Herbal cigarettes, kreteks, bidis, roll-your-own, waterpipes & cannabis

If you smoke any plant matter you inhale carbon monoxide and tar, which may harm your health.^{1, 2}

Herbal cigarettes

Herbal cigarettes are not safe to smoke. Some brands, particularly those made in China, contain tobacco and have high levels of tar and nicotine.³ The smoke from brands that have no tobacco or nicotine still deliver similar levels of tar and carbon monoxide compared to tobacco cigarettes.^{1, 2} Therefore herbal cigarettes are potentially harmful to health.^{1, 2}

Most Australian state and territory governments have banned the sale of herbal cigarettes to persons under the age of 18.^{4, 5}

Herbal cigarettes are sometimes promoted as quitting aids. However, there is no evidence that they have any benefits other than a placebo effect (no physical effect but may improve some people's confidence at quitting).²

Kretek or clove cigarettes

Kreteks are a type of small cigarette that contains tobacco (about 60%), ground clove buds (about 40%) and cocoa.⁶ They are made in Indonesia where they are the most popular type of cigarette.^{6, 7} A small number of brands are imported into Australia; a common brand is Gudang Garam.⁸

Although kreteks are smaller than regular cigarettes, tests show that they can deliver similar levels of nicotine and carbon monoxide to smokers.⁹ Compared to regular U.S. cigarettes, clove cigarettes contain up to 360,000 times more eugenol, a natural compound found in high concentrations in clove buds.^{6, 10} The long term effects of inhaling high amounts of eugenol are not clear, but some evidence suggests that it may be involved in cancer.^10-12 Eugenol also acts as a numbing agent (local anaesthetic). After taking effect, it may lessen the harshness of the smoke on the throat, but this does not make it safer.^12-14

The American Medical Association reviewed the medical evidence concerning clove cigarettes in 1988 and reached the following conclusions¹⁴:

• Clove cigarettes are tobacco products. Therefore they possess all the harms associated with smoking tobacco cigarettes.
• Inhaling clove cigarette smoke has been associated with severe lung injury in a few susceptible persons. People with asthma or with a throat or lung infection in its early stages may have an increased risk of harm from inhaling clove cigarette smoke.

Bidis

Bidis are popular in India and several south-east Asian countries.⁶ They are made with locally grown coarse tobacco flakes and hand-rolled in temburni leaf, which is tied up with a thread. Their size varies between 4cm and 8cm.⁶ Bidi smoke delivers similar or higher levels of nicotine and cancer-causing chemicals to smokers, compared to regular cigarettes.⁶

Bidis sold in western countries often have a variety of flavours such as clove, mango, chocolate, vanilla or strawberry.^{6, 10} Certain tobacco flavourings contain toxic or cancer-causing chemicals.¹⁰ Some evidence supports concerns that flavour-related compounds deemed safe for eating may not necessarily be considered safe when inhaled in cigarette smoke.^{10, 13} Bidis cannot be considered less harmful to health than regular cigarettes.⁶

Roll-you-own tobacco

Loose tobacco, or roll-your-own cigarettes (RYO) appear to be becoming more popular.^{6, 15} This may be partly because they are cheaper than factory-made cigarettes.¹⁵ About 24% of Australian smokers use RYO tobacco; 9% use RYO tobacco only, while the other 15% also use factory-made cigarettes (mixed smokers).¹⁵

Some smokers misguidedly believe that RYO cigarettes are less harmful than other forms of tobacco, perhaps because they think that loose tobacco is more "natural".¹⁵ However, many of the 4000 chemicals in cigarette smoke come from burning the tobacco itself. These include agents involved in disease such as carbon monoxide, nicotine and tar.⁶

Research suggests that RYO tobacco is at least as harmful or possibly more harmful than smoking factory-made cigarettes. Studies show that RYO smokers tend to make cigarettes that can yield high levels of tar and nicotine.^{6, 15} They may also not use a filter. Both RYO only and mixed smokers report inhaling more deeply than factory-made cigarette smokers. But without studies that measure the levels of chemicals inhaled by RYO smokers, it is uncertain if RYO smokers have higher exposure to chemicals in smoke than factory-made cigarette smokers. However, there is some evidence that RYO smokers are more vulnerable to developing cancer of the oesophagus and larynx, on top of the other risks of smoking-related diseases.¹⁵

Water pipes

Water pipes used to smoke tobacco are common in the Middle East, Africa and the Indian Subcontinent.^{16, 17} They may be used in communities from these countries in Australia. Water pipes may also be called "narghile", "hookah" or "hubble bubble".¹⁶ Although research on water pipes is limited, it is clear that water pipe smoke is harmful.^{16, 17} It contains similar or higher levels of dangerous substances such as carbon monoxide, nicotine, tar and heavy metals including arsenic, cobalt, chromium and lead. Studies link water pipe use with addiction to tobacco, cancer, and heart and lung disease. Pregnant women who use water pipes increase their risk of having a low weight baby, who will be more vulnerable to illness and death. As well, sharing a water pipe with others can spread infectious diseases such as viruses and tuberculosis.^{16, 17}

