Smokeless Tobacco

What is spit or smokeless tobacco?

There are 2 basic forms of smokeless tobacco: chewing tobacco and snuff.

Chewing tobacco

Chewing tobacco comes as long strands of loose leaves, plugs, or twists of tobacco. Pieces, commonly called plugs, wads, or chew, are chewed or placed between the cheek and gum or teeth. The nicotine in the piece of chewing tobacco is absorbed through the mouth tissues. The user spits out the brown saliva that has soaked through the tobacco.

Snuff

Snuff is finely ground tobacco packaged in cans or pouches. It’s sold as dry or moist.

Moist snuff is used by placing a pinch, dip, lipper, or quid, between the lower lip or cheek and gum. The nicotine in the snuff is absorbed through the tissues of the mouth. Moist snuff is also available in small, teabag-like pouches or sachets that can be placed between the cheek and gum. These are designed to be both “smoke-free” and “spit-free” and are marketed as a discreet way to use tobacco.

Dry snuff is sold in a powdered form and is used by sniffing or inhaling the powder up the nose.

Snuff also comes in other forms. Snus (sounds like snoose) is a finely ground form of moist snuff made of air-cured tobacco, water, salt, and flavorings that first came from Sweden and Norway. Snus is most commonly packaged in small pouches, but can also be used like loose moist snuff (see the section “More on snus”).

Tobacco companies have now created dissolvable forms of smokeless tobacco. Some that are sold or are being test-marketed include tobacco lozenges, tablets (orbs or pellets), strips, and sticks that contain tobacco and nicotine. Depending on the type, they are designed to be held in the mouth, chewed, or sucked until they dissolve. Some of these new smokeless tobacco products are mint-flavored and look like candy. Others look like toothpicks or meltaway mouthwash strips. Because they are so tempting, they can easily poison children and pets.

Who uses smokeless tobacco?

Data collected in 2011 showed that about 3.2% of people aged 12 and older in the US used smokeless tobacco — that’s about 8.2 million people. Use of smokeless tobacco was higher in younger age groups, with more than 5% of people aged 18 to 25 saying they were current users.

About 1.3 million people age 12 and older started using smokeless tobacco in the year before the survey. About 44% of the new users were younger than 18 when they first used it.

This data is supported by the CDC’s 2011 Youth Risk Behavior Survey, which found that use of smokeless tobacco among high school kids is even higher than for young adults. They found that about 13% of male high school students and more than 2% of female high school students had used smokeless tobacco in the month before the survey.

The CDC Youth Tobacco Survey looked at even younger children. In their 2011 survey, 3% of middle school boys and 1.4% of middle school girls reported using smokeless tobacco at least once in the 30 days before the survey.

Although flavorings are not allowed in cigarettes, the tobacco industry offers sweeteners and flavorings in smokeless tobacco. It can taste more like candy with flavors such as vanilla, mint, and fruit, which makes it more appealing to young people. In fact, a 2012 study showed that most smokeless tobacco users chose mint or wintergreen flavored products.

Certain factors seem to be linked to whether young people will use tobacco. They include:

• Examples set by parents
• Peer pressure
• Local lifestyles and fashions
• General attitudes toward authority
• Economic conditions
• Examples set by teachers and school staff
• Presence of gangs
• Use of illegal drugs and alcohol

In 2003, more than 1 in 3 major league baseball players used smokeless tobacco, mainly moist snuff, and many still do today. Athletes are a large marketing source for smokeless tobacco, and are often seen on TV using it during a game. As role models, they can influence youth to be more open to and accepting of smokeless tobacco.

State-enforced smoking bans are a more recent influence on the use of smokeless tobacco. In response to these bans, tobacco companies have been marketing smokeless tobacco products more heavily. They are advertising smokeless tobacco products as alternatives to cigarettes in places where smoking is not allowed. When smokers use these products as substitutes instead of trying to quit tobacco, it continues to support the tobacco industry.

New studies seem to show that marketing efforts are succeeding in keeping people hooked on smoking while they are still using smokeless tobacco, especially young adults. The use of cigarettes or other forms of smoked tobacco (such as cigars, clove cigarettes, or hookahs) along with smokeless tobacco is often called dual use. The health risks posed by dual use may be higher than either alone, especially for heart disease.

