Smokeless / Oral Tobacco's Nicotine
Smokeless tobacco (ST) use is often overlooked in research on tobacco control and in medical student education.1
This highly addictive substance2,3 contains many known carcinogens.4,5 ST also generally contains a higher concentration of nicotine relative to cigarettes. The typical single dose of nicotine in snuff is almost twice that of cigarettes, whereas the single dose of nicotine in chewing tobacco can be more than 15 times greater.6 Because of these nicotine levels, the addictive potential for ST use is likely greater than for cigarette smoking.6
The two most common forms of smokeless tobacco are chewing tobacco (plug or loose-leaf) and snuff (dry or moist powder and powder in small teabag-like sachets). Although most tobaccorelated cancer studies have focused on cigarette smoking, ST use also has carcinogenic potential, particularly for oral cancer and a number of other cancers as well (see Table 1).7-9
A number of studies10-16 indicate that ST has a unique epidemiology, different in many respects than cigarette smoking. For example, in 2005, approximately 21% of U.S. adults were current smokers; men (24%) and American Indian and Alaskan Natives (32%) had the highest prevalence of use. By contrast, the prevalence of current smokeless tobacco use was 2.3%.15 Smokeless tobacco use in the United States is higher among young White males (6%) and American Indians/Alaska Natives (9%). Rates are also above the national average for people living in southern and north central states and for people who are employed in blue-collar occupations or service/laborer jobs or who are unemployed.16 ST users tend to be older than cigarette smokers and tend to live in rural areas. A higher percentage of ST users are women compared to cigarette smokers, particularly older, minority women.10-16 ST use is associated with oral lesions, such as leukoplakia, gum recession, periodontal disease, and tooth abrasion.5 There is strong evidence in the literature for other health effects associated with ST use including cardiovascular disease.9 Combined with its unique epidemiology, nicotine pharmacology, and carcinogenic and health effects, specific training by clinicians in both ST cessation and smoking cessation is extremely important.
In 2002, we reported on the dearth of studies that have evaluated smokeless tobacco cessation educational efforts in U.S. medical schools.1 Since that report, no additional studies on this topic have emerged. Indeed, in 2005, the tobacco control competencies promulgated by the Prevention and Cessation Education Consortium-a group of 12 U.S. medical schools-did not list training in basic and clinical sciences of ST control.17
1. Spangler JG, George G, Foley KL, Crandall SJ. Tobacco intervention training: Current efforts and gaps inUSmedical schools. Journal of theAmerican Medical
2. Glover ED, Schroeder KL, Henningfield JE, Severson HH, Christen AG. An interpretive review of smokeless tobacco research in the United States: Part I. Journal of Drug Education 1988;18:285-310.
3. Glover ED, Glover PN. Smokeless tobacco cessation and nicotine reduction therapy. In: Smokeless tobacco or health: An international perspective (NIH Publication No. 93-3461, pp. 291-296). Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, September 1992.
4. Hoffman D, Adams JD, Lisk D, et al. Toxic and carcinogenic agents in dry and moist snuff. Journal of the National Cancer Institute 1987;79:1281-6.
5. NIH Consensus Development Panel. National Institutes of Health consensus statement: Health implications of smokeless tobacco use. Biomedical Pharmacotherapy 1988;42:93-8.
6. Benowitz NL. Pharmacology of smokeless tobacco use: Nicotine addiction and nicotine-related health consequences. In: Smokeless tobacco or health: An international perspective (NIH Publication No. 93-3461, pp.
219-228). Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, September 1992.
7. Winn DM, Blot WJ, Shy CM, et al. Snuff dipping and oral cancer among women in the southern U.S. New England Journal of Medicine 1981;304:745.
8. Winn DM. Epidemiology of cancer and other systemic effects associated with the use of smokeless tobacco. Advances in Dental Research 1997;11:313-21.
9. Critchley JA, Unal B. Health effects associated with smokeless tobacco: A systematic review. Thorax 2003;58:435-43.
10. Spangler JG, Dignan MD, Michielutte R. Tobacco use among Native American women in western North Carolina: Demographic, social support, health behavioral and cultural correlates. American Journal of Public
11. Spangler JG, Bell RA, Dignan MB, Michielutte R. Prevalence and predictors of tobacco use among Lumbee Indian women, Robeson County, North Carolina. Journal of Community Health 1997;22:115-25.
12. Spangler JG, Bell RA, Knick S, Michielutte R, Dignan MB. Epidemiology of tobacco use among Lumbee Indians. Journal of Cancer Education 1999; 14:34-40.
13. Spangler JG, Bell RA, Knick S, Michielutte R, Dignan MB, Summerson JH. Church related correlates of tobacco use among Lumbee Indians in North Carolina. Ethnicity and Disease 1998;8:73-80.
14. Spangler JG, Michielutte R, Bell RA, Knick S, Dignan MB, Summerson JH. Dual tobacco use among Native American adults in southeastern North Carolina. Preventive Medicine 2001;32:521-8.
15. Centers for Disease Control and Prevention. Tobacco use among adults- United States. Morbidity and Mortality Weekly Report 2005;55:1145-8.
16. U.S. Department of Health and Human Services. Reducing the health consequences of smoking-25 years of progress: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services,
Public Health Service, Centers for Disease Control and Prevention. http://profiles.nlm.nih.gov/NN/B/B/X/S/ Accessed October 26, 2007.
17. Geller AC, Sapka J, Brooks KR, et al. Tobacco control competencies for US medical students. American Journal of Public Health 2005;95:950-5.