1 Tobacco: deadly in any form or disguise World no tobacco day 2006 www.who.int/tobacco/wntd

2 WHO Library Cataloguing-in-Publication Data Tobacco : deadly in any form or disguise. obacco Free 1. Tobacco - adverse effects. 2. Tobacco industry - legislation. 3. Tobacco use disorder. I.World Health Organization. II.WHO T Initiative. ISBN 92 4 156322 2 (NLM classification: QV 137) ISBN 978 92 4 156322 2 © World Health Organization 2006 0 Avenue All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 2 ission to Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for perm reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press , at the above address (fax: +41 22 791 4806; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion w hatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authori ties, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may no t yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, th e names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publica tion. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising fr om its use. Printed in France

3 Tobacco: deadly in any form or disguise

4 of Contents TABLE 01 03 02 p. 10 - 15 p. 10 - 12 p. 16 - 27 p. 13 - 15 p. 6 - 9 p. 16 - 31 Tobacco Introduction A global Health effects The many Trends in of tobacco the tobacco products forms of and overview epidemic of epidemic of today addiction tobacco and disease 4

5 6 5 04 p. 28 - 31 p. 40 - 45 p. 32 - 33 p. 36 - 39 p. 35 p. 33 - 34 The WHO Tobacco The future Regulating a Conclusions References deadly product horizon for Framework products of Convention on tobacco testing tomorrow and safety claims Tobacco Control

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7 Introduction and overview Tobacco addiction is a global epidemic that is ravaging the countries and regions that can least afford its toll of disability, disease, lost productivity and death. The epidemic follows a course that has been charcoal heating elements, aluminium nicotine documented in country after country, driven by cartridges and computer-chip-controlled smoke- an industry that puts profi ts ahead of life; its own delivery systems. The truth is clear: all tobacco growth ahead of the health of future generations; products are dangerous and addictive, and every its own economic gain ahead of the sustainable effort should be made to discourage their use in development of struggling countries. any form. Governments should, in the meantime, make every effort to regulate all types of tobacco Now, as nations have begun to fi ght back and, in and raise awareness about its harmful and deadly some countries, to turn back the epidemic, tobacco effects. companies continue to develop new products to maintain their profi ts, often disguising these new Accurate information on tobacco product ingredients, products in a cloak of attractiveness and reduced toxin deliveries and health effects is needed for all harmfulness. tobacco products. For cigarettes, there have been some regulatory efforts to monitor the ingredients of The challenge to health comes from large companies the product and communications efforts to pass this and small ones, from blockbuster cigarette brands, health information on to the public, but even these so-called organic cigarettes, chewing tobacco, efforts have been challenged and misrepresented waterpipes, cigars, and new hybrid products with by tobacco companies in their continuing attempts

8 to maintain the appeal of their products. Thus, cause death, disease and disability, and that there despite a few governmental efforts, the only source is a time lag between the exposure to smoking and the other uses of tobacco products and the onset of of information for most consumers is that provided voluntarily by the industry itself, with results that “Tobacco products” are tobacco-related diseases”. “products entirely or partly defi ned in Article 1(f) as remain deleterious for the health of individuals made of the leaf tobacco as raw material which are and populations. Tobacco companies give many manufactured to be used for smoking, sucking, reasons for failure to fully disclose the truth about chewing or snuffi ng”. their products. A few of these companies are part of corporations that also manufacture foods, beverages Therefore, the goals of World No Tobacco Day 2006 and even pharmaceuticals, for which truthful are to emphasize the harm associated with any use labelling is required in many jurisdictions. There is no of any tobacco product, to highlight the role of the reason other than profi t for the companies not to be tobacco industry in undermining efforts to assess the similarly forthcoming about tobacco products, and real harm done by tobacco and to call on governments such disclosure is one purpose of regulation. to enact stronger and wider regulation of tobacco products. The WHO Framework Convention paves the way for a better understanding of methods of regulating and controlling tobacco products. World World No Tobacco Day 2006 No Tobacco Day 2006 aims to empower people and organizations with the knowledge they need to is a tool for stripping away the control tobacco more effectively and improve global health. It is a tool for stripping away the disguise disguise and reveiling the truth and revealing the truth behind tobacco products – traditional, new and future. behind tobacco products Fortunately, tobacco control professionals learned th valuable lessons from their studies of the 20 century strategies of the tobacco industry, as well as from the successes and failures of tobacco control efforts. This knowledge can be applied in order to gain a better understanding of the complexities of the various tobacco products and the motivations and misinformation spread by tobacco companies. Global health also benefi ts from the combined forces of the Parties to the World Health Organization’s Framework Convention on Tobacco Control. The WHO Framework Convention is a powerful tool for containment of tobacco industry strategies aimed at undermining advances in public health. The WHO Framework Convention was the global response of countries to the globalization of the tobacco epidemic. The preamble states: “...scientifi c evidence has unequivocally established that tobacco consumption and exposure to tobacco smoke 8

9 Article 1(f) of the WHO FCTC “...“ tobacco products” means products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffi ng”. The following paragraph is in the preamble of the Treaty: “ ...scientifi c evidence has unequivocally established that tobacco consumption and exposure to tobacco smoke cause death, disease and disability, and that there is a time lag between the exposure to smoking and the other uses of tobacco products and the onset of tobacco- © 2001 John Noltner Photography, Source: www.noltner.com/travel2_cigars.html related diseases ”. Introduction and overview

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11 A global epidemic of addiction and disease in the tobacco epidemic TRENDS Currently, there are an estimated 1.3 billion smokers in the world. The death toll from tobacco consumption is now 5 million people a year; if present consumption patterns continue, he number of deaths will nearly double, reaching close to 10 million t by the year 2020. The higher burden of death and disease Despite what we know about tobacco use today, is rapidly shifting to developing countries. tobacco consumption continues to increase Approximately one half of continuing cigarette worldwide. The epidemic is still expanding, smokers die prematurely from tobacco use. That especially in low- and middle-income countries. is to say that about 650 million people (half the The tobacco industry has a huge potential market current smokers) alive today will eventually die in these countries, where they often face weaker from a tobacco-related disease, if they continue tobacco control measures and fi nd a great number to smoke. of possible new customers, among women in particular. The above is the fundamental reason for regulating tobacco now. Governments, and especially The tobacco epidemic has recently expanded legislators, have a responsibility to contribute among women worldwide. Recent surveys show towards regulating an industry whose main that tobacco consumption among girls is increasing objective is to sell a product that causes harm drastically around the globe, and that prevalence is, and death. in many cases, comparable to or even greater than

12 I that among boys. many developed nations have begun to slow and Furthermore, youth tobacco even reverse the tide of tobacco use and disease, use in India appears to be accelerating among the very young, with sixth-grade boys and girls greatly projected deaths in developing nations are on the exceeding eighth-grade boys and girls in tobacco increase. consumption. These trends raise the possibility that estimates of the mortality caused by tobacco Comprehensive tobacco control measures aimed are conservative and that the health impact will at reducing use and exposure can reduce disease exceed even the dire fi gures above. This increases risk and premature death. Regulation of tobacco the urgency of implementation of strong tobacco products is one of the necessary components control measures, as recommended by the WHO of comprehensive and effective tobacco control Framework Convention. programmes. Although tobacco control is vital in all countries, the increasing burden of tobacco poses a particular challenge to economic and public health advances in developing countries. Many of these nations are making enormous efforts to improve health conditions during childbirth and decrease maternal and infant mortality, but are now facing an added burden in achieving this goal as the number of mothers who use tobacco products increases. It is the poor and the poorest who tend to smoke the most. Premature death generally follows several years or more of excess disease and disability in tobacco users. This suffering and disease, in turn, contributes to the enormous tobacco- related costs. This is especially damaging to the economic development of countries with emerging economies. In fact, it is the economically emerging countries that are witnessing the greatest increases in tobacco use and hence in projected disease and death. It is the poor and the poorest who tend to smoke the most. In developed countries, smoking rates are highest among those with lower incomes. Currently, of the total number of smokers worldwide, 84% (that is, 1.09 billion people) live in developing and II And so, while transitional economy countries. 12

13 HEALTH effects of tobacco Tobacco consumption continues to be the leading preventable cause of death in the world. VII The wide range of serious health effects has concluded that smoking causes cervical cancer, been extensively reviewed. the leading killer among cancers in women worldwide. However, the list of conditions caused by tobacco There is a growing body of evidence linking smoking consumption has grown. It is now also known that and an increased risk of tuberculosis infection, tobacco use contributes to cataracts, pneumonia, disease and mortality. Studies carried out in India, acute myeloid leukaemia, abdominal aortic aneurysm, stomach cancer, pancreatic cancer, for instance, show that half the male tuberculosis VIII cervical cancer, kidney cancer, periodontitis and deaths in that country are caused by smoking. III other diseases. The incidence of tuberculosis in some developing countries is high and has been aggravated lately These diseases join the familiar list of tobacco-related by the HIV/AIDS epidemic. An increase in smoking diseases, including cancer of the lung, vesicle, prevalence in these countries could seriously oesophagus, larynx, mouth and throat; chronic increase the incidence of tuberculosis infection and pulmonary disease, emphysema and bronchitis; mortality. stroke, heart attacks and other cardiovascular diseases. In fact, we know today that tobacco Combustible (or smoked) tobacco products are IV:1180 Tobacco causes 90% of all lung cancers. also among the leading causes of residential and seriously damages the reproductive system too, forest fi res in many countries. These fi res destroy contributing to miscarriage, premature delivery, low natural habitats, homes and other property, and kill birth weight, sudden infant death and paediatric smokers and non-smokers alike, including many diseases, such as attention hyperactivity defi cit children. III Babies born to women who smoke are, disorders. on average, 200 grams lighter than babies born to Addiction to a deadly III:565 comparable mothers who do not smoke. product: no-one is safe However, those who consume tobacco are not Tobacco is an addictive plant containing the only ones exposed to its negative effects. IX and other toxins. nicotine, many carcinogens Millions of people, including one half of the world’s When transformed into products designed children, are exposed to second-hand tobacco to deliver nicotine effi ciently, its toxic effects, smoke, known also as passive smoking. There responsible for causing many diseases, are is conclusive evidence linking passive smoking often magnifi ed because the process of to an increased risk of cardiovascular diseases, increasing exposure to nicotine often results lung cancer and other cancers, asthma and in increases in exposure to the many poisons other respiratory diseases in adults and asthma in the products. Furthermore, the addiction and other respiratory diseases, ear infection and results in decades of exposure to high levels sudden infant death syndrome in children, to name of tobacco poison for most users. The diverse V, VI but a few of passive smoking’s harmful effects. poisons in the plant, the poisons resulting from its processing and (in the case of combustible Smoking has also been linked to a risk of developing products) combustion, are powerful and easily cervical cancer which is four times higher than in absorbed by many routes into the human body. non-smoking women. The latest United States Much of the disease and premature mortality Surgeon General’s report on tobacco and health A global epidemic of addiction and disease

