Nicotine delivery capabilities of smokeless tobacco products and implications for control of tobacco dependence in South Africa

Psychometric properties of Fagerström Tolerance Questionnaire among Turkmen Nass (Naswar) users

BACKGROUND

Smokeless tobacco (SLT) products are gaining popularity around the globe, particularly in Asia, Africa, and the Middle East. Among these products, Nass (aka Naswar) is popular among the Turkmen ethnicity in Iran. Although several studies reported nicotine dependence (ND) among SLT users, psychometric instruments have never been utilized to specifically measure ND among Nass users. Therefore, in this study, we aimed to evaluate the reliability and validity of the Fagerström Tolerance Questionnaire (FTQ) among Turkmen Nass users.

METHODS

A cross-sectional, descriptive study was conducted in June-December 2018 among 411 Turkmen adults who currently (past 30 days) used Nass. Two bilinguals (Persian English) individuals translated and back-translated the FTQ-SLT, which maintained both the questionnaire's accuracy and cultural sensitivity. Construct validity was assessed using exploratory and confirmatory factor analysis.

RESULTS

The mean age and standard deviation for initiating Nass were 22.5 ± 11.81 years. Exploratory and confirmatory factor analysis indicated a single-factor solution with 8-items that captured several important ND components. Using Nass frequently, soon after waking, when sick, and experiencing a craving were some of the main components. Subgroups comparison revealed that higher scores occurred among those who were married, had Nass user(s) in their immediate family, and consumed bulk form of Turkmen Nass directly without using a tissue.

CONCLUSION

Our findings show that the FTQ- SLT is a fairly reliable and valid scale to measure ND among Turkmen Nass users and warrants further testing to accommodate cross-cultural differences in other populations.

Awareness of health risks associated with smokeless tobacco use among users in Pretoria

BACKGROUND

Smokeless tobacco (ST) refers to all tobacco-containing products that are not smoked but rather consumed through other means. Contrary to the popular belief that ST products are safe, the use of such products exposes users to health risks. To assess the awareness of health risks associated with ST use among users in a Pretoria community, the study was conducted in Ramotse community, located in Tshwane region 2, Gauteng, South Africa.

METHODS

This was a cross-sectional design, using a piloted, structured and self-administered questionnaire.

RESULTS

Of 479 participants with a mean age of 43 years (ranging from 18 to 89 years), most were in the age group 30-39 years (148; 31.6%), followed by ≥ 50 years (138; 29.4%). There were more females (371; 77.5%), more unemployed (263; 54.9%), married (236; 49.7%), had reached the secondary level of education (270; 56.4%), did not have any chronic illness (274; 57.2%), used snuff by nose (338; 70.6%), and were unaware of health risks associated with ST use (452; 94.4%).

CONCLUSION

This study has demonstrated a poor awareness of health risks associated with ST use among the users in a Pretoria community. As a result, health education at various levels of the community (clinic, schools, ward-based outreach team or WBOT, etc.) could be one strategy for resolving the problem.

Formulation of Smokeless Tobacco Products with a Wide Range of pH to Study Nicotine Pharmacokinetics and Pharmacodynamics

The rate of nicotine absorption from tobacco products is a determinant of addiction potential and other detrimental health effects. Oral nicotine bioavailability from moist snuff smokeless tobacco (ST) is influenced by nicotine content, pH, flavors, and tobacco cut. For use in a clinical study testing the effect of pH on nicotine pharmacokinetics, four investigational ST products that differed only in pH were produced. A commercial ST product (Copenhagen Long Cut Original, pH 7.7) was modified with citric acid monohydrate (23 mg/g tobacco) or sodium carbonate (4.6 and 11 mg/g) to create products with pH 5.0, 8.2, and 8.6, respectively. All products - including the original product with pH 7.7 - were individually packaged (approximately 2g) in aluminum foil pouches and stored frozen (-20 °C); pH, nicotine, tobacco-specific nitrosamines, moisture content, and mold and yeast counts were tested for up to 19 months to verify stability. Remarkable stability was demonstrated in this packaging/storage combination. For example, pH from all products were within 0.1 pH units and never exceeded 0.2 units. Nicotine concentration averaged 9.07 mg/g at baseline, maximal deviations from baseline in the four products averaged 0.30 mg/g. Similarly, TSNA, moisture content, yeast, and mold did not materially change. This study illustrates a method of investigational tobacco products formulation by manipulating a single design feature (or component) with the purpose of independently and systematically assessing its influence on nicotine bioavailability in a clinical study.

