1. Tobacco Use Is a Risky Behaviour
Mini Lecture 2
Module: Tobacco Issues in
Basic Medical Practice
Key References:
World Health Organization. WHO Report on the Global Tobacco Epidemic. Geneva: World Health Organization; 2008.
US Department of Health and Health Services and Centers for Disease Control. Health consequences of tobacco use: a report of the Surgeon General. Washington, D.C.: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.
Shadel WG, Shiffman S, Niaura R, Nichter M, Abrams DB. Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth. Drug Alcohol Depend. 2000; 59(Suppl 1):S9-22.
Benowitz NL. Neurobiology of nicotine addiction: implications for smoking cessation treatment. Am J Med. 2008; 121:S3-10.

2. Objectives of the Mini Lecture
GOAL OF MINI LECTURE: Provide students with an overview of the effects of tobacco use at the patient, family, and household level.
LEARNING OBJECTIVES
Students will be able to:
Understand the health impacts of smoking and secondhand smoke as well as the economic impact on the nation and family.
Module Description:
This module is intended to provide students with an overview of the health impacts of active smoking and secondhand smoke, and how nicotine can affect the smoker, the family, and the nation.

3. Contents Core Slides Optional Slides
Major Health Effects from Oral Tobacco Use
Secondhand Smoke (SHS)
Economic Impact of Tobacco on Family and Nation
Diversity in Tobacco Use: India (1)
Diversity in Tobacco Use: India (2)
Diversity in Tobacco Use: India (3)
Chew Products: India
Smoking Harms Nearly Every Organ of the Body
Every Cigarette Is Harmful
Are Beedies More Dangerous than Cigarettes?
Optional Slides
Harm of Tobacco
Major Health Effects from Oral Tobacco Use
Even Light Smoking Is Harmful
Tobacco Expenditure in India

4. CORE SLIDES Tobacco Use is a Risky Behaviour Mini Lecture 2
Module: Tobacco Issues in
Basic Medical Practice
The core slides include eleven slides:
Diversity in Tobacco Use: India (1)
Diversity in Tobacco Use: India (2)
Diversity in Tobacco Use: India (3)
Chew Products: India
Smoking Harms Nearly Every Organ of the Body
Every Cigarette Is Harmful
Are Beedies More Dangerous than Cigarettes?
Major Health Effects from Oral Tobacco Use
Secondhand Smoke (SHS)
Economic Impact of Tobacco on Family and Nation

5. Diversity in Tobacco Use: India (1)
Smoking
Chewing
Snuff
Application
Cigarettes
Pan Masala
Fine Powder
Powder
Beedies
Zarda
Paste
Hookah
Gutkha
Dhumti
Khaini
Chutta
Paan
Hookli
Cigars
Notes:
Beedies are small cigarettes consisting of indigenously grown tobacco wrapped in a temburni leaf (Diospyros melanoxylon). They are hand-rolled as a cottage industry in India and sold in packets of 20–30 beedies. Although smaller than cigarettes, smoking beedies yields more than three times as much carbon monoxide and more than five times as much nicotine and tar as cigarettes.1 Since the leaf is not porous, the beedie smoker has to inhale more often and deeply to keep it lit.2 In fact, a beedie smoker must take three to four times as many puffs as one does with a cigarette. The topography of beedie use in addition to the contents of beedies make them particularly harmful for health.
Beedies are the most popular tobacco product on the Indian market, particularly among agricultural laborers, and account for 55% of tobacco consumption in India.
References:
Jayant K, Pakhale S. Toxic constituents in bidi smoke. In L.V. Sanghi LV, Notani P (Eds). Tobacco and health: the Indian scene. Bombay: Tata Memorial Centre; Pp 101–10.
Gupta PC, Ball K. India: tobacco tragedy. Lancet. 1990; 335:594–5.

6. Diversity in Tobacco Use: India (2)
There are many products which are utilized in India for tobacco use; the type of smoking varies by region.

