There’s not always smoke where there’s fire

You may not smell cigarette smoke on your child, but that doesn’t mean they aren’t addicted to nicotine. The sophomores on the hockey team? They may be getting an invisible energy boost on the bench and the coach has no idea. Meanwhile, that college freshman who’s hooked on cigarettes gets through a two-and-half hour lab class by sucking on nicotine lozenges. And a middle-schooler got started by stealing his mom’s nicotine gum, which she chews to help her quit smoking.

Other tobacco products or “OTPs” are nicotine-containing products that are not lighted and burned. They’re also known as non-combustibles and smokeless tobacco.

“There is no such thing as a harmless or safe tobacco product,” said Albee Budnitz, M.D., who practices and is board-certified in pulmonary medicine and internal medicine in Nashua, and is a Breathe New Hampshire board member.

“Tobacco-related disease killed 1,900 people in New Hampshire in 2015, and tobacco is still the number one cause of premature death and disability in the state and the country,” he said.

But while the number of youth who are smoking cigarettes is down, other forms of nicotine — in candy flavors and kid-attractive packaging — are rampant. Sold in convenience stores and gas stations alongside cigarettes, these non-combustibles pack a nicotine wallop.

In young people in particular, Dr. Budnitz said, “Nicotine has been continually shown to be a gateway drug, affecting the developing brain, hard-wiring it to be susceptible to other addicting substances, including opiates and alcohol.”

Off to a bad start

According to the National Institutes of Health, more than 80 percent of adult smokers begin smoking by 18, and an estimated 3,000 youth start smoking cigarettes every day. The Centers for Disease Control and Prevention (CDC) reports that almost half-million American kids age 12 to 17 start using smokeless tobacco (versus combustible cigarettes) for the first time.

The 2013 National Tobacco Survey found that 22.9 percent of high school students reported current use of a tobacco product, including 12.6 percent who reported current use of two or more tobacco products, including smokeless tobacco.

Male high-school athletes in the United States use OTPs at a rate of 17.4 percent; the more sports participated in, the higher the rates of smokeless tobacco use, according to the CDC. They may believe that a nicotine charge gives them an edge, and/or they may use it because teammates do.

Why nicotine?

Nicotine is a highly addictive, poisonous substance that is found in tobacco. (In much smaller amounts, nicotine is also present in a few vegetables.) It’s a stimulant that increases heart rate and blood pressure by triggering a release of dopamine and epinephrine in the brain. This makes users feel more alert, gives a mood boost or buzz, and may suppress appetite (think supermodels). In heavy users accustomed to it, nicotine may just give a feeling of relaxation.

But nicotine is a drug that is known to be as addictive as heroin or cocaine, and along with the nicotine comes tar, nitrosamines and many other cancer-causing chemicals.

Because their brains are still growing, children, teens and young adults are more susceptible to becoming addicted to substances. Some smokeless tobacco products deliver more nicotine into the bloodstream than cigarettes, making them more addictive and dangerous.

According to the CDC and the U.S. Food & Drug Administration (FDA), all OTPs are made from tobacco, contain nicotine and carry the risk of addiction. Tobacco plants are the number one cost-effective source to produce nicotine. Nicotine amounts vary from one product to another, but some OTPs such as snuff have several times the amount of nicotine in a single cigarette. They all carry a risk of oral cancer, gum disease, tooth loss, heart disease and pancreatic cancer, according to the National Cancer Institute.

Kids are attracted to smokeless forms of tobacco because they are easier to hide and use, don’t look like an illegal substance, and are cheaper than cigarettes.

Nicotine is highly toxic, especially to younger children and pets. So if an adult does not store liquid nicotine for e-cigarettes or OTPs such as nicotine strips or lozenges safely, the results can be deadly.

Symptoms of nicotine withdrawal

As with any addiction, the more you use, the more you want. Stopping nicotine, as with cigarettes, causes a physical reaction. Withdrawal symptoms may include:

  •  Stomach cramps and nausea
  •  Agitation
  •  Tingling of feet and hands
  •  Headaches
  •  Cough and sore throat
  •  Sweating
  •  Feeling depressed and/or anxious.

These unpleasant side effects are accompanied by a craving for more nicotine. Symptoms are usually worse in the first few days of going without nicotine, but some may feel the effects of withdrawal for a few months, depending on how much and how often they used it, as well as environmental triggers they may still be exposed to.