The pH of Smokeless Tobacco Determines Nicotine Buccal Absorption: Results of a Randomized Crossover Trial

Nicotine absorption rate influences tobacco products' addictiveness. For smokeless tobacco, nicotine buccal absorption is associated with its free-base form; the pH of smokeless tobacco defines the proportion of free-base (i.e., unprotonated) vs. protonated nicotine. This was the first study to compare nicotine pharmacokinetics (PK) and pharmacodynamics (PD) after the use of commercial smokeless tobacco products that were experimentally manipulated to differ only in pH and percent free-base nicotine. Moist snuff users (N = 40) completed four crossover visits and used a single 2 g portion of Copenhagen Original Long Cut amended to 4 pH levels: 5.0, 7.7, 8.2, and 8.6 (free-base nicotine 0.1, 32, 60, and 79%) for 30 minutes. Nicotine PK and PD were assessed for 4 hours post-use. Nicotine PK substantially depends on its free-base proportion, with more than 4-fold increases in mean plasma nicotine maximum concentration and area under the curve over 240 minutes (3.9 to 16.7 ng/mL; 385 to 1810 ng min/mL, respectively, both P < 0.001) from pH 5.0 to 8.6. The autonomic cardiovascular effects of smokeless tobacco use reflected percent free-base nicotine, with small (albeit significant) systematic increases in heart rate and blood pressure associated with free-base nicotine. Smokeless tobacco product pH and percent free-base nicotine play a major role in the rate and extent of nicotine absorption, determining product PD effects and abuse potential. Research and regulation of smokeless tobacco products should consider both total nicotine content and product pH. Further research may address the impact of modifying pH on the addictiveness of smokeless tobacco and associated use behaviors.

Naswar (Smokeless Tobacco) Use and the Risk of Oral Cancer in Pakistan: A Systematic Review With Meta-Analysis

Introduction

With an annual increase of 16000 new cases each year, oral cancer is the second most common cancer in Pakistan. There is conflicting evidence regarding the carcinogenicity of different forms of smokeless tobacco (SLT) from different countries. This difference in evidence may be attributed to the varied composition of SLT products used around the world, necessitating the establishment of individual risks related to each SLT product.

Methods

An electronic search in relevant databases yielded 119 publications, out of which six were included in this review. Effect estimates (odds ratios (ORs)) were abstracted or calculated from the given data. A fixed effects meta-analysis was performed to assess the risk of oral cancer with the use of Naswar. Population attributable fractions (PAF) were also calculated.

Results

The Meta Odds Ratio (mOR) for oral cancer associated with the "ever use" of Naswar compared to "never use" was 11.8 (95% CI = 8.4-16.4), I2 = 67%. The pooled estimate for oral cancer in "Ever-users" of Naswar compared to "Never-users," in the Khyber Pakhtunkhwa province was 18.3 (95% CI = 8.7-38.5), I2 = 0%. The PAF for oral cancer associated with the use of Naswar in Pakistan was 44% (95% CI = 35-53).

Discussion

This review highlights a strong relationship between oral cancer incidence and the use of Naswar in Pakistan and adds to the evidence base on the carcinogenicity of SLT products in humans. Although the synthesized evidence may not be of a high quality, it represents the "best available evidence" which can be used to inform policy.

Implications

The carcinogenicity of Naswar, a form of smokeless tobacco used extensively in Pakistan, Afghanistan, and Central Asia, has yet to be recognized by the International Agency for Research on Cancer (IARC), partly due to the lack of evidence on the association of Naswar use and cancer. Additionally, Naswar is yet un-regulated in Pakistan and evades the tax net, resulting in it being freely available to both adults and children at very cheap prices compared to cigarettes, which has been the main focus of tobacco control in Pakistan. This review provides ample evidence for the IARC to declare Naswar as carcinogenic, as well as the Government of Pakistan to regulate the production and sale of Naswar.