7. Diversity in Tobacco Use: India (3)
Notes:
There are many indigenous forms of oral tobacco products as shown here.
The oral use of smokeless tobacco is widely prevalent in India; the different methods of consumption include chewing, sucking, and applying tobacco preparations to the teeth and gums. Smokeless tobacco products are often made at home but are also manufactured.
Paan (betel quid) with tobacco—Paan consists of four main ingredients: betel leaf (Piper betle), areca nut (Areca catechu), slaked lime [Ca(OH2)], and catechu (Acacia catechu). Betel leaves contain volatile oils such as eugenol and terpenes, nitrates and small quantities of sugar, starch, tannin and several other substances. For some users, tobacco is the most important ingredient of paan.
Paan masala—Paan masala is a commercial preparation containing areca nut, slaked lime, catechu, and condiments, with or without powdered tobacco. It comes in attractive sachets and tins, which can be stored and carried conveniently. Paan masala is very popular in urban areas and is fast becoming popular in rural areas.
Mawa—This preparation contains thin shavings of areca nut with the addition of some tobacco and slaked lime.
Khaini—Use of a mixture of sun-dried tobacco and slaked lime, known in some areas as khaini, is widespread in Maharashtra and several states of north India. A regular khaini user may carry a double-ended metal container, one side of which is filled with tobacco and the other with slightly moistened slaked lime.
Snus—Swedish snuff called snus is available in teabag like pouches. The pouch can be kept in the buccal or labial groove and sucked. It is marketed in India by the Swedish Match Company under the brand name Click.
Mishri—Mishri is a roasted, powdered preparation made by baking tobacco on a hot metal plate until it is uniformly black.
Gul—Gul is a pyrolysed tobacco product. It is marketed under different brand names in small tin cans and used as a dentifrice in the eastern part of India
Bajjar—Bajjar is dry snuff (also known as tapkeer) applied commonly by women in Gujarat on the teeth and gums.
Lal dantmanjan—Lal dantmanjan is a dentifrice; a red-coloured tooth powder. Traditionally, it contained tobacco but after the passage of a law banning the use of tobacco in dental care products, the listing of tobacco as an ingredient was stopped.
Gudhaku—Gudhaku is a paste made of tobacco and molasses. It is available commercially and is carried in a metal container but can be made by the users themselves. It is commonly used in Bihar, Orissa, Uttar Pradesh, and Uttaranchal. Gudhaku is applied to the teeth and gums, predominantly by women.
Creamy snuff—Commercial preparations of tobacco paste are marketed in toothpaste-like tubes. They are advertised as possessing anti-bacterial activity and being good for the gums and teeth.
Tobacco water—Tobacco water (known as tuibur in Mizoram and hidakphu in Manipur) is manufactured by passing tobacco smoke through water.
Reference:
Report on Tobacco Control in India. Reddy KS, Gupta PC, editors. Ministry of Health & Family Welfare, Government of India, Centers for Disease Control and Prevention, USA & World Health Organization; 2004.

8. Chew Products: India India Notes:
Oral use of smokeless tobacco is very common in India and is both prepared by the user as well as available prepackaged. Paan or betel quid is hand rolled at the time of consumption. Condiments and sweetening agents may be added. Paan chewing is a widespread cultural practice engaged in at important events such as marriages, funerals, and ritual performances.
Gutkha, a prepackaged mixture of chewing tobacco, arecanut, lime, and aromatic spices is sold in small packets. It is widely available in small roadside shops and costs between Rs 1.50 and Rs 4 (US $0.04–0.11 per packet), depending on the size of the packet. Gutkha has been a source of public health concern because regular chewers of this product have been observed to experience a rapid progression to pre-cancerous oral lesions and submucuous fibrosis.1
Reference:
Halarnkar, S. Paan Masala: A New Way to Die? India Today. 1997; August 11:72–3.

9. Smoking Harms Nearly Every Organ of the Body
Notes:
The 2004 Surgeon General’s Report on Smoking and Tobacco Use, published by the US Public Health Service, is a landmark report which reviewed over 1600 scientific articles and concluded that smoking harms nearly every organ of the body. Systemic distribution of tobacco smoke components and other toxic agents might explain the wide range of target organs that are susceptible to tobacco-related diseases.
There is now sufficient evidence to infer a causal relationship between smoking and a wide range of cancers; coronary heart diseases; cerebrovascular diseases; atherosclerosis; aortic aneurysm; chronic obstructive pulmonary disease; pneumonia; respiratory diseases in childhood, adolescence, and adulthood; fetal death and stillbirths; infertility; low birth weight; pregnancy complication; cataract; hip fractures; and diminished health status.
Several diseases found to be caused by smoking that were not previously causally associated with smoking include: cancers of the stomach, uterine cervix, pancreas, and kidney; acute myeloid leukemia; pneumonia; abdominal aortic aneurysm; cataract; and periodontitis.
Reference:
US Department of Health and Health Services and Centers for Disease Control. Health consequences of tobacco use: a report of the Surgeon General. Washington, D.C.: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.
WHO, 2004

