New and traditional smokeless tobacco: comparison of toxicant and carcinogen levels

Declining cigarette use and spreading bans on smoking in public places in the United States are encouraging the U.S. cigarette industry to turn to another tobacco category, smokeless tobacco products. Currently, a number of new brands are being test marketed, including Taboka, Marlboro Snus, Camel Snus, and Skoal Dry. We report here levels of tobacco-specific nitrosamines (TSNAs), alkaloids, anions, polycyclic aromatic hydrocarbons (PAH), and volatile aldehydes in these products, and compare them to the most popular traditional moist snuff brands. Total TSNAs averaged 1.97 microg/g dry weight tobacco in Taboka, Marlboro Snus, and Camel Snus, 4.54 microg/g tobacco in Skoal Dry, and 7.42 microg/g tobacco in traditional brands. The amounts of unprotonated nicotine averaged 0.961 mg/g tobacco in Taboka, Marlboro Snus, and Skoal Dry, 7.22 mg/g tobacco in Camel Snus, and 7.57 mg/g tobacco in traditional brands. Levels of minor tobacco alkaloids were relatively high in Taboka, Marlboro Snus, and Skoal Dry, as compared to other products analyzed here. Levels of nitrite and nitrate in new U.S. smokeless tobacco products and the Swedish snus General were lower than those in the other products. Remarkably high levels of chloride and some PAH were observed in the traditional moist snuff. Crotonaldehyde levels were about five times higher in Taboka and Marlboro Snus than in traditional products. The large variation in the levels of some toxicants and carcinogens analyzed here indicates that more effort is required from the U.S. tobacco industry to further reduce their amounts in new and traditional smokeless tobacco products.

Smokeless tobacco and cancer

Use of smokeless tobacco products is common worldwide, with increasing consumption in many countries. Although epidemiological data from the USA and Asia show a raised risk of oral cancer (overall relative risk 2.6 [95% CI 1.3-5.2]), these are not confirmed in northern European studies (1.0 [0.7-1.3]). Risks of oesophageal cancer (1.6 [1.1-2.3]) and pancreatic cancer (1.6 [1.1-2.2]) have also increased, as shown in northern European studies. Results on lung cancer have been inconsistent, with northern European studies suggesting no excess risk. In India and Sudan, more than 50% of oral cancers are attributable to smokeless tobacco products used in those countries, as are about 4% of oral cancers in US men and 20% of oesophageal and pancreatic cancers in Swedish men. Smokeless tobacco products are a major source of carcinogenic nitrosamines; biomarkers of exposure have been developed to quantify exposure as a framework for a carcinogenesis model in people. Animal carcinogenicity studies strongly support clinical results. Cancer risk of smokeless tobacco users is probably lower than that of smokers, but higher than that of non-tobacco users.

A comparative study of the mutagenicity of various types of tobacco products

Toxicological data are an important aspect of tobacco product characterization. In this study, TPM (Total Particulate Matter) (three replicates) was collected from cigarettes [five brands, ISO conditions: puff volume, 35 mL; duration, 2s; interval, 60s (35/2/60)], cigars (two brands, 45/2/30), cigarillos (two brands, 35/2/60), bidis (two brands, 45/2/30), and pipe tobacco (two brands, 50/2/12). TPM was extracted from the Cambridge filter pad using dimethyl sulfoxide (DMSO). Smokeless tobacco (ST) (six brands) was extracted with DMSO using an ultrasonic homogenizer. Both types of extracts were filtered and stored at -80 degrees C. All extracts were analyzed for humectants, water and nicotine. Mutagenic activity was assessed per OECD guideline 471 using Salmonella typhimurium TA98+S9 and TA100+S9. TA98+S9 response (specific activity expressed as revertants/mg nicotine) was greatest for the cigarette fabricated with dark, air-cured tobaccos. Average product responses with TA98+S9 based on nicotine and relative to cigarettes (excluding dark tobacco) were cigars, 242%; cigarillos, 238%; bidis, 91%; and pipe tobacco, 44%. ST response was not significant for TA98+S9. Corresponding values for TA100+S9 were cigars, 189%; cigarillos, 155%; pipe tobacco, 130%; bidis, 114% and ST, 34%. ST TA100+S9 response ranged from a low of 501 to a high of 8547 revertants/mg nicotine, depending on ST composition.

