Child and Teen Tobacco Use

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Teens like different forms of tobacco and nicotine

Many people think of cigarettes when they think of teens and tobacco, but kids have a growing number of options now.

Cigars

Cigars are often thought to be less harmful, less addictive, and more stylish than cigarettes – though this is not true. Since 1998, smaller cigars have been the fastest growing product on the cigar market. Many of these cigars look much the same as cigarettes except for being brown. They’re also sold in packs.

The flavorings commonly used in smaller cigars are another way to appeal to youth. Fruit, candy, and chocolate flavors attract kids. US laws have made flavored cigarettes illegal, which seems to have prompted some to use flavored small cigars instead. It’s expected that the small and flavored cigar problem will get even worse as tobacco companies take advantage of the lack of regulation of these products.

Because they’re cigars, most of them are not taxed as much or regulated the way cigarettes are. This makes them cheaper and easier for kids to get, too.

Cigars are just as addictive and deadly as cigarettes. The smaller ones are often smoked every day and inhaled just like cigarettes. Even when cigar smoke is not inhaled, smokers are breathing cigar smoke from the air around them. It’s no wonder that cigars cause many of the same types of cancer and other illnesses as cigarettes.

You can learn more about cigars and the ways tobacco companies are using them to get around tobacco taxes and regulations in Cigar Smoking.

Spit or smokeless tobacco

Spit or smokeless tobacco is a less lethal, but still unsafe, alternative to smoking. Tobacco that is put into the mouth is called many things: spit, spitless, or oral tobacco, and chewing or snuff tobacco.

The use of spit or smokeless tobacco by any name can cause:

  • Cancers of the mouth
  • Cancers of the pharynx (throat) and larynx (voice box)
  • Cancers of the esophagus (swallowing tube) and stomach
  • Cancer of the pancreas
  • Receding gums and gum disease, which can worsen to the point that the teeth fall out
  • Pre-cancerous spots in the mouth, called leukoplakia (loo-ko-PLAY-key-uh)
  • Nicotine addiction

There is also a link to heart disease and stroke. And research has shown that teens who use spit or other oral tobacco are more likely to become smokers than non-users.

Snus and dissolvable tobacco

Snus and dissolvable tobacco are two forms of smokeless tobacco that are now being used by kids and teens.

Snus (pronounced “snoose”) is a finely ground form of moist snuff made of tobacco and flavorings. Snus is often packaged in small pouches, but can also be used like loose moist snuff. In the 2013 CDC survey, 1.8% of high school students had used snus in the past month, although 6.2% had tried it before.

Dissolvables are sold as lozenges, tablets (orbs or pellets), strips, and sticks that contain tobacco and nicotine. Depending on the type, they are held in the mouth, chewed, or sucked until they are absorbed by the tissues of the mouth. Some of these products are mint-flavored and look like candy. Others look like toothpicks or meltaway mouthwash strips. In 2013, about 1% of high school students had ever tried them.

For more on snus and dissolvables, see Smokeless Tobacco.

Smokeless tobacco is promoted where smoking is banned

Unfortunately, tobacco companies have used the smoking bans in many states to push for people to use spit and other smokeless tobacco. As recommended by the Centers for Disease and Prevention (CDC), many schools no longer allow students, staff, parents, or visitors to smoke on school grounds, in school vehicles, or at school functions. Many workplaces are making changes like this, too. Tobacco companies have quickly stepped in to market their smokeless products. Many of these new tobacco products are being advertised as more discreet alternatives to smoking in places where smoking is not allowed.

Using spit or smokeless tobacco to quit smoking

Some companies promote using spit or smokeless tobacco as a way to help quit smoking, but there’s no proof that spit tobacco or any other oral tobacco products help smokers quit smoking. Unlike US Food and Drug Administration (FDA)-approved standard treatments that have been proven to work (such as nicotine replacement, specific types of anti-depressants, nicotine receptor blockers, and behavioral therapy), oral tobacco products have not been tested thoroughly to see if they can help a person stop smoking. And even if it works to help some people give up smoking, smokeless tobacco can cause cancer. It’s also addictive and hard to quit. For more, see Guide to Quitting Smokeless Tobacco.

Hookahs (water pipes)

Hookah is also called narghile (nar-guh-lee) smoking. It started in Asia and the Middle East. Tobacco that has been mixed with flavors such as honey, mint, licorice, molasses, or fruit in a water pipe is burned and the flavored smoke is inhaled through a long hose. Usually, the tobacco mixture, which is called shisha (she-shuh), is heated using charcoal. Hookah smoking is often a social event which allows the smokers to spend time together and talk as they pass the mouthpiece around.

Hookah smoking has become popular among younger people in Western countries. More than 5% of US high school students surveyed in 2013 had used a hookah in the past month. For young people, hookahs are a popular and socially acceptable way to smoke tobacco.

Hookahs are marketed as a safe alternative to cigarettes. This claim is false. The water does not filter out the toxins. In fact, hookah smoke has been shown to contain concentrations of toxins, such as carbon monoxide, nicotine, tar, and heavy metals, that are as high, or higher, than those that are seen with cigarette smoke. And people tested after hookah smoking have been found to have higher levels of carbon monoxide in their blood than those who had smoked a cigarette.