10. Every Cigarette Is Harmful
There is no safe cigarette and no safe number of cigarettes that can be consumed.1
Switching to “low tar” or “light” cigarettes does not reduce the health risks of smoking.2
A Kerala survey found that one-third of physicians and students believed that smoking <6 cigarettes a day was not harmful to health.
This points to the common misconception that low-level smoking is not harmful to health.3
Notes:
Tobacco smoke is a very toxic substance that contains more than 4000 chemicals, many of which are known poisons and carcinogens. Cutting down on the number of cigarettes smoked each day is a common strategy used by smokers to reduce harm, to move towards quitting, or to save money. Some health professionals also advocate cutting down if smokers cannot or will not stop. No evidence exists, however, that major health risks are reduced by this strategy. The likely explanation for this is that smoking is primarily a nicotine seeking behaviour, and smokers who cut down tend to compensate by taking more and deeper puffs from each cigarette, and smoking more of it. This results in a much smaller proportional reduction in intake of nicotine (and in associated tar and other toxins) than the reduction in number of cigarettes smoked suggests. 2
Many smokers who are concerned about the health effects of smoking switch to "low tar" cigarettes, in the belief that these are less dangerous than ordinary cigarettes. However, tar yields from cigarettes are measured by machines that artificially "smoke" the cigarettes, and much of the reduction in the tar yield of low tar cigarettes, as measured by a smoking machine, results from ventilation holes introduced in the filter to dilute the smoke drawn in by the machine. The ratio of tar to nicotine produced in the tobacco smoke of low tar cigarettes is in fact closely similar to that of conventional cigarettes. 2
A substantial proportion of current smokers among physicians (29%) and students (33.9%) in Kerala, India reported quitting as unnecessary given that “they smoke so little”. This may point to the misconception that low-level smoking is permissible and, unlike heavy smoking, is not harmful. This has serious implications for tobacco control as many smokers in India have been found to be low-level smokers (Nichter et al., 2004).4 This belief might hinder physicians from effectively delivering tobacco cessation messages to patients as well as advising them to quit.3
While most of the research on harm from smoking has focused on cigarettes, there is a growing body of research done in India and elsewhere that shows beedie smoking is likely even more harmful than cigarettes.
References:
Wynder EL, Hoffmann D. Some practical aspects of the smoking and cancer problem. N Engl J Med. 1960; 262:540–5.
McNeill A. ABC of smoking cessation harm reduction. BMJ.  2004; 328:885–7.
Mohan S, Pradeepkumar AS, Thresia CU, Thankappan KR , Poston WSC, Haddock CK, et al. Tobacco use among medical professionals in Kerala, India: the need for enhanced tobacco cessation and control efforts. Addict Behav. 2006; 31(12):2313–18.
Nichter, Mimi, Nichter, Mark, Van Sickle D. Popular perceptions of tobacco products and patterns of use among male college students in India. Soc Sci Med. 2004; 59:415–31.
1. Wynder et al.1960; 2. McNeill 2004; 3. Mohan et al. 2006

