A review of the International Agency for Research on Cancer (IARC) in 2004, found that there is sufficient evidence, based on epidemiologic and laboratory studies, to conclude that Smokeless Tobacco (ST) causes oral cancer, esophageal cancer, and pancreatic cancer in humans. More than 30 carcinogens have been identified in ST products, including tobacco-specific nitrosamines (TSNAs), which cause tumors affecting the nasal cavity, lung, trachea, pancreas, liver, and esophagus in animal models. Smokeless tobacco use also causes adverse oral health outcomes including oral mucosal lesions, leukoplakia, and periodontal disease.

More than 30 carcinogens have been identified in ST products, including tobacco-specific nitrosamines (TSNAs), which cause tumors affecting the nasal cavity, lung, trachea, pancreas, liver, and esophagus in animal models

Moreover, ST products contain nicotine, and users of ST products demonstrate signs of dependence similar to those of cigarette smokers, including tolerance with repeated use and symptoms of withdrawal upon cessation of use.

A wide range of ST products with different characteristics are in use around the world, including chewing tobacco, snuff, gutka, betel quid with tobacco, snus, toombak, iqmik, tobacco lozenges, and others.

Limited data are available on the properties of these products as to how they are being used and their prevalence within different population groups. The ways in which ST products are produced, sold, used, and regulated also differ widely across countries and regions.

The overall public health impact of ST use also depends on a range of health and environmental factors, including the prevalence and patterns of use of different products in the population, the impact of marketing messages, and the effectiveness of prevention and cessation efforts.

Data available as to why particular populations begin to use ST and what factors are most important in preventing or promoting initiation of ST use are also limited.

Tobacco manufacturers have introduced varied ST products with appealing and attractive flavourings. They have even carried their existing brand names along with these new products.

Tobacco control experts warn that increased marketing of these products may have an adverse impact on population health by appealing to young, new users or by helping current smokers maintain their nicotine dependence. Electronic cigarettes with novel nicotine delivery devices are also being marketed in many countries as an alternative to conventional cigarettes.

The International Smokeless Tobacco Symposium was held on March 8, 2009, in Mumbai, India, in conjunction with the World Conference on Tobacco or Health. More than 150 participants representing dozens of countries from around the world attended the 1-day meeting. The presentations highlighted a number of challenges related to ST products, including relatively low prices for these products (which makes them appealing), the targeting of products toward youth, and the lack of organized public health and policy efforts focused on smokeless tobacco.

At the end of the conference, the participants agreed on several key conclusions:
•  Smokeless tobacco use adversely affects all countries and regions.

•  Increasing use and industry promotion of ST represents an increasing threat to public health worldwide.

•  All forms of ST have an adverse impact on health.

•  Smokeless tobacco should not be promoted as a harm-reduction product.

•  Smokeless tobacco poses substantial challenges to regulatory and control efforts because of the wide variety of products and production methods in use, including individual point-of-use production, home- and village-based production, as well as manufacture by international corporations.

•  Smokeless tobacco has not received adequate attention from researchers and policymakers, including the WHO Framework Convention on Tobacco Control (FCTC).

•  Smokeless tobacco should receive increased attention (such as increased surveillance and monitoring) in all parts of the world.

Another important conference was held in  2010 –  International Smokeless Tobacco Meeting, hosted by the Tobacco Harm Reduction Network (THRN), funded by the National Cancer Institute (United States), in collaboration with the Centers for Disease Control and Prevention and the American Cancer Society.

This meeting brought together leading global ST researchers to develop a coordinated and collaborative process to better understand and address the public health burden of ST worldwide.

The meeting agenda included presentations highlighting findings and recommendations from previous meetings and reports; regional ST trends among populations in Asia, Africa, Europe, North America, South America, and the Eastern Mediterranean; existing research surveillance tools, databases, and networks; and opportunities and implications for ST product regulation through the FCTC and the U.S. Food and Drug Administration’s new authority under the 2009 Family Smoking Prevention and Tobacco Control Act.
Among other recommendations and conclusions, the meeting identified three critical action steps to expand efforts against the ST epidemic.

•  First, coordinate action to elevate the profile of ST within the broader tobacco control community. Specifically, it is urgent that reducing ST use be included as a priority in ongoing tobacco control efforts. These efforts should also focus on capacity building by attracting and supporting new researchers, especially those in low- and middle-income countries.

•  Second, develop and expand global ST product monitoring and surveillance systems. These systems must address the significant heterogeneity of ST products, both commercial and local or homegrown, and their toxic constituents and additives; systems should also monitor and assess product trends and prevalence across population groups.

•  Third, build the infrastructure needed to expand the evidence base critical for effective regulatory action. Strategies for developing this infrastructure should focus on building collaborations between scientists, tobacco control advocates, and policymakers. Research is urgently needed to address the diversity of ST products, changing patterns of ST use, and varied types of ST production. Timely and high-quality research is essential to the development and implementation of effective regulatory action.

The National Cancer Institute and the Centers for Disease Control and Prevention under the editorial direction of Dorothy Hatsukami, Mitch Zeller, Prakash Gupta, Mark Parascandola, and Samira Asma published Smokeless Tobacco and Public Health: a Global Perspective

Thirty-two authors with expertise in ST, representing all six World Health Organization (WHO) regions, were involved in planning, researching, and writing this report.

The goals of this study and preparation of this report were as follows;
1.  Bring together experts and information on ST use from all regions of the globe. The aim of this report is not to provide a comprehensive review of all the science on the health effects of ST use, which has been covered elsewhere, but to provide a snapshot of current knowledge and data sources on ST use, characteristics of products, and related policy efforts.

2.  Summarize current survey information about the prevalence and characteristics of ST use and its health effects in different regions, as well as laboratory data on the contents of different products from around the world.

3.  Outline what is currently known about the changing ST product market, industry marketing efforts, and economic and policy factors.

4.  Provide an overview of the current state of scientific knowledge, public health information, and policy initiatives focused on ST in each major region.

5.  Identify gaps and needs related to monitoring and surveillance of ST products and other information collection, and make recommendations for strengthening international collaboration and building a scientific basis for ST product control and regulation.

It is mentioned in this report that some tobacco companies are advertising ST products to smokers as a temporary alternative to cigarettes in situations where smoke-free indoor air laws are enacted. This marketing strategy may impede smoking cessation efforts by making it easier for smokers to maintain their nicotine addiction between cigarettes and in situations where cigarette smoking is not allowed, thus reducing their motivation to quit.
Evidence suggests that users who begin with low-nicotine “starter” products are more likely to subsequently “graduate” to products with higher nicotine content. A number of studies suggest that ST use is associated with and reinforces use of other tobacco products, including cigarettes. Thus, adolescents who use ST products may also be more likely to move on to cigarette smoking.

Some scientists have suggested that ST use may actually reduce harm to smokers by providing an alternative to cigarettes—that is, smokers who switch completely to ST, which does not carry the same risk of lung cancer and respiratory diseases as cigarette smoking, might reduce their overall risk. While smokeless tobacco also causes cancer and other diseases, the overall health risks for a lifetime ST user may be lower than those for a lifetime cigarette smoker.
To be continued…