years old).28
Waterpipe apparatus vary widely in design, but the method of use requires heating with burning charcoal of moist tobacco (usually sweetened and flavoured) to produce smoke. This is passed through water before being inhaled via a mouthpiece on the end of a hose.31, 32 Electronically heated systems have also been developed in recent years, but the effects of these on smokers and the environment have not been well-studied.33 Waterpipe smoking usually occurs in a social setting with a number of participants seated around the waterpipe, taking it in turns to inhale. 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 waterpipe smoking in the Eastern Mediterranean Region, and its increased popularity.32, 34, 35 At least in some cultures, women and girls are more likely to use a waterpipe than to use other forms of tobacco, and it is popular among younger smokers. Because the smoke passes through a reservoir of water, waterpipe smoking may mistakenly36 be perceived as being less lethal than other methods of tobacco use.32, 37-39
Although the moist smoke produced by waterpipe smoking may be more palatable than cigarette smoke,31 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.32, 40 Waterpipe smoke contains many harmful substances including carcinogens (that cause cancer), genotoxic chemicals (that mutate DNA sequences), heavy metals, BTEX chemicals (benzene, toluene, ethylbenzene or xylene) and a range of pathogenic bacteria.41, 42 Smoking a waterpipe increases oxidative stress—a form of cell damage that underlies conditions such as inflammation and cardiovascular disease.43, 44 Waterpipe smoke increases the levels of many DNA damage markers and inhibits the production of DNA repair genes, that protect against cancer formation.41
Waterpipe smokers are typically exposed to smoke over a longer period than cigarette smokers. A session lasts somewhere between 45 minutes to an hour, but some sessions may continue for many hours.31 Although waterpipe smokers do not usually smoke as frequently as do cigarette smokers,37, 45 it has been estimated that during a typical session, a waterpipe smoker inhales more than 100 times the volume of smoke produced by smoking a single cigarette.28 Relative to a single cigarette, a single waterpipe session exposes the smoker to 3–9 times the carbon monoxide and 1.7 times the nicotine.46
Waterpipe smoking is associated with features of dependence, such as drug-seeking behaviour, inability to quit despite repeated attempts, and abstinence-induced withdrawal that is suppressed by subsequent waterpipe use.47
Health effects associated with waterpipe smoking:
Research has shown tobacco waterpipe smoking to be significantly associated with a range of negative health effects, including, but not limited to; head and neck cancers,48, 49 oesophageal cancer,48, 50 lung cancer,48-51 cardiovascular49, 52 and respiratory diseases,49, 51, 53-55 periodontal disease,51 metabolic syndrome49 and obesity,56 low birthweight,49, 51 mental health problems49 and spreading of infectious diseases.57-59 Waterpipe smoking is also associated with injuries and other acute effects, such as burns, vomiting, fainting and severe carbon monoxide poisoning, particularly among young adults.60, 61
A 2010 systematic review found that waterpipe smoking of tobacco was significantly associated with double the risk of lung cancer (OR 2.12; 95% CI, 1.32– 3.42).51 Several systematic reviews and meta-analyses conducted in 2016 confirmed this finding.48-50 Cancers of the head and neck, including oral and oesophageal cancer, have also been found to be significantly associated with waterpipe tobacco smoking. However, while two 2016 meta-analyses found significant positive associations between waterpipe smoking and oesophageal cancer, another that same year did not find a significant association (OR=4.14, 95% CI=0.93,18.46).
