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including the United Kingdom . High smoking-related
morbidity and mortality are expected for at least several
decades more in the European countries that now have high
smoking prevalence.
3.2.5. Oceania
Two of the wealthiest countries in Oceania, Australia and
New Zealand, have been quite successful in reducing
smoking prevalence in both men and women, from >30%
in the 1980s to <18% in 2013 in men and women combined
. However, similar to the smoking pattern in
Southeast Asia, the male smoking prevalence in most other
countries on this continent (eg, Papua–New Guinea and
Tonga) is high ).
3.3. Blond and black (dark) tobacco
Blond tobacco is flue-cured tobacco that is high in sugar
and produces a milder, more inhalable smoke compared
with black (dark) tobacco. More than 90% of cigarettes
smoked globally in 2013 were Virginia or American
blended cigarettes both of which are blond tobacco.
Black tobacco is chiefly smoked in Latin America, Spain,
and France and is processed with open-air curing or
air curing in barns with no or limited artificial heat. The
strong varieties are usually used to make cigars, while
light varieties are used in some cigarette blends in the
countries above. With blond tobacco being more popular
among smokers globally, black tobacco use is decreasing
. For example, the share of black tobacco in the
tobacco market in Peru decreased from 17.6% in 2000 to
1.5% in 2009; the respective decrease in Spain was from
23.5% to 9.2%
The few laboratory studies that exist on potentially
carcinogenic compounds in black and blond tobacco and
their effects on the human body have shown higher
concentrations of N-nitrosamine and 2-napthylamine in
black tobacco and higher urine mutagenicity and blood DNA
adduct levels in black tobacco smokers . However,
the clinical significance of these differences is unclear.
3.4. Tobacco products other than cigarettes
Cigarettes are the most common smoking product world-
wide. However, there are other tobacco products that are
relatively commonly used in some populations. Water pipe
(hookah) smoking has traditionally been common in the
Middle East and North Africa and in some parts of Southeast
Asia . Water pipe use has increased among young
people, particularly college students, in Europe and North
America . In the United States, for example, 7–20% of
college students and 5.4% of high school students
reported past-year/current water pipe use. The use of bidi
(tobacco flakes wrapped in a leaf of the tendu or temburni
tree), a relatively inexpensive tobacco product, is common
in South Asia, in particular in low-income groups In
India, bidi is the most commonly used smoking product
(prevalence: 9.2%), followed by cigarettes (5.7%), water
pipes (0.9%), and other products (1%)
Global consumption of roll-your-own (RYO) tobacco
increased by 45% from 2000 to 2013, with approximately
101 billion RYO cigarettes smoked worldwide in 2013
(compared with nearly 6 trillion regular cigarettes). Approxi-
mately 86% of RYO cigarettes were smoked in the European
Union, where RYO cigarettes were much cheaper than regular
cigarettes Global consumption of cigars and cigarillos (a
cigarillo is a smaller, narrower version of a cigar) has not
changed since the late 2000s and is approximately 24 billion
per year, nearly half of which are smoked in the United
States All smoking tobacco products are included in the
smoking rates shown in this article, unless stated otherwise.
Smokeless tobacco use is common in South Asia, Central
Asia, the Nordic countries, and Africa (Supplementary
Table 1). For example, smokeless tobacco use in India is
more common than smoking: 32.9% of men and 18.4%
women are smokeless tobacco users . Among children
aged 13–15 yr in South Asia, Central Asia, the Middle East,
and Africa, the use of tobacco products other than cigarettes
is more common than cigarette smoking .
3.5. E-cigarettes
3.5.1. What is an e-cigarette?
Electronic cigarettes (e-cigarettes), also called electronic
nicotine delivery systems (ENDS), are battery-powered
devices that vaporize a liquid solution called e-liquid using
a heating element known as an atomizer E-liquid
generally contains nicotine, propylene glycol, vegetable
glycerin, and various additives . E-cigarette smokers
inhale the resulting aerosol, which some say gives the
feeling of cigarette smoking. E-cigarettes are produced with
various features (eg, nonrefillable or refillable), but many of
these products resemble cigarettes.
As e-cigarettes do not include combustion, their
potential to deliver nicotine to users in a safer way than
regular cigarettes and to aid tobacco smokers in quitting
are of high interest; however, significantlymore research is
necessary to evaluate this potential rigorously. While two
randomized controlled clinical trials have shown modest
effectiveness of e-cigarettes in helping smokers to quit
, two longitudinal epidemiological studies have not
shown such a benefit at the population level or in
cancer patients .In addition to research on e-cigarettes
as a smoking cessation tool, there is a crucial need for more
analysis on the long-term health effects of e-cigarette use
, particularly because propylene glycol and other
compounds in e-liquids may expose e-cigarette users to
increased levels of toxic chemicals . Also, nicotine is
an addictive substance, and e-cigarette initiation by
nonsmokers may eventually lead to their taking up
traditional cigarettes For these reasons, regulations
have been recommended by some health authorities to
reduce the initiation of e-cigarette smoking in nonsmokers
(see section 3.7, Regulating e-cigarettes).
3.5.2. Prevalence of use
As e-cigarettes have been marketed only recently, their
prevalence of use is generally much lower than cigarette
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