Pitfalls in the assessment of smoking status detected in a cohort of South African RA patients

This study was conceived in an attempt to explain the unexpectedly high frequency of elevated levels of serum cotinine measured retrospectively in a cohort of predominantly black South African females with rheumatoid arthritis (RA), findings that were inconsistent with the smoking histories derived from health questionnaires. The discrepant findings suggested either a greater tendency towards underreporting of smoking status in the study cohort, or possible confounding effects of the use of smokeless tobacco products. In addition to the cohort of RA patients (n = 138, of whom 115 (83 %) were female), blood samples were also taken from a second cohort consisting of 29 declared smokers, 18 (62 %) of whom where females, 29 smokeless tobacco (SLT) users (all female), and 22 non-users of any tobacco products, 18 (82 %) of whom were females. Serum cotinine levels were determined using an ELISA procedure. Cotinine levels of >10.0 ng/ml were detected in serum specimens from 43 (31 %), RA patients of whom 35 (81 %) were female, with a median value of 50.1 ng/ml and interquartile range (iqr) of 68.6. Only 18 of the 35 females indicated that they smoked. The groups of declared smokers and SLT users had equivalent median serum cotinine levels of 88.0 ng/ml (iqr = 10.8 ng/ml) and 87.0 ng/ml (iqr = 15.6 ng/ml), respectively, while cotinine was undetectable in specimens from non-tobacco product users (<0.2 ng/ml). Users of SLT products in South Africa are predominantly female and have serum cotinine levels which are comparable with those of current smokers, raising concerns about the validity of measurement of cotinine as the sole objective marker of smoking status in populations with high usage of SLTs. This situation can be rectified by ensuring that usage of SLT products is accurately recorded in health questionnaires, while inclusion of measurement of one or more additional, objective biomarkers of smoking in combination with cotinine may enable reliable distinction between smoking and usage of SLTs which, given the associated risks, is a strategy of particular relevance in RA.

Reducing the Role of the Food, Tobacco, and Alcohol Industries in Noncommunicable Disease Risk in South Africa

Noncommunicable diseases (NCDs) impose a growing burden on the health, economy, and development of South Africa. According to the World Health Organization, four risk factors, tobacco use, alcohol consumption, unhealthy diets, and physical inactivity, account for a significant proportion of major NCDs. We analyze the role of tobacco, alcohol, and food corporations in promoting NCD risk and unhealthy lifestyles in South Africa and in exacerbating inequities in NCD distribution among populations. Through their business practices such as product design, marketing, retail distribution, and pricing and their business practices such as lobbying, public relations, philanthropy, and sponsored research, national and transnational corporations in South Africa shape the social and physical environments that structure opportunities for NCD risk behavior. Since the election of a democratic government in 1994, the South African government and civil society groups have used regulation, public education, health services, and community mobilization to modify corporate practices that increase NCD risk. By expanding the practice of health education to include activities that seek to modify the practices of corporations as well as individuals, South Africa can reduce the growing burden of NCDs.

Body composition in the Study of Women Entering and in Endocrine Transition (SWEET): A perspective of African women who have a high prevalence of obesity and HIV infection

OBJECTIVES

Little data are available for sub-Saharan African women on changes in body composition in menopause transition (MT). The study aimed to determine whether there are differences in body adiposity, lean muscle mass, and bone mineral density (BMD) across MT groups in urban African women, who have a high prevalence of obesity and HIV infection, and if this is related to an altered hormonal milieu.

DESIGN

Participants were 702 black urban women. Menopause stage was defined using STRAW+10 criteria. Levels of follicle stimulating hormone (FSH), estradiol (E2), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), testosterone (T) and sex hormone blinding globulin (SHBG) were measured. Body composition was measured with dual-energy X-ray absorptiometry (DXA) and ultrasound scans.

RESULTS

Whole body lean mass (p=0.002) and BMD (p<0.0005) were significantly lower in postmenopausal compared to premenopausal groups. Estradiol (p<0.0005), SHBG (p<0.0005) and DHEAS (p=0007) were significantly lower in post- than premenopausal groups, while FSH was higher (p<0.0005). FSH correlated negatively (β=-2.06, p<0.0005) with total lean mass while E2 correlated positively (β=20.0, p=0.002) with BMD. Use of antiretroviral therapy (ART) correlated negatively with total fat mass (β=-2.92, p=0.008) and total bone mineral content (BMC; β=-78.8, p=0.003).

CONCLUSIONS

The MT in this population is characterized by lower whole body lean mass and BMD in post- compared to premenopausal subjects but there are minimal differences in fat mass. Lower lean mass and BMD were associated with higher FSH and lower E2 serum levels, respectively. Use of ART was associated with lower fat mass and BMC.