Waterpipe tobacco smokers are significantly more likely to suffer the effects of metabolic syndrome, including hyper-triglyceridaemia (high blood fat levels), hyper-glycaemia (high blood sugar levels), hypertension (high blood pressure) and abdominal obesity.49, 62 A 2019 systematic review of five studies on the association between waterpipe smoking and higher risk of obesity, comprising of a total of 16,779 participants, found a higher prevalence of obesity and/or a higher association between obesity and waterpipe smoking than for non-smokers and cigarette smokers (when comparisons were available) regardless of gender, and among all ages.56
A Scientific Statement from the American Heart Association and a meta-analysis on waterpipe tobacco smoking and cardiovascular disease risk give an overview of the growing body of evidence that waterpipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term.52, 63 Long-term waterpipe use is associated with increased risk of coronary artery disease.64 A 2016 systematic review and meta-analysis also found tobacco waterpipe smoking to be significantly associated with cardiovascular disease (OR = 1.67, 95% CI= 1.25,2.24).49 A study of over 200 people who had ‘first ever ischemic strokes’ found that, after controlling for numerous cofactors, waterpipe smoking was a strong risk factor for these stroke events.65
Systematic reviews have found that tobacco waterpipe smoking to be associated with several health indicators such as increased vascular resistance, increased heart rate, increased blood pressure, lower PFT scores, shortness of breath, chronic cough, and health conditions such as bronchitis and chronic bronchitis, COPD, nasal polyposis, cellular damage, low immunity, among other conditions already covered.53, 63 Even one session of waterpipe smoking can increase the heart rate and blood pressure.63
Another systematic review and meta-analysis of six cross-sectional studies was conducted to examine the effects of waterpipe tobacco smoking on lung function compared with no smoking. Despite methodological limitations in the reviewed studies, the authors were able to conclude that waterpipe smoking of tobacco negatively affects lung function, may be as harmful as cigarette smoking and is likely to be a cause of chronic obstructive pulmonary disease (COPD).55 Significant associations between waterpipe tobacco smoking and respiratory diseases (COPD odds ratio (OR)= 3.18, 95% CI= 1.25, 8.08; bronchitis odds ratio (OR)= 2.37, 95% CI= 1.49, 3.77; passive water-pipe smoking and wheezes odds ratio (OR)= 1.97, 95% CI= 1.28, 3.04) were later confirmed in a 2016 systematic review and meta-analysis on the effects of waterpipe tobacco smoking on a range of health outcomes.49
A 2016 systematic review and meta-analysis also found waterpipe use to be significantly associated with poor mental health (OR 1.30-2.4 95% CI 1.20,2.80), and low birth weight (OR=2.39, 95% CI =1.32,4.32),49 and an earlier systematic review found that waterpipe smoking of tobacco was significantly associated with at least a trebling in the risk of periodontal disease.51
Waterpipe smoking in groups may also be increasing the transmission of infectious diseases. Sharing a waterpipe has been associated with increased risks of herpes, hepatitis,66 tuberculosis58, 59, 66 and mumps.57
Waterpipe smoking-related emissions can also cause harm to non-smokers. Secondhand smoke from waterpipe tobacco use produces a similar level of air pollutants as cigarettes. For more on the harms of secondhand smoke from sources other than cigarettes see Chapter 4, Section 4.2.1.
Kreteks are cigarettes that contain a combination of cloves and clove oil, tobacco and other additives. Originating in Indonesia, where they account for about 90% of the market,67 a small number of brands are currently imported into Australia.
Although kreteks are smaller than typical cigarettes, they can deliver similar levels of nicotine and carbon monoxide to smokers.68 Gas chromatographic analysis of kreteks has revealed high levels of eugenol, anethole and coumarin compounds. The authors of one study noted that compounds such as eugenol are known to be hazardous to humans when inhaled in high concentrations, and pose significant health concerns. The researchers concluded that usage of such compounds in smoking products, particularly at high levels, should be discouraged pending the availability of detailed toxicity information.69 Another analysis found that the levels of these compounds found in kreteks are significantly higher than those typically found in commercial cigarette brands.70
Long-term research on the health effects of smoking kreteks is scant, but it can be reasonably assumed that they pose at least the same dangers to health as conventional cigarettes, due to a comparable exposure to harmful constituents and the method of consumption. Popular use of these cigarettes in the US commenced in about 1980. By the mid-1980s, warnings had begun to appear in the literature, notably so when 13 cases of severe illness with clove cigarette smoking were reported to the Centers for Disease Control and the California Department of Health Services. The effects of this illness on people included haemorrhagic pulmonary oedema (bleeding from the lungs), pneumonia, bronchitis and hemoptysis (spitting up or coughing up of blood).71