14 caused by tobacco may be considered as are designed to enhance the speed of delivery side-effects of the disease of addiction. Tobacco and to release higher quantities of the most potent dependence itself is a disease, described chemical form of nicotine, namely “free base” or International classifi cation of diseases in the “non–ionized” nicotine. Adding chemicals to raise X As a chronic disease, often involving (ICD-10). the pH makes the tobacco and smoke less acidic, XVI, XVII, XVIII relapses, nicotine addiction requires proper thereby freeing up the nicotine. treatment. Smokeless tobacco products are also designed Addiction occurs in most (not all) tobacco users, and manufactured “in a manner that promotes but all are vulnerable. Nicotine is the drug in tolerance and addiction”, as concluded by the United tobacco that causes addiction. However, there are States Food and Drug Administration following its other chemicals in tobacco that contribute to its extensive analysis of United States and Swedish XIX:45108 addictive effects. Specifi cally, manufacturers control products. the highly addictive “free base” portion of nicotine in the products, using buffering agents such as sodium carbonate and ammonium carbonate to manipulate the nicotine-dosing characteristics of the addiction results in decades the products. For example, products marketed as “starter” products are lower in free base nicotine of exposure to high levels of and are fl avoured to make them more attractive to XIX, XX, XXI young people. tobacco poison for most users. Tobacco-delivered nicotine is a chemical cocktail of substances that enhance the addictive effects of nicotine (see box – page 19 “Cigarettes: the ultimate chemical cocktail”). Modern tobacco products are engineered to regulate the speed and amount of nicotine delivery, which contributes to the risk of developing and sustaining addiction. For example, cigarettes are designed to deliver very small doses of nicotine with each puff, but to make it possible for users to obtain much larger doses by slightly larger puffs, more frequent puffs, or holding the cigarette more deeply in the mouth. Some smokeless tobacco companies market what they have named “starter” products, targeted at young people: the starter products are slower and lower in nicotine delivery than the “maintenance” products which most experienced XI, XII, XIII smokeless tobacco users move on to use. The potential of addiction is also enhanced by increasing the speed of nicotine delivery to increase what tobacco companies call the “nicotine kick” or XIV, XV Tobacco products “impact” of their products. 14

15 What’s Your Poison? Hydrogen Cyanide When you smoke you (Poison used in gas chambers) inhale up to 4000 ❉ Toluidine chemicals including these poisons: Ammonia (Floor cleaner) Acetone (Paint stripper) ❉ Urethane Toluene ❉ Naphthylamine (Industrial solvent) Arsenic Methanol (White ant poison) (Rocket fuel) ❉ Dibenzacridine ❉ Pyrene Phenol Dimethylnitrosamine Butane Napthalene (Lighter fuel) (Mothballs) ❉ Polonium-210 ❉ Cadmium (Used in car batteries) DDT Carbon Monoxide (Insecticide) (Poisonous gas in car exhausts) It’s enough to Benzopyrene make you sick. Reproduced with permission from Tobacco Control Branch, Population Health Division, Department of Health, Western Australia Very sick. ❉ Vinyl Chloride Known cancer-causing substances ❉ HP 1532 Produced by Quit WA Program, Population Health Division © Department of Health 2002 A global epidemic of addiction and disease

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17 The many forms of tobacco of today TOBACCO PRODUCTS Tobacco comes in many forms and with various methods of use, with various names and claims attached to them. The manufactured products appear to be intended Some involve regional culture and technology, to enable the extraction and consumption of high whereas others are global. enough doses of nicotine to alter the brain in order to provide pleasure and other addicting effects. Comparison of the relative toxicity of these All tobacco products share this ability and use. products is fraught with peril. Typically, their toxicity is compared with the risks associated with smoking Tobacco products in widespread use and cigarettes, and far more epidemiological studies commercial production are derived from three have been conducted on cigarette smokers than types of tobacco preparation: on users of other tobacco products. Traditional users of other tobacco products often consume rolls of tobacco which are smoked (e.g. bidi, > less tobacco (e.g. they smoke fewer bidis or cigars cigar, cigarette) or use less tobacco in waterpipes) than cigarette pipes > (including waterpipes) smokers. The limited epidemiology for these oral preparations > for chewing and holding in products therefore relates to lower consumption the mouth or placing in the nose (e.g. snuff, snus, rates and is thus not directly comparable in betel quid). evaluating the relative risks of these products.

18 Furthermore, it may happen that, in order to Understanding these will provide the basis for receive the nicotine dose to which they have understanding the toxicity of other products and become addicted, users of cigarettes who switch the regulatory challenges they pose. to alternative tobacco products may end up using a higher quantity of tobacco than traditional users. The modern cigarette evolved from a 16th- century variant on the cigar, which enabled scrap tobacco pieces to be smoked by wrapping them in a small paper tube. Cigarettes then started to be manufactured with tobacco that was cured in such a manner that the tobacco and resultant smoke Different types of tobacco were acidic. Acidic smoke must be inhaled for products are associated with effi cient nicotine absorption, and the acidic smoke of cigarettes is easier to inhale than the mildly different types of diseases. alkaline smoke typical of cigars. As tobacco companies manipulate the ingredients of the tobacco in these alternative products to make them less harsh, this may enable more people to smoke and increase the tobacco consumption per person; also, changes in the chemistry of the tobacco products may make the nicotine itself more addictive, as has happened for cigarettes. Furthermore, different types of tobacco products are associated with different types of diseases. For example, although smokeless tobacco products Despite decades of advertised innovation, might not cause lung cancer and other diseases extravagant claims, allusions to reduced risk linked to smoke inhalation, their many other adverse XXII and healthy imagery, there is little evidence that still make them the major public health effects the health risks of smoking modern cigarettes is health concern in some populations and regions. th - substantially lower than those of smoking mid-20 The comparative risks of using different tobacco century cigarettes. Examples of the enhancements products are, therefore, not analysed in this used by the industry to portray the new products document: we present only some existing factual as safer are the use of fi lters or the development of evidence of the dangers associated with each “light and mild” cigarettes. product. See “Chronology of Deception” (central pages) for more details of the perils of these so-called “health Cigarettes improvements”. Cigarettes are among the most deadly and addictive products ever produced by mankind. “Organic”, “natural” and When used as intended by their manufacturers, “additive-free” cigarettes they kill approximately one half of their users. The terms “organic”, “natural” and “additive-free”, There are several aspects of the cigarette and its when applied to cigarettes, do not have the same evolution that have a great impact on the extent meaning as for foods, for which many countries of the damage it does in public health terms. 18

19 Cigarettes: the ultimate chemical cocktail Many of today’s tobacco products have evolved over decades and centuries. Mass-produced modern cigarettes multiply the global death toll by the use of features that mask the poisons with smoother, less visible and less smelly smoke, making them more attractive and easier to use. The cigarette is actually an elaborately designed miniature chemical factory, manufactured according to hundreds of specifi cations, incorporating patent-protected features and ingredients, and delivering nicotine within a range of doses calculated to maximize its addiction potential. None of these “advances” have been demonstrated to reduce health risks, but they do reinforce the image of the modern cigarette as a “clean” product, minimally contaminated by toxins. As far as the ingredients are concerned, the core health problem starts with the tobacco itself, which contains many cancer-causing chemicals. Although some cigarette companies post partial ingredient lists on their web sites, they do not list the many ingredients in the fi nal cigarette that might deter many people from smoking them: residual pesticides, herbicides, fertilizer, heavy metals, arsenic, cyanide and other toxins may add to the overall risk. Tobacco processing aids, such as ammonia compounds, may or may not be listed. Substances used in the manufacture of reconstituted tobacco are not necessarily listed, including the true nature of the “tobacco extract” that is sprayed on to the reconstituted tobacco material. Manufacturers do not list the many substances in the paper, glue and fi lters or the decorative dyes and inks in the cigarette and fi lter paper. Furthermore, the ingredients which are present in unburned cigarettes go on to yield more than 4 000 additional chemicals in the miniature blast furnace of the cigarette where temperatures may exceed 800 degrees Celsius. The burning cigarette works as a miniature chemical waste dump that results in the formation of still more toxins. These include the odourless, colourless deadly gas carbon monoxide (CO), increased levels of acetaldehyde, acrolein, formaldehyde and many other substances. In fact, seemingly harmless-sounding ingredients, such as chocolate, licorice and sugars, can contribute to increased carcinogenic and addictive effects. Substances such as menthol and sweeteners can also make it easier to inhale this toxic mixture deep into the lungs, by smoothing the smoke and deadening the senses. Finally, tobacco smoke forms an aerosol that carries thousands of substances into the deepest cavities of the lung, where the poisons are concentrated and quickly spread throughout the body, leading to a diverse range of diseases. Although it is commonly assumed that the modern cigarette fi lter reduces disease risk by trapping toxins, in fact its main function appears to be to help to make the cigarette a more acceptable product to the consumer. Filters are advertised and portrayed as devices that reduce exposure to dangerous toxins, but the actual health benefi ts have not been clearly demonstrated. This does not mean that fi lters should not be used, but they need to be regulated as an integral component of the cigarette. Allusions to alleged health benefi ts should not be made or implied in consumer communications without scientifi c evidence accepted by the appropriate regulatory agencies. The many forms of tobacco