11. Are Beedies More Dangerous Than Cigarettes?
India
Are Beedies More Dangerous Than Cigarettes?
The relative risk for all-cause mortality among beedie smokers was 64% higher and cigarette smokers 37% higher compared with never-users of tobacco.1
Beedie smoking can cause cancers of respiratory and digestive sites, including mouth, oropharynx, larynx, lung, esophagus, and stomach, and threefold higher risk of COPD.2,4
There is a greater risk of developing TAO from beedie smoking than cigarettes.3
Beedies hasten the closure of the growth plates in the long bones—stopping them from ever reaching their full height in children and adolescents.5
Notes:
Although a beedie contains a much smaller amount of tobacco (~0.2 g) than a cigarette (~1 g), a beedie delivers a comparable or higher amount of tar and nicotine. Low intensity, every day use of beedies may a cause excess all-cause mortality. For smokers who consumed <5 beedies per day, the relative risk was 42% higher compared with never users of tobacco. Age-specific mortality rates among smokers showed a greater difference in younger age groups: the relative risk for cigarette smokers at age 35–49 years was 1.9 (vs. 1.3 for >50 years) and for beedie smokers at age 35–49 years, 2.8 (vs. 1.5 for >50 years).1
Beedie smoking is the most common form of tobacco smoking in India and is predominantly a habit of men. On the basis of case–controlled studies, it is found that beedie smoking can cause cancers of respiratory and digestive sites, including mouth, oropharynx, larynx, lung, esophagus, and stomach (39–44). In almost all studies a dose–response relationship was found. In the studies that collected covariate information, the risk was persistently increased after adjustment for cigarette smoking or tobacco chewing, diet, alcohol use, and education level.2
Over half of all tobacco consumed in India is smoked as beedies (54%). The National Sample Survey of 1999–2000 showed that:
(i) beedies are smoked by at least one member of each household in:
• Over one-third of households in rural areas.
• One-fifth of households in urban areas.
Beedie smoking delivers more nicotine to the user per gram of tobacco than do cigarettes, despite containing much less tobacco per stick (one-fifth to two-thirds the amount found in one conventional cigarette)—this is due both to the type of tobacco used and to the non-porous leaf wrapper, which does not permit much air dilution of the smoke during puffing.3
Thromboangitis obliterans is another disease found among smokers. It mainly affects the legs, leading to poor mobility and sometimes gangrene and the need for amputation. It is a disease that typically develops in beedie smokers who start smoking in childhood. Beedie smokers had a nearly threefold higher risk of chronic obstructive pulmonary disease (COPD) (OR = 2.7 (95% CI: 2.3–3.1)) compared to non-smokers.4
Children who smoked cigarettes were significantly lighter and shorter than their non-smoking peers. The early onset of puberty was seen in young smokers but then the further maturation of secondary sex characteristics in these smokers was delayed, as was made evident by later appearance of the second stages of pubic, axillary, and facial hair. Smoking causes a fall in the serum testosterone level in alcoholics. The increased testicular size in boy smokers may therefore be a sort of compensatory hypertrophy. This reduction in serum testosterone levels following adoption of the smoking habit may also explain the delayed appearance of secondary sex characteristics related to the growth of pubic, axillary, and facial hair, because a certain level of androgen is required for the transformation of vellus hair into terminal hair.5
References:
Gupta PC, Pednekar MS, Parkin DM, Sankaranarayanan R, Tobacco associated mortality in Mumbai (Bombay) India. Results of the Bombay Cohort Study, Int J Epidemiol. 2005; 34(6): Epub 2005 Oct 25.
Vineis P, Alavanja M, Buffler P, Fontham E, Franceschi S, Gao YT, et al. Tobacco and cancer: recent epidemiological evidence. J Natl Cancer Inst. 2004; 96(2):
Rahman M, Chowdhury AS, Fukui T, Hira K, Shimbo T. Association of thromboangiitis obliterans with cigarette and bidi smoking in Bangladesh: a case-control study. Int J Epidemiol. 2000; 29:
Ray CS, Gupta PC. Bidis and smokeless tobacco, Curr Sci. 2009; 96(10):
Lall KB, Singhi S, Gurnani M, Singhi P, Garg OP. Somatotype, physical growth, and sexual maturation in young male smokers. J Epidemiol Community Health. 1980; 34(4):295-8.
1. Gupta et al. 2005; 2. Vineis et al. 2004; 3. Rahman et al. 2000; 4. Ray et al. 2009; 5. Lall 1980

