Smokeless Tobacco

Smokeless tobacco is tobacco consumed orally and not burned. A variety of types of smokeless tobacco are consumed throughout the world. In the United States, the principal types of smokeless tobacco are chewing tobacco (cut tobacco leaves) and snuff (moist ground tobacco). In Sweden, "snus" (finely ground moist tobacco) is used. In India, smokeless tobacco contains tobacco leaf mixed with other ingredients, such as areca nut and lime.¹

In 2006, 8 million² (3.3 percent) of Americans over age 12 were current (past month) smokeless tobacco users.² Among individuals in this age group, the prevalence of smokeless tobacco use is higher in males than females (6.6 percent versus 0.3 percent), lowest in large metropolitan areas (2 percent) and highest in completely rural non-metropolitan counties (10 percent)² In 2006 among persons over age 18, the highest prevalence rates of past month smokeless tobacco use within each ethnic/racial category was observed among non-Hispanic or Latino, American Indian and Alaska Natives (7 percent, about 76,000 users in the U.S.), whites (4.3 percent, about 6.6 million users in the U.S.), and Native Hawaiian or other Pacific Islanders (4.4 percent, about 36,000 users in the U.S.). Smokeless tobacco use is uncommon among non-Hispanic Black or African American (1.9 percent) Asians (1.5 percent) and Hispanic or Latino populations (1 percent).³

Available literature suggests that adverse health consequences may vary by the type of smokeless tobacco used, which is strongly associated with geography (i.e., United States, Sweden, and India). Smokeless tobacco consumed in the United States has been associated with significant adverse health consequences.

Smokeless tobacco use leads to tobacco dependence and long-term tobacco use. Recent studies have observed that exposure to the potent tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) are similar between smokeless tobacco users and smokers.⁴ Among U.S. populations, long-term smokeless tobacco use has been associated with periodontal disease^{5, 6} and precancerous oral lesions.⁷ Long-term smokeless tobacco use may increase the risk for oral cancer⁸ and cancer of the kidney^{9, 10} and pancreas.¹¹ The long-term risk of smokeless tobacco use has been examined in the large, prospective Cancer Prevention Studies I and II (CPS-I and CPS-II). In CPS-I, current smokeless tobacco use was statistically significantly associated with death from coronary heart disease, stroke, and diseases of the respiratory, digestive, and genitourinary systems.¹² In CPS-II, current smokeless tobacco use was significantly associated with death from coronary heart disease, stroke, all cancers combined, lung cancer specifically, and cirrhosis.¹²

The prevalence of smokeless tobacco use among Americans over age 12 has increased significantly from 2004 to 2006 (3 percent versus 3.3 percent; P < 0.05). Recently, Phillip Morris USA and R.J. Reynolds have entered the smokeless tobacco market. Phillip Morris USA is test marketing a smokeless tobacco product called "Taboka," and R.J. Reynolds has launched "Camel Snus." Both products have been designed to appeal to smokers with the presumed purpose of "supporting" smoking quit attempts motivated by personal health concerns about cigarette smoking, clean indoor air policies and increased cigarette excise taxes.¹³ At the same time, smokeless tobacco is also increasingly being proposed as a harm-reduction strategy for cigarette smokers.^{14, 15}

While the risks are different between using smokeless tobacco and smoking, risks none-the-less persist. At the Nicotine Dependence Center, researchers are actively pursuing the development of interventions to help smokeless tobacco users quit.

Additional information on smokeless tobacco can be obtained on the following Web sites:

• Centers for Disease Control and Prevention
• National Cancer Institute
• National Spit Tobacco Education Program
• National Institute of Dental and Craniofacial Research

References

1. Critchley JA, Unal B. Health effects associated with smokeless tobacco: a systematic review. Thorax 2003; 58(5):435-43.
2. Substance Abuse and Mental Health Services Administration. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.
3. Ibid.
4. Hecht SS, Carmella SG, Murphy SE, et al. Similar exposure to a tobacco-specific carcinogen in smokeless tobacco users and cigarette smokers. Cancer Epidemiology, Biomarkers and Prevention 2007; 16(8):1567-72.
5. Ernster VL, Grady DG, Greene JC, et al. Smokeless tobacco use and health effects among baseball players. JAMA 1990; 264(2):218-24.
6. Fisher MA, Taylor GW, Tilashalski KR. Smokeless tobacco and severe active periodontal disease, NHANES III. Journal of Dental Research 2005; 84(8):705-10.
7. Mattson ME, Winn DM. Smokeless tobacco: association with increased cancer risk. National Cancer Institute Monograph 1989; (8):13-6.
8. Stockwell HG, Lyman GH. Impact of smoking and smokeless tobacco on the risk of cancer of the head and neck. Head and Neck Surgery 1986; 9(2):104-10.
9. Goodman MT, Morgenstern H, Wynder EL. A case-control study of factors affecting the development of renal cell cancer. American Journal of Epidemiology 1986; 124(6):926-41.
10. Muscat JE, Hoffmann D, Wynder EL. The epidemiology of renal cell carcinoma. A second look. Cancer 1995; 75(10):2552-7.
11. Muscat JE, Stellman SD, Hoffmann D, Wynder EL. Smoking and pancreatic cancer in men and women. Cancer Epidemiol Biomarkers Prev 1997; 6(1):15-9.
12. Henley SJ, Thun MJ, Connell C, Calle EE. Two large prospective studies of mortality among men who use snuff or chewing tobacco (United States). Cancer Causes and Control 2005;16(4):347-58.
13. R.J. Reynolds Entry Into Smokeless Tobacco Market Cause For Major Concern. 2006. (Accessed Dec. 15, 2007: http://www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=911)
14. McNeill A. Harm reduction. British Medical Journal 2004; 328(7444):885-7.
15. National Institutes of Health. National Institutes of Health State-of-the-Science conference statement: tobacco use: prevention, cessation, and control. Annals of Internal Medicine 2006; 145(11):839-44.