Differential patterns of tobacco use among black men and women in Cape Town: the cardiovascular risk in black South Africans study

INTRODUCTION

To examine the prevalence and determinants of tobacco use in the 25-74-year-old urban Black population of Cape Town and to examine the changes between 1990 and 2008-2009 in the 25-64-year-old sample.

METHODS

In 2008-2009 (n = 1,099), a representative cross-sectional sample was randomly selected from the same townships sampled in 1990 (n = 986). Sociodemographic characteristics, tobacco use by the World Health Organization (WHO) STEP-wise questionnaire, and psychosocial stress, including sense of coherence (SOC), locus of control, and adverse life events, were determined. Survey logistic regression analysis assessed the determinants of smoking ≥ 1 cigarette/day.

RESULTS

There were 392 men and 707 women. Age-standardized prevalence of smoking ≥ 1 cigarette/day was 48.5% (95% confidence interval [CI] = 43.0-54.0) in men and 7.8% (95% CI = 5.8-10.5) in women (p < .001). Prevalence in men was lower in 2008-2009 (51.0%, 95% CI = 45.2-56.7) compared with 1990 (59.7%, 95% CI = 53.8-65.4) but unchanged in women (2008/09: 8.0%, 95% CI = 5.9-10.7; 1990: 8.4%, 95% CI = 6.0-11.8). In the logistic model for men, smoking was associated with younger age (p = .005) and being poor (p = .024). In women, spending more than half their lives in the city (p < .001), being poor (p = .002), and coping poorly with stress (defined by lower SOC; OR = 1.04, 95% CI = 1.01-1.08; p = .035) were associated with smoking. Increasing number of adverse events, which replaced SOC in the same models, was significant for women (OR = 1.10, 95% CI = 1.01-1.21; p = .047) but not for men. Education level, employment status, and housing quality were not relevant for men or women.

CONCLUSIONS

The high smoking prevalence in men and unchanged rate in women require additional interventions to curtail this behavior.

Prevalence and correlates of smokeless tobacco use among grade 8-11 school students in South Africa: a nationwide study

INTRODUCTION

Smokeless tobacco in South Africa is commonly used in the form of snuff or chewing tobacco. This paper reports its use among secondary school students and provides evidence of its association with demographic characteristics, tobacco smoking, and socioeconomic status.

METHODS

Data were derived from a nationally representative study conducted in 2008 among 10,270 grade 8-11 students from 192 schools in South Africa. Data were collected with self-administered questionnaires. Multiple logistic regression analyses were used to examine correlates of past-month smokeless tobacco use.

RESULTS

Nationally, 12.4% of students used smokeless tobacco such as chewing tobacco or snuff in the month preceding the survey, with significantly higher rates among males (13.6%) than females (10.6%). Smokeless tobacco use differed between racial groups, with African (12.8%) and colored (11.7%) students having the highest rates of past-month use. Grade 8 students (15.3%) reported significantly higher rates of use than grade 11 students (9.1%). Current cigarette smokers (21.3%) reported a higher prevalence of smokeless tobacco use than noncurrent smokers (10.1%). Logistic regression of past-month smokeless tobacco use showed significant associations with race, grade, school socioeconomic level, urbanicity, current cigarette smoking, and having first smoked a cigarette before the age of 10 years.

CONCLUSIONS

These findings provide evidence for policy makers and program developers to develop targeted and tailored interventions for young people regarding smokeless tobacco use.

Water pipe and smokeless tobacco use among medical students in South Africa

INTRODUCTION

This study sought to determine the sociodemographic and behavioral factors associated with water pipe and smokeless tobacco (SLT) use among a population of medical students in the Pretoria area, South Africa.

METHODS

Undergraduate medical students (N = 722) in their 2nd and 6th year of study in 2 medical schools in South Africa completed a self-administered questionnaire during 2008. Information on ever and current use of water pipe and SLT was obtained along with information on sociodemographic variables, alcohol use, and cigarette smoking status. Multiple logistic regression analysis were used to determine factors associated with current use of water pipe and SLT.

RESULTS

The mean age of study participants was 23 years. Of the participants, 53% were female and 55% were self-identified as Black Africans. Of the study participants, 18.6% were current water pipe users, 3.1% were current SLT users, while 17.3% were current cigarette smokers. Factors independently associated with current water pipe use were having an alcohol drinking-problem (odds ratio [OR] = 2.43; 95% CI = 1.48-3.40), currently smoking cigarettes (3.40; 2.04-5.67), and reporting exposure to smoking in places other than home (2.51; 1.29-4.90). Compared with Black students, White medical students were more likely to have smoked a water pipe in the past month (3.14; 1.74-5.70) but less likely to have ever used SLT (0.37; 0.19-0.73).

