TOBACCO: SMOKELESS

Since tobacco is a plant native to the New World, Native Americans were the first to use it. In addition to smoking it, they used it in smokeless forms—mainly chewing it, making teas and drinks from it, even using the ash in rituals that ranged from South America to Central America and the Caribbean to North America. It was used along with many other plants for both ritual and medicinal purposes.

The use of tobacco was brought to Europe by Columbus and other explorers, where it was taken up for recreation in both the smoked form (cigars and pipes) and the smokeless. Smokeless tobacco (ST) became popular in British society in the practice called sniffing, but British colonists in the Americas preferred to chew tobacco or use snuff. In the 1800s, chewing tobacco was widespread in the United States; its use decreased, however, when the spitting that resulted (into spittoons or cuspidors or wherever the spit fell) was linked to the spread of tuberculosis, one of the most dreaded and fatal of diseases. In addition, the mass production of machine-rolled cigarettes further decreased smokeless tobacco consumption. Around 1900, 52 percent of all tobacco used was smokeless; by 1952, that number had dropped to 6 percent (Lewis, Harrell, Deng, & Bradley, 1999). Indeed, the twentieth century saw declining sales of chewing tobacco until about 1970.

In the twentieth century, there have primarily been two types of ST: (1) snuff, the type one dips by placing it between the cheek and gum, or (2) chewing tobacco, the type one chews and places in the cheek area. Snuff is a cured, ground tobacco that comes in three forms: (1) fine-cut tobacco, (2) moist snuff, or (3) dry snuff (Glover et al., 1988; Christen et al., 1982; Christen & Glover, 1987). Fine-cut tobacco and moist snuff are used by placing a pinch between the cheek and gum or lower lip and gum. Dry snuff may be used by inhaling a pinch through each nostril or by placing a pinch between the cheek and the gum or the lower lip and the gum. Chewing tobacco is also produced in three forms: (1) looseleaf tobacco; (2) plug tobacco; or (3) twist chewing tobacco (Christen et al., 1982; Penn, 1902; Christen & Glover, 1987; Voges, 1984; U.S. Department of Agriculture, 1969; Smokeless Tobacco Council, 1984). All three forms are used by placing a "chaw" in the cheek and periodically chewing.

In the 1970s, the use of ST surged in the United States, with smokers showing a preference for moist snuff. It is increasingly evident that youngsters and adolescents are using ST products much more than they did in the recent past—of the six million users ST users in the U.S. in 1995, up to 25 percent were aged nineteen or younger (Lewis, Harrell, Deng, & Bradley, 1999). This resurgence of popularity over the last thirty years has been attributed to innovative advertising campaigns by tobacco companies that used sports superstars, cowboy celebrities, and entertainers to promote their products. These campaigns represented an attempt to overcome or erase the old, unsanitary image of the habit, and replace it with a manly or "macho" image (Christen et al., 1982; Shelton, 1982; Glover, Christen, & Henderson, 1981, 1982).

Nicotine, a dependence-producing drug found in ST, is the same drug that is found in smoking tobacco. Cigarette smokers inhale smoke containing nicotine into their lungs, and the nicotine is then transported into the bloodstream. ST users absorb nicotine directly through the lining of their mouths. Each time smokers smoke a cigarette, they absorb approximately 1 milligram of nicotine into their system. By comparison, people who use chewing tobacco receive approximately 4.5 milligrams of nicotine per chaw, and people who use snuff receive approximately 3.6 milligrams of nicotine per pinch (Benowitz, 1988).

ST is sometimes viewed as a safe alternative to cigarettes, but it is not. ST is directly related to a variety of health problems: bad breath, abrasion of teeth, gum recession, periodontal bone loss, tooth loss, leukoplakia, nicotine dependency, and various forms of oral cancer (Christen, 1985; Schroeder, Chen, & Kuthy, 1985). There are indications that smokeless tobacco also plays a role in cardiovascular alterations and neuromuscular toxicity (Schroeder & Chen, 1985; Squires et al., 1984).

Survey data as of the mid-1980s indicated that predominantly males use smokeless tobacco. In a large national survey of smokeless tobacco use in college, Glover and colleagues reported that about 22 percent of collegiate males were users of smokeless tobacco, whereas only 2 percent of collegiate females used it (Glover et al., 1986). In a study of 5,078 students from 67 high schools throughout the state of Massachusetts, 16 percent of males and 2 percent of females reported using it "once or twice." Eight and 4 percent of the males studied reported using it "several times" and "very often," respectively (McCarty & Krakow, 1985).

The increasing numbers of individuals who use ST demonstrated a need for education and cessation programs. In 1994, Oral Health America created the National Spit Tobacco Education Program (NSTEP) as part of its Oral Health 2000 initiative. NSTEP has received the endorsement of Major League Baseball and encourages players and users to quit-but the main goal is to reduce ST use among kids. NSTEP's chairman is Hall of Fame broadcaster Joe Garagiola, and baseball stars Frank Thomas and Jeff Bagwell, as well as all-time home run king Hank Aaron, endorse the program. County music superstar Garth Brooks did a public service announcement supporting the NSTEP cause, as did Philadelphia Phillies star Lenny Dykstra, who had all his teeth pulled because of overuse of ST. During spring training in 1997, NSTEP counseled sixteen major league teams on ST education, providing intervention and cessation programs (Walsh et al., 1998). Not only is it important to help the players quit, of course, but it is equally important to reduce the number of ST-using players whom kids idolize and watch every day on cable television.

NSTEP offers users several tips on quitting ST, among them: Be committed, and don't be discouraged by setbacks; quit with a friend or ask for support from non-chewing friends; put three dollars in a jar every day to see the financial benefits of quitting; if tobacco use is sports-related, chew seeds or gum instead; and when the quit date is set, visit the dentist for a teeth cleaning, which should help ease the initial nicotine craving.

Although survey data indicates that ST is used predominantly by men, it is enjoyed by a number of women, particularly Native American women, according to Dr. John D. Spangler, researcher at Wake Forest University Baptist Medical Center. A 2000 study among a group of Eastern Band Cherokee Indian women in North Carolina found that women who used ST were at an eight times greater risk of breast cancer than non-users.

(See also: Adolescents and Drug Use ; Advertising and Tobacco Use )

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Elbert Glover

Penny N. Glover

Revised by Matthew Miskelly