12. Major Health Effects from Oral Tobacco Use
Chewing betel quid and tobacco is associated with risk of oral cancers in India.1
Snuff use increases the risk of chronic bronchitis and oral cancer.2
Products used in South Asia increase the risk of oral cancer and pancreatic cancer substantially.3
Individuals who used oral tobacco and did not smoke had a significantly increased risk of myocardial infarction compared to non smokers.4
Mothers using oral tobacco had babies that had lower birth weight than non chewing mothers.5
Notes :
Snuff use increases the risk of chronic bronchitis and oral cancer, challenging the idea that snuff may be a much less harmful alternative to smoking.2 Compared to non-users of snuff, snuff users were not only more likely to present with a history of tuberculosis (TB) (23.3% vs 15.9%; p = 0.06), but they were also more likely to present with chronic bronchitis (CB) (5.3% vs 2.8%; p<0.01) and a lower peak expiratory flow rate (PEFR) (275 litres/min vs 293 litres/min; p<0.01). Significant determinants of CB included snuff use >8 times/day (OR 2.86; 95% CI = ), a history of TB (OR 7.23; 95% CI = ), current smoking (OR 2.84; 95% CI = ), and exposure to smoky cooking fuels (OR 1.98; 95% CI = ).7
Tobacco chewing is a major risk factor for oral and pharyngeal cancer in Asia. Smokeless tobacco might cause other cancers, in particular those linked to tobacco smoking, but limited data are available. Although tobacco snuff and chewing entail very little exposure to polycylic aromatic compounds, exposure to N-nitrosamines is substantial. Tobacco-specific nitrosamines are experimental carcinogens and are heavily suspected to cause cancer, in particular adenocarcinoma, in humans. Tobacco-specific nitrosamines have been identified in the pancreatic juice of smokers and, to a lesser extent, of non-smokers. Experimental studies have shown the ability of tobacco-specific nitrosamines to produce pancreatic cancer in exposed rats and, in one experiment, oral administration of Nicotine-derived nitrosamine ketone (NNK, one of the main tobacco-specific nitrosamines) was more effective in causing pancreatic cancer than other routes of exposure.3
Current smoking was associated with a greater risk of non-fatal AMI compared with never smoking; risk increased by 5.6% for every additional cigarette smoked. Smoking beedies alone (indigenous to South Asia) was associated with increased risk similar to that associated with cigarette smoking. Young male current smokers had the highest population attributable risk and older women the lowest .4 Mothers using smokeless tobacco had babies that were, on average, 105 g lighter than non-users, with a significant dose–response relationship.5 The annual incidence of oral cancer in men in India is estimated to be 10 per
References:
Critchley JA, Unal B. Health effects associated with smokeless tobacco: a systematic review. Thorax. 2003; 58:
Ayo-Yusuf OA, Reddy PS, van den Borne BW. Association of snuff use with chronic bronchitis among South African women: implications for tobacco harm reduction. Tob Control. 2008; 17:
Boffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer. 2005; 114:992–5.
Teo KK, Ounpuu S, Hawken S, Pandey MR, Valentin V, Hunt D, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006; 368:647–58.
Gupta PC, Sreevidya S. Smokeless tobacco use, birth weight, and gestational age: population based, prospective cohort study of 1217 women in Mumbai, India. BMJ. 2004; 328:1538.
Moore SR, Johnson NW, Pierce AM, Wilson D. The epidemiology of mouth cancer: a review of global incidence. Oral Dis. 2000; 6:65-74.
Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, Fraumeni JJF. Snuff dipping and oral cancer among women in the southern United States. N Engl J Med. 1981; 304:745–9.
Critchley et al 2003; 2. Ayo-Yusuf et al. 2000; 3. Boffetta et al. 2005; 4. Teo et al. 2006; 5. Gupta et al.2004

13. Secondhand Smoke (SHS)
SHS causes disease in both adults and children:
Coronary heart disease, lung cancer, asthma, otitis media and sudden infant death syndrome.
SHS leads to increased prevalence of various CVD and increases risk of death by at least 20%.
Children may be more vulnerable to damage from SHS because of their partially developed cardiovascular, endocrine, and immune systems.
1. USDHHS 2006; 2. Metsios et al 2011
Notes:
Secondhand smoke (SHS) is when a person inhales the smoke from someone else’s cigarette. It can be either the smoke the smoker has exhaled, or the smoke from the burning end of the cigarette. It can also be tobacco smoke from cigars or pipes.1
SHS is very harmful and has been shown to cause serious health problems for non-smokers such as coronary heart disease, lung cancer, asthma exacerbations, ear infections, and acute respiratory infections. Children are especially vulnerable to the harm from passive smoke exposure. Pregnant women exposed to passive tobacco smoke have infants with lower birth weights.1
Passive smoke occurs in many places: homes, cars, workplaces, restaurants, hotels, offices, and shopping malls. No matter where it occurs, passive smoke places non-smokers, especially children, at higher risk for significant health problems.
References:
US Department of Health and Health Services and Centers for Disease Control. The Health Consequences of Involuntary Exposure to Tobacco Smoke: a report of the Surgeon General. Washington, D.C. : United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006.
Metsios GS, Flouris AD, Angioi M, Koutedakis Y. Passive smoking and the development of cardiovascular disease in children: a systematic review. Cardiol Res Pract Aug 29;2011. pii:

14. Economic Impact of Tobacco on Family and Nation
Households of sick smokers lose income due to:
Lost wages when the ill can not work
Direct and indirect costs of medical care.1
In developing countries, among poor families, the proportion of household expenditures used to purchase tobacco products can easily represent up to 10% of total household expenditures.2
Benefits of reducing smoking at the national level accrue quickly; a reduction in tobacco use rapidly decreases NCDs and health-care costs within 1 year.3
Notes:
Although the tobacco industry claims it creates jobs and generates revenues that enhance local and national economies, the industry’s overriding contribution to any country is suffering, disease, death—and economic losses. Tobacco use currently costs the world hundreds of billions of dollars each year.2
Tobacco expenditures exacerbate the effects of poverty and cause significant deterioration in living standards among the poor. This aspect of tobacco use has been largely neglected by those working in poverty and tobacco control. Strong tobacco control measures could have immediate impact on the health of the poor by decreasing tobacco expenditures and thus significantly increasing the resources of the poor. Addressing the issue of tobacco and poverty together could make tobacco control a higher priority for poor countries.3
References:
de Beyer J, Lovelace C, Yurekli A. Poverty and tobacco. Tob Control. 2001; 10(3):
WHO Report On The Global Tobacco Epidemic, 2008: The global tobacco crisis. The Mpower Package. Geneva: World Health Organization; 2008.
Efroymson D, Ahmed S, Townsend J, Alam SM, Dey AR, Saha R, et al. Hungry for tobacco: an analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tob Control. 2001; 10:
Glantz S, Gonzalez M. Effective tobacco control is key to rapid progress in reduction on non-communicable diseases. Lancet. 2011; 378(Sept. 29): doi: /S (11) E-pub ahead of print.
1. de Beyer et al. 2001; 2. WHO 2008; 3. Glantz and Gonzalez 2011

15. OPTIONAL SLIDES Tobacco Use is a Risky Behaviour Mini Lecture 2
Module: Tobacco Issues in
Basic Medical Practice
The optional slides include four slides:
Major Health Effects from Oral Tobacco Use
Even Light Smoking is Harmful
Tobacco Expenditure in India

16. Harm of Tobacco Tobacco smoke contains more than 4,000 chemicals.
60 substances have been identified as carcinogenic.
Notes:
Tobacco smoke contains chemicals that are harmful to both smokers and nonsmokers. Breathing even a little tobacco smoke can be harmful.
Of the more than 7,000 chemicals in tobacco smoke, at least 250 are known to be harmful, including hydrogen cyanide, carbon monoxide, and ammonia. Among the 250 known harmful chemicals in tobacco smoke, at least 69 can cause cancer. These cancer-causing chemicals include the following: arsenic, benzene, beryllium (a toxic metal), 1,3-butadiene (a hazardous gas), cadmium (a toxic metal), chromium (a metallic element), ethylene oxide, nickel (a metallic element), polonium-210 (a radioactive chemical element), and vinyl chloride.
Other toxic chemicals in tobacco smoke are suspected to cause cancer, including formaldehyde, benzo[α]pyrene, and toluene.
References: 16

17. Major Health Effects from Oral Tobacco Use
India
Chewing and Smoking
Contributed to 86% of the two oral premalignant diseases: oral leukoplakia and oral submucousa fibrosis.1
Former cigarette smokers who switched to chew tobacco had higher risks of dying from major tobacco-related diseases than those who quit using tobacco entirely.2
Gutkha induced pathogens by decreasing the antioxidant defense system and long-term inflammation (study done in rats).3
Smokeless tobacco also generates systemic alteration such as increase in blood pressure and tachycardia.4
Notes:
The relative risk for death due to tobacco use in cohort studies from rural India is:
40% to 80% higher for any type of tobacco use;
50% to 60% higher for smoking;
90% higher for reverse smoking;
15% and 30% higher for tobacco chewing in men and women, respectively;
40% higher for chewing and smoking combined.4
Switching from smoking to using chew tobacco compares unfavourably with both complete tobacco cessation and complete abstinence from all tobacco products and supports the stance that smokers who want to quit should be counseled for smoking cessation, and if available, given medication (NRT).2
Both smokeless tobacco users and smokers showed higher prevalence of circulatory and respiratory disorders. Hypertension was most common in smokeless tobacco users. The higher heart rates and blood pressures noted during the daytime in smokers and smokeless tobacco users were most likely due to the effects of nicotine. A strong positive relationship was found between cotinine (major nicotine metabolite) and blood pressure in smokeless tobacco users, whereas an inverse relationship was found in smokers, indicating additional and more complex influences on vascular tone in smokers than the influence of nicotine in smokeless tobacco users.4
References:
Lee C-H, Ko Y-C, Huang H-L, Chao Y-Y, Tsai C-C, Shieh T-Y, et al. The precancer risk of betel quid chewing, tobacco use and alcohol consumption in oral leukoplakia and oral submucous fibrosis in southern Taiwan. Br J Cancer. 2003; 88:366–72.
Henley SJ, Connell CJ, Richter P, Husten C, Pechacek T, Calle EE, et al. Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco. Tob Control. 2007; 16:22–8.
Avti PK, Kumar S, Pathak CM, Vaiphei K, Khanduja KL. Smokeless tobacco impairs the antioxidant defense in liver, lung, and kidney of rats. Toxicol Sci. 2006; 89(2):547–53.
Schroeder KL, Chen MS Jr. Smokeless tobacco and blood pressure. New Engl J Med. 1985; 312(14):919.
1. Lee et al. 2003; 2. Henley et al. 2007; 3. Avti et al.2006; 4. Schroeder et al.1985

