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January 7th, 2015:

Health Risks of E-cigarettes, Smokeless Tobacco, and Waterpipes

Approved by the Cancer.Net Editorial Board, 01/2015

Key Messages:

Alternatives to smoking, such as e-cigarettes, smokeless tobacco, and waterpipes still contain the addictive chemical nicotine, in addition to other chemicals.
While many of these alternatives may be marketed as being safer alternatives to smoking, they can also cause health risks.
If you smoke or use these products talk with your doctor about ways to quit.
Although cigarette smoking has been steadily—but slowly—declining in the United States, many different alternative tobacco and nicotine delivery products have been gaining popularity. This is partly because many alternative tobacco products—which come in various sizes, flavors, and forms—are marketed and often perceived as being relatively safe.

However, alternative tobacco products, such as e-cigarettes, smokeless tobacco, and waterpipes can cause serious potential health problems, including cancer, because of the chemicals and toxins they contain.


Electronic cigarettes, also known as e-cigarettes or vapor cigarettes, are battery-operated devices that resemble traditional cigarettes. However, instead of burning tobacco, they generally contain cartridges filled with nicotine and other chemicals. When the e-cigarette is used, the liquid chemicals in the cartridge are turned into a vapor or steam that is inhaled by the smoker.

Because e-cigarettes have only been readily available in the United States since 2006, there is limited research on their health risks. According to one analysis by the U.S. Food and Drug Administration (FDA), the tobacco solution used in e-cigarettes contains a toxic chemical found in antifreeze and several cancer-causing chemicals, such as nitrosamines. Little more is known about the types or concentrations of chemicals, including nicotine, in e-cigarettes. However, the chemicals in e-cigarettes, the potential harmful effects, and the addictiveness vary based on the brand.

Among all of the alternative tobacco products, e-cigarettes are the least regulated. They have no warning labels and can be sold to people of any age. The FDA has not approved e-cigarettes as a way to quit smoking. People with cancer who want to quit smoking should use the approved methods for quitting smoking.

Learn more about ASCO’s efforts in regulating e-cigarettes.

Smokeless tobacco

Smokeless tobacco products contain tobacco or tobacco blends that are either chewed, sucked, or sniffed. Most smokeless tobacco products are placed between the cheek or lips and gums for a few minutes to hours. They have many names, such as spit tobacco, chew, pinch, or dip, and fall into several categories.

Chewing tobacco.

This is tobacco in the form of loose leaves, leaves pressed together that is commonly known as “plug”, or leaves twisted together to resemble a rope that is commonly known as “twist.” Chewing tobacco is held between the cheek and gum. Usually the tobacco juices are spit out, but long-time users tend to swallow some of the juices.


This is finely ground tobacco that comes in dry or moist forms and is sometimes packaged in ready-to-use pouches. Dry snuff is usually sniffed or swallowed, whereas moist snuff—similar to snus (see below)—is placed between the gum and the lip or cheek and slowly absorbed.


This is a tobacco product that originated in Sweden before being introduced to the United States. The moist tobacco powder is usually packaged in a pouch and placed in the mouth, inside the cheek, for absorption. It does not require the user to spit out tobacco juice; however, the pouch must be thrown away after use, not swallowed. Tobacco companies often market snus as a product that cigarette smokers can use in places where smoking is banned. Public health advocates worry that laws banning smoking in certain public places will not effectively encourage people to quit using tobacco products as long as snus is available.

Dissolvable tobacco.

This is powdered tobacco that is compressed to resemble a small, hard candy that dissolves in the mouth. It does not produce any tobacco juice that needs to be spit out or leave behind any substance that the user must throw away.

Prolonged use of smokeless tobacco products can lead to serious health issues, such as cancer and heart disease. Some smokeless tobacco contains greater amounts of nicotine—three to four times more—than cigarettes. These products also contain numerous substances that increase the risk of cancer of the mouth and throat. Chewing tobacco also may lead to white patches, called leukoplakia, on the gums, tongue, or lining of the mouth. Although most of these are noncancerous, some show early signs of cancer, and oral cancer often occurs near patches of leukoplakia. Chewing tobacco and other forms of smokeless tobacco can also cause gum disease and increase tooth decay.

Another popular alternative tobacco product in the United States is the waterpipe. Waterpipes, also called hookahs, among other names, have been smoked in regions such as the Middle East, Asia, and Africa for more than four centuries.

Modern-day waterpipes, which are relatively inexpensive, are composed of four main parts:

  • A small bowl on top of the waterpipe, which holds a special mixture of shredded tobacco and sweetener
  • A broad base to hold water
  • A pipe connecting the bowl to the base
  • A rubber hose attached to a mouthpiece through which smoke is pulled
  • Small packets of the tobacco mixture burned in waterpipes are sold in a variety of flavors, such as apple, mint, and cappuccino. People can smoke waterpipes alone, but waterpipes are often used in social settings, with multiple people sharing the same mouthpiece.

Beyond their low cost and appeal as a traditional and communal activity, unfounded assumptions about their relative safety are driving the waterpipe trend, especially among college students and young people. According to one historical account of the waterpipe’s origin, an Indian physician created the device, believing that by having the smoke first pass through a small amount of water, it would be a less harmful method of inhaling tobacco. Even though there is no proof that water can “filter” tobacco smoke and make it less harmful, this misperception still persists today.

Health concerns about smoking waterpipes include the following:

Exposure to the same toxins as cigarettes but in higher quantities. The smoke produced by a waterpipe contains high levels of many of the same toxic compounds found in cigarettes, including carbon monoxide, heavy metals, and chemicals linked to cancer. These toxins and chemicals are associated with lung, stomach, bladder, and esophageal cancers and have been known to clog arteries and cause heart disease and respiratory diseases, such a lung disease called emphysema that causes difficulty breathing.

In most cases, waterpipe smoking sessions, which typically last up to one hour, expose smokers to much higher levels of these toxins than cigarettes. For example, a smoker may inhale 100% to 200% more smoke during a waterpipe session, compared with a single cigarette.

Potential to spread infectious disease. Sharing a waterpipe with other people can increase the risk of contracting or transmitting diseases, such as tuberculosis, and viruses, such as herpes and hepatitis, especially if the mouthpieces are not cleaned properly.

Nicotine addiction.

The tobacco used in waterpipes contains about the same amount of nicotine as cigarettes, which often leads to addiction.

Exclusive: American Red Cross Pressured to Rid Itself of Tobacco Money

New York (Reuters) – The American Red Cross risks damaging the reputation of the global Red Cross brand because of its refusal to stop accepting donations from tobacco companies, a top official with the humanitarian network said.

These concerns are prompting the International Red Cross and public health organizations to press the U.S. group to end its longtime policy of taking tobacco money, Reuters has learned.

The International Red Cross, which recently rolled out a global disease prevention program with a strong anti-smoking component, hasn’t accepted tobacco donations since 2008. Most of the group’s 189 national affiliates don’t accept money either, but the powerful U.S. member does, as do about half a dozen other countries, including Germany, Russia and Vietnam.

While precise figures are not available, the American Red Cross and its U.S. affiliates have received at least $12 million from tobacco companies such as Altria Group, Reynolds American and Philip Morris International since 2001, according to Red Cross tax records and tobacco company press releases and annual reports.

An American Red Cross spokeswoman, Laura Howe, declined to comment on the dispute with its parent body – whose guidelines are not binding on its affiliates – but said it was happy to accept any funds that support its efforts to assist disaster victims. She also declined to say how much it received from each company.

International Red Cross officials say that by accepting the donations, the U.S. group risks damaging not only its own reputation but that of the entire global humanitarian network. Some public health advocates agree, saying there is a contradiction between the Red Cross’s mandate to aid the vulnerable and its acceptance of money from an industry whose product may cause death.

Matthias Schmale, under secretary general for the International Federation of Red Cross and Red Crescent Societies, said officials have talked with American Red Cross officials and asked them to drop the tobacco funding.

