Internal medicine

Nitrosamine

Population

Biology

Cancer

Carcinogen

Smokeless tobacco

Tobacco smoke

Nicotine

Cancer prevention

Toxicology

Tobacco use

Genetics

Medicine

Environmental health

Nature reviews. Cancer

Tobacco products present a deadly combination of nicotine addiction and carcinogen exposure resulting in millions of cancer deaths per year worldwide. A plethora of smokeless tobacco products lead to unacceptable exposure to multiple carcinogens, including the tobacco-specific nitrosamine N′-nitrosonornicotine, a likely cause of the commonly occurring oral cavity cancers observed particularly in South-East Asian countries. Cigarettes continue to deliver a large number of carcinogens, including tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons and volatile organic compounds. The multiple carcinogens in cigarette smoke are responsible for the complex mutations observed in critical cancer genes. The exposure of smokeless tobacco users and smokers to carcinogens and toxicants can now be monitored by urinary and DNA adduct biomarkers that may be able to identify those individuals at highest risk of cancer so that effective cancer prevention interventions can be initiated. Regulation of the levels of carcinogens, toxicants and nicotine in tobacco products and evidence-based tobacco control efforts are now recognized as established pathways to preventing tobacco related cancer. This Review discusses carcinogens in smokeless tobacco products and cigarette smoke and biomarkers that may be able to identify those individuals at highest risk of tobacco-related cancers. It also discusses regulation of the levels of carcinogens and nicotine in these products as approaches to cancer prevention.

Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention