Smokeless tobacco

[6] Approximately 28 chemical constituents present in smokeless tobacco can cause cancer, among which nitrosamine is the most prominent.

[1] Types of smokeless tobacco include: Since there are varied manufacturing methods, products can differ greatly in chemical arrangement and nicotine level.

[28][29] Smokeless tobacco can cause white or gray patches inside the mouth (leukoplakia) that can develop into oral cancer.

[6][12] These carcinogenic compounds occurring in smokeless tobacco vary widely, and depend upon the kind of product and how it was manufactured.

[24] Products such as 3-(methylnitrosamino)-proprionitrile, nitrosamines, and nicotine initiate the production of reactive oxygen species in smokeless tobacco, eventually leading to fibroblast, DNA, and RNA damage with carcinogenic effects in the mouth of tobacco consumers.

[12] The metabolic activation of nitrosamine in tobacco by cytochrome P450 enzymes may lead to the formation of N-nitrosonornicotine, a major carcinogen, and micronuclei, which are an indicator of genotoxicity.

[27] Furthermore tobacco contains harmful metals such as arsenic, beryllium, cadmium, chromium, cobalt, lead, nickel, and mercury.

[5][7] Use of smokeless tobacco also seems to greatly raise the risk of non-fatal ischaemic heart disease among users in Asia, although not in Europe.

[5][27] Nicotine in smokeless tobacco products that are used during pregnancy can affect how a baby's brain develops before birth.

[32] People of many regions, including India, Pakistan, other Asian countries, and North America, have a long history of smokeless tobacco use.

[6] Smokeless tobacco use for adolescents aged 12 to 17 was higher during the mid-2000s, but the 2014 estimates were closer to the lower levels seen in the early 2000s.

The sale of smokeless tobacco to minors (Article 16 of FCTC) is restricted only in 13 countries and the WHO-defined Eastern Mediterranean region.

However if taxation is higher for smoking products only people might switch to cheaper alternatives like smokeless tobacco.

[33] The manufacture, distribution and sale of smokeless tobacco is banned completely in Bhutan, Singapore, and Sri Lanka.

Partial bans on import and sales on some products are in effect in Australia, Bahrain, Brazil, India, Iran, Tanzania, Thailand, New Zealand, the UK and the European Union.

[35] As long ago as 1986, the advisory committee to the Surgeon General concluded that the use of smokeless tobacco "is not a safe substitute for smoking cigarettes.

It can cause cancer and a number of noncancerous oral conditions and can lead to nicotine addiction and dependence".

[21] According to a 2002 report by the Royal College of Physicians, "As a way of using nicotine, the consumption of non-combustible tobacco is of the order of 10–1,000 times less hazardous than smoking, depending on the product".

[22] A panel of experts convened by the National Institutes of Health (NIH) in 2006 stated that the "range of risks, including nicotine addiction, from smokeless tobacco products may vary extensively because of differing levels of nicotine, carcinogens, and other toxins in different products".

[21] In 2015 the American Cancer Society stated that "Using any kind of spit or smokeless tobacco is a major health risk.

[6] In South and South-East Asia these products are considered part of the cultural heritage and there is little enthusiasm for regulation.