Several types of cancer, including lung cancer, have been linked to hookah smoking. Hookah is also linked to other unique risks not associated with cigarette smoking. For example, infectious diseases including tuberculosis (which can infect the lungs or other parts of the body), aspergillus (a fungus that can cause serious lung infections), helicobacter (which can cause stomach ulcers), and Epstein-Barr virus (EBV, which can cause mononucleosis and is linked to a few types of cancer) may be spread by sharing the pipe or through the way the tobacco is prepared.

Newer forms of hookah smoking can include steam stones or even battery powered hookah pens. Both of these create a vapor that is inhaled, but steam stones are heated by smoldering charcoal, which produces carbon monoxide and other toxins. Hookah pens work the same way as electronic cigarettes (see the section “Electronic cigarettes” for more information.) Some sellers advertise that these are purer and healthier alternatives to regular hookahs, even though their safety is unproven.

Electronic cigarettes

Electronic cigarettes (e-cigarettes) are small refillable devices that can look like cigarettes, but kids often like the colorful e-cigarettes called “vape pens” or “e-hookahs.” All these devices use battery power to vaporize nicotine solutions so they can be inhaled. The vapor can be flavored like fruit and candy, which appeals to youth. As of late 2014, there are no national restrictions on sale of these products to children, although many states forbid sales to minors.

The percentage of US middle and high school students who used e-cigarettes nearly doubled between 2011 and 2012. In 2013 it continued to climb, with 4.5% of high school students and 1% of middle school students reporting use of e-cigarettes in the past month.

High school students who reported ever using e-cigarettes more than doubled from 2011 to 2012, from 4.7% to 10.0%. In 2013, it climbed to 12%, with 3% of middle school students reporting that they’d tried or used e-cigs in the past. A number of kids used both cigarettes and e-cigarettes, although some students used only e-cigarettes.

Although the vapor from e-cigarettes is not likely to be as bad as the smoke from burning tobacco, there are concerns because these products are not regulated. There are many differences between e-cigarette makers, and a lot of safety questions haven’t been answered yet. Even if it turns out that they’re otherwise low-risk, e-cigarettes can hook kids on nicotine. They can still create a lifelong nicotine addiction that could lead to the use of more harmful tobacco products.

Kreteks and bidis

Clove and other flavored cigarettes are used mostly by younger smokers. They are nearly ideal in design as a “trainer cigarette” – giving kids another way to experiment with tobacco and get addicted to nicotine. The false image of these products as clean, natural, and safer than regular cigarettes seems to attract some young people who might otherwise not start smoking. But they are not safer than cigarettes, and each has its own additional problems.

Federal laws banned flavored cigarettes (including kreteks and bidis) as of October 2009; it’s still legal to have or smoke them, but it’s illegal to sell them in the US. They can sometimes be found in online shops hosted from other countries, even though the US FDA has warned both foreign and domestic websites that flavored cigarettes can’t be sold here. US tobacco companies are working around this ban by making flavored small cigars (see the section, “Cigars”) as a replacement product.

Clove cigarettes (kreteks)

Clove cigarettes, also called kreteks (kree-teks), are a tobacco product with the same health risks as cigarettes. Kreteks contain 60% to 70% tobacco and 30% to 40% ground cloves, clove oil, and other additives. They deliver more nicotine, carbon monoxide, and tar than regular cigarettes. They mainly come from Indonesia and other Southeast Asian countries, although kids can also make their own.

Kretek smokers have higher risks of asthma and other lung diseases than non-smokers. Kreteks can cause lung problems right away, such as lower oxygen levels, fluid in the lungs, and inflammation. Regular kretek smokers have up to 20 times the risk for abnormal lung function (blocked airways or poor oxygen uptake) compared with non-smokers.

Despite the laws against selling or importing flavored cigarettes, nearly 3% of high school students had tried them at least once as of 2013.

Flavored cigarettes (bidis)

Flavored cigarettes, called bidis or beedies, often come from India and other Southeast Asian countries. They’re fairly popular with young people in the United States. This is in part because they are sold in candy-like flavors such as chocolate, cherry, strawberry, licorice, and orange. Some people think they are safer and more natural than regular cigarettes. They tend to cost less than regular cigarettes and they give the smoker a quick buzz due to the high levels of nicotine.

Bidis are tobacco hand-rolled in a tendu or temburi leaf (plants native to Asia) and tied with colorful strings on the ends. Even though bidis contain less tobacco than regular cigarettes, they deliver 3 to 5 times more nicotine than regular cigarettes. They are unfiltered. And because they are thinner than regular cigarettes, they require about 3 times as many puffs per cigarette. As of 2013, about 3% of high school students had tried bidis.

Bidis appear to have all of the same health risks of regular cigarettes, if not more. Bidi smokers have much higher risks of heart attacks, heart disease, emphysema, chronic bronchitis, and some cancers than non-smokers.


Last Medical Review: 12/16/2014
Last Revised: 03/06/2015