Expression of NF-kappaB parallels COX-2 expression in oral precancer and cancer: association with smokeless tobacco

Nuclear Factor-kappaB (NF-kappaB) activation and COX-2 overexpression have been reported in head and neck cancer, but the relationship between these proteins remains to be investigated. To determine the relationship between NF-kappaB and COX-2 in Smokeless Tobacco (ST) associated oral tumorigenesis, we performed immunohistochemistry in serial sections from 107 OSCCs, 78 oral precancerous lesions (OPLs) (58 hyperplasias, 20 dysplasias) and 15 histologically normal oral tissues and correlated with clinicopathological data. Significant increase in NF-kappaB and COX-2 immunopositivity was observed from normal oral mucosa to OPLs to OSCCs (p = 0.009 and p = 0.002 respectively). Upregulation of NF-kappaB and COX-2 was observed as early as in hyperplasia [p = 0.006; OR = 6.1 and p = 0.003; OR = 7.6, respectively]. Expression of both proteins was found to be significantly associated in OPLs (p = 0.000; OR = 12.6) and OSCCs (p = 0.001; OR = 4.0). Intriguingly, khaini consumption correlated with NF-kappaB immunopositivity in OPLs (p = 0.05, OR = 3.8) and OSCCs (p = 0.01, OR = 3.4) and with COX-2 expression in OPLs (p = 0.03; OR = 4.3). In vitro experimental system of ST associated oral carcinogenesis was used to demonstrate ST (khaini) and NNK mediated activation of NF-kappaB and COX-2, supporting the clinical data. In conclusion, this study demonstrates correlation between over expression of NF-kappaB and COX-2 in early precancerous stages of development of oral cancer and sustained elevation down the tumorigenic pathway, underscoring their potential as targets for early intervention. In vitro studies demonstrated that NNK may be one of the carcinogenic components of ST (khaini) inducing activation of NF-kappaB and COX-2 in oral precancer and cancer cells, suggesting plausible role in ST-induced oral carcinogenesis.

Public health implications of smokeless tobacco use as a harm reduction strategy

Harm reduction strategies involve promoting a product that has adverse health consequences as a substitute for one that has more severe adverse health consequences. Smokeless tobacco low in nitrosamine content offers potential benefits in reducing smoking prevalence rates. Possible harm arises from the potential for such products to serve as a gateway to more harmful tobacco products, public misinterpretation of "less harmful" as "safe," distraction from the public health goal of tobacco elimination, and ethical issues involved in advising those marketing these harmful products. We offer a research agenda to provide a stronger basis for evaluating the risks and benefits of smokeless tobacco as a means of reducing the adverse health effects of tobacco.

The potential impact of a low-nitrosamine smokeless tobacco product on cigarette smoking in the United States: estimates of a panel of experts

OBJECTIVE

To predict the impact on tobacco use in the US of a "harm reduction" policy that requires that the smokeless tobacco product meet low nitrosamine standards, but could be marketed with a warning label consistent with the evidence of relative health risks.

METHODS

Low nitrosamine smokeless tobacco (LN-SLT) and cigarette use are predicted by a panel of experts using a modified Delphi approach. We specify a thought experiment to isolate the changes that would occur after the new LN-SLT policy was implemented.

RESULTS

The panel predicted that the new policy would accelerate a decrease in smoking prevalence from 1.3 to 3.1 percentage points over 5 years compared to the current SLT product policy, with greater effects on males than females. Introduction of the new product was also predicted to result in modest additional use of SLT overall, with the greatest increases among males who initiated tobacco use under the new policy.