20 have strict standards and for which these terms In some countries (e.g. the United States of America, imply that the healthiest ingredient is provided, Norway and New Zealand), loose-leaf roll-your- without substances suspected as being unhealthy own cigarettes represent a signifi cant and/or XXVI, XXVII or posing risks to humans. In the case of cigarettes, growing segment of the tobacco market. In New Zealand, for example, roll-your-own cigarettes the most deadly ingredient is the tobacco itself and account for about 30% of the tobacco smoked, the by-products generated when tobacco – even and over one third of all smokers there, including theoretically “pure” tobacco – is burned. These over 60% of Maori, reportedly regularly smoke cigarettes are sometimes sold in health-food XXVI Similarly, over half of all roll-your-own cigarettes. stores. Norwegian smokers smoke roll-your-own cigarettes. In addition, a manufactured cigarette, whether Materials sold for roll-your-own cigarettes are often advertised with claims that imply they are healthier, or at least less harmful, than the materials used in commercial cigarette production. This impression is also given by the fact that they may contain less tobacco than manufactured cigarettes. Basic data on emissions of these products are severely lacking, and reliable data on how people smoke these products are not openly available. The fact is that there are no data to indicate that roll- your-own cigarettes are less toxic than commercially manufactured cigarettes. Nor are there data “natural” or conventional, has many ingredients confi rming that roll-your-own cigarettes cause that keep it from decomposing, keep it moist, higher rates of disease and premature mortality give it additional fl avours and keep it burning, than manufactured cigarettes. However, recent not to mention the paper, the glue in the unpublished data collected by the New Zealand paper, and the fi lter materials. Furthermore, Ministry of Health suggest that they may lead to cigarettes claimed to be without additives higher levels of tar exposure on a cigarette-by- XXVIII and made of “organic” tobacco have never cigarette basis. been demonstrated to be less dangerous or A 1998 study from the United Kingdom found that addictive than conventional cigarettes. In fact, the mean tar yields from cigarettes produced by tests on some brands indicate higher levels of 57% of the smokers using roll-your-own cigarettes tar and nicotine delivery than those produced were above the current maximum of 15 mg per by conventional cigarettes in smoking-machine XXIX XXIII Yet such cigarettes are increasingly cigarette for manufactured cigarettes. studies. popular, appealing to health-conscious addicted consumers in much the same way as “light” Bidis and kreteks XXIV, XXV cigarettes did a few decades ago. In the South-East Asian and Middle Eastern regions, tobacco has been traditionally smoked in a variety Roll-your-own (RYO) cigarettes of forms other than conventional cigarettes. These Increasing numbers of people roll their own include the smaller and often handmade bidis and cigarettes, partly for cultural reasons and partly to kreteks. They draw heavily on regional preferences for save money owing to the rising costs (including spices and herbs, using tobacco as a major, but not taxes) of commercially manufactured cigarettes. necessarily the main, ingredient. Regionally, they are often made by children and women, in small shops 20

21 and sold by street vendors individually and not in and chocolate. A youth survey in Massachusetts standardized packaging. They are promoted locally indicates their potential attractiveness outside the and internationally as less harmful than cigarettes, South-East Asia region. Among 642 youth surveyed, and these claims appear to be supporting their 40% had tried smoking bidis and 16% claimed to be XXX, XXXI XXXII A common misperception recent and apparently rapid global diffusion. current bidi smokers. among these young people was that bidis were As with the so-called “organic” cigarettes, bidis and less hazardous than cigarettes. In fact, a study in kreteks are also often sold in health-food and herbal VIII India estimated that about a quarter of male bidi or medicine stores worldwide. cigarette smokers at 25-69 years of age are killed by their smoking and overall, smoking caused 552 000 deaths among men in India aged 25-69 years. The fact is that there are no Recent studies indicate that delivery of nicotine and other substances by bidis are at least as great data to indicate that XXXII, XXXIII as levels delivered by ordinary cigarettes. Moreover, they tend to be smoked more intensively roll-your-own cigarettes are with more frequent puffs, thus resulting in higher actual nicotine intake and cardiovascular effect less toxic than commercially XXXIV as well as 2-3 times greater tar than cigarettes, XXXV manufactured cigarettes. In cohort studies, bidi smoking has inhalation. been shown to result in high excess mortality and high risk for diseases that are caused by cigarette XXXVI Bidi smoking has been associated smoking. with a threefold risk of oral cancer compared > Bidis XXXV, XXXVII with people who have never smoked, XXXVII Bidis are small hand-rolled cigarettes, made and an increased risk for cancer of the lung, XXXVII, XXXVIII XXXVII and oesophagus. Studies stomach typically in India and other South-East Asian have also shown bidi smoking to be an important countries. Although bidis tend to be smaller than VIII, XXXIX, XL risk factor for cardiovascular disease. conventional cigarettes and exotically fl avoured Risk of thromboangiitis obliterans is greater with with ingredients promoted as natural and healthy, XLI bidi smoke compared with cigarette smoke. they can be every bit as deadly and addictive as conventional cigarettes. They typically contain a few hundred milligrams of tobacco wrapped in a > Kreteks (clove cigarettes) tendu or temburni leaf (Diospyros melanoxylon) . Kreteks are also known as clove cigarettes, as they typically contain 40% cloves and 60% tobacco. These Although most commonly used in South-East Asian cigarettes are the dominant form found in Indonesia, countries, they are increasingly exported as exotic and and are now sold in other countries and on the Internet less harmful alternatives to conventional cigarettes. XLII ): they are becoming more (e.g. the “Kretek Pages” Exported bidis vary widely in their incorporation of commonly available and used worldwide. Smoking- spices and fl avourings. For example, on the Internet machine yields for these products are rarely provided, it is possible to obtain fl avours such as mango, cherry and their diversity in actual size and content suggests that nicotine and other toxins might vary more widely than for commercially manufactured or conventional cigarettes with similar characteristics. One study showed that volunteers who alternated smoking kreteks with conventional cigarettes obtained similar levels of nicotine and carbon monoxide, and The many forms of tobacco

22 displayed similar cardiovascular effects. Although the as a “great opportunity to signifi cantly expand our kreteks were smaller than cigarettes, the volunteers business in the world’s fi fth largest and growing puffed them more frequently and intensively than cigarette market”. What impact this transaction XXXIII The toxicology of inhaled conventional cigarettes. will have in expanding the kretek market worldwide clove smoke has not been well studied. In addition to is not known, but there is an obvious potential its potential direct toxicity, cloves provide an aroma for synergy with Philip Morris International’s that may mask the irritant qualities of tobacco smoke marketing and distribution system to implement XLVII and thereby enable inhalation of large quantities of this expansion. smoke. Similarly, cloves can also release eugenol, which can mitigate sensory effects and also facilitate Cigars deep inhalation of large quantities of smoke. Cigars are rolls of tobacco wrapped in tobacco leaf, although machine-manufactured cigars, as Although the epidemiology of disease associated well as some hand-rolled cigars, are wrapped with kretek smoking is not as well documented as with paper made from tobacco that is called for conventional cigarette smoking, the available “reconstituted” or “sheet” tobacco. They generally evidence indicates health risks consistent with the contain several times as much tobacco as fact that kreteks are fi lled primarily with tobacco and cigarettes, but their size is much more variable, burned as conventional cigarettes; that is, disease ranging from the size of a cigarette to products could be very similar to that for conventional that are several times the diameter and containing cigarettes. For example, a recent study from as much tobacco as a package of 20 cigarettes or Indonesia found that lung cancer risk among XLVIII, XLIX, L Cigar smoking causes cancer of more. kretek smokers was increased by the number of XLVIII XLIII the lung, oesophagus, larynx and oral cavity. cigarettes per day, years of smoking and age. Many people who have never used cigarettes but Similar fi ndings have been repeatedly documented XLIV Kretek for conventional cigarette smoking. are primary cigar smokers inhale less smoke than smoking is associated with an increased risk of cigarette smokers and have a lower risk of lung acute lung injury, especially among susceptible diseases (although the risk is elevated compared XLV individuals with asthma or respiratory infections. with non-cigar-smokers). Former cigarette smokers Research in Indonesia has shown that regular kretek are more likely to inhale cigar smoke than those XLVIII smokers have 13–20 times the risk for abnormal Cigar who have never smoked cigarettes. XLVI lung function compared with non-smokers. smokers are also exposed to their own second- hand smoke, which is at quite a high level in cigars XLVIII While it is not clear that the high levels of cloves as compared with cigarettes. in kreteks increase their toxicity compared with conventional tobacco cigarettes, there is no scientifi c basis for concluding that kreteks are any less hazardous than cigarettes. The potential of this market seems to attract the tobacco industry. In March 2005, Philip Cigar smoking causes cancer Morris International, the largest multinational of the lung, oesophagus, tobacco company, and the international tobacco company arm of Altria Group Inc. announced larynx and oral cavity. the acquisition of Sampoerna, Indonesia’s third largest tobacco company, with approximately 19% of the domestic market in kreteks (41 billion units). According to Philip Morris International’s press releases, the company saw the acquisition 22