18. Even Light Smoking Is Harmful
Among males who inhale
Using as little as 6–9 grams of tobacco/day increased risk of heart attack by 210%.
All causes of mortality are increased by up to 200%.
Those who did not inhale
Also had increased risk for heart attack.
Also had increased risk of death from all causes.
Notes:
Many people and even doctors in Indonesia mistakenly believe that light smoking, up to 10 cigarettes per day, is not harmful (in India, it was smoking up to 6 cigarettes a day that was viewed as not harmful to health). It is important to correct this misconception because tobacco smoke is extremely toxic, containing many harmful chemicals including powerful poisons and carcinogens. There is no safe level of exposure to tobacco smoke.
Studies on the effect of light smoking on cardiovascular disease also have shown that even light smoking significantly increases the risk of myocardial infarction. The Copenhagen Heart Study, which had a sample of 12,149 men and women who were followed for 22 years, found that males smoking only 6–9 grams of tobacco/day more than doubled their risk of heart attack, and also doubled their risk of death from any cause. Even those smokers who did not inhale had increased risk of myocardial infarction and death from any cause.
Reference:
Prescott E, Scharling H, Osler M, Schnohr P. Importance of light smoking and inhalation habit on risk of myocardial infarction and all cause mortality . A 22 year follow-up of men and women in The Copenhagen Heart Study. J Epidemiol Community Health. 2002; 56:702–6.
Prescott et al. 2002

19. Tobacco Expenditure in India
Tobacco consuming households had lower consumption of certain commodities/facilities such as milk, education, clean fuels, and entertainment, which may have more direct bearing on women and children.1
The proportion of total expenditure met through borrowing or distress selling during hospitalization is greater among individuals who use tobacco. 2
Notes:
Tobacco consuming households had lower consumption of certain commodities such as milk, education, clean fuels, and entertainment, which may have more direct bearing on women and children in the household than on men, suggesting possible “gender effects” and biases in the allocation of goods and services within the household. Tobacco spending was also found to have negative effects on per capita nutrition intake.1
The likelihood of borrowing/distress selling, and the proportion of total expenditure met through borrowing/distress selling, during hospitalization is greater among individuals who use tobacco or non-users from households that use alcohol and tobacco, or tobacco alone. Almost 16% of the total borrowing/distress asset selling during hospitalization can be attributed to tobacco or alcohol use at the population level. Maybe the users of addictive goods are more inclined to risk-taking and less concerned about the future, thus having no savings set aside for emergencies. Maybe the money spent to purchase alcohol and tobacco slices into the family budget to the extent that there is insufficient money left for hospital costs. Maybe the tobacco/alcohol users have a higher likelihood of episodes of hospitalization that increases their vulnerability to borrow or sell assets to meet the costs. 2
References:
John RM. Crowding out effect of tobacco expenditure and its implications on household resource allocation in India. Soc Sci Med. 2008; 66(6):
Bonu S, Rani M, Peters DH, Jha P, Nguyen SN. Does use of tobacco or alcohol contribute to impoverishment from hospitalization costs in India? Health Policy Plan 2005; 20(1):41–9.
John 2008; 2. Bonu et al. 2005

20. The most important health message a doctor can give to patients is to quit smoking.