CONCLUSION

An overall consensus was reached that the introduction of a new LN-SLT product under strict regulations would increase SLT use, but reduce overall smoking prevalence. This reduction would likely yield substantial health benefits, but uncertainties surround the role of marketing and other tobacco control policies.

Levels of toxins in oral tobacco products in the UK

OBJECTIVE

This study examined the constituents of smokeless tobacco products available in the UK and compared them with products available in India, Sweden, and the USA.

METHODS

Seven UK brands of smokeless tobacco, including a tooth cleaning powder, and four international brands of smokeless tobacco were tested for a range of toxins and known carcinogens, such as tobacco specific N-nitrosamines (TSNA), as well as nicotine availability.

RESULTS

Ten of the 11 brands tested had detectable levels of tobacco specific nitrosamines, which are proven carcinogens, and levels varied 130-fold. All had detectable levels of benzo(a)pyrene, another proven carcinogen (with around 175-fold variation) and several toxic metals (with nearly 150-fold variation). Nicotine availability varied in the UK products from 0.1 mg/g to 63.2 mg/g. All the tobacco products tested are likely to be hazardous to users' health, but the data indicate that it should be possible to reduce key toxins to non-detectable levels.

CONCLUSIONS

Smokeless tobacco products should be regulated and standards set for maximum levels of toxins and carcinogens.

Tobacco-specific nitrosamines in new tobacco products

New tobacco products, designed to attract consumers who are concerned about the health effects of tobacco, have been appearing on the market. Objective evaluation of these products requires, as a first step, data on their potentially toxic constituents. Tobacco-specific nitrosamines (TSNAs) are an important class of carcinogens in tobacco products, but virtually no data were available on their levels in these products. In the present study, we analyzed several new products-Ariva, Stonewall, Exalt, Revel, Smokey Mountain, and Quest-for TSNAs and compared their TSNA levels with those in nicotine replacement products and conventional smokeless tobacco and cigarette brands. TSNAs were not detected in Smokey Mountain, which is a tobacco-free snuff product. The lowest levels among the new products containing tobacco were in Ariva and Stonewall (0.26-0.28 microg/g wet weight of product). The highest levels in the new products were found in Exalt (3.3 microg/g tobacco), whereas Revel and Quest had intermediate amounts. Only trace amounts were found in nicotine replacement products, and conventional brands had levels consistent with those reported in the literature. These results demonstrate that TSNA levels in new tobacco products range from relatively low to comparable with those found in some conventional brands.

Iqmik: a form of smokeless tobacco used among Alaska natives

OBJECTIVES

To describe a homemade form of smokeless tobacco known as Iqmik used among Alaska Natives residing in western Alaska.

METHODS

Individual and small-group interviews were conducted with 23 adult Alaska Natives. The major themes from the interview data were summarized. A chemical analysis was conducted of the alkalinity of a sample of fungus ash used to prepare Iqmik.

RESULTS

Few adverse health effects of using Iqmik were reported. The alkalinity of the sample of fungus ash was high (pH=10.9).

CONCLUSION

The high alkalinity of Iqmik may contribute to the higher rates of tobacco use in this population.

Smokeless tobacco impairs the antioxidant defense in liver, lung, and kidney of rats

