Smokeless Tobacco

Key Points

• Snuff users have a 50-fold increased risk of cancer of the cheek and gum.

• The carcinogens in smokeless tobacco have a greater concentration than in cigarette tobacco; the level of nitrosamines is more than 10,000 times that allowed in bacon and beer.

Smokeless tobacco comes in two types: snuff, which is dry or moist, and chewing (spitting) tobacco, which comes as a loose leaf, plug, or twist. Smokeless tobacco contains many of the same carcinogens as cigarette tobacco, but some are present in much greater concentrations. Nitrosamines, which are powerful chemical carcinogens, are present at levels up to 14,000 times higher than the federal government allows in bacon and beer (Connolly et al., 1986).

A variation on smokeless tobacco is called snus, which contains powdered, flavored tobacco in small satchets placed under the lip, releasing nicotine through the buccal mucosa. Because of differences in manufacturing, snus has comparatively small levels of the carcinogenic compounds found in traditional smokeless products. No spitting is required. Snus marketing campaigns emphasize its use when smoking is not allowed, and most U.S. snus users also smoke cigarettes. In Sweden, snus use has eclipsed smoking, and many smokers have used snus to quit smoking but have continued using snus, and many appear to be dependent. Again, in the United States, this has sparked a fierce debate about the use of snus and similar products as agents for "harm reduction," and whether smokers should be advised to switch as a means of smoking cessation, since exclusive smokeless tobacco use avoids many of the dangers of combustible tobacco.

Treatment of smokeless tobacco use is difficult, because none of the standard medications used for smoking cessation has shown effectiveness for smokeless tobacco users, although behavioral counseling has a modest effect (Fiore et al., 2008). The nicotine patch and lozenge have been suggested, and clinical trials of combination therapy are ongoing. Behavioral interventions such as mailings, oral or dental screenings, group discussions, workplace interventions, and telephone support showed the best evidence for smokeless tobacco cessation (SOR: B). There was no benefit from the use of bupropion SR or nicotine patches or gum (Cayley, 2009; SOR: a).

Use of smokeless tobacco increases the frequency of oro-pharyngeal cancer and causes gum recession and tooth loss. Overall, the RR for oral cancer among snuff users is 2.6; for esophageal and pancreatic cancer, 1.6 (Boffetta et al., 2008). Leukoplakia is found in 18% to 64% of users (Connolly et al., 1986). Snus has been associated with a higher risk of oropharyngeal cancer in some studies (Roosar et al., 2008), but not others (Luo et al., 2007), and also has a small risk of pancreatic cancer. A systematic review and meta-analysis of the risk for myocardial infarction and stroke among current smokeless tobacco users found small increases in relative risk for these conditions (Boffetta and Straif, 2009).

Although educational programs have been launched by the National Cancer Institute and Major League Baseball, smokeless tobacco use has trended upward in adolescents. College athletes often believe that male peers, coaches, and professional athletes are indifferent to the use of spitting tobacco (Hilton et al., 1994). An estimated 8.6% of high school students are current smokeless tobacco users. Smokeless tobacco is more common among high school boys (14%) than girls (2.2%). As with college students, many high school spit tobacco users participate in organized sports. Enlisting the support of coaches to help with tobacco use prevention is an untapped resource that should be explored.

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