Are you a current smokeless tobacco user or thinking about becoming one? Is it a safe alternative to smoking cigarettes? Find out all about smokeless tobacco: the various health risks, how to quit, and the controversy surrounding its role as a smoking cessation technique.

With an estimated 8.1 million users in the United States, smokeless tobacco (ST) products have become increasingly popular and widely marketed (1). What is most concerning, however, is the fact that a large majority of these users are between the ages of 16 and 24. Studies have shown that on average 6.1% of all high school students use such products, and this value can approach nearly 17% in certain rural areas (2,3). Despite the Surgeon General’s declaration that ST “is not a safe substitute for smoking cigarettes,” many view this as a suitable alternative to acquire their nicotine high (4). The reality is that even though ST is not accompanied by harmful smoke inhalation, it can be almost as addicting as cigarettes and is associated with the development of serious health issues (5).

Types of Smokeless Tobacco

While many forms of ST exist worldwide, the two predominant types currently used in the U.S. are snuff and chewing tobacco.

Snuff

Snuff constitutes nearly 76% of the ST usage and consists of finely ground tobacco sold in either moist or dry forms. A pinch or dip of moist snuff is placed between the lip or cheek and gums allowing the nicotine to be absorbed through the mouth tissue. It is also available in sachets or teabag-like pouches that are used in a similar manner. Dry snuff exists as a powder and is generally used through nasal inhalation but can also be orally consumed (2).

Chewing Tobacco

Chewing tobacco is the second most popular ST product, accounting for 23% of the total usage. It is sold as strands of loose leaves, plugs, or twists of tobacco that are broken into pieces commonly called chew orwads. These are either chewed or placed between the cheek and gum allowing the nicotine to be absorbed through oral tissue. Users of these products tend to spit out saliva that has soaked into the tobacco (2).

Snus

Snus (pronounced snoos) is a newer, finely ground form of moist snuff that has been widely used in countries such as Sweden but is just beginning to gain popularity in the U.S.  This flavored tobacco is sold in pouch form and does not require any spitting.

Health Risks

Cancer

Over 30 different carcinogens or cancer causing agents have been recognized in ST products, and of these, nitrosamines have been identified as being particularly important in the development of tobacco-related cancers (6). In association with ST, cancers are likely to arise in the oral cavity and pharynx due to the repeated contact with the various cancer-causing agents. Multiple studies have demonstrated that ST users in the United States are anywhere from 2 to 5 times more likely to develop oral cancer as compared to their non-using counterparts (5,7). This heightened risk of oral cancer is unique to the U.S. and could potentially be attributed to the fact that ST sold in this country contains as much as 15 to 23 times the level of cancer-causing nitrosamines as those sold in certain other countries (5). Leaukoplakia or white pre-cancerous plaques are also common in ST users and can potentially progress to oral cancer if left untreated. Additionally, studies have indicated that ST is associated with a 40% increased risk for pancreatic cancer and a 20% increased risk for esophageal cancer (7).

Cardiovascular

Recent research findings have established an association between heart disease and ST usage. In fact, Hergens and colleagues demonstrated a 28% increased risk of fatal heart attacks in moist snuff users (8). The increased risk for fatal stroke is considerably higher ranging between 44% and 72% for ST users (9). Additionally, the stimulating effects of nicotine can produce increased heart rate and elevated blood pressure (10)

Oral Health

Oral issues are some of the most universally seen effects of ST use and range in severity. Mild consequences include permanent discoloration of teeth and halitosis or bad breath. More severe conditions such as tooth decay and receding gums can be devastating for daily living and are attributed to the chemical conversion of sugars found in ST to acid within the mouth (2,11).

Nicotine addiction

Due to the high levels of nicotine, smokeless tobacco products present a significant risk for addiction. In fact, the amount of nicotine delivered from using an average sized dip in the mouth for 30 minutes is equivalent to smoking three cigarettes (12). Developing a nicotine addiction through ST may lead users to begin smoking as well.

Quitting

In addition to the obvious health risks, common reasons to quit using ST products include the financial burden of such a habit and setting an example for one’s family. Just like smoking cessation, quitting ST can be a challenging process but can be managed by developing and following a plan. Some users have success quitting cold turkey, while others may resort to pharmacological interventions such as nicotine replacement therapy or prescription drugs (13). Consulting with a healthcare professional can be a critical element in this process, especially when considering the use of such therapies. The following link from the American Cancer Society is a great source of detailed information on everything from where to begin to remaining ST free.

http://www.cancer.org/Cancer/CancerCauses/TobaccoCancer/SmokelessTobaccoandHowtoQuit/index

Controversy

The notion of promoting ST products as a form of smoking cessation has recently been at the center of significant debate. Those supporting this idea insist that smokers may instead use ST to satisfy their nicotine addiction without exposure to extremely harmful smoke inhalation. While ST has serious health risks as described above, it is commonly accepted that cigarette smoking is associated with much more severe conditions including lung cancer (14). One estimate suggests that using ST poses only 2% of the mortality risk of cigarette smoking and nearly half of the risk of oral cancer (5).

In contrast, opposition to this strategy contends that promoting ST will lead many non-smokers to begin using ST and that this could potentially serve as a gateway to smoking through nicotine addiction. A study from the University of Florida indicated that compared to their non-using counterparts, young males who regularly used ST were more than three times as likely to become smokers within 4 years (15). Additionally, it is believed that increased ST marketing will lead many smokers to use ST when inconvenient to smoke a cigarette, thus compounding their health risks (5).

 

Sources

1. Piano MR, Benowitz NL, Fitzgerald GA, et al. Impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association. Circulation. Oct 12;122(15):1520-1544.

http://circ.ahajournals.org/content/122/15/1520.full

2. Smokeless Tobacco Facts. CDC. 4 Aug. 2011. Web. 30 Jan. 2012.

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/smokeless_facts/index.htm

3. Glover E, Glover P. Smokeless Tobacco or Health: An International Perspective. Chapter 1: Epidemiology

http://cancercontrol.cancer.gov/tcrb/monographs/2/m2_1.pdf

4. Smokeless Tobacco and Cancer. National Cancer Institute. 25 Oct. 2010. Web. 30 Jan. 2012.

http://www.cancer.gov/cancertopics/factsheet/Tobacco/smokeless

5. Hatsukami DK, Lemmonds C, Tomar SL. Smokeless tobacco use: harm reduction or induction approach? Prev Med. Mar 2004;38(3):309-317.

http://www.ncbi.nlm.nih.gov/pubmed/14766113

6. Luo J, Ye W, Zendehdel K, Adami J, Adami H-O, Boffetta P, Nyrén O. Oral use of Swedish moist snuff (snus) and risk of cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet. 2007;369:2015–2020.

http://www.ncbi.nlm.nih.gov/pubmed/17498797

7. Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncology 2008; 9: 667–75

http://www.ncbi.nlm.nih.gov/pubmed/18598931

8. Hergens M, Alfredsson L, Bolinder G, Lambe M, Pershagen G. Long-term use of Swedish moist snuff and the risk of myocardial infarction Amongst Men. J Intern Med 262 (2007), pp. 351-359.

http://www.ncbi.nlm.nih.gov/pubmed/17697156

9. Underner M, Perriot J, Sosner P, Herpin D. Snus and cardiovascular risk. Ann Cardiol Angeiol. Aug 17.

http://www.ncbi.nlm.nih.gov/pubmed/21872211

10. Smokeless Tobacco. American Academy of Otolaryngology-Head and Neck Surgery. Dec. 2010. Web. 30 Jan. 2012.

http://www.entnet.org/HealthInformation/Smokeless-Tobacco.cfm

11. Smokeless Tobacco and How to Quit. American Cancer Society. 16 Dec. 2011. Web. 30 Jan. 2012.

http://www.cancer.org/Cancer/CancerCauses/TobaccoCancer/SmokelessTobaccoandHowtoQuit/smokeless-tobacco-intro

12. Smokeless Tobacco. National Institute of Dental and Craniofacial Research. 25 Mar. 2011. Web. 30 Jan. 2012.

http://www.nidcr.nih.gov/OralHealth/Topics/SmokelessTobacco

13. Ebbert JO, Fagerstrom K. Pharmacological interventions for the treatment of smokeless tobacco use. CNS Drugs. Jan 1;26(1):1-10.

http://www.ncbi.nlm.nih.gov/pubmed/22136150

14. Benowitz NL. Smokeless tobacco as a nicotine delivery device: harm or harm reduction? Clin Pharmacol Ther. Oct 2011;90(4):491-493.

http://www.ncbi.nlm.nih.gov/pubmed/21934719

15. Tomar SL. Is use of smokeless tobacco a risk factor for cigarette smoking? The U.S. experience. Nicotine Tob Res. Aug 2003;5(4):561-569.

http://www.ncbi.nlm.nih.gov/pubmed/12959794