Early education and greater awareness about the dangers of tobacco is one effective way to prevent nicotine addiction, in whatever form, the CDC and U.S. Surgeon General reported last year. The first teachers are always parents, then schools. With the current opioid crisis, recognizing and stopping the cycle of addiction in developing brains caused by substances is vital.

Start by having an age-appropriate discussion at the dinner table or while carpooling. Does your son or daughter know about these products, know anyone using them? Do they understand the danger and how powerful an addiction can be? Find out what their school is teaching about tobacco and if smokeless versions are included.

A good resource for parents to get you ready to have important conversations is a quiz, What’s Your Message? on The Youth Council website:

Examples of smokeless or non-combustible tobacco products

E-cigarettes/ENDS: The number-one way kids get addicted to nicotine today is by “vaping,” that is, using electronic nicotine delivery systems (ENDS devices), also called e-cigarettes.

"E-cigarette use among U.S. youth and young adults is now a major public health concern. E-cigarette use has increased considerably in recent years, growing an astounding 900 percent among high school students from 2011 to 2015,” U.S. Surgeon General Dr. Vivek H. Murthy reported in December 2016.

These products are now the most commonly used form of tobacco among youth in the United States, surpassing conventional combustible tobacco products. These devices, which may be decorated with everything from skulls to Hello Kitty to sparkles, use batteries to heat liquid nicotine in an atomizer. Vapor is produced and inhaled, delivering nicotine to the lungs.

“In New Hampshire, the Youth Risk Behavior Survey (YRBS) shows there has been a markedly increased use of e-cigs over the last three to five years,” Dr. Budnitz, chairman of the Tobacco Free NH network (TFNH), said.

The Surgeon General’s report also noted that the secondhand aerosol emitted from e-cigs is not harmless water vapor. It can contain nicotine and volatile organic compounds such as benzene, and heavy metals, among others. For more on e-cigarettes, go to and look for the article in the October 2015 digital issue.

Chewing tobacco: Cured tobacco in the form of plugs, twists or looseleaf (see below). This needs to be spit out once the “flavor” and nicotine jolt is gone.

Dip: Smokeless tobacco that is shredded finely and comes in a tin. Users put a pinch between their bottom lip and gums, which sends nicotine (more than in a cigarette) into the bloodstream through the tongue and gum tissue.

Dissolvables: Lozenges, strips, sticks, and orbs or pellets that melt inside the mouth, releasing nicotine. They come in a variety of minty flavors and may come with cartoon characters on the package. The strips look like breath strips; the pellets and orbs like Tic Tacs—down to the container. They disappear inside the mouth, so there’s no evidence.

Hookah: This is another type of OTP with a special kind of tobacco (shisha) that is smoked through a waterpipe. There are many flavors from fruit to candy to cappuccino.

Looseleaf tobacco: The most popular kind of smokeless tobacco, it’s made from scraps of tobacco left over from making plug tobacco (see below). It’s sweet like plug but sold in packets and put in the mouth.

Nicotine gel: Packaged in a small tube, this is a hand gel intended to get smokers through airline flights and meals where no smoking is allowed.

Orbs, Pellets: See dissolvables above. They look like breath mints or candy.

Plug: Cured tobacco pressed together into sheets or small bricks using syrup such as molasses. Users chew a piece off the plug.

Smokeless tobacco: Any form of tobacco that is not smoked.

Snuff: Finer texture of tobacco that comes in a teabag-like pouch. It’s used like dip (above), but the advantage is the tobacco is contained so it doesn’t get between teeth. It comes in dry and moist forms, with the moist snuff usually sold in tins. You may be familiar with Copenhagen and Skoal brands. According to the Campaign for Tobacco-Free Kids, moist snuff is the most popular form of smokeless tobacco. Dry snuff is powdered or very fine tobacco that is snorted through the nose.

Snus: Rhymes with “loose,” this is the Scandinavian term for snuff.

Sticks: Toothpick-sized wooden sticks with tobacco coating one half.

Strips: See dissolvables above. They look like gel mouthwash strips.

Twist: Like a plug, but the tobacco leaves come twisted together. Users cut or chew a piece off.

Mary Ellen Hettinger, APR, is an award-winning reporter, editor and writer, and accredited public relations professional. She’s also the Director of Public Relations and Communications for Breathe New Hampshire, a 100-year-old nonprofit dedicated to lung health.