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Table 1 Smokeless tobacco products consumed most commonly across the world

From: Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries

Smokeless tobacco products Regions (WHO) Countries (highest consumption) Other ingredients Preparation and use pHa Nicotinea (mg/g) Total TSNAa (ng/g)
Snus (Swedish) Europe (region A) Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) Water, sodium carbonate, sodium chloride, moisturisers, flavouring A heat treatment process; placed between the gum and upper lip 6.6–7.2 7.8–15.2 601–723
Plug, Snuff (US), Snus (US) Americas (regions A and B) The USA, Canada, Mexico Sweeteners, liquorice Plug; air cured 4.7–7.8 3.9–40.1 313–76,500
Dry or moist snuff; finely ground and fire cured
Snus; steam cured
Snuff; kept between lip and gum, dry snuff can be inhaled too
Chimó Americas (region B) Venezuela, Colombia Sodium bicarbonate, brown sugar, Mamo’n tree ashes Tobacco paste made from tobacco leaves; placed between the lip or cheek and gum and left there for some time 6.9–9.4 5.3–30.1 9390
Nass (Naswar) Europe (region B) and Eastern Mediterranean (region D) Uzbekistan, Kyrgyzstan, Tajikistan, Afghanistan, Pakistan, Iran Lime, ash, flavourings (cardamom), indigo Sundried and powdered; placed between lip or cheek and gum 8.4–9.1 8.9–14.2 478–1380
Toombak Eastern Mediterranean (region D) and Africa (region D) Sudan, Chad Mixed with moist sodium bicarbonate Fermented and grounded; placed and kept in mouth 7.3–10.1 9.6–28.2 295,000–992,000
Snuff (North and West African) Africa (region D) Nigeria, Ghana, Algeria, Cameroon, Chad, Senegal Dried tobacco leaves mixed with potassium nitrate and other salts Dry snuff; finely ground and inhaled as a pinch 9.0–9.4 2.5–7.4 1520–2420
Moist snuff is placed in mouth
Snuff (South African) Africa (region E) South Africa Dried tobacco leaves mixed with ash Dry snuff; finely ground and inhaled as a pinch 6.5–10.1 1.2–17.2 1710–20,500
Khaini South East Asia (regions B and D),Western Pacific (region B), Eastern Mediterranean (region D), and Europe (region A) India, Bangladesh, Nepal, Bhutan Slaked lime, menthol, flavourings, areca nut Shredded; kept in mouth between lips and gum 9.6–9.8 2.5–4.8 21,600–23,900
Zarda Bangladesh, India, Pakistan, Myanmar, Thailand, Indonesia, Nepal, Maldives, Sri Lanka, UK Served wrapped in a betel leaf with lime, catechu, areca nuts Shredded tobacco leaves are boiled with lime and saffron; the mixture is dried then chewed and spat 5.2–6.5 9.5–30.4 5490–53,700
Gutkha India, Pakistan, Bangladesh, Nepal, Myanmar, Sri Lanka, UK Betel nut, catechu, flavourings, sweeteners Commercially manufactured; sucked, chewed, and spat 7.4–8.9 0.2–4.2 83–23,900
Afzal Eastern Mediterranean (region B) Oman Dried tobacco mixed with various additives Fermented; kept in mouth between lips and gums, users suck the juice, and spit out the rest 10.4 48.7 3573
Iq’mik Americas (region A) The USA Tobacco combined with fungus or plant ash Involves a burning process to make fungus ash; chewed 11.0 35.0–43.0 15–4910
Rapé Americas (region B) Brazil Tobacco mixed with finely ground plant materials (tonka bean, cinnamon, clove buds, etc.) or alkaline ashes Nasal snuff; air cured or heated, then pulverised, finely sifted, and mixed 5.2–10.2 6.3–47.6 88–24,200
Pituri/Mingkulpa Western Pacific (region B) Australia Tobacco mixed with wood ash Chewed as quid, kept in mouth and/or held against skin 5.47–11.6 4.8 15,280
  1. WHO World Health Organization, TSNA tobacco-specific nitrosamines
  2. aFigures are adapted from [1, 2, 18,19,20,21,22,23]