In most of the world, children are more likely to be introduced to tobacco through products such as gutkha, kreteks, or bidis rather than the familiar American 20-to-a-pack cigarettes.

Gutkha - a chewable sweetened mix of tobacco, betel (areca nut extract), spices, and fruit flavors - is so widely used by young people in South Asia that 30 percent of children in India's government-run schools are addicted to it, according to Devika Chadha of the Salaam Bombay Foundation.

Ms. Chadha's report was one of many focusing on tobacco products other than cigarettes during the 13th World Conference on Tobacco OR Health (WCTOH) held in Washington, D.C., July 12-15. Together, the presentations filled in details of a picture sketched by the Global Youth Tobacco Survey, which released figures in May showing that more than 1 in 10 (11.2 percent) of schoolchildren aged 13 through 15 worldwide currently use a tobacco product other than cigarettes, compared with 8.9 percent who are current cigarette smokers.

Chewable tobacco accounts for nearly 3 times as much tobacco use (41.2 percent compared with 14.7 percent) as does cigarette smoking among urban Nepalese students in grades 8, 9, and 10, Deepak Paudel of CARE Nepal told a WCTOH audience. "Advertisements say nothing about nicotine or the health dangers of chewable tobacco. It is regarded more as a popular chewing gum, not tobacco," he said. One manufacturer, India's M. R. Tobacco Private Limited, makes no secret of its target audience: "Gutkha is basically a sweetened mixture of tobacco, betel, and catechu chewed together. Packed in attractive satches to target the lower income group, it has slowly become a hot favorite amongst the youth across all income groups."

Even in regions of the world where smoked tobacco is more popular than oral products like gutkha, conventional cigarettes are likely to be less popular among smokers than are bidis or kreteks. In Indonesia, for example, clove-flavored kreteks are the most commonly smoked cigarette. In addition to clove, kreteks contain a variety of other flavorings, as well as eugenol, a mild anesthetic that allows deeper inhalation of the kretek's high nicotine and tar content tobacco.

Masking the product's inherent harshness has made it possible to market kreteks to inexperienced young users, Dr. Tjandra Aditama of the Department of Pulmonary and Respiratory Medicine at the University of Indonesia said in a WCTOH panel discussion on worldwide diversity of tobacco products. "But using eugenol may actually make the kreteks more dangerous. Eugenol…is considered carcinogenic," he added. However, for PT Djarum the world's largest kretek maker, additives are part of the appeal. The company's Web site boasts (in five languages) that "our LA Lights Menthol kretek has been a roaring success in Malaysia, where the brand is associated with a youthful and trendy lifestyle."

Bidis, hand-rolled and very inexpensive, are the most widely smoked tobacco product in India, where annual consumption is nearly 800 billion pieces, Dr. Prakash Gupta, of the Sekhsaria Institute of Public Health in India, told a WCTOH audience. "The increasing popularity of bidis among young users has heightened attention to the serious consequences associated with bidi use. These consequences include increased risk of coronary disease and cancers of the oral cavity, pharynx, esophagus, stomach, and liver. Bidis produce higher levels of tar, nicotine, and carbon monoxide than conventional cigarettes." Use of bidis among young American smokers has increased, in large part because of fruit flavoring added to the rolled tobacco leaf to mask the product's otherwise harsh flavor, he said.

The tobacco industry has long recognized the value of adding flavorings to make the taste and smell of tobacco more palatable, particularly in products aimed at first-time tobacco users. Industry documents reveal sophisticated flavor-based strategies dating back decades, Carrie Carpenter of the Harvard School of Public Health said in a WCTOH panel presentation. "The concept of flavored cigarettes has always been associated with new and young smokers," she said, citing a Brown & Williamson Tobacco Corporation internal memo from 1972 that noted, "Apples connote goodness and freshness, and we see many possibilities for our youth-oriented cigarette with this flavor."

Tobacco makers are still exploring flavors and new ways to expose nonsmokers to tobacco in cigarettes and nonsmoked products. Philip Morris is testing a menthol-flavored "spitless" chewing tobacco called Taboca Green, and R.J. Reynolds Tobacco Company has test marketed at least a dozen flavored cigarettes in the past decade ranging from Winter Mochamint to Twista Lime.

By Patrick Zickler