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Smokeless tobacco Smokeless tobaccocomposed of fermented plant materials, alkaline additives (e.g., sodium carbonate), and carcinogenic nitrosaminesdiffers fundamentally from combustible cigarettes and aerosolized ECs by delivering nicotine and toxins through direct mucosal contact rather than inhalation, a distinction that reshapes its biological interactions and uniquely perturbs oral microbial ecosystems through pH modulation, xenobiotic exposure, and epithelial barrier disruption

While the majority of states have adopted and implemented T21, Alaska, Arizona, Idaho, Kansas, Michigan, Mississippi, Missouri, Montana, North Carolina, South Carolina, West Virginia, and Wisconsin have not

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