“We have been very clear about the potential reputational damage not just for them but for all of us,” Schmale said in a telephone interview from Geneva. “So far we have not taken the route of public condemnation. We want to respect that they are an important supporter of ours.”

He said the parent body would continue “to put pressure” on the American Red Cross to change its policy, although he would not say what form that pressure would take.

Despite the controversy, there has been little public debate about the donations. And the dispute between the American Red Cross and its parent body has not been reported until now.

How the dispute is resolved could be felt beyond the American Red Cross. Anti-tobacco activists hope that if the U.S. group bows to pressure, it could influence other nonprofits to reject millions of dollars in donations.

John Stewart of Corporate Accountability International, a watchdog group, said if the American Red Cross stopped accepting tobacco money it would undercut the tobacco industry’s global public relations strategy to gloss over its “tarnished image.”

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Critics argue that by accepting donations from tobacco interests, the organization, one of the largest charities in the United States with 2013 revenue of $3.4 billion, is muddying its public health mission while providing the tobacco industry with a public-relations boost.

Major U.S. and European tobacco companies including Reynolds American, Altria and Lorillard as well as Philip Morris International and British American Tobacco Plc acknowledged the donations and said they were among some of the millions of dollars they give away.

“When there are important disasters, and people have significant needs, that is the right thing for corporations to do,” said Altria spokesman David Sylvia.

Howe, the American Red Cross spokeswoman, said in an email that all donations “are important to the American Red Cross and the disaster victims they assist.” “Collectively, donations of all amounts allow us to provide disaster victims with food, shelter and emotional support.”

Asked about any pressure from the international body to stop taking money from tobacco interests, Howe said: “As a matter of practice, we don’t share the details of private conversations between Red Cross officials.”


The International Red Cross has been encouraging its U.S member to drop the funding since 2008, but it stepped up the pressure in 2014 after implementing a new healthy living program that includes smoking cessation.

Pressure on the American Red Cross is coming on other fronts as well. On Dec. 19, some of the largest U.S. public health advocacy organizations, including the Public Health Law Center and Action on Smoking & Health, wrote to American Red Cross President Gail McGovern, urging the organization to stop taking tobacco donations.

“The Red Cross/Red Crescent Movement is respected around the world for protecting life, health and human dignity,” the letter said. “To lend its enormous credibility, connection and influence to an industry that sells and promotes a product that kills 6 million people a year is a serious violation of the most basic principles of public health.”

The American Red Cross would not comment on the letter, which has not been made public before.


The tobacco money represents a steady but small percentage of the American Red Cross’s annual contributions – it took in more than $1 billion in donations in fiscal 2013.

Tobacco companies have been donating to the American Red Cross in some instances as far back as the 1960s, but confirming the size and dates of donations made before 2001 is difficult because historical documents are not easily obtainable.

The Red Cross may take the money from tobacco companies because like most nonprofits it is under pressure to raise money each year for its general fund whether or not there is a disaster that brings in donations, said Ken Berger, president and CEO of Charity Navigator, which rates charities for donors.

“One reality is no matter what size a nonprofit is, they are usually strapped for cash,” he said. “To have money that is unrestricted and could be used for general operations are the most precious (donations).”

Altria’s Sylvia said it has donated to the organization for decades and now contributes $500,000 annually to the American Red Cross Annual Disaster Giving Program. It also has provided many one-time donations after specific disasters.

Reynolds American, its foundation and subsidiaries have given more than $1 million to the American Red Cross during the last five years, according to the company. Philip Morris International has given $123,000 since 2008.

(Reporting By Jilian Mincer in New York; Additional reporting by Ece Toksabay in Turkey and Thomas Wilson in Japan; Editing by Eric Effron and Ross Colvin)

Double tobacco tax, Council on Smoking and Health urges Hong Kong government

Clear the Air says:

YES this request shown in SCMP below was one year ago in 2015, and what did the Almighty do (aka John Tsang, Financial Secretary) ?