CONCLUSIONS

These findings suggest that the use of alternative tobacco products is common among South African medical students and may form part of a pattern of risk-taking behavior. Furthermore, there appear to be cultural differences in the use of certain tobacco products.

[Smokeless tobacco]

Use of smokeless tobacco (ST) (chewing tobacco and snuff) can lead to a number of consequences detrimental to health. ST rapidly delivers high doses of nicotine, which can lead to dependence and is also a source of carcinogenic nitrosamines. Changes usually develop in the mouth area where the ST is most often placed. Non-malignant oral lesions include leuko-oedema, hyperkeratotic lesions of the oral mucosa and localised periodontal disease. Oral premalignant lesions are leukoplakia, erythroplakia, submucosal fibrosis and lichen planus. Betel chewing, with or without tobacco, may increase the incidence of oral cancer. There is conflicting evidence with regard to snuff users about the risk of oral and gastro-oesophageal cancer. ST use is a risk factor for pancreatic cancer and may increase the risk of fatal myocardial infarction and ischemic stroke. During pregnancy, ST is associated with an increase in pre-eclampsia, preterm delivery and stillbirth. Nicotine replacement therapy and bupropion reduce withdrawal symptoms and tobacco craving during ST cessation. However, they have not been shown to help long-term abstinence. Information concerning the potential hazards of ST products should be incorporated into educational programmes to discourage its use and to help users to quit. Smokeless tobacco is not recommended to help smoking cessation.

Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study

BACKGROUND

Primary health care (PHC) settings offer opportunities for tobacco use screening and brief cessation advice, but data on such activities in South Africa are limited. The aim of this study was to determine the extent to which participants were screened for and advised against tobacco use during consultations.

METHODS

This cross-sectional study involved 500 participants, 18 years and older, attended by doctors or PHC nurses. Using an exit-interview questionnaire, information was obtained on participants' tobacco use status, reason(s) for seeking medical care, whether participants had been screened for and advised about their tobacco use and patients' level of comfort about being asked about and advised to quit tobacco use. Main outcome measures included patients' self-reports on having been screened and advised about tobacco use during their current clinic visit and/or any other visit within the last year. Data analysis included the use of chi-square statistics, t-tests and multiple logistic regression analysis.

RESULTS

Of the 500 participants, 14.9% were current smokers and 12.1% were smokeless tobacco users. Only 12.9% of the participants were screened for tobacco use during their current visit, indicating the vast majority were not screened. Among the 134 tobacco users, 11.9% reported being advised against tobacco use during the current visit and 35.1% during any other visit within the last year. Of the participants not screened, 88% indicated they would be 'very comfortable' with being screened. A pregnancy-related clinic visit was the single most significant predictor for being screened during the current clinic visit (OR = 4.59; 95%CI = 2.13-9.88).

CONCLUSION

Opportunities for tobacco use screening and brief cessation advice were largely missed by clinicians. Incorporating tobacco use status into the clinical vital signs as is done for pregnant patients during antenatal care visits in South Africa has the potential to improve tobacco use screening rates and subsequent cessation.

Tobacco use and secondhand smoke exposure during pregnancy in two African countries: Zambia and the Democratic Republic of the Congo

OBJECTIVE

To study pregnant women's knowledge, attitudes and behaviors towards tobacco use and secondhand smoke (SHS) exposure, and exposure to advertising for and against tobacco products in Zambia and the Democratic Republic of the Congo (DRC).

DESIGN

Prospective cross-sectional survey between November 2004 and September 2005.

SETTING

Antenatal care clinics in Lusaka, Zambia, and Kinshasa, DRC.

POPULATION

Pregnant women in Zambia (909) and the DRC (847).

METHODS

Research staff administered a structured questionnaire to pregnant women attending antenatal care clinics.

MAIN OUTCOME MEASURES

Pregnant women's use of tobacco, exposure to SHS, knowledge of the harms of tobacco and exposure to advertising for and against tobacco products.

