Appendix 19
Hookah
What is a hookah?
A hookah is a waterpipe used to smoke specially-flavored tobacco called “shisha”. The
tobacco is heated with charcoal and filtered through the water-filled body of the pipe before
being inhaled through a hose. Hookah smoking is a social activity, often done in bars or
cafés, with a single session lasting up to 60 minutes. The device has been used for centuries
in the Middle East and Asia. U.S. brands of shisha include Social Smoke and Fumari.
Hookah smoking is NOT safer than smoking cigarettes. Smoking
hookah carries many of the same health risks as cigarette smoking: cancer, respiratory
illness and lung damage. Hookah smoke may feel smoother and not “burn” when you inhale,
but the smoke still contains dangerous toxins such as tar and carbon monoxide.
Photo courtesy of
Wake Forest Baptist Health
Smoking a hookah is NOT less addictive than smoking a cigarette.
Similar to the tobacco in cigarettes, shisha contains nicotine and carries the same risk of getting hooked as any
other tobacco product. Hookah smokers can inhale 100 times more smoke during a one hour session than a
single cigarette!
The water does NOT filter out harmful chemicals. Even after it passes through water, hookah
smoke contains high levels of carbon monoxide, heavy metals and cancer-causing toxins making it just as
harmful to the body as cigarette smoke.
Heating tobacco is NOT healthier than burning it. It doesn’t matter how the smoke is
produced, hookah smoke is just as dangerous as cigarette smoke. In fact, hookah smokers puff more often
and inhale more deeply, absorbing higher concentrations of the same toxins in cigarette smoke.
Herbal shisha is NOT a safe alternative. Herbal shisha may not contain nicotine, but you are still
exposed to cancer-causing substances. The charcoal used to heat it produces large amounts of carbon
monoxide and tar.
Even if you don’t inhale you are still putting yourself at risk. The health risks include
gum disease, tooth loss, oral cancer and the effects of secondhand smoke. Sharing mouthpieces not properly
washed between uses also exposes you to bacteria and viruses such as hepatitis, mono, flu and herpes.
Just being around hookah smoking is dangerous. Charcoal used to burn the tobacco
generates high levels of carbon monoxide, an extremely toxic chemical. Even without inhaling directly, those
around hookah smoking are exposed to the carbon-monoxide filled smoke.
THE BOTTOM LINE: CHOOSE NOT TO SMOKE HOOKAH.
For free help to quit smoking or using tobacco call 1-800-QUIT-NOW or visit www.smokefree.gov.
For more information about Tobacco Free Colleges or for assistance in adopting and implementing tobacco-free policies and
promoting cessation visit www.tobaccofreecollegesnc.com.
Sources: Knishkowy, B., Amitai, Y. (2005). Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior. Pediatrics, 116, 113–119.; WHO Study Group on Tobacco Product Regulation. (2005)
Waterpipe Tobacco Smoking: Health Effects, Research Needs, and Recommended Actions by Regulators.
Developed by Wake Forest School of Medicine (2012)
Appendix 20
Little Cigars & Cigarillos
What are little cigars and cigarillos?
Little cigars are slightly larger than cigarettes, while cigarillos
resemble full-sized cigars, but are smaller. Both contain pipe
tobacco wrapped in tobacco leaves and come in flavored
varieties. They are available with and without a filter and/or tip.
Brands include Swisher Sweets, Black & Mild and Optimos.
Cigar
Cigarillo
Little Cigar
Cigarette
Little cigars and cigarillos are NOT safer than cigarettes.
Photo courtesy of Wake Forest Baptist Health
Little cigars and cigarillos contain many of the same toxic ingredients as cigarettes. Smoking little
cigars and cigarillos can increase the risk of mouth, throat and lung cancers, as well as heart disease,
gum disease and tooth loss.
Little cigars and cigarillos are NOT less addictive than cigarettes. Little cigars and
cigarillos have more nicotine than cigarettes, and can be just as addictive. Even if you don’t inhale
the smoke, you can absorb the nicotine through the lining of the mouth.
Removing the liner does NOT make them less harmful. Taking the liner paper out of the
tube of cigarillos (also called hyping or freaking) does not make them less harmful.
Even if you don’t inhale you are still putting yourself at risk. Smoking little cigars and
cigarillos directly exposes your lips, mouth and throat to smoke and its harmful chemicals. You also
still breathe in large amounts of smoke from the lit end of the cigar. Whether or not you inhale, you
are still at risk for lung cancer, heart disease, lung disease and oral problems.
Just being around smokers is dangerous. Little cigar and cigarillo smoke is very harmful
even to non-smokers around them. Secondhand smoke exposure is associated with lung cancer,
heart disease and premature death.
THE BOTTOM LINE: CHOOSE NOT TO SMOKE.
For free help to quit smoking or using tobacco call 1-800-QUIT-NOW or visit
www.smokefree.gov.