Cannabis

The main forms of cannabis are marijuana, hashish (cannabis resin) and hashish oil.^{18, 19} Marijuana is made up of the dried leaves, flowering tops, stems or seeds of the cannabis plant.^{18, 19} The smoke from marijuana contains a similar range of harmful chemicals to tobacco. These include carbon monoxide, irritants, tar and cancer-causing chemicals.¹⁹ Cannabis does not contain nicotine; its main active drugs are cannabinoids.¹⁹

In an Australian survey, about one-third of cannabis users (who used more than five times in the past year) had a cannabis use disorder (dependence or abuse).²⁰ Some heavy users develop withdrawal symptoms on stopping use.^{18, 21}

Cannabis can produce euphoria, but also unpleasant side effects such as anxiety and panic, especially in high doses or in new users.^{18, 21} Short-term memory and attention, motor skills, reaction time and skilled activities such as driving, are impaired while the person is intoxicated.^{18, 21, 22} Smoking cannabis raises heart rate and blood pressure, and can be dangerous to those with heart or vascular disease.^{21, 22} It may also interact with prescription drugs.^{21, 22} Regular cannabis smoking can produce chronic inflammation of the lungs in young adults; symptoms include wheeze, cough, phlegm and shortness of breath.^{18, 22, 23} Long term users of both tobacco and cannabis have higher rates of these symptoms than those who smoke either only tobacco or only cannabis.^{21, 23}

There are few reliable long-term studies on the health effects of regular cannabis use. However, smoking cannabis produces pre-cancerous changes in the lung cells, which suggests that it may cause cancer.^{22, 23} There is growing evidence that cannabis plays a role in mental illness, including schizophrenia and in some young people, psychosis.²⁴ Long-term heavy use of cannabis can affect memory, attention and the processing of complex information. It's not clear if these problems reverse after quitting.^{18, 19, 21}

For more information on cannabis, visit the Australian Drug Foundation's Drug info clearing house website at http://druginfo.adf.org.au/.

References

1. Groman E, Bernhard G, Blauensteiner D, et al. A harmful aid to stopping smoking. Lancet 1999;353(9151):466-7.
2. Mattick RP, Baillie A. An outline for approaches to smoking cessation: quality assurance in the treatment of drug dependence project. Canberra: Australian Government Publishing Service; 1992.
3. Zimmerman C. Herbal cigarettes: blending ancient Chinese medicine. Tobacco Reporter 1991(March):29.
4. Commonwealth Department of Health and Ageing. National tobacco legislation analysis. Summary of existing legislation. Available at: http://www.ashaust.org.au/lv4/NatLegisl0502.doc. Accessed 5th June 2006.
5. Office of Parliamentary Counsel, Tasmania. Public Health Act 1997 - Part 4. In: AustLII Databases. http://www.austlii.edu.au/au/legis/tas/consol_act/pha1997126/; 1997.
6. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Tobacco smoke and involuntary smoking. Lyon, France: International Agency for Research on Cancer; 2004.
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11. IARC Working Group on the evaluation of the carcinogenic risk of chemicals to humans: tobacco smoking. Tobacco smoking. Lyon, France: World Health Organization; 1985.
12. American Academy of Pediatrics Committee on Substance Abuse: Hazards of clove cigarettes. Pediatrics 1991;88(2):395-6.
13. Bates C, Jarvis DM, Connolly DG. Tobacco additives: cigarette engineering and nicotine addiction. Available at: http://www.ash.org.uk/html/regulation/html/additives.html. Accessed 20th June 2006.
14. Evaluation of the health hazard of clove cigarettes. Council on Scientific Affairs. JAMA 1988;260(24):3641-4.
15. Young D, Borland R, Hammond D, et al. Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tob Control 2006;15 Suppl 3:iii76-iii82.
16. Maziak W, Ward KD, Afifi Soweid RA, et al. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control 2004;13(4):327-33.
17. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics 2005;116(1):e113-9.
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21. Ashton CH. Adverse effects of cannabis and cannabinoids. Br J Anaesth 1999;83(4):637-49.
22. Kalant H. Adverse effects of cannabis on health: an update of the literature since 1996. Prog Neuropsychopharmacol Biol Psychiatry 2004;28(5):849-63.
23. Taylor DR, Hall W. Respiratory health effects of cannabis: position statement of the Thoracic Society of Australia and New Zealand. Intern Med J 2003;33(7):310-3.
24. Hall W, Degenhardt L, Teesson M. Cannabis use and psychotic disorders: an update. Drug Alcohol Rev 2004;23(4):433-43.