Rates of dual use vary by sex and the main form of tobacco used. For example, 28% of male smokeless tobacco users sometimes also smoke. Of female smokeless tobacco users, some 42% also smoke. Among people who mainly smoke cigarettes, more than 2% of the women and more than 8% of the men also use smokeless tobacco at times. Younger people and those with lower education levels are more likely to use both cigarettes and oral tobacco.

Smokers who put off quitting by using smokeless tobacco to get a nicotine fix while in smoke-free settings do not decrease their lung cancer risk. Lung cancer risk is affected most by how long a person smokes. And these people are still using tobacco and smoking cigarettes. Research has shown that people who use smokeless tobacco and also smoke often find it harder to quit tobacco.

How is smokeless or spit tobacco different from smoking?

The route is different, but the nicotine addiction is the same. Nicotine in smokeless tobacco products absorbs from the mouth or nose along with other compounds in the tobacco. Cigarettes, pipes, and cigars burn the tobacco, and the nicotine from the smoke gets into the body through the mouth, nose, and lungs along with other particles generated by combustion. Burning tobacco sends out secondhand smoke, which other people and the smoker breathe in as it lingers in the air and settles on surfaces.

All forms of tobacco and nicotine can harm or kill children and pets if accidentally or otherwise ingested.

What kinds of illness are caused by oral or smokeless tobacco

Harmful health effects of smokeless tobacco include:

• Mouth, tongue, and throat cancer
• Cancer in the esophagus (the swallowing tube that goes from your mouth to your stomach)
• Stomach cancer
• Pancreatic cancer
• Possible increase in risk of heart disease, heart attacks, and stroke
• Addiction to nicotine
• Leukoplakia (white sores in the mouth that can become cancer)
• Receding gums (gums slowly shrink from around the teeth)
• Bone loss around the roots of the teeth
• Abrasion (scratching and wearing down) of teeth
• Tooth loss
• Stained and discolored teeth
• Bad breath

Mouth lesions

Leukoplakia is a white patch in the mouth that can become cancer. These are sometimes called sores but they are usually painless. Many studies have shown high rates of leukoplakia at the place in the mouth where users place their chew or dip. One study found that nearly 3 of 4 of daily users of moist snuff and chewing tobacco had non-cancerous or pre-cancerous lesions (sores) in the mouth. The longer a person uses oral tobacco, the more likely they are to have leukoplakia.

Tobacco can irritate or destroy gum tissue. Many regular smokeless tobacco users have receding gums, gum disease, tooth decay (from the high sugar content in the tobacco), and bone loss around the teeth. The surface of the tooth root may be exposed where gums have shrunken. All this can cause teeth to loosen and fall out.

Heart disease

Smokeless tobacco may also play a role in heart disease and high blood pressure. Results from a large American Cancer Society study showed that men who switched from cigarettes to snuff or chewing tobacco had higher death rates from heart disease stroke, cancer of the mouth and lung, and all causes of death combined than former smokers who stopped using all tobacco products. It’s unclear whether the heart disease was caused by the smokeless tobacco products in this study.

Later studies have been mixed, with some showing a slight increase in heart disease among users of smokeless tobacco. Studies in Sweden found that no increase in heart attacks, but snuff (snus) users were more likely to die from their heart attacks than non-users. More US studies are needed to identify outcomes related to use of smokeless tobacco.

Cancer

The snuff and chewing tobacco products most widely used in the United States have very high levels of cancer-causing agents (carcinogens) called tobacco-specific nitrosamines. These carcinogens cause lung cancer in animals, even when injected into their blood. There are other kinds of cancer-causing agents in smokeless tobacco, too, such as benzo[a]pyrene and other polycyclic aromatic carcinogens. These carcinogens may be why several types of cancer are linked to use of smokeless tobacco (see above list).

How do the risks of using smokeless tobacco compare with cigarette smoking?

