Surveillance of and Knowledge About Cancer Associated With Smokeless Tobacco Use

Tobacco consumption—most notably smokeless tobacco use—has become one of the fastest growing detrimental health habits in North America. Adolescents still perceive ST as a safe alternative to cigarettes. This paper provides state-specific information about the prevalence of ST use in the United States. A review of the literature reveals that the groups at highest risk are white youth and young adults, aged 10 to 30, with the most vulnerable being those living in the southern United States. It is suggested that further research in several areas is needed for the effectiveness of smokeless tobacco control to be enhanced. Columbus discovered Native Americans using tobacco in various forms (e.g., dipping, chewing, rubbing, smoking), and on his return, he introduced tobacco to the Old World. Actually many of his crew were viewed as being possessed by the devil when they expelled smoke from their nostrils; consequently, they were imprisoned (Christen and Glover, 1987; Christen et al., 1982; Penn, 1902). Once Britain established its colonies in North America, the use of ST became deeply entrenched. Before 1900, the dominant form of tobacco used in North America was smokeless tobacco. Three events occurred that began to move North American tobacco users from smokeless tobacco to cigarette smoking: (1) the invention of the cigarette rolling machine, which allowed for mass production of cigarettes; (2) the INTRODUCTION Perhaps one of the fastest growing detrimental health habits in North America over the past few years has been the use of smokeless tobacco. There has been an upswing in the popularity of ST among young adults and children. As a result, the topic has captured the attention of the North American press and public as health professionals and legislators seek to alert the populace about health problems associated with the use of smokeless tobacco (Glover et al., 1988). There are two types of ST—snuff and chewing tobacco. Snuff is a finely ground tobacco of which the user places a pinch (called a dip or rub) in the gingival groove. Snuff can be dry, moist, or in sachets (tea bag-like pouches). The most common position to place snuff is in the mandibular labial mucosa (cuspid to cuspid); however, this is more common in many European countries, especially Sweden. In European countries, sniffing (inhaling) dry snuff through the nostrils is more common than in North America. Chewing tobacco comes in the form of loose leaf, plug, or twist, and the user places a bolus of tobacco (a golf ball-sized piece) inside the cheek. Typically, whenever a user chews tobacco, one will see an extended cheek. This manuscript provides state-specific information regarding the prevalence of ST and reviews the groups at risk for ST use (Christen and Glover, 1987; Christen et al., 1982; Penn, 1902; Smokeless Tobacco Research Council, 1984; USDA, 1969; Vogues, 1984). The use of ST in North America appears to have originated with Native Americans. On his trip to the New World, Christopher HISTORICAL PERSPECTIVE Smoking and Tobacco Control Monograph No. 2 4 postulation of the germ theory, which at the time created a fear that tuberculosis could be spread by spitting tobacco juices; and (3) World War I. Cigarettes were offered and given freely to American combat soldiers, allowing a nation to become hooked on tobacco. Since the turn of the century, smokeless tobacco use declined until the 1970’s when, through clever advertising by the tobacco industry, it began to experience a resurgence (Glover et al., 1984; Harper, 1980; Smight, 1981). The annual increase of 10 to 11 percent continued until 1986, when two significant events occurred: (1) a consensus development conference on smokeless tobacco was held in Bethesda, Maryland (Consensus Conference, 1986); and (2) the Surgeon General’s first report on smokeless tobacco was published (US DHHS, 1986). These reports helped create a national awareness of ST’s effect on health for the first time, along with the much publicized case of Sean Marsee, product labeling, and an advertisement ban. As a result, tobacco sales declined over the next 18 mo (1986 to 1987). Sales and usage bounced back by 1988. Today, it appears that tobacco use continues to increase, especially among young people. Specifically, moist snuff (e.g., Copenhagen, Skoal), sachets (e.g., Skoal Bandits, Renegades), and loose leaf tobacco (e.g., Red Man, Chattanooga Chew, Levi Garrett) are the smokeless tobacco products that young adults and youth are using (Glover et al., 1988). On the other hand, dry snuff (e.g., Bruton, Dental Snuff), plug (e.g., Bull of the Woods, Red Man Plug), and twist (e.g., Mammoth Cave, Samson) are declining in use. These last products are used primarily by older adults (Glover et al., 1988). There are an estimated 10 to 12 million ST users in the United States alone (Consensus Conference, 1986; US DHHS, 1986). Youth are using smokeless tobacco products at alarming rates. This resurgence of popularity is attributed to innovative advertising campaigns by tobacco companies. Sports figures promote the product in an attempt to erase the old, unsanitary image of the habit and replace it with a “macho” image (Christen and Glover, 1981; Glover et al., 1981, 1982, and 1988). Because of public pressure, the tobacco companies stopped using current and former sports personalities to promote their products in 1985 (Consensus Conference, 1986; US DHHS, 1986). Today, the tobacco companies focus their advertisements on young white males, using masculine role models in activities such as fishing, hunting, rock climbing, and white-water rafting (Glover et. al., 1988). Children tend to model the behavior and accept the values of significant others (e.g., parents, teachers, coaches); consequently, these sport figures are contemporary role models (Glover, 1978). substantial emphasis by advertisers on the 18to 20-yr-old group (Maxwell, 1980). However, younger people (as young as 10 to 12) also appear to be influenced by the trend of ST use (Christen, 1980; Hunter et al., 1986; Marty et al., 1986; Schroeder et al., 1987). Some reports indicate that smokeless tobacco is sometimes consumed by individuals younger than age 10 (US DHHS, 1986). A statewide study of 5,392 Texas children in grades 7 through 12 reported that approximately 9 percent were regular ST users (Schaefer et al., 1985). In an Oklahoma statewide study, approximately 13 percent of The average consumer of ST is in the 18to 30-yr age bracket, with PREVALENCE