A Reader Responds to "Seven Pharmacotherapies Do Promote Smoking Abstinence at 6 and 12 Months"

Arunabh Talwar, MD, FCCP; Mukesh Jain, MD; Guljit Arora, PhD


December 26, 2008

To the Editor:

Tobacco use is emerging as the world's largest, single preventable cause of illness and death. It can be consumed in a variety of different ways, including smoking, chewing, snuffing, etc. In developed countries, cigarettes account for at least 80% of overall tobacco consumption, but in most developing countries other ways of using tobacco are still practiced frequently. The results of the meta-analysis, as quoted by Dr. Lundberg,[1] are essential to disseminate knowledge among healthcare providers that pharmacotherapeutic interventions do provide[2] help with smoking cessation. However, tobacco consumption all over the world still results in major health problems, increasing progressively. It is estimated that worldwide only about 55% of tobacco is used for cigarettes.[3] However, the majority of research on the health hazards of tobacco has been related to cigarette smoking or, at best, tobacco chewing. Little emphasis has been given on research on other nontraditional forms tobacco consumption.

In the Indian subcontinent, "bidi" is a common smoking device. It consists of tobacco flakes that are loosely packed and hand-rolled in a tendu or temburni leaf (Diospyros melanoxylon). In many other areas of the world, tobacco is used in similar other hand-rolled devices, or in some form of pipe. In Thailand they can contain strong tobacco and a mixture of koi bark (Streblus asper), dry tamarind pod (Tamarindus indica), khai bark (Homonoia riparia, Euphorbiaceae), Areca palm bark (Areca catechu), or other tree bark rolled in a banana leaf.[4] Similarly, "reverse smoking" is one unusual habit that is seen in many parts of the world: the Philippines,[5] Aruba, Venezuela, Colombia, Panama, The Netherlands Antilles,[6] and the states of Andhra Pradesh in India.[7] To practice reverse smoking, the tobacco user places the lit end of the cigarette or bidi inside his or her mouth. Thus, the flame of the cigarette or bidi is in the mouth; air is drawn in through the unlit end of the cigarette; and smoke is blown out between the thinly parted lips or through the body of the bidi itself. This practice is more common in women. It is associated with the lekoplakia and precancerous lesions of the hard palate.[8] Except for a few publications,[9] most information about the epidemiology of reverse smoking and its association with palatal cancer risk[10] is derived from clinical case series and case reports only.

There is a need to systematically study human health hazards of such nonconventional methods of using tobacco like reverse smoking. To begin with, more epidemiologic studies are needed to further document the extent of the problem. We need better information to understand and educate other physicians about the impact of this habit. International travel and changing immigration patterns have made such third-world problems as part of the scope of medicine throughout the world. In addition, the role of established biomarkers (salivary or urinary cotinine) to monitor early detection of harmful exposures to toxic tobacco products from such nonconventional methods of tobacco consumption should to be determined. Unless and until all forms of tobacco addiction are prevented, the goal of preventing the ill health of tobacco exposure from this world will remain a utopia.

Arunabh Talwar, MD, FCCP
Department of Medicine
Division of Pulmonary and Critical Care Medicine
North Shore University Hospital, Manhasset, New York
Department Of Medicine
NYU School of Medicine, New York, NY

Mukesh Jain, MD
Department of Medicine
Philadelphia VA Medical Center, Philadelphia, Pennsylvania

Guljit Arora, PhD
Department of Economics
Zakir Husain College/University of Delhi
Jawaharlal Nehru Marg, New Delhi, India

Editor's Note:
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