– well, absolutely nothing! He must prefer gathering the profits tax from the tobacco companies instead and thereby knowingly ignoring a binding

WHO International Instrument lodged with the UN Treaties office.

So here we are in 2016 and COSH, the Government Council on Smoking OR Health  funded body of experts with a deputy director of the Health Department on their Panel, again recommended an increase in tobacco tax to Almighty Tsang, and what did Almighty Tsang do?

– well he said in his budget he was going to provide more hospital beds and no mention of the required preventative measure excise tax increase.

COSH are clear on what they were repeatedly asking of the Almighty: obey the WHO FCTC Treaty requirements binding Hong Kong!

Here is the COSH overpolite response to the nondescript 2016 Almighty’s Budget, on non- preventative healthcare:

So much for the Almighty’s Duty of Care to the people of Hong Kong and the smokers and the inquisitive youth, one of every two of these smokers will DIE, slowly and painfully from their inexpensive habit.

But the Amighty’s arrogance cuts far deeper; COSH is a Government funded body and the Financial Secretary has repeatedly ignored their expert advice and openly failed to follow the FCTC Treaty requirements.

Is this COSH, a Value-for-Money Organisation then if the Almighty can just repeatedly ignore their expertise?

Is it better to Prevent youth starting smoking, or to have to treat the effects of tobacco: nicotine addiction, cancer, emphysema and COPD, loss of productivity, increased health care, just build more hospital beds for them?

Is it Value-for-Money to use tax-payer money to subvent the tobacco companies, which Almighty Tsang repeatedly does, just pay for more hospital beds to treat the ravages caused by the tobacco companies and more doctors, nurses and medicines; instead of prevention of addiction by following WHO FCTC directives (increase tax annually, also increase tax in excess of the inflation rate) as a supposed ratified party to the FCTC Treaty ?

And why is Hong Kong not suing the tobacco companies for the costs of healthcare caused by the use of their consumer product?


An anti-smoking body has told the government it should double tobacco tax in a bid to reduce the habit among Hongkongers.

The Council on Smoking and Health (COSH) proposes that a 100 per cent tax increase should to be implemented in the next fiscal year, in the hope of cutting the smoking rate from 10.7 per cent, to a single digit figure, between 9.5 and 9.9 per cent, in one to two years.

“At least now we have a preliminary goal and hope the smoking rate will have a further drop in the future,” said the council’s chairman, Antonio Kwong Cho-shing.

The proposal was supported by a survey on tobacco control policy, jointly conducted by COSH and the University of Hong Kong from May to September last year. Some 2,419 people were surveyed, including 800 current smokers, 800 former smokers and 819 people who had never smoked.

More than 65 per cent of the respondents replied that the 11.8 per-cent increase in tobacco tax last year was not effective in bringing smokers to quit, while 72.9 per cent supported increasing tobacco tax annually.

The retail price of a pack of cigarettes should be increased from the current HK$55 to HK$106, the respondents suggested as a mean average. The smokers went even further, suggesting on average that the price should be raised to HK$171.

COSH’s executive director, Vienna Lai Wai-yin, said that increasing tobacco tax is effective in encouraging smokers to quit. “This is more influential among youngsters and the elderly who are more price responsive,” she said.

She added that the World Health Organisation suggested tobacco tax as an “effective and important means” to reduce tobacco consumption.

Tobacco tax in the city was raised 300 per cent in 1983, which lead to a 4.6 per cent decline in the smoking rate over two years. However, tobacco tax has been frozen 12 times since 1999 with only two significant increases – a 50 per cent hike in 2009 and 41.5 per cent rise in 2011.

According to government thematic household survey reports, the smoking prevalence of people aged 15 or above dropped from 11.8 per cent in 2008 to 10.7 per cent in 2012. Secondary school pupils showed a more significant drop from 6.9 per cent to 3 per cent.

“If tax can increase 300 per cent, we will totally support it. It is indeed more effective than television advertisements,” said Professor Lam Tai-hing from the HKU School of Public Health.