The present study was designed to evaluate the effects of long-term use of aqueous extract of gutkha (a form of smokeless tobacco) on the antioxidant defense status and histopathological changes in liver, lung, and kidney of male Wistar rats. Animals were orally administered aqueous extract of smokeless tobacco (AEST) at a low dose (96 mg/kg body weight per day) for 2 and 32 weeks, and at a high dose (960 mg/kg body weight per day) for 2 weeks. High-dose AEST for 2 weeks decreased the hepatic glutathione (GSH) and glutathione peroxidase (GPx), and increased lipid peroxidation (Lpx) by 17%, 19%, and 20%, respectively. Low-dose AEST for 32 weeks significantly decreased (p < 0.05) the antioxidant status in these organs. In liver, AEST decreased GSH levels and the activities of superoxide dismutase (SOD), catalase (CAT), and GPx by 34.6%, 29%, 17.1%, and 17.4%, respectively, but it increased Lpx by 64%. In kidney, GSH, SOD, CAT, and GPx were decreased by 26.6%, 23%, 33%, and 18%, respectively, with an increase of Lpx by 65%. AEST decreased the lung GSH, SOD, CAT, and GPx, and increased lung Lpx by 43%, 28.5%, 37%, 40%, and 24%, respectively. However, no change in the plasma levels of vitamins A, C, and E were observed with AEST treatment. Histopathological findings suggest that administration of AEST at the high dose for 2 weeks or at the low dose for 32 weeks could cause mild to moderate inflammation in liver and lungs. In conclusion, a decrease in the antioxidant defense system and long-term inflammation caused by smokeless tobacco may be risk factors for gutkha-induced pathogenesis.

Polyphenolic antioxidants enhance IgE production

Epidemiological data showed that total IgE and IL-4 levels in cigarette smokers were elevated, comparable to those in the asthmatics. The etiological agent(s) elevating IgE production are not clear. We evaluate whether tobacco polyphenols potentiate IgE production in a rodent model. Mice were fed with rutin or CGA in drinking water during antigen sensitization, followed by antigenic challenge i.p. in alum. CGA and rutin were also delivered in a bolus intraperitoneally or intranasally along with antigens during immunization. Antigen-specific IgE and IgG responses were measured. Enhancement of total IgE responses via i.p. and drinking routes can be achieved at concentrations as low as 0.1% CGA. Furthermore, IgG1 responses but not IgG2a and IgG2b were augmented, indicating a Th2 type of response by CGA. Moreover, both antigen-specific and serum IgE production can be achieved when CGA and antigenic challenges were delivered intranasally in the absence of alum. In contrast, nicotine does not enhance antigen-specific IgE production, and only marginally affects serum IgE levels. The more polarized Th2 development in CGA-treated mice may account for enhancement of both antigen-specific and total IgE responses. High levels of IL-4 but not IFN-gamma or IL-12, were observed in antigen-challenged mesenteric lymph nodes (MLN) cultures from CGA-treated mice. In contrast, significant levels of IL-4, IL-12, and IFN-gamma were observed in antigen-challenged cultures from nicotine-treated mice. This study shows that tobacco polyphenols, CGA and rutin potentiated IgE production in vivo. Polyphenolic antioxidants enhance Th2 development. We propose that IgE production and T cell dichotomy may be critically influenced by the redox microenvironment. Enhanced Th2 development and IgE production henceforth may counteract more severe Th1-mediated tissue damage triggered by environmental oxidative stress.

Tobacco-specific nitrosamines in smokeless tobacco products marketed in India

Smokeless tobacco products are a known cause of oral cancer in India. Carcinogenic tobacco-specific nitrosamines in these products are believed to be at least partially responsible for cancer induction, but there have been no recent analyses of their amounts. We quantified levels of 4 tobacco-specific nitrosamines, N'-nitrosonornicotine (NNN), N'-nitrosoanatabine (NAT), N'-nitrosoanabasine (NAB) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), in 32 products marketed currently in India. Levels of nitrate, nitrite and nicotine were also determined. The highest levels of tobacco-specific nitrosamines were found in certain brands of khaini, zarda and other smokeless tobacco products. Concentrations of NNN and NNK in these products ranged from 1.74-76.9 and 0.08-28.4 microg/g, respectively. Levels of tobacco-specific nitrosamines in gutka were generally somewhat lower than in these products, but still considerably higher than nitrosamine levels in food. Tobacco-specific nitrosamines were rarely detected in supari, which does not contain tobacco, or in tooth powders. The results of our study demonstrate that exposure to substantial amounts of carcinogenic tobacco-specific nitrosamines through use of smokeless tobacco products remains a major problem in India.