23 However, even cigar smokers who do not inhale themselves to very high levels of tobacco still have a lung cancer risk 2-5 times higher than toxins. IV:848 that of lifelong non-smokers. Cigars do not even need to be lit to expose users to nicotine and other substances. Merely holding an unlit cigar in the mouth exposes the user to tobacco and its poisons. This is due to the alkaline nature of the tobacco, as compared with the acidic tobacco of cigarettes, which makes it possible for nicotine to L be absorbed even from an unlit cigar. Pipes Pipe smoking has received much less study than cigarette, or even cigar smoking: however, much of what is true of cigars appears also to be true of pipe smoking. For example, the smoke tends to be more alkaline than cigarette smoke and thus does not need to be directly inhaled to sustain high levels of nicotine addiction. Owing to the relatively large quantities of tobacco that are commonly put into the pipe, the pipe smoker and non-smokers may be exposed to smoke equivalent to that from several cigarettes. Pipe smokers carry a substantially higher risk of diseases including chronic obstructive pulmonary disease, oral head and neck cancer, laryngeal cancer, oesophageal cancer and lung LIII cancer. The relative risk for lip cancer associated with pipe smoking is 1.5. A study in China found that the Furthermore, lung cancer risk among cigar smokers odds ratio for oral cancer among pipe smokers is similar to that found in cigarette smokers if they is 5.7 in men and 4.9 in women. In fact, these XLVIII, LI, LII regularly inhale the smoke as they puff. estimates are even greater than those associated IV:846-7 The risk of head and neck cancer and many other with cigarette smoking. diseases is the same as for cigarette smoking. The amount of pipe smoking, and possibly the level For instance, the relative risk of death from cancer of inhalation, are determinants of the associated of the oral cavity and pharynx is 7.9 among all health risk. cigar smokers, relative to lifelong non-smokers. It increases with the number of cigars smoked per day to 15.9 in men who smoke fi ve or more cigars Waterpipes (hookahs, IV:846 per day. bhangs, narghiles, shishas) Remarkably, some people who claim to have Waterpipes are popular throughout the South-East “quit smoking” actually switched from cigarettes Asia and Middle East regions and have been used for many centuries under the illusion that they were to cigars and many believe that cigars are less LIV, LV Regional names harmful which, as we have seen, is not true, as a safe way to smoke tobacco. include “hookah”, “bhang”, “narghile”, “shisha”. they continue to inhale the smoke and expose The many forms of tobacco

24 Waterpipes are made in a variety of designs in in the Middle East and becoming quite popular which the smoke of the substance is passed globally on college campuses and elsewhere, through water (“bubbled”) before inhalation. The owing in part to its mystique assumptions of substance is placed in a small bowl with holes relative safety and the socialization afforded by LV in the bottom, to which is attached a tubing that multiple-user pipes. allows the smoke to be drawn to the bottom of a The absence in most countries and regions of the standardized warnings used for cigarettes may reinforce the assumption of relative safety. Special tobacco mixtures are sold, often highly fl avoured with fruit, honey, molasses and herbs. Waterpipes are commonly used Some of these are labelled with the technically accurate, but extremely misleading, statement by families, including children, “contains no tar”. This is technically accurate, and by women in regions in which since the tar is produced during the combustion of the tobacco. However, because the waterpipe conventional tobacco use occurs bowl is typically fi lled with several times as much tobacco as is contained in cigarettes, once lit, at very low rates among women. large amounts of tar could be produced when the tobacco is burned and pyrolized by the smouldering coals. water container. The tobacco or other substance does not burn independently, but is heated and partially burned by the addition of a hot coal or burning ember to the bowl. One or more tubes are attached to the top of the water container to allow the user(s) to inhale and thereby draw smoke out of the bowl, through the water and into the lungs. The illusion that waterpipes are a safe form of tobacco smoking goes back at least to the 16th century, when physician Abul Fath suggested that the “smoke should be fi rst passed through a small receptacle of water so that it would be rendered LVI This early “disguise” of tobacco’s harmless”. toxicity was presumably well-intentioned, but created the illusion of safety with no evidence – then or now – of actual reduction in disease risk. Lung toxins and carcinogens are probably reduced little, if at all, by the passage of the smoke through Waterpipes are commonly used by families, water. Absorption of the cardiovascular poison, including children, and by women in regions in carbon monoxide, can be very high, owing to the which conventional tobacco use occurs at very large volumes inhaled and to the fact that the heat LIV Furthermore, with the low rates among women. source is typically coal or smouldering embers, introduction of fl avoured tobacco, waterpipe usage which generate very high carbon monoxide is increasing dramatically among young people levels. Whereas a cigarette is typically smoked 24

25 LV over approximately fi ve minutes with 300-500 ml Other ailments have also as herpes or hepatitis. been associated with waterpipe use, e.g. eczema of smoke inhaled, waterpipe smoking sessions LXIX “dry socket” following tooth can easily last from 20-60 minutes with volumes of the hand, LXX and vertical extraction (postextraction alveolitis) of 10 litres or more inhaled. LXXI periodontal bone loss. It is plausible that some water-soluble substances Waterpipe smoking also involves risks to nearby are partially absorbed into the water and thus non-smokers and the fetus of a pregnant reduced in concentration, but whether the toxicity LXXII In a study with Lebanese children, for woman. is reduced suffi ciently to diminish adverse health the 8.5% of children who reported being exposed effects is not known. It is plausible that the nicotine at home to waterpipe smoke only, the odds ratio concentration of the smoke is reduced, and this of having respiratory illness was 2.5 relative to a is suggested by the extraordinarily high volumes non-exposed group; this odds ratio was similar to of smoke inhaled as compared with cigarettes. that of children exposed to cigarette smoke only The health effect of this may be negative, because LXXII Exposure to carbon monoxide during (i.e. 3.2). enough nicotine can still be absorbed to cause pregnancy can harm the fetus, and is thought to addiction, while the lower concentration could underlie the low birth weight and low Apgar scores result in a much higher intake of cancer-causing observed in neonates born to smoking mothers substances and other toxins. LXXIII Clearly, fetal tobacco (fetal tobacco syndrome). syndrome is a risk for babies born to women who Serious lung disease, cancer and other adverse use waterpipes during pregnancy: these women health effects have been documented and linked to face an increased risk of having babies with low waterpipe smoking. However, information on patterns birth weight. of use, content and health effects are more limited than for cigarettes. Nonetheless, waterpipe smoking is tobacco smoking, and a growing body of evidence confi rms that the health effects are largely those expected from tobacco smoke exposure, including lung disease, cardiovascular disease and cancer. Oral non-combusted products For example, recent work from Egypt reveals that, are highly addictive and can relative to non-smokers, waterpipe users displayed greater levels of pulmonary i mpairment (assessed cause cancer. LVII, LVIII, LIX, L X ). These impairments via spirometry. are probably refl ected in the greater incidence of chronic obstructive pulmonary disease observed LXI, LXII in waterpipe users, relative to non-smokers. For cardiovascular disease, one preliminary report Non-combusted “oral” or on 292 waterpipe users and 233 non-smokers with “smokeless” tobacco products coronary heart disease notes that 31% of cases In some regions of the world, the use of oral had ever used waterpipes, compared with 19% of LXIII The potential link between waterpipe smokeless tobacco remains the dominant form of controls. use and cardiovascular disease deserves more tobacco use and tobacco-caused disease. Oral investigation. Waterpipe use has been associated non-combusted products are highly addictive and LXV LXIV as well as oral with bronchogenic carcinoma can cause cancer of the head, neck, throat and LXVI, LXVII cancers. and bladder oesophagus, as well as many serious oral and dental conditions. In some countries, including In addition to these tobacco-related diseases, India, it is also a major form of tobacco addiction. sharing a waterpipe may increase the risk of Its consumption is prominent in Scandinavia and XXX, XXXI LXVIII and viruses such transmission of tuberculosis the United States of America. The many forms of tobacco

26 The popularity of oral smokeless tobacco is Smokeless tobacco products with variations such as growing following increasing marketing efforts by controlled pH, fl avouring and unit-dose pouches have the tobacco industry. In a recent study published been marketed for several decades, aiming particularly in the Journal of School Health, the analysis of at young people in order to promote initiation of XIX, LXXVI, LXXVII, LXXVIII More recently, several the reports on gender differences in tobacco use tobacco use. companies have more aggressively marketed them among young people in all regions of the world to cigarette smokers as an alternative in situations carried out by the United States Centers for Disease in which smoking is not allowed, thus promoting the Control (CDC) and WHO revealed a surprisingly LXXIX dual use of smokeless and smoked products. high use of other tobacco products compared with cigarette smoking, including smokeless Mixing tobacco with various chewable mixtures tobacco. Furthermore, there was little difference of herbs, spices, areca nut, betel leaf and other between the use of cigarettes and other tobacco LXXIV Specifi c country studies, like one substances was adopted in the South-East Asia products. th th and 17 centuries, and many carried out in South Africa among black secondary region in the 16 variations exist. Dry powdered tobacco which was school students in 2001, reported a prevalence of “snuffed” into the nose was particularly popular in 8.4% of snuff users among girls, and 3.9% among LXXV England, northern Europe and parts of China in the boys. th th and 19 centuries. 18 Oral smokeless tobacco is the dominant form of tobacco use in India, where Indian products are Smokeless tobacco overwhelmingly dominant. Most commonly, tobacco XXX Areca nut, is added to paan, a betel quid mixture. products contain addictive a common component of betel quid, contains the levels of nicotine, many alkaloid drugs arecoline, muscarine and pilocarpine, which in small doses can produce calming and carcinogens, heavy sometimes mildly stimulating effects. The mixtures are also considered to aid digestion and are commonly metals, and other toxins. taken after meals. The incorporation of tobacco into paan increases its addiction potential and contributes to its adverse health effects because of the more XXX persistent use caused by the addiction. There are four major forms of oral smokeless The speed of nicotine absorption is pH-dependent. tobacco: Often, buffering substances, such as ashes, is shredded like short cut > chewing tobacco historically, or calcium hydroxide (slaked lime) or grass, generally mildly acidic and intended to sodium carbonate more recently, are added to raise be chewed throughout the day as desired the pH and enable more rapid absorption and hence > snuff is chopped into particles like large coffee a stronger nicotine effect or “kick”. grounds, moistened and used by holding between gum and cheek Oral tobacco has been recognized since at least the > is a variant on snuff that is Swedish snus 1980s to cause addiction, several forms of cancer and LXXVI The adverse health effects processed differently so that some variants various dental diseases. of oral tobacco mixtures have been extensively review must be kept refrigerated: it is typically more IV, XI, XXX, LXXVI, LXXX, LXXXI All concur that smokeless ed. moist > gutkha and other oral smokeless tobacco tobacco products contain addictive levels of nicotine, products are used in India and South-East many carcinogens, heavy metals, and other toxins, Asia. though recognizing that the levels of nicotine and 26

