Child and Teen Tobacco Use

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Other forms of tobacco favored by young people

Cigars

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

Another appeal to youth is the flavorings commonly used in small cigars. 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 inhaled and smoked every day, 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 our document called Cigar Smoking.

Spit or smokeless tobacco use among kids

Spit or smokeless tobacco is a less lethal, but still unsafe, alternative to smoking. Many terms are used to describe tobacco that is put into the mouth, such as spit, spitless, 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 new 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 2012 survey, 2.5% of high school students had used snus in the past month.

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 2012, about 1% of high school students had recently used them. For more on snus and dissolvables, see our document 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 to see if they can help a person stop smoking.

Hookahs (water pipes)

Hookah is also called narghile (nar-guh-lee) smoking. It started in Asia and the Middle East. It involves burning tobacco that has been mixed with flavors such as honey, molasses, or fruit in a water pipe and inhaling the flavored smoke 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 pipe around.

Hookah smoking has become popular among younger people in Western countries. More than 5% of high school students surveyed in 2012 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 being 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), and helicobacter (which can cause stomach ulcers), or even 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, which makes them more much like electronic cigarettes. Some advertise that they are purer and healthier alternatives to regular hookahs, even though less is known about them.

Electronic cigarettes

Electronic cigarettes are small refillable devices that look like cigarettes. They 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 2013, there are no national restrictions on sale of these products to children, although many states forbid sales to minors.

Among middle school students, those who had ever used e-cigarettes nearly doubled from 1.4% to 2.7% during 2011–2012. Students reporting e-cigarette use in the month before the survey climbed from 0.6% to 1.1%. As of 2012, 0.7% used both e-cigarettes and conventional cigarettes.

High school students who reported ever using e-cigarettes more than doubled, from 4.7% to 10.0% during 2011–2012. Students reporting e-cigarette use in the past month increased from 1.5% to 2.8%. As of 2012, 2.2% used both cigarettes and e-cigarettes, although some students used only e-cigarettes.

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.

New federal laws banned flavored cigarettes 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 there is information on the internet on how to make your 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. But kretek users often have the mistaken notion that smoking clove cigarettes is a safe alternative to smoking tobacco – this is not true. Laws against flavored cigarettes also apply to kreteks, and the FDA has warned companies that they can’t be sold in the United States.

Flavored cigarettes (bidis)

Flavored cigarettes, called bidis or beedies, often come from India and other Southeast Asian countries. They have become 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.

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: 11/15/2013
Last Revised: 11/15/2013