Decreased levels of tobacco-specific N-nitrosamines in moist snuff on the Swedish market

Moist snuff, or snus, on the Swedish market in 2001 and 2002 was analyzed for tobacco-specific N-nitrosamines (TSNAs) using a recently developed LC-MS/MS method. All samples of moist snuff analyzed were found to contain detectable levels of N'-nitrosonornicotine (NNN), N'-nitrosoanatabine (NAT), N'-nitrosoanabasine (NAB), and 4-(N-methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). In the survey in 2001, all samples except for one were produced by Swedish Match (n = 14), which is the dominating manufacturer on the Swedish snuff market. In the survey in 2002, samples from both Swedish Match (n = 7) and seven smaller manufacturers (n = 20) were analyzed. Total TSNA levels of between 0.15 and 3.0 microg/g wet weight were found. In the survey in 2001 and 2002, the mean level of the total TSNA content in moist snuff was 1.1 microg/g (n = 14) and 1.0 microg/g (n = 27), respectively. The result of the survey shows that the level of TSNAs in moist snuff on the Swedish market has been greatly reduced since the middle of the 1980s. Clearly, efforts have been made by the manufacturers to reduce the level of TSNAs in snuff.

Surveillance of smokeless tobacco nicotine, pH, moisture, and unprotonated nicotine content

Smokeless tobacco is a complex chemical mixture, including not only the components of the tobacco leaf but also chemicals added during the manufacturing process. Smokeless tobacco contains the addictive chemical nicotine and more than 20 cancer-causing chemicals, including the potent tobacco-specific nitrosamines. The National Toxicology Program of the National Institutes of Health has concluded that oral use of smokeless tobacco is a human carcinogen. Therefore, smokeless tobacco is not a safe alternative to cigarettes. In fact, smokeless tobacco use begins primarily during early adolescence and can lead to nicotine dependence and increased risk of becoming a cigarette smoker. Under the Comprehensive Smokeless Tobacco Health Education Act of 1986 (15 U.S.C. 4401 et seq., Pub. L. 99-252), tobacco manufacturers report annually to the Centers for Disease Control and Prevention (CDC) on the total nicotine, unprotonated nicotine, pH, and moisture content of their smokeless tobacco products. This information is considered "trade secret," or confidential, in accordance with 5 U.S.C. 552(b)(4) and 18 U.S.C. 1905 and cannot be released to the public. In an effort to provide consumers and researchers with information on the nicotine content of smokeless tobacco, CDC arranged for the analysis of popular brands of smokeless tobacco. The results of this CDC study show that pH is a primary factor in the amount of nicotine that is in the most readily absorbable, unprotonated form. Furthermore, this study found that the brands of moist snuff smokeless tobacco with the largest amount of unprotonated nicotine also are the most frequently sold brands.

Polyphenolic antioxidants inhibit peptide presentation by antigen-presenting cells

Antigen-presenting cells (APC) provide two essential signals, e.g., antigenic peptides as well as costimulatory molecules for T-cell activation. Small molecules of smoke tobacco extracts (SM-STE) inhibited antigen presentation of A20 to OVAp-specific T-cell hybridomas. Pretreatment of A20 but not T hybridomas abrogates the APC function. Viability of APC and levels of MHCII, CD40 and B7 of APC were not affected by this treatment. The active principle, inhibiting APC was reproduced with pure tobacco polyphenols, quercetin and its glycoside, rutin. Antioxidant activity of rutin is relevant since rutin downregulated levels of reactive oxygen species (ROS) in phorbol ester-stimulated A20; moreover, another antioxidant, N-acetyl cysteine (NAC) also inhibited antigen presentation, albeit at a higher concentration. Other types of APC, such as bone marrow-derived mast cells (BMMC), MHCII-transfected fibroblast, and splenocytes are affected by tobacco polyphenols. We propose that polyphenols may affect redox-sensitive signal transduction pathway since APC function of PD 98059, MEK inhibitor-pretreated A20 were similarly abrogated. Taken together, we propose that maintaining appropriate intracellular redox of APC is crucial for its antigen-presenting function.