RESULTS

Only about 10% of pregnant women reported ever having tried cigarettes (6.6% Zambia; 14.1% DRC). However, in the DRC, 41.8% of pregnant women had tried other forms of tobacco, primarily snuff. About 10% of pregnant women and young children were frequently or always exposed to SHS. Pregnant women's knowledge of the hazards of smoking and SHS exposure was extremely limited. About 13% of pregnant women had seen or heard advertising for tobacco products in the last 30 days.

CONCLUSIONS

Tobacco use and SHS exposure pose serious threats to the health of women, infants and children. In many African countries, maternal and infant health outcomes are often poor and will likely worsen if maternal tobacco use increases. Our findings suggest that a 'window of opportunity' exists to prevent increased tobacco use and SHS exposure of pregnant women in Zambia and the DRC.

Global patterns of nicotine and tobacco consumption

Humans consume tobacco in dozens of guises, all of which are toxic; globally, a tenth of deaths among adults are caused by tobacco. Tobacco may be combusted (e.g., cigarettes, bidis, kreteks); heated (e.g., waterpipes, hookah, nargile); or taken orally or nasally (e.g., snuff, betel quid, chewing tobacco). The predominant forms vary among cultures, but the use of cigarettes has grown most dramatically in the past century. While smoking rates among women are comparable to those among men in Europe and North America, in other regions the rate is ten or more times higher among men; this gender gap is closing among young people. Per capita tobacco use in the USA doubled in the first half of the twentieth century, and has since declined to less than the 1900 levels. While cigarettes were only 2% of tobacco consumed in the USA in 1900 (half was chewing tobacco) 50 years later they were over 80%. A similar increase in tobacco consumption, and a shift to cigarettes, has been occurring globally, with a concomitant increase in tobacco-related death and disease that is not expected to peak for another two decades.

Approaches, challenges, and experience in assessing free nicotine

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 and emissions. In addition to evaluating the total nicotine delivered to the user, measuring the fraction of nicotine in the free-base form is critical in understanding and controlling the influence of nicotine on tobacco use.

Nicotine content and delivery across tobacco products

Nicotine is the principal alkaloid in both commercial and homemade products (e.g., cigarettes, smokeless tobacco, bidis, waterpipes) followed by nornicotine, anabasine, anatabine, and many other basic substances that contain a cyclic nitrogenous nucleus. Tobacco types, leaf position on the plant, agricultural practices, fertilizer treatment, and degree of ripening are among some prominent factors that determine the levels of alkaloids in tobacco leaf. From a random examination of 152 cultivated varieties of Nicotiana tabacum, a range of alkaloid variation between 0.17 and 4.93% was determined. In fact, every step in tobacco production that affects plant metabolism will influence the level of alkaloid content to a certain degree. Depending on blending recipe, type and amount of additives, and product design, all types of tobacco products contain a very wide range of nicotine concentration. However, the ultimate emission of nicotine to the user, exposure, and psychophar-macological effects depend not only on the content and emission, but also on the relationship between the product and the user.

Changing smokeless tobacco products new tobacco-delivery systems

Smokeless or noncombusted oral tobacco use as a substitute for cigarette smoking has been gaining greater interest and attention by the public health community and the tobacco industry. In order for the product to appeal to smokers, tobacco companies have been manufacturing new noncombusted oral tobacco (i.e., moist snuff) that is lower in moisture content and nitrosamine levels, packaged in small sachets and "spitless." While the primary motives of the major tobacco companies are to maintain or increase tobacco use, some members of the public health community perceive the use of noncombusted oral tobacco products as a harm reduction tool. Because cigarette smoking is associated with greater toxicant exposure compared to noncombusted oral tobacco, reduced mortality and morbidity are hypothesized to ensue, if cigarette smokers switched completely to these products. However, variability exists in levels of nicotine and toxicants and potential health consequences from use within and across countries. Therefore, promulgating noncombusted oral tobacco products as a safer alternative to smoking or as a substitute for smoking may engender more rather than less harm. To date, limited research is available on the effects of marketing noncombusted oral tobacco products to smokers, to support the use of these products as a harm reduction tool, and to determine the effects of varying levels of tobacco toxicants including nicotine on health. The need exists for manufacturing standards to lower toxicant levels of all noncombusted oral tobacco products, for the formulation of appropriate tobacco-product regulations and for the development of a strategic plan by the public health community to address this controversial topic.