For more information about Tobacco Free Colleges or for assistance in adopting and implementing tobacco-free policies and
promoting cessation visit www.tobaccofreecollegesnc.com.
Sources: National Cancer Institute (1998). Smoking and tobacco control monographs. Monograph 9: Cigars: Health effects and trends, Bethesda, MD. NIH Pub. No. 98-430; U.S. Department of
Health and Human Services (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Rockville, MD: U.S.
Developed by Wake Forest School of Medicine (2012)
Appendix 21
Bidis & Kreteks
What are bidis & kreteks?
Bidi
Bidis (pronounced “bee-dees”) are small, thin hand-rolled filtered or unfiltered
cigarettes imported primarily from India and other Southeast Asian countries that
contain shredded tobacco rolled in brown leaves and tied with a string. They
come unflavored or in a variety of flavors such as pineapple, chocolate or vanilla.
Kretek (Clove cigarette)
Photo courtesy of Ludvig Dave
Kreteks (pronounced “cree-techs”) are cigarettes imported from Indonesia that contain
tobacco, ground cloves, clove oil and other additives and can be either filtered or
unfiltered. They typically release a sweet smell.
Bidis and kreteks are NOT safer than cigarettes. Natural does not make it
safer. Bidi and kretek smokers are at risk for cancer, heart disease, heart attack, and
lung problems. Unfilitered bidis and kreteks can actually contain more tar, nicotine
and carbon monoxide than regular cigarettes.
Photo courtesy of Wake Forest Baptist Health
Bidis and kreteks are NOT less addictive than cigarettes. Bidi smoke contains 3 to 5
times more nicotine than a regular cigarette. Bidi and kretek smoking carries the same risk of getting
hooked as any other tobacco product.
No warning label does NOT mean they are safe. They may not always have a health
warning, but it is a misconception to think they are safe. Smoking bidis and kreteks is just as
dangerous as smoking regular cigarettes and several states have laws banning their sale and
distribution. Research shows that smoking bidis and kreteks can lead to oral cancers, lung cancers,
and other health risks similar to the ones experienced by cigarette smokers.
The fruit and candy flavorings may appeal to youth. The FDA, the Centers for Disease
Control and Prevention, and the American Academy of Pediatrics have all expressed concern that
flavorings may be appealing to youth and may increase youth tobacco use.
THE BOTTOM LINE: CHOOSE NOT TO SMOKE.
For free help to quit smoking or using tobacco call 1-800-QUIT-NOW or visit
www.smokefree.gov.
For more information about Tobacco Free Colleges or for assistance in adopting and implementing
tobacco-free policies and promoting cessation visit www.tobaccofreecollegesnc.com.
Source: Centers for Disease Control and Prevention (n.d.) Bidis and Kreteks. Retrieved June 7, 2012 from www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/bidis_kreteks/.
Developed by Wake Forest School of Medicine (2012)
Appendix 22
Electronic Cigarettes
What is an electronic cigarette?
Electronic cigarettes (or e-cigarettes, e-cigs) are battery operated
nicotine delivery devices made to look and feel like regular
cigarettes. Or, they can be made to look like an everyday item
such as a pen or USB memory stick, for people who want to use
them without being noticed. Liquid nicotine and other chemicals
Photo courtesy of Wake Forest Baptist Health
in the cartridge are heated and vaporized by an internal battery,
then inhaled through the mouthpiece. The act of smoking an e-cigarette is often called “vaping”. The
nicotine cartridges come in various nicotine strengths and fruit and candy flavors. Brands include Blu,
NJoy, V2 and Smoke Tip.
There is NO proof e-cigarettes help people quit smoking. E-cigarettes have not been
approved by the FDA as a nicotine replacement therapy and are not recommended to help quit
smoking.
You can NOT use e-cigarettes anywhere. Many smoke-free venues, including workplaces,
airlines, restaurants and bars prohibit the use of e-cigarettes. It is completely legal for an owner or
manager of an establishment to ban e-cigarettes.
There are NO quality controls on e-cigarettes. While candy flavored cigarettes have been
banned by the FDA, e-cigarettes are still produced in candy and fruit flavors such as strawberry, mint,
and chocolate. Very limited research has been conducted on the safety of e-cigarettes and the risks
posed by them are unknown. There’s no way to know what’s in the product and what you are putting
in your body.
The fruit and candy flavorings may appeal to youth. The FDA, the Centers for Disease
Control and Prevention, and the American Academy of Pediatrics have all expressed concern that ecigarettes may be appealing to youth and may increase youth tobacco use.
THE BOTTOM LINE: CHOOSE NOT TO VAPE.
For free help to quit smoking or using tobacco call 1-800-QUIT-NOW or visit
www.smokefree.gov.
For more information about Tobacco Free Colleges or for assistance in adopting and implementing tobacco-free policies and
promoting cessation visit www.tobaccofreecollegesnc.com.