COSH urged the government to allocate more resources towards smoking cessation and education, as tax revenue from tobacco products increased to HK$5.8 billion in 2013.

The current tax rate on a price of cigarettes is 69 per cent.

Source URL (modified on Jan 7th 2015, 5:43pm):

Call for doubling of tobacco tax

The Hong Kong Council on Smoking and Health on Wednesday called for tobacco tax to be doubled to encourage smokers to quit and prevent youngsters from smoking.

In a survey conducted by the Council, 73 percent of respondents, including smokers and those who have never smoked, supported raising tobacco tax annually.

More than 2,400 people were polled from May and September last year.

Sixty-five percent of them felt the 11.8 percent tobacco tax hike that was introduced in the current fiscal year had failed to encourage smokers to quit.

The majority of them also felt the price of cigarettes should be raised from HK$55 dollars a pack to HK$106, although said some smokers even supported raising the price to HK$171 dollars.


SMOKERS are almost twice as likely to notice health warnings on tobacco products that have packaging free of advertising, according to a report.

The British Heart Foundation (BHF) said its study of almost 3,000 smokers and ex-smokers in Australia and the UK found that the number of those in Australia who took notice of health warnings almost doubled after tobacco packets were stripped of branding there in December 2012.

The BHF’s Standardised Packaging for Tobacco Products report said just a third (34 per cent) of smokers and ex-smokers noticed the health warnings before any other information in 2010, compared with two thirds (66 per cent) after the legislation was implemented.

In the UK, where branded packaging still exists, just 24 per cent of people noticed the health warnings before other messages such as advertising.

The report also found 82 per cent of Australians did not like the look of tobacco products after standardised packaging was introduced.

The BHF said support for the new legislation in Australia among smokers and ex-smokers had almost doubled from 28 per cent in 2010 to 51 per cent in 2013, noting that just over a third (37 per cent) of smokers and ex-smokers in the UK backed standardised packaging being enforced here.

The Scottish Government supports plain packaging for tobacco and ministers at Westminster said in April last year that they expected to proceed “as swiftly as possible” with the measure.

BHF chief executive Simon Gillespie said: “The evidence couldn’t be clearer.

“Stripping tobacco products of their branded packaging means important health warnings have more impact. These are toxic products so it’s vital these messages are communicated clearly.

“Standardised packaging is an effective and important public health measure which is already having a significant impact in Australia.

“There can be no more delay and the UK Government must act now to make sure standardised packaging is law before the election.”

JTI tobacco ad banned following complaint from Cancer Research UK

A press ad for Gallaher-owned JTI tobacco has been banned by the Advertising Standards Authority (ASA) after 13 complaints, including one from Cancer Research UK, were submitted to the body over misleading information.

The advert, which appeared in April 2013, included an e-mail from the UK Department of Health to the Australian Department of Health and Ageing. The email featured text, which stated, “I work on the UK Government’s Tobacco Policy Team … you will be aware that the UK Government is considering the introduction of plain packaging of tobacco products. As I’m sure you’re aware, one of the difficulties regarding this is that nobody has done this and therefore, there isn’t any hard evidence to show that it works”.

The text “there isn’t any hard evidence to show that it works” was highlighted in the ad followed by wording “We couldn’t have put it better ourselves”.

The majority of complainants felt that the email, which predated research and the introduction of standardised packaging in Australia, there misleading implied that no evidence existed to support plain packaging of tobacco products.

Gallaher said the ad was intended to question the rationale of the Department of Health’s (DoH) approach in 2011 and said at the time the ad appeared, JTI’s UK managing director publicly stated “We are using this media campaign to demonstrate that in 2011 even the DoH accepted that these proposals are not supported by any hard evidence”.

They company added that the ad did not state or imply that at the time the ad appeared there existed no evidence to support the introduction of plain packaging.

However the ASA disagreed and said the ad was likely to give readers the misleading impression that there was no hard evidence of any kind to support the introduction of plain packaging in 2013.