Smokeless tobacco products are less lethal than cigarettes: on average, they kill fewer people than cigarettes. But smokeless tobacco hurts and kills people all the same. Even though they are marketed as a less harmful alternative to smoking, smokeless products can be deadly. And they have not been proven to help smokers quit.

Smokers who delay quitting by using smokeless products between cigarettes greatly increase their risk of lung cancer. They also set themselves up for new health problems caused by smokeless tobacco.

Marketing smokeless tobacco products

Tobacco companies have responded to the popular laws that ban smoking in public places by selling smokeless products that can be used in no-smoking settings. They use ad slogans such as “Anytime. Anywhere” and “No Smoking, No Problem” to target smokers who crave nicotine while they are in smoke-free places. Free samples and coupons are also offered to encourage people to try these new products. But without smokeless products, these smokers might be motivated to quit smoking completely.

The tobacco industry is also promoting the idea that switching to smokeless products is a good way to quit smoking. These claims are implied rather than stated outright, to avoid having these products regulated as drugs.

There’s no proof that smokeless tobacco products can actually help smokers quit. But there are proven treatments for tobacco addiction, such as nicotine replacement products, prescription drugs, nicotine receptor blockers, and behavioral therapies. These standard treatments have been carefully tested and have been proven to help people quit smoking.

Laws that affect tobacco marketing

The Family Smoking Prevention and Tobacco Control Act went into effect in October 2009. This law gives the Food and Drug Administration (FDA) power to regulate tobacco products in the US. One of the goals of the law is to restrict the marketing and advertising of tobacco products — including smokeless tobacco products. Colorful ads and store displays are no longer permitted. Only black and white text ads are allowed. Since 2010, all outdoor tobacco ads within 1,000 feet of schools and playgrounds have been illegal.

Under the law, new smokeless tobacco and other products claiming to have lower health risks must be approved by the FDA. Such claims are only allowed if makers can show that the product would not encourage many non-smokers or would-be quitters to try them, rather than not using tobacco at all.

More on snus

Some people believe that snus is a safe tobacco to use. Because it’s steam-heated rather than fermented, Swedish snus has fewer tobacco-specific nitrosamines (TSNAs) that are known to cause cancer. Still, there are other carcinogens in snus besides TSNAs.

It’s true that snus users in Sweden have lower rates of some types of cancer than Swedish smokers. But snus users may have a higher risk of cancer of the pancreas than non-users. They also get sores or spots in the mouth (lesions) where the snus is held. It appears that snus users may have mouth cancer more often than non-users, though more studies need to be done to confirm this. (See the section called “What are the risks of using smokeless tobacco?”)

It’s also important to know that Swedish snus is processed in a special way that limits some of its toxins, and it has very specific manufacturing standards. The Swedish makers also provide consumer information about the product. American snus doesn’t have this kind of regulation or requirements on its processing or labeling.

Since US tobacco sellers are not required to list what’s in their products, it’s hard to know how the US versions of snus might compare to the Swedish versions without more research. The studies done so far show that American versions of snus contain varying amounts of TSNAs depending on brand and region of the United States. There’s no requirement as to levels of TSNAs in American snus, nor is there a requirement for labeling this carcinogen.

Snus contains tobacco, so it’s not helpful if you want to quit; it’s as addictive as any other form of tobacco. American snus has not been proven safer than the more common forms of smokeless tobacco. To date, snus has not been tested in controlled clinical trials.

Nicotine levels in American snus also vary, which makes it hard to know how much nicotine replacement you might need if you try to quit. Since snus is still new in the United States, it’s uncertain what other health problems it might cause.

Internet marketing

At present, there seems to be nothing to stop users of smokeless tobacco from posting videos online showing or describing the use of “dip” tobacco by young people or teens. Studies have found dozens of such videos readily available. Most of the videos reviewed were pro-tobacco.

Many of these videos were watched thousands of times, with no age restrictions. In one study, more than 1 in 5 videos were created by professionals or professional groups. Whether and how this affects the use of smokeless tobacco still needs to be clarified.

To learn more

More information from your American Cancer Society

Here is more information you might find helpful. You also can order free copies of most of our documents from our toll-free number, 1-800-227-2345, or read them on our Web site, www.cancer.org.