Sources: U.S. Food and Drug Administration (2009). FDA and Public Health Experts Warn About Electronic Cigarettes; Wollscheid, K. A., & Kremzner, M. E. (2009). Electronic cigarettes: Safety
concerns and regulatory issues. American Journal of Health-System Pharmacy, 66(19), 1740-1742.
Developed by Wake Forest School of Medicine (2012)
Appendix 23
Snus
What is snus?
Snus (pronounced “snoose”) is a flavored, smokeless tobacco product
that does not require spitting. Originally created in Sweden, snus
comes in small, teabag-like pouches that are placed between the lip
and gums. Snus is available in a variety of flavors and may be highly
appealing to youth. Brands include Camel, Marlboro, Skoal and
Discreet. Snus was the first smokeless tobacco product to be cobranded (i.e., share the same name) with cigarettes.
You CAN’T hide it. You may think you can hide it because snus
Photo courtesy of Wake Forest Baptist Health
is spitless, but your mouth will give you away through stained teeth, gum disease and dental cavities.
Snus is NOT a safe substitute for cigarettes. There is no safe form of tobacco. Using snus
may put you at risk for pancreatic cancer, gum disease and sores on the mouth.
Smokeless tobacco is NOT less addictive than cigarettes. Snus contains nicotine and
can lead to addiction. In fact, there is some evidence that smokeless tobacco users may also smoke
cigarettes.
There is NO proof snus can help you quit smoking. There is no scientific evidence that
snus is an aid to help you quit smoking. Although snus has been promoted as a potential harm-reduction
strategy for cigarette smokers, it has not be shown that smokers switch products and there is some evidence
that those who use both cigarettes and snus actually have an increased risk of tobacco-related morbidity and
mortality.
THE BOTTOM LINE: CHOOSE NOT TO USE SNUS.
For free help to quit smoking or using tobacco call 1-800-QUIT-NOW or visit
www.smokefree.gov.
For more information about Tobacco Free Colleges or for assistance in adopting and implementing tobacco-free policies and
promoting cessation visit www.tobaccofreecollegesnc.com.
Sources: Foulds, J., & Furberg, H. (2008). Is low nicotine Marlboro snus really snus? Harm Reduction Journal, 5(9), 1-5; Campaign for Tobacco Free Kids (2006). The United States isn’t Sweden.;
Mejia, A. B., Ling, P. M., & Glantz, S. A. (2010). Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA. Tobacco Control, 19, 297–305; Wetter, D. W.,
Kenford, S. L., Welsch, S. K., Smith, S. S., Fouladi, R. T., Fiore, M. C., & Baker, T. B. (2004). Prevalence and predictors of transitions in smoking behavior among college students. Health
Psychology, 23(2), 168-177.
Developed by Wake Forest School of Medicine (2012)
Appendix 24
Dissolvables
What are dissolvables?
Dissolvables are new flavored smokeless tobacco products made
from finely ground tobacco that are designed to dissolve in the mouth
within 30 minutes. The products come as pellets (Orbs) that
resemble mints, a twisted stick that looks like a toothpick (Sticks) and
a film strip for the tongue (Strips) similar to breath strips. Brands
include Camel Sticks, Strips and Orbs, Marlboro Sticks, Skoal Sticks,
Ariva and Stonewall Lozenges. While the Ariva and Stonewall
products are available nationwide, the Camel products are being test
marketed in Charlotte, NC and Denver, CO; and the Marlboro and Skoal
products are being test marketed in Kansas.
You CAN’T hide it. You may think you can use these products without
being noticed, but your mouth will give you away through stained teeth,
gum disease and dental cavities.
Dissolvables are NOT a safe substitute for cigarettes. There
is no safe form of tobacco. Using dissolvables may put you at risk for oral cancer.
Photos courtesy of
Wake Forest Baptist Health
Smokeless tobacco is NOT less addictive than cigarettes. Smokeless tobacco
products, including dissolvables, contain nicotine and can lead to addiction. In most cases, the
products deliver a level of nicotine equal to or higher than smoking a cigarette.
There is NO proof dissolvables can help you quit smoking. There is no scientific
evidence that smokeless tobacco products can help you quit smoking. All forms of tobacco are
harmful- there is no safe level of tobacco use.
THE BOTTOM LINE: CHOOSE NOT TO USE TOBACCO.
For free help to quit smoking or using tobacco call 1-800-QUIT-NOW or visit
www.smokefree.gov.
For more information about Tobacco Free Colleges or for assistance in adopting and implementing tobacco-free policies and
promoting cessation visit www.tobaccofreecollegesnc.com.
Source: U.S. Food and Drug Administration (2012). TPSAC Report on Dissolvable Tobacco Products. Accessed on February 28, 2012 from
http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/UCM290182.pdf.
Developed by Wake Forest School of Medicine (2012)