27 toxins vary widely across products. In general, products that appear to differ in risk. For example, oral tobacco products are highly addictive, and studies in India and the United States of America typically contain several carcinogens that cause are unequivocal in their fi ndings that oral smokeless XXX, LXXVI head, neck and throat cancers with high rates of tobacco use is a major public health problem. IX, XI On the other hand, in Sweden, where it is claimed premature mortality. by the manufacturers that the most widely used products are lower in carcinogens (owing to a Tobacco use, including smokeless tobacco, and processing technology patented by the Swedish excessive alcohol consumption are prominent risk LXXXVIII Match tobacco company ), the oral cancer risk factors in oral cancer, being estimated to account for LXXXII appears lower than that observed in countries where cancers. about 90% of oral tobacco products are higher in carcinogens, such LXXX, LXXXIX as India and the United States of America. It is worth noting that, despite the differences in relative health risks compared with other tobacco products, a recent review of smokeless tobacco by the International Agency for Research on Cancer concluded that smokeless tobacco is carcinogenic, IV making no exception for Swedish snus. Gutkha A major category of commercially manufactured oral smokeless tobacco in India and the South-East Asia region is termed gutkha. Gutkha is a fl avoured and sweetened dry mixture of areca nut, catechu, slaked XC The lime with tobacco and other condiments. commercial production and marketing of tobacco Worldwide, there are approximately 274 000 new products have been considerably increased since LXXXIII of oral cancer every year. In South Asian cases the introduction of gutkha in India. The rate of and South-East Asian countries, oral cancer is a growth of gutkha use has overtaken that of smoking LXXXIV India has a high major public health problem. forms of tobacco. incidence of oral cancer, accounting for one third of the LXXXV It is one of the fi ve leading causes world burden. In India, gutkha has attracted the younger generation LXXXVI The of cancer at fi ve leading sites in either sex. more than the older generation. The wider availability vast majority of cancers in India are preceded by of gutkha has even attracted women and made it precancerous lesions and conditions caused by the easier for them to chew tobacco without attracting XXX use of tobacco in some form, and these are increasing social sanction. XXX, LXXXV,LXXXVII among the younger population. Gutkha and paan masala (areca nut products without Oral tobacco mixtures also cause numerous other tobacco) have been strongly implicated in the recent oral and dental diseases that can be debilitating, such increase in the incidence of oral submucous fi brosis, as lesions in the oral cavity and gingival recession, especially in the very young, even after a short period which are typically reversible upon cessation of of use. The condition has a high rate of malignant LXXX but that can also, in some cases, be life- use transformation, is extremely debilitating and has LXXXV, XC This previously uncommon threatening. The risks of oral smokeless tobacco use no known cure. disease, found mainly among old persons in India, is and the relative risk compared with other tobacco emerging as a new epidemic mainly among young products, have been the subject of debate owing, LXXXV, XCI, XCII people (below 35 years). in part, to differences across populations and The many forms of tobacco

28 TOBACCO PRODUCTS of tomorrow and safety claims As just seen, there are many different types of tobacco products around the world. For some of them, like cigarettes, there is before it was conclusively established, decades extensive evidence and scientifi c research which later, that there was no health benefi t to be gained proves their deadly effects. For some of the from smoking “light” and/or “mild” cigarettes XCVIII, XCIX This products, research is still lacking. Regulation is compared with full-fl avour cigarettes. public health debacle was one of the driving forces inadequate for all products. In the meantime, behind the call for a global framework convention the use of these products continues to expand, to support the regulation of tobacco products. aided by an industry constantly hungry for profi t. The tobacco industry continues to develop new The WHO Framework Convention on Tobacco products, spending huge budgets on research Control (WHO FCTC) requires countries to ban into new “reduced-harm” products, all of which descriptors such as “light”, “mild”, etc. However, are still untested in their long-term health effects; the tobacco industry will continue to fi ght effective meanwhile, the industry gains addicts and market measures. One example of this is the effort share. made by the tobacco industry in countries, like Brazil, that banned “light” and “mild” descriptors Historically, several techniques have been introduced prior to the adoption of the WHO Framework to make supposedly “safer” cigarettes. To date, none of these modifi cations has been proven to Convention: companies attempted to reproduce produce a safe product. Those products which have these descriptors with colour codes supported by been in use long enough for their associated health marketing campaigns, in an attempt to undermine effects to be studied have been shown to remain the regulatory measures. Any claims of harm reduction without deadly. Perhaps the most important lesson learned solid epidemiogical data should be viewed Currently, we have identifi ed only from the “light and mild” cigarette debacle with suspicion. a small percentage of the toxins in tobacco smoke; was that the well intentioned efforts by public these alone account for a tiny fraction of the known health organizations and governments to morbidity and mortality. Therefore, reductions in address the needs of continuing smokers these alone may not reduce the risk substantially, was used by the industry as a marketing especially since there are many more thousands of tool to stimulate initiation in non-smokers toxins which are still unknown. and perpetuate tobacco use in existing smokers. It is clear nowadays that public Caution is needed with new products. All existing health authorities cannot trust the tobacco and new products put on to the market must be industry’s claims, nor can they endorse them. regulated. The following case-study on cigarettes As with the “light and mild” campaigns, such a marketed as “light”, “low tar” and “mild” shows mistake can take decades to comprehend and how deceptive the tobacco industry has been in more decades to undo. Perpetuating smoking the past: the lessons learned from this one case is deadly because, even if the cigarettes should be wisely used in order to avoid similar really were lower-risk (which “light and mild” situations in the future. cigarettes were not), disease risks are very strongly determined by years of exposure. The most tragic consequence of all is that millions of Delaying cessation through false reassurance smokers died worldwide smoking these cigarettes is deadly. 28

29 A case-study in deception and disguise The evolution of the cigarette, 1950-2000: th century, the tobacco As scientifi c evidence of the adverse effects of smoking cigarettes accumulated in the mid-20 industry began making product changes to make the cigarettes appear safe and discourage people from quitting. Filters Before 1950, fi lters were used only in speciality cigarettes. However, as scientifi c studies were published that showed that smoking caused 90% of lung cancer deaths in the United Kingdom and United States of America, the tobacco companies introduced fi ltered cigarettes into the broader market. Filters are advertised and portrayed as devices that reduce exposure to serious toxins. However, fi ltered cigarettes still kill half of those who smoke them and cause disease in many others. Meanwhile, smokers fl ocked to the fi lter cigarettes, and by 1975 they accounted for 87% of cigarettes sold. The tobacco industry knew the health claim was false: lter cigarette was getting as much ... nicotine and tar as he would have gotten from a “the smoker of a fi regular cigarette. He had abandoned the regular cigarette, however, on the ground of reduced risk to health” XCIII (Quote from Ernest Pepples, Vice-President of Brown & Williamson, February 1976). XCIV “Light” and “ultralight” cigarettes The publication of the United Kingdom Royal College of Physicians report in 1962 XCV had a profound impact in the and the United States Surgeon General’s Report on the health effects of smoking in 1964 United States of America and much of the developed world. Until then, the smoking rate had increased throughout the 20th century; after the Surgeon General’s report, the cigarette smoking rate began a steady decline in the United States of America and other developed countries that continues to this day. However, the tobacco industry responded aggressively to produce a product which it could market as “safe”: in this case, it developed a product and a “test” designed to deceive smokers and the public. “Light” cigarette brands were developed to create the illusion of reduced exposure and reduced harmfulness by delivering generally smoother, cooler smoke to reinforce advertising claims of reduced tar and other toxins. The marketing messages were reinforced by cigarette designs that yielded lower tar and nicotine ratings in the International Organization for Standardization (ISO) and United States Federal Trade Commission (FTC) testing systems, which had been endorsed by many national governments but had been developed with major input from the tobacco companies. Smokers responded to claims of a safer product, and switched to “light” cigarettes; while these cigarettes accounted for less than 4% XCVI In reality, “light” cigarettes could deliver of the market in 1970, that share increased to 45% in 1980 and 87% by 2000. several times more tar and nicotine than advertised: they undermined public health campaigns aimed at prevention and cessation, and they did not reduce the risk of disease relative to their so-called “full-fl avour” counterparts. One of the techniques used by the tobacco industry was to perforate the cigarette fi lter with ventilation holes that allowed large quantities of air to be mixed with the smoke and thus have the effect of diluting and cooling it. By perforating the fi lters, the levels of tar and nicotine yielded by the ISO and FTC testing were lower, and the numbers were advertised and printed on cigarette packs, luring many consumers to use the “light” products in the belief that the lower yields would reduce health risks. However, the ventilation holes could be easily covered by smokers who were unaware of their presence and/or their purpose and who sought the nicotine doses to which they were addicted. Most deceptive of all was the discovery that the tobacco industry knew that there was no change in their deadly product, as internal documents prove. However, these companies not only failed to reveal the truth, but covered it up with powerful marketing tactics, spreading the misconception about “light and mild” cigarettes, misleading consumers and public opinion. One previously secret memo by senior British American Tobacco employees urged that they modify their cigarettes, using designs that would not invite obvious criticism, in order to cheat the “league tables” (i.e. the tar and nicotine charts based on ISO testing methods). Quote from a released industry memo: “You already know about the EEC mandate to reduce all deliveries to As we knew this was going to happen as early as 1988, we began to develop a strategy to react ... The 15 mg. 3 year effort resulted in a new method (now known as the ‘new ISO’) which reduces the smoke delivery results by about 1 mg at the 16 mg level. The Marlboro sold in the EEC was initially delivering about 15.5 mg prior to any analytical new technology change. When the new system was implemented, the deliveries were around 14.5 XCVII mg, but remember, no product change ever took place...” The many forms of tobacco

30 Finally, it is clear that the tobacco industry continues The 21st century challenge to design and market products to perpetuate and Since the 1990s, tobacco companies have increased expand its markets and that it will exploit opportunities the development and marketing of products which to undermine prevention and cessation efforts. they claim have the potential to reduce the risk of disease and death compared with conventional XI, LXXVIII, LXXIX, C, CI None of these tobacco products. claims have been evaluated by independent, scientifi cally based regulatory authorities, nor have the health effects been studied. Any scientifi c evaluation must start with the recognition that these products are diverse in nature, intent and apparent claims. The table below shows the diversity of product offerings from large and small companies. The different products include modifi cations of more traditional products: all, however, contain tobacco and deliver nicotine and tobacco toxins. Little information is available about the contents or emissions of most of these products, and what is available comes primarily from the companies that make and sell the products. Although new tobacco products have the theoretical potential to reduce the risk of disease in people who are unable to abstain from tobacco completely, the risks and overall public health harm could be increased, depending upon how the products are actually used. The sheer diversity of product offerings makes it even more urgent to introduce regulation to protect health-conscious smokers from being misled by this new generation of unevaluated and unapproved products. Without strong regulatory oversight aimed at protecting health, people will continue to be hostages of the promises of tobacco product developers and marketers. The extent of the tobacco industry’s true knowledge of the addictiveness and disease-causing effects of its products may never be known. What has been revealed makes every effort to implement the WHO Framework Convention more urgent, if we are to rein in this industry which has consistently put its own profi t over humanity and health. 30