If you or someone you care about is trying to quit dip or chew

Guide to Quitting Smokeless Tobacco

For more information on the health effects of tobacco

Questions About Smoking, Tobacco, and Health (also in Spanish)

Child and Teen Tobacco Use (also in Spanish)

Tobacco-Related Cancers Fact Sheet

National organizations and Web sites*

Along with the American Cancer Society, other sources of information and support include:

Kill the Can
Web site: www.killthecan.org

Online information and support for those committed to quitting smokeless tobacco

Nicotine Anonymous (NicA)
Toll-free number: 1-877-879-6422 (1-877-TRY-NICA)
Web site: www.nicotine-anonymous.org

For free information on their 12-step program, meeting schedules, print materials, or information on how to start a group in your area

Centers for Disease Control and Prevention
Office on Smoking and Health
Toll-free number: 1-800-232-4636 (1-800-CDC-INFO)
Free quit support line: 1-800-784-8669 (1-800-QUIT-NOW)
TTY: 1-800-332-8615
Web site: www.cdc.gov/tobacco

Free information on smoking and health; phone hotline for people who want to quit

National Cancer Institute
Toll-free number: 1-800-422-6237 (1-800-4-CANCER) for cancer information
Web site: www.cancer.gov
Toll-free tobacco quit line: 1-877-448-7848 (1-877-44U-QUIT)
Direct tobacco Web site: www.smokefree.gov

Quitting information, quit-smoking guide, and counseling is offered, as well as state telephone-based quit programs

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

References

Bromberg JE, Augustson EM, Backinger CL. Portrayal of Smokeless Tobacco in YouTube Videos. Nicotine Tob Res. 2012;14(4):455-462.

Centers for Disease Control and Prevention (CDC). Tobacco use, access, and exposure to tobacco in media among middle and high school students --- United States, 2004. MMWR. 2005;54;297-301. Accessed at www.cdc.gov/mmwr/preview/mmwrhtml/mm5412a1.htm on October 1, 2012.

Centers for Disease Control and Prevention (CDC). Current tobacco use among middle and high school students -- United States, 2011. MMWR. 2012;61:581-585. Accessed at www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a1.htm on October 1, 2012.

Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance -- United States, 2011. MMWR Surveill Summ. 2012;61(4):1-162. Accessed at www.cdc.gov/mmwr/preview/mmwrhtml/ss6104a1.htm on October 1, 2012.

Centers for Disease Control and Prevention (CDC). Smokeless Tobacco Facts. Accessed at www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/smokeless_facts/index.htm on October 1, 2012.

Henley SJ, Connell CJ, Richter P, et al. Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco. Tobacco Control. 2007;16:22-28.

Klesges RC, Ebbert JO, Morgan GD, Sherrill-Mittleman D, et al. Impact of differing definitions of dual tobacco use: implications for studying dual use and a call for operational definitions. Nicotine Tob Res. 2011;13(7):523-531.

Mushtaq N, Williams MB, Beebe LA. Concurrent use of cigarettes and smokeless tobacco among US males and females. J Environ Public Health. 2012;2012:984561. Accessed at www.ncbi.nlm.nih.gov/pmc/articles/PMC3362120/ on October 1, 2012.

Oliver AJ, Jensen JA, Vogel RI, Anderson AJ, Hatsukami DK. Flavored and Nonflavored Smokeless Tobacco Products: Rate, Pattern of Use, and Effects. Nicotine Tob Res. 2012 Apr 22.

Piano MR, Benowitz NL, Fitzgerald GA, Corbridge S, 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. 2010;122(15):1520-1544.

Post A, Gilljam H, Rosendahl I, Bremberg S, Galanti MR. Symptoms of nicotine dependence in a cohort of Swedish youths: a comparison between smokers, smokeless tobacco users and dual tobacco users. Addiction. 2010;105(4):740-746.

Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the missing link between youth prevention and adult cessation. J Environ Public Health. 2012;2012:679134.

Seidenberg AB, Rodgers EJ, Rees VW, Connolly GN. Youth access, creation, and content of smokeless tobacco (“dip”) videos in social media. J Adolesc Health. 2012;50(4):334-338.

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