The influence of pH and nicotine concentration in oral moist snuff on mucosal changes and salivary pH in Swedish snuff users

The use of Swedish oral moist snuff is a widespread habit in Sweden. In 1999, 25% of the adult male population and 3.1% of the female population were users of snuff. The aim of the present study was to evaluate how variations in pH and nicotine concentrations of snuff affect the oral mucosa, clinically and histologically, salivary pH and daily nicotine intake in 20 habitual users of loose snuff. The subjects were studied during use of their usual brand, after 12 weeks use of a snuff with lower pH and after another 12 weeks use of a snuff with both lower pH and lower nicotine concentration. Consumption data, oral soft tissue changes, salivary pH and nicotine intake were measured. Further, biopsies were taken from the central part of the clinically observed lesions and histological changes were analysed. The subjects maintained their snuff consumption during the observation periods. The average salivary pH was higher during snuff use than in the morning. Further, it was higher shortly after the snuff was removed than during snuff use. After having switched to the snuff with both lower pH and lower nicotine concentrations, they showed a significant reduction in daily nicotine intake and developed significantly less pronounced clinical and histological changes. These results indicate that nicotine is one of the substances in snuff that has a biological effect on the oral mucosa. However, there also seems to be a synergistic effect between the pH and nicotine concentration in the snuff.

Analysis of tobacco-specific N-nitrosamines in snuff by ethyl acetate extraction and liquid chromatography-tandem mass spectrometry

A rapid, selective and sensitive method for routine analysis of the four tobacco-specific N-nitrosamines, N'-nitrosonornicotine, N'-nitrosoanatabine, N'-nitrosoanabasine and 4-(methyl-nitrosamino)-1-(3-pyridyl)-1-butanone in snuff has been developed. The nitrosamines were isolated by ethyl acetate extraction and analysed by LC-MS-MS. Except for evaporation and filtration, no additional clean-up steps are needed in the proposed method. The detection limits for standard in solvent are between 0.0005 and 0.001 microg/ml (0.005 and 0.01 microg/g).

A sensitive gas chromatographic-tandem mass spectrometric method for detection of alkylating agents in water: application to acrylamide in drinking water, coffee and snuff

A sensitive analytical method for the analysis of acrylamide and other electrophilic agents in water has been developed. The amino acid L-valine served as a nucleophilic trapping agent. The method was applied to the analysis of acrylamide in 0.2-1 mL samples of drinking water or Millipore-filtered water, brewed coffee, or water extracts of snuff. The reaction product, N-(2-carbamoylethyl)valine, was incubated with pentafluorophenyl isothiocyanate to give a pentafluorophenylthiohydantoin (PFPTH) derivative. This derivative was extracted with diethyl ether, separated from excess reagent and impurities by a simple extraction procedure, and analyzed by gas chromatography-tandem mass spectrometry. (2H3)Acrylamide, added before the reaction with L-valine, was used as internal standard. Acrylamide and the related compound, N-methylolacrylamide, gave the same PFPTH derivative. The concentrations of acrylamides were < or = 0.4 nmol L(-1) (< or = 0.03 microg acrylamide L(-1)) in water, 200 to 350 nmol L(-1) in brewed coffee, and 10 to 34 nmol g(-1) snuff in portion bags, respectively. The precision (the coefficient of variation was 5%) and accuracy of the method were good. The detection limit was considerably lower than that of previously published methods for the analysis of acrylamide.