31 Can you see a pattern here? Any claims of harm reduction without solid epidemiological data should be viewed with suspicion. Contents Contains Proven safe regulated for Contains Addictive? Product consumer to use? other toxins? carcinogens? safety? Cigarettes Yes Yes Yes No No Cig. with fi lters N o N o Ye s Ye s Ye s “Light and Yes Yes No No Yes mild” cig. Roll-your-own Yes Yes Yes No No “Organic”, “natural”, Yes Yes Yes No No “additive-free” Bidis Yes Yes Yes No No Kreteks Yes Yes Yes No No Cigars Yes Yes Yes No No Pipes Yes Yes Yes No No Waterpipes Yes Yes Yes No No Oral or Yes Yes Yes No No smokeless Gutkha Yes Yes No No Yes Tobacco products of “tomorrow” * Eclipse Yes Yes Yes No No Accord Yes Yes Yes No No Omni Yes No No Yes Yes Ariva Yes Yes Yes No No Quest Yes No No Yes Yes Firebreak Yes Yes Yes No No Trionic Filter and Advanced No No Yes Yes Yes Light Cigarette Filligent cigarette fi lter and Fact No No Yes Yes Yes cigarette Click No No Yes Yes Yes *Since the 1990s, tobacco companies have been marketing products that they claimed would have potential to reduce the risk of d isease compared with conventional tobacco products. Some of the products in the table above are known as “potential reduced exposure products” or (PREPS). Most of the names used above are trademarks registered by their respective manufacturers. This table is not intended to be comprehensive, a nd some products are sold by different companies under different brand names: it is not known whether these apparently similar products are actually identical. These products have each been described on the web sites of the product manufacturers or in news media discussions that can be accessed by Int ernet search. In the unregulated environment that presently exists, there is no certainty that the descriptions of the products and their associ ated claims are accurate or consistent with their physical makeup or health effects. The many forms of tobacco

32 04 32

33 Regulating a deadly product THE WHO FRAMEWORK CONVENTION on tobacco control The challenges raised by the diversity of existing tobacco products, the efforts of the tobacco industry to conceal and disguise their addictive and toxic effects and the speed with which the tobacco industry is able to modify its products poses enormous challenges to global health. The WHO Framework Convention is an impor- from both the supply-side and the demand- tant tool for addressing these challenges. side perspective; it includes provisions for consideration of and cooperation on questions of The WHO Framework Convention is a global public criminal and civil liability; and it embraces scientifi c health treaty developed as a global response evidence-based approaches, that is, measures to the globalization of the tobacco epidemic. It that have proved effective in reducing tobacco is aimed at reducing the burden of disease and consumption. death caused by tobacco. Its entry into force on 27 February 2005 reaffi rmed the right of all people The fi nal text of the WHO Framework Convention to the highest possible standard of health. was adopted unanimously by the World Health Assembly in May 2003, following nearly four years The WHO Framework Convention is the fi rst treaty of negotiations. The WHO Framework Convention ever initiated by the World Health Organization. became one of the most quickly embraced It is unique among treaties addressing addictive treaties in United Nations history; within two and substances because it addresses tobacco control a half years, it boasted more than 100 Parties.

34 The fi rst session of the Conference of the Parties These articles will help reduce tobacco demand by supporting efforts to prevent tobacco use. The was held in Geneva from 6 to 17 February CII implies detailed description in each of the articles 2006, and mobilized 113 full Parties, as well as the need for an objective science-based approach to representatives from other countries and civil implementation through tobacco product research society, in support of the common goal of curbing and testing designed to inform public health policy- the tobacco epidemic. makers. As mentioned in the introduction, Article 1(f) of the Research and scientifi c evidence informed the WHO Framework Convention defi nes tobacco negotiation of provisions contained in Articles 9, 10 products as all products made entirely or partly from and 11 of the WHO Framework Convention. This tobacco leaf. Further, a preambular paragraph research contributed to the consensus position in the Convention recognizes that “... scientifi c among parties that regulation would serve public evidence has unequivocally established that health goals by providing meaningful oversight over tobacco consumption and exposure to tobacco the manufacturing, packaging and labelling and smoke cause death, disease and disability ...”. distribution of tobacco products. The same scientifi c Consequently, the WHO Framework Convention basis guiding the implementation of Articles 9 and 10 does not make a distinction between cigarettes also underscores the principles guiding Article 11. For and other tobacco products. this reason, and in order to achieve the synergistic effect of these provisions, all three articles should be Following the preamble and articles addressing the treated conceptually as one set of regulations. primacy of health, terminology and the obligations of the Contracting Parties, the WHO Framework Achievement of product regulation goals will be Convention addresses demand reduction in articles facilitated through Article 20 (Research, surveillance 6-14. It also addresses supply reduction in articles and exchange of information) which promotes 15-17. Three articles lay the groundwork for the the establishment of research, testing and regulation of tobacco product contents, emissions, information exchange considered fundamental design and labelling. They are as follows: to the implementation of Articles 9-11. Article 22 > Article 9: Regulation of the contents and (Cooperation in the scientifi c, technical, and legal fi elds emissions of tobacco products and provision of related expertise) lays an additional > Regulation of tobacco product Article 10: foundation by recognizing the vital importance of disclosures international collaboration, mutual support and > Packaging and labelling of tobacco Article 11: facilitation of relevant technical capacity. products. of the WHO FCTC states that Article 1(f) tobacco products” means products entirely or partly made of the leaf tobacco as raw material “...“ . Further, a preambular which are manufactured to be used for smoking, sucking, chewing or snuffi ng” ...scientifi c evidence has unequivocally established that tobacco paragraph in the Treaty reconizes that “ and that there is death, disease and disability, consumption and exposure to tobacco smoke cause a time lag between the exposure to smoking and the other uses of tobacco products and the onset of ”. Consequently, the WHO Framework Convention does not make a distinction tobacco-related diseases between cigarettes and other tobacco products. 34

35 THE FUTURE HORIZON for tobacco testing To enable progress towards fulfi lment of the obligations of articles 9, 10 and 11, and consistent with Articles 20 and 22, the WHO Study 1 issued a recommendation, in Group on Tobacco Regulation (TobReg) 2004, outlining some guiding principles and technical considerations for establishing global tobacco product testing and research capacity. The recommendations of TobReg emphasize The report led to the establishment of the WHO the importance of expanding current research Tobacco Laboratory Network (TobLabNet) in and testing capacity – currently concentrated in a 2005 to facilitate transnational and regional testing few nations – across the world so that all Parties and research into tobacco products of all forms. to the WHO Framework Convention, and other TobLabNet was developed with support and co- countries, can have access to resources and data sponsorship by the United States National Cancer to enable requirements in relation to regulation Institute, the United States Centers for Disease of contents, disclosure and labelling of tobacco Control and Prevention (CDC), the Dutch National products to be fulfi lled. Institute for Public Health and the Environment (RIVM) and the European Network of Government Laboratories on Tobacco and Tobacco Products (ENGL). The Conference of the Parties to the WHO Framework Convention, during its fi rst session in February 2006, decided on a template for the elaboration of guidelines on product regulation. The guidelines will be based on the work already done by TobReg and the WHO Tobacco Free Initiative (TFI), confi rming the signifi cance of the groundwork done by TobReg. 1. In November 2003, the WHO Director-General formalized the Scientifi c Advisory Committee on Tobacco Product Regulation (SACTo b) by changing its status to that of a study group. Following the status change, the SACTob became the «WHO Study Group on Tobacco Product Regulation» (TobReg). It is composed of national and international scientifi c experts on product regulation, tobacco de pendence treatment and laboratory analysis of tobacco ingredients and emissions. Its work is based on cutting-edge research on tobacco p roduct issues. It conducts research in order to fi ll regulatory gaps in tobacco control. As a WHO Study Group, the TobReg has a mechan ism to report to the WHO’s Executive Board in order to draw attention of Member States to WHO’s efforts in tobacco product regulation, which is a novel and complex area of tobacco control. Regulating a deadly product

36 05 36

37 Conclusions The marketing and distribution of tobacco products has created an epidemic that will kill approximately 5 million people in 2006, with the annual death toll nearly doubling by 2020. Regulation of tobacco products is vital in order regions only, such as waterpipes, kreteks and to control the escalating global tobacco epidemic. bidis, are sweeping the world under the allure of their exotic appeal and illusions of relative safety. Although cigarettes and cigarette substitutes are the major focus of many national tobacco control The tobacco industry has proven itself efforts, this report highlights the fact that all untrustworthy when it comes to safety claims, tobacco products are harmful and addictive product improvements or ethical behaviour The and all can cause disease and death. in its marketing tactics. Public health agents use of deception and disguise by the makers and and governments have a responsibility to stop marketers of tobacco products seems to know no erroneous and misleading claims about the safety bounds, and the number of new products in the of new products. These mistakes take years to pipeline is escalating. Products include cigarette undo, and cost millions of lives, as the example of fi lters with claims ranging from improved health “mild and light” has shown. to whiter teeth, smokeless tobacco products marketed with claims of purity and negligible harm For new products and for those under development, and new high-technology products that bear little additional research is needed to understand more resemblance to conventional tobacco products. precisely whether their risks are the same as the Ancient products traditionally used in selected products they would replace. Such research will