The influence of maternal cigarette smoking, snuff use and passive smoking on pregnancy outcomes: the Birth To Ten Study

This article describes the patterns and effects of maternal snuff use, cigarette smoking and exposure to environmental tobacco smoke during pregnancy on birthweight and gestational age, in women living in Johannesburg and Soweto in 1990. A cohort of 1593 women with singleton live births provided information about their own and household members' usage of tobacco products during pregnancy. The women completed a questionnaire while attending antenatal services. Data on gestational age and birthweight were obtained from birth records. Women who smoked cigarettes or used snuff during pregnancy accounted for 6.1% and 7.5% of the study population respectively. The mean birthweight of non-tobacco users was 3148 g [95% CI 3123, 3173] and that of the smokers 2982 g [95% CI 2875, 3090], resulting in a significantly lower mean birthweight of 165 g for babies of smoking mothers (P = 0.005). In contrast, women using snuff gave birth to infants with a mean birthweight of 3118 g [95% CI 3043, 3192], which is a non-significant (P = 0.52) decrease (29.4 g) in their infants' birthweights compared with those not using tobacco. A linear regression analysis identified short gestational age, female infant, a mother without hypertension during pregnancy, coloured (mixed racial ancestry), and Asian infants compared with black infants, lower parity, less than 12 years of education and smoking cigarettes as significant predictors of low birthweight, while the use of snuff during pregnancy was not associated with low birthweight. The snuff users, however, had a significant shorter gestational age than the other two groups of women. The birthweight reduction adjusted for possible confounders was 137 g [95% CI 26.6, 247.3 (P = 0.015)] for cigarette smokers and 17.1 g [95% CI -69.5, -102.7, P = 0.69] for snuff users respectively, compared with the birthweight of non-tobacco users. Among women who did not smoke cigarettes or use snuff, exposure to environmental tobacco smoke did not result in significant effects on the birthweight of their infants. In conclusion, infants of cigarette smokers had significantly lower birthweights than those of non-tobacco users or snuff users who are exposed to nicotine during pregnancy. Passive smoking did not affect birthweight significantly in this population.

Traditional healers' perceptions of smokeless tobacco use and health in the Limpopo Province of South Africa

Traditional healers (THs) exert a significant influence in indigenous South African communities, where smokeless tobacco (SLT) use and dependence is common among women. This study was conducted during 2002. It sought to explore THs' beliefs about SLT use and its health effects. In-depth interviews were conducted with 28--mostly female (68%)--registered THs, with a mean age of 55 years and with an average of 17 years of practice experience. These listed THs were randomly selected from two culturally diverse regions of the (largely rural) Limpopo Province in South Africa. The THs perceive the ritual (external) use of SLT as an absolute necessity in divination, but 32% have also prescribed its 'internal' use to their clients, usually following a "directive from the ancestors." Almost all the THs who themselves regularly consume SLT condemned the recreational use of SLT and believe that SLT is addictive. However, 39% of them claimed to be able to treat addiction resulting from tobacco use not sanctioned by the ancestors. This study has identified opportunities for enlisting THs' collaboration in future community-based tobacco dependence interventions.

Toward a comprehensive long term nicotine policy

Global tobacco deaths are high and rising. Tobacco use is primarily driven by nicotine addiction. Overall tobacco control policy is relatively well agreed upon but a long term nicotine policy has been less well considered and requires further debate. Reaching consensus is important because a nicotine policy is integral to the target of reducing tobacco caused disease, and the contentious issues need to be resolved before the necessary political changes can be sought. A long term and comprehensive nicotine policy is proposed here. It envisages both reducing the attractiveness and addictiveness of existing tobacco based nicotine delivery systems as well as providing alternative sources of acceptable clean nicotine as competition for tobacco. Clean nicotine is defined as nicotine free enough of tobacco toxicants to pass regulatory approval. A three phase policy is proposed. The initial phase requires regulatory capture of cigarette and smoke constituents liberalising the market for clean nicotine; regulating all nicotine sources from the same agency; and research into nicotine absorption and the role of tobacco additives in this process. The second phase anticipates clean nicotine overtaking tobacco as the primary source of the drug (facilitated by use of regulatory and taxation measures); simplification of tobacco products by limitation of additives which make tobacco attractive and easier to smoke (but tobacco would still be able to provide a satisfying dose of nicotine). The third phase includes a progressive reduction in the nicotine content of cigarettes, with clean nicotine freely available to take the place of tobacco as society's main nicotine source.