A systematic review of 32 Indonesian studies found that kretek-smoking was associated with oral cancer, cardiovascular disease, myocardial infarction, asthma, and oral diseases. However, the available studies were mostly low quality, reducing the strength the evidence for these health effects. The health effects associated with kretek in terms of oral cancer, cardiovascular disease and coronary heart diseases, were generally similar to those from regular cigarettes in studies that compared to two.67
Research from Indonesia has shown that regular high-dose kretek smokers have 13‒20 times the risk of abnormal lung function than non-smokers.72 Kretek use is associated with a higher risk of acute lung injury, particularly in susceptible individuals such as those with asthma or respiratory infections.73 There is also evidence that clove cigarettes are linked with a greatly increased risk of dental disease. In a longitudinal study of more than 1000 male bus drivers in Jakarta, 27% of those who had smoked for 10 years or less had dental caries. This proportion increased to 79.6% among those smoking for 11–15 years and rose to 89.3% among those smoking for more than 15 years. People who smoked 7–12 cigarettes a day were more than twice as likely (RR 2.66, p<0.0001) to develop dental caries compared to those smoking 0–6 cigarettes a day. Those categorised as smoking either 13–18 cigarettes a day (RR 3.19, p<0.0001) or more than 18 cigarettes a day (RR 2.96, p<0.0001) were three times more likely to do so.74 A small 2014 Indonesian study examining the association between kretek smoking and risk of oral cancer found those who smoked kreteks increased their risk of oral cancer by almost three-fold. Moreover, those who smoked kreteks were found to have almost double the risk of oral cancer compared to cigarette smokers.75
As previously noted, cloves contain a substance called eugenol, which when inhaled has the characteristics of a local anaesthetic. In the past this attribute has lent kreteks a reputation as soothing for sore throats and asthma,76 but in fact it can reduce the gag reflex, leading to pulmonary aspiration (when substances such as food or drink enter the lungs).73 The American Medical Association reviewed the medical evidence concerning clove cigarettes in 1988 and reached the following conclusions:
(i) clove cigarettes are tobacco products, therefore they possess all the harms associated with smoking tobacco cigarettes; and
(ii) inhaling clove cigarette smoke has been associated with severe lung injury in a few susceptible persons. People with asthma or with a throat or lung infection in its early stages may have an increased risk of harm from inhaling clove cigarette smoke.73
3.27.7 Bidis (beedis, beedies, biris)
Bidis are small, thin, hand-rolled cigarettes consisting of sun-dried and cured tobacco flakes rolled up in a piece of dried tendu or temburni leaf (from plants native to Asia). They may be flavoured with a variety of sweet or fruit essences (e.g. chocolate, cherry and mango) or unflavoured, and are secured at either end with colourful threads.77 Bidi use is most prevalent in India, Bangladesh, Nepal, Sri Lanka, Pakistan and the Maldives.78, 79 A paper published in 2000 estimated that 21% to 56% of men in South Asian countries smoke bidis.78 Smoke from a bidi contains 3–5 times the amount of nicotine as a regular cigarette and places users at risk of nicotine addiction.78, 80 The compounds added to provide flavouring (such as clove, cinnamon, vanilla, cardamom, strawberry, mango, grape, lemon-lime and chocolate) are also present in high levels and may contribute to long-term health damage, particularly in the case of cloves.81 Tobacco factory employees who hand-roll bidis are chronically exposed to potentially harmful levels of tobacco via inhalation of dust and flakes, and through the skin.78 Bidi smoking increases the risk of oral cancer,82-84 lung cancer,82, 85 stomach cancer, and oesophageal cancer;78, 86 is associated with a more than three-fold increased risk for coronary heart disease and acute myocardial infarction (heart attack);78 is associated with a nearly four-fold increased risk for chronic bronchitis;78 and is also associated with chronic obstructive pulmonary disease (COPD).87 Bidi use during pregnancy has been shown to be associated with perinatal mortality.77
Relevant news and research
For recent news items and research on this topic, click here. (Last updated October 2021)
1. Australian Institute of Health and Welfare. Data tables: National Drug Strategy Household Survey 2019 - 2. Tobacco smoking chapter, Supplementary data tables. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data.
2. Australian Institute of Health and Welfare. Table 2.55 Use of unbranded tobacco: National Drug Strategy Household Survey 2019 - 2. Tobacco smoking chapter, Supplementary data tables. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data.
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