38 take years, or even decades. Until such research is The WHO Framework Convention observes completed, the most prudent course is to assume that widest possible international cooperation is that their health risks are extraordinarily high necessary to control tobacco-caused illnesses. compared with any ordinary consumer product and to make every effort to prevent their use along Tobacco companies must be held accountable for with all other tobacco products. their actions and marketing practices. Stringent and more comprehensive enforceable regulation is a critical course of action to ensure that this is done. In combination with other comprehensive tobacco control measures, all included in the provisions of the WHO Framework Convention, we now have the tools to bring the tobacco It is vital that all these products epidemic and its devastating health and economic consequences under control – a truly global public be regulated because they health achievement. are all harmful and addictive. Tobacco products are not regulated to the standards expected of most other consumer goods and consumer products. Therefore, it is vital to develop comprehensive regulation of all tobacco product ingredients and emissions, harm, manufacture, communications and marketing, as endorsed by the WHO Framework Convention. And in line with the intent and the text of the Convention, this call for regulation of all tobacco products will help to empower people and governments to make decisions based on truth about the products and not premised on disguise and deception. It is vital that all these products be regulated, however, because they are all harmful and addictive. The need for regulation is of increasing urgency as the harm to individuals, families, populations and nations is projected to continue increasing at a devastating rate if it continues on its current course. The WHO Framework Convention is an important catalyst in such regulation. It emphasizes the right of Parties to protect the health of their people, as well as the individual rights of people to health and wellness by protecting themselves from tobacco. 38

39 Conclusions

40 06 40

41 References I Warren CW et al., for the Global Tobacco Surveillance System (GTSS) Collaborative Group. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. 17 February 2006, DOI:10.1016/S0140-6736(06) 68192-0 II Past, current and future trends in tobacco use (HNP Discussion Paper No. 6, Guindon GE, Boisclair D. Economics of Tobacco Control Paper No. 6). Washington, DC, World Bank, 2003. III Health Consequences of Smoking. A Report of the Surgeon General. Atlanta, GA, United States Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Promotion, Office on Smoking and Health, 2004. IV IARC Working Group. Tobacco smoke and involuntary smoking (IARC Monographs, No.83). Lyon, IARCPress, 2004. V State of California Air Resources Board. Rulemaking to consider proposed identification of environmental tobacco smoke as a toxic air contaminant (http://www.arb.ca.gov/regact/ets2006/ets2006.htm, accessed 1 April 2006). VI International consultation on environmental tobacco smoke (ETS) and child health. Consultation report (WHO document WHO/NCD/TFI/99.10). Geneva, World Health Organization, 1999. VII Health consequences of smoking: a report of the Surgeon General. Factsheet No. 2: Smoking among Washington, DC, United States Department of Health and Human adults in the United States: Cancer. Services/ Centers for Disease Control and Prevention/ National Center for Chronic Disease Prevention and Health Promotion/ Office on Smoking and Health, 2004 (http://www.cdc.gov/tobacco/sgr/sgr_2004/ Factsheets/2.htm, accessed 25 March 2006). VIII Gajalakshmi V et al. Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43 000 adult male deaths and 35 000 controls. Lancet, 2003, 362:507515. IX IARC Working Group. Smokeless tobacco products (IARC Monographs, No.89, in press 2006). X 10th revision. Geneva, International statistical classification of diseases and related health problems, World Health Organization, 2003. XI Hatsukami DK, Severson HH. Oral spit tobacco: addiction, prevention and treatment. Nicotine and 1999, 1(1):2144 (Review). Tobacco Research, XII Severson HH, Hatsukami DK. Smokeless tobacco cessation. Primary Care, 1999, 26(3):529551. XIII Fant RV et al. Pharmacokinetics and pharmacodynamics of moist snuff in humans. Tobacco Control, 1999, 8(4):387392. XIV Hurt RD, Robertson CR. Prying open the door to the tobacco industry’s secrets about nicotine: the Minnesota Tobacco Trial. Journal of the American Medical Association, 1998, 280(13):117381. XV Slade J et al. Nicotine addiction: the Brown and Williamson documents. Journal of the American Medical Association, 1995, 274(3):225233. XVI Pankow JF et al. Percent free base nicotine in the tobacco smoke particulate matter of selected commercial and reference cigarettes. Chemical Research in Toxicology, 2003, 16(8):101418. XVII Watson CH, Trommel JS, Ashley DL. Solid-phase microextraction-based approach to determine free- base nicotine and trapped mainstream cigarette smoke total particulate matter. Journal of Agricultural and Food Chemistry, 2004, 52:724045.

42 XVIII Henningfield JE, Pankow JF, Garrett BE. Ammonia and other chemical based tobacco additives Nicotine and Tobacco Research, 2004, and cigarette nicotine delivery: issues and research needs. 6(2):199205. XIX United States Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and adolescents; final rule. 1996, Federal Register, 61(168):44396-45318. XX Tomar SL, Giovino GA, Eriksen MP. Smokeless tobacco brand preference and brand switching among Tobacco Control, 1995, 4(1):6772. US adolescents and young adults. XXI 1995, Tobacco Control, Connolly GN. The marketing of nicotine addiction by one oral snuff maker. 4(1):7379. XXII United States National Institute on Aging. Smoking: it’s never too late to stop (http://www.niapublications. org/agepages/smoking.asp, accessed 2 April 2006). XXIII Pickworth WB et al. Sensory and physiologic effects of menthol and non-menthol cigarettes with Pharmacology, Biochemistry and Behavior, 2002, 71(1-2):5561. differing nicotine delivery. XXIV Cigarettes without additives are a hit on the Danish tobacco market, despite being just as unhealthy Copenhagen Post, 3 October 2005 (http://www.cphpost.dk/get/91200.html, accessed as the usual kind. 26 March 2006). XXV O’Bryan W. Additive-free cigarettes may pack a more toxic tobacco punch. Health Behavior News Service, 3 December 2002 (http://www.hbns.org/news/bidis12-03-02.cfm, accessed 26 March 2006). XXVI Roll-your-own cigarette emissions [unpublished data]. New Zealand Ministry of Health, report from Labstat International, Inc., 2005. XXVII United States Department of Agriculture Economic Research Service. (ERS/ Tobacco: background. USDA Briefing Room ERS-TBS-246; 3 January 2001, http://ers.usda.gov/briefing/tobacco/background. htm, accessed 26 March 2006) XXVIII Modified re-engineered cigarettes and other tobacco products (Tobacco Fowles J, Henningfield JE. Control Monograph No.19). Bethesda, MD, United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (in press). XXIX Darrall KG, Figgins JA. Roll-your-own smoke yields: theoretical and practical aspects. Tobacco Control, 1998, 7:168175. XXX Report on tobacco control in India. New Delhi, Ministry of Health and Srinath Reddy K, Gupta PC, eds. Family Welfare, Government of India, 2004. XXXI Corrao MA et al. Building the evidence base for global tobacco control. Bulletin of the World Health Organization, 2000, 78(7):884890. XXXII United States Centers for Disease Control. Bidi use among urban youth: Massachusetts, March-April Morbidity and Mortality Weekly Report, 1999, 48(36):796799. 1999. XXXIII Malson JL et al. Comparison of the nicotine content of tobacco used in bidis and conventional cigarettes. 2001, 10(2):181183. Tobacco Control, XXXIV Malson JL et al. Nicotine delivery from smoking bidis and an additive-free cigarette. Nicotine and 2002, 4(4):485490. Tobacco Research, XXXV Rahman M, Fukui T. Bidi smoking and health. Public Health, 2000, 114:123–127. XXXVI Gupta PC et al. A cohort study of 99,570 individuals in Mumbai, India for tobacco-associated mortality. International Journal of Epidemiology, 25 October 2005 [Epub ahead of print] XXXVII Rahman M, Sakamoto J, Fukui T. Bidi smoking and oral cancer: a meta-analysis. International Journal of Cancer, 2003, 106:600–604. XXXVIII International Sankaranarayanan R et al. Risk factors for cancer of the oesophagus in Kerala, India. Journal of Cancer, 1991, 49:485–489. XXXIX Pais P et al. Risk factors for acute myocardial infarction in Indians: a case-control study. Lancet, 1996, 348:358–363. XL Pais P, Fay MP, Yusuf S. Increased risk of acute myocardial infarction associated with beedi and cigarette smoking in Indians: final report on tobacco risks from a case-control study. Indian Heart Journal, 2001, 53:731-735. XLI Rahman M et al. Association of thromboangiitis obliterans with cigarette and bidi smoking in Bangladesh: a case control study. International Journal of Epidemiology, 2000, 29:266-270. XLII http://www.gimonca.com/kretek/ (accessed 26 March 2006). 42

