Tob Control 21:181-190 doi:10.1136/tobaccocontrol-2011-050281
  • Reviews

Non-cigarette tobacco products: what have we learnt and where are we headed?

  1. Richard J O'Connor
  1. Correspondence to Professor Richard J O'Connor, Associate Professor of Oncology, Department of Health Behavior, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York 14263, USA; richard.oconnor{at}
  • Accepted 20 October 2011


A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.


  • Funding RJO is supported by research grants and contracts from the US National Cancer Institute.

  • Competing interests RJO has served as a consultant to the WHO and to the US Food and Drug Administration regarding tobacco product regulation, and serves on a committee of the Institute of Medicine charged with recommending scientific standards for studies of modified risk tobacco products.

  • Provenance and peer review Commissioned; externally peer reviewed.

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