43 XLIII Situmeang, Sutan Bahasa Taufan. Hubungan merokok kretek dengan kanker paru [The relationship Jakarta, Department of Pulmonology, Faculty of between clove cigarette smoking and lung cancer]. Medicine, University of Indonesia [Thesis]. 2001, 53pp. XLIV Nicotine addiction in Britain. London, Royal College of Physicians, 2000. XLV American Medical Association Council on Scientific Affairs. Evaluation of the health hazard of clove Journal of the American Medical Association, 1988, 260:3641–44. cigarettes. XLVI Mangunnegoro H, Sutoyo DK. Environmental and occupational lung diseases in Indonesia. Respirology, 1996, 1:85–93. XLVII Philip Morris International Inc. (PMI) announces agreement to purchase 40% stake in PT HM Sampoerna Tbk, Indonesia’s third largest tobacco company [press release] (http://www.philipmorrisinternational. com/PMINTL/pages/eng/press/pr_20050314.asp, accessed 26 March 2006. Philip Morris International Indonesia website: http://www.pmicareers.com/country/idn/default.asp). XLVIII Journal of the American Medical Association, Baker F et al. Health risks associated with cigar smoking. 2000, 284(6):735740. XLIX Journal of the Henningfield JE, Hariharan M, Kozlowski LT. Nicotine content and health risks of cigars. 1996, 276:1857-58. American Medical Association, L Henningfield JE et al. Nicotine concentration, smoke pH and whole tobacco aqueous pH of some cigar 1999, 1(2):163168. brands and types popular in the United States. Nicotine and Tobacco Research, LI Cigars: health effects and trends National Cancer Institute. (Smoking and Tobacco Control Monograph No. 9). Bethesda, MD, United States Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1998. LII Wald NJ, Watt HC. Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases. 1997, 314:1860-63. British Medical Journal, LIII Nelson DE et al. Pipe smoking in the United States, 1965-1991: Prevalence and attributable mortality. Preventive Medicine, 1996, 25:9199. LIV Shihadeh A, Eissenberg T. Tobacco smoking using a waterpipe: product, prevalence, chemistry/ toxicology, pharmacological effects, and health hazards. Geneva, World Health Organization Study Group on Tobacco Product Regulation (TobReg), 2005. LV WHO TobReg advisory: waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators. Working Group draft. Geneva, World Health Organization Study Group on Tobacco Product Regulation (TobReg), draft 2005. LV I Chattopadhyay A. Emperor Akbar as a healer and his eminent physicians. Bulletin of the Indian Institute 2000, 30:154. of History of Medicine (Hyderabad), LV I I Hamada G et al. Pulmonary dysfunction from large airway versus small airways among waterpipe smokers [Poster presented at the 11th annual meeting of the Society for Research on Nicotine and Tobacco, March 2005]. LVIII Is peak expiratory flow (PEF) a good indicator for assessing airway obstruction in Hamada G et al. [Poster presented at the 11th annual meeting of the Society for Research on Nicotine waterpipe smokers? and Tobacco, March 2005]. LIX Respiratory Medicine, 2000, 94:891-894. Kiter G et al. Water-pipe smoking and pulmonary functions. LX Al-Fayez SF et al. Effects of sheesha and cigarette smoking on pulmonary function of Saudi males and females. Tropical and Geographical Medicine, 1988, 40:115-123. LXI Zakaria M et al. Who ends up with COPD among smokers in a community setting? [Poster presented at the11th annual meeting of the Society for Research on Nicotine and Tobacco, March 2005]. LXII Mazen A, Aurabia S. The effect of Maassel water-pipe smoking versus cigarette smoking on pulmonary arterial pressure and left ventricular and right ventricular function indices in COPD patients: an echodoppler Scientific Journal of Al-Azhar Medical Faculty (Girls), 2000:649-86. [Abstract]. LXIII Jabbour S, El-Roueiheb Z, Sibai AM. Narghile (water-pipe) smoking and incident coronary heart disease: a case-control study [Abstract]. Annals of Epidemiology, 2003, 13:570. LXIV Nafae A et al. Bronchogenic carcinoma in Kashmir valley. The Indian Journal of Chest Diseases, 1973,15(4):285-295. LXV El-Hakim IE, Uthman MAE. Squamous cell carcinoma and keratoacanthoma of the lower lip associated with “Goza” and “Shisha” smoking. International Journal of Dermatology, 1999, 38:108-110. LXVI Roohullah et al. Cancer urinary bladder - 5 year experience at Cenar, Quetta. Journal of Ayub Medical College, Abbottabad, 2001, 13(2):14-16. References

44 LXVII Bedwani R. Epidemiology of bladder cancer in Alexandria, Egypt: tobacco smoking. International 1997, 73(1):64-67. Journal of Cancer, LXVIII Journal of the Egyptian Society of Parasitology, Radwan GN et al. Review on water pipe smoking. 2003, 33(3 Suppl):1051-71. LXIX International Onder M, Oztas M, Arnavut O. Nargile (Hubble-Bubble) smoking-induced hand eczema. 2002, 41:771-772. Journal of Dermatology, LXX Journal of Al-Belasy FA. The relationship of “shisha” (water pipe) smoking to postextraction dry socket. Oral and Maxillofacial Surgery, 2004, 62:10-14. LXXI Baljoon M et al. Smoking and vertical bone defects in a Saudi Arabian population. Oral Health & 2005, 3:173-182. Preventive Dentistry, LXXII Tamim H et al. Exposure of children to environmental tobacco smoke (ETS) and its association with Journal of Asthma, 2003, 40:571-576. respiratory ailments. LXXIII Journal of the American Medical Association, 1985, Nieburg P et al. The fetal tobacco syndrome. 253:2998-99. LXXIV Differences in worldwide tobacco use by gender: findings from the Global Youth Tobacco Survey. 2003, 73(6):207-215. Journal of School Health, LXXV Peltzer K. Smokeless tobacco and cigarette use among black secondary school students in South 2003, 38(7):1003-16. Africa. Substance Use & Misuse, LXXVI Health consequences of using smokeless tobacco. A report of the Surgeon General (NIH Pub. No. 86-2874). Bethesda, MD, United States Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1986. LXXVII United States Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco products to protect children and adolescents; proposed rule analysis regarding FDA’s jurisdiction over nicotine-containing cigarettes and smokeless tobacco products; notice. 1995, 60:41314-41787. Federal Register, LXXVIII Stratton K et al., eds. Clearing the smoke: assessing the science base for tobacco harm reduction. Washington, DC, Institute of Medicine/National Academy Press, 2001. LXXIX Henningfield JE, Rose CA, Giovino GA. Brave new world of tobacco disease prevention: promoting American Journal of Preventative Medicine, 2002, 23(3):226-228. dual tobacco product use. LXXX Recommendation on Smokeless Tobacco Products. Geneva, World Health Organization Scientific Advisory Committee on Tobacco Product Regulation (SACTob), 2003. LXXXI Cnattingius S et al. Health risks with Swedish snus [in Swedish]. Stockholm, Swedish National Institute of Public Health, Karolinska Institutet, 2005. LXXXII Global data on incidence of oral cancer map. Geneva, World Health Organization, 2005 (http://www. who.int/oral_health/publications/cancer_maps/en/index.html, accessed 28 March 2006). LXXXIII Parkin DM et al. Global cancer statistics, 2002. CA: A Cancer Journal for Clinicians, 2005, 55(2):74- 108. (http://caonline.amcancersoc.org/cgi/reprint/55/2/74, accessed 28 March 2006). LXXXIV Chaudhry K. Is pan masala-containing tobacco carcinogenic? National Medical Journal of India, 1999, 12(1):21-27. LXXXV Gupta PC et al. Oral submucous fibrosis in India: a new epidemic? National Medical Journal of India, 1998, 11:113-116. LXXXVI British Journal of Cancer, Wu MT et al. Risk of betel chewing for oesophageal cancer in Taiwan. 2001; 85(5):658-660. LXXXVII Daftary DK et al. Oral precancerous lesions and conditions of tropical interest. In: Prabhu SR et al., eds. Oral diseases in the tropics. Oxford, Oxford Medical Publications, 1992:402-428. LXXXVIII http://www.swedishmatch.se/Eng/FirstPage_fp.asp, accessed 27 March 2006. LXXXIX Tobacco Foulds J et al. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Control, 2003, 12:349-359. XC Nair U, Bartsch H, Nair J. Alert for an epidemic of oral cancer due to use of the betel quid substitutes gutkha and pan masala: a review of agents and causative mechanisms. Mutagenesis, 2004, 19:251- 262. XCI Pindoborg JJ et al. Frequency of oral carcinoma, leukokeratosis, leukoedema, submucous fibrosis and 1968, 22:646654. lichen planus in 10,000 Indian villagers. British Journal of Cancer, 44

45 XCII World Health Organization Tobacco Free Initiative, Tobacco and youth in the South East Asian region. 2002, 39:1-33. Indian Journal of Cancer, XCIII [Brown & Williamson Tobacco Corporation Pepples E. Industry response to cigarette/health controversy internal memorandum, 4 February 1976] (http://tobaccodocuments.org/youth/ShToBWC19760204. Rg.html, accessed 2 April 2006). XCIV Royal College of Physicians. Smoking and health. A report of the Royal College of Physicians on smoking in relation to cancer of the lung and other diseases. London, Pitman Medical Publishing Co Ltd, 1962. XCV Smoking and health. Report of the Advisory Committee to the Surgeon General of the Public Health Rockville, MD, United States Department of Health, Education and Welfare, Public Health Service, Service. 1964. XCVI Kozlowski LT, Pillitteri JL. Beliefs about “Light” and “Ultra Light” cigarettes and efforts to change those beliefs: an overview of early efforts and published research. Tobacco Control, 2001, 10(Suppl.1):i12-i16. XCVII Bourlas M. Marlboro product quality in the EEC/tar reduction [memo to P. Alvis, 19 April 1993, accessed June 2000], Bates no. 2500055616/5616A (www.pmdocs.com, accessed 28 March 2006). XCVIII WHO Monograph: advancing knowledge on regulating tobacco products. Geneva, World Health Organization, 2001. XCIX Risks associated with smoking cigarettes with low machine-measured yields National Cancer Institute. (Smoking and Tobacco Control Monograph No. 13, NIH Publication No. 02-5047). of tar and nicotine Bethesda, MD, United States Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 2001. C Hatsukami DK, Hecht SS. Hope or hazard? What research tells us about “potentially reduced-exposure” tobacco products. Minneapolis, MN, University of Minnesota Transdisciplinary Tobacco Use Research Center, 2005. CI Slade J, Henningfield JE. Tobacco product regulation: context and issues. Food and Drug Law Journal, 1998, 53(Suppl):43-74. CII WHO Framework Convention on Tobacco Control. Geneva, World Health Organization, 2005. References

46 Acknowledgements: The WHO Tobacco Free Initiative would like to thank all the contributors and lead reviewers for their work on this document. Particular thanks go to Dr Jack Henningfield (Johns Hopkins University and Pinney Associates) for his role as lead author and to Dr Katharine Hammond (University of California, Berkeley) for her thorough reviews and critical inputs. The Tobacco Free Initiative would also like to thank all other contributors and reviewers, all experts from the tobacco control community, and physicians, professors and scientists from all regions of the world, whose contribution to this year’s World No Tobacco Day publication has been fundamental. Tobacco Free Initiative WHO/Noncommunicable Disease and Mental Health 20 Avenue Appia 1211 Geneva 27 Switzerland Telephone: +41 22 791 2126 Fax: + 41 22 791 4832 E-mail: [email protected] Web: www.who.int/tobacco


48 Tobacco Free Initiative WHO/Noncommunicable Disease and Mental Health 20 Avenue Appia 1211 Geneva 27 Switzerland Telephone: +41 22 791 2126 Fax: + 41 22 791 4832 E-mail: [email protected] Web: www.who.int/tobacco www.who.int/tobacco/wntd

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