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Smokeless Tobacco Use in the United States - Behavioral Risk Factor Surveillance System, 1986

Between 1970 and 1985, national consumption of smokeless tobacco products (snuff and chewing tobacco) increased markedly in the United States (1). Several regional surveys have reported that 7% to 36% of the nation's children and teenagers are using these products (2-5). The National Institute on Drug Abuse's National Household Survey showed that, in 1985, the prevalence of use among men and women >= 21 years of age was 19% and 3%, respectively. Results also indicated that the prevalence of use was generally lower in the Northeast and higher in the South than in other regions (6).

To establish state-specific prevalences of smokeless tobacco use, the 1986 Behavioral Risk Factor Surveillance System (BRFSS) included questions on current and former use (7). Twenty-five states and the District of Columbia collected data by monthly telephone interviews using random-digit dialing techniques. The results were weighted to account for the age, race, and sex distribution of adults >= 18 years of age in each state and for each respondent's probability of selection.

State-specific prevalences of ever use and current use of smokeless tobacco are shown in Table 1. The rates of ever use varied over fourfold among states -- from 4.9% in Rhode Island to 23.2% in West Virginia. However, among current users of smokeless tobacco the prevalence varied more than twentyfold -- from a low of 0.4% in Massachusetts and New York to a high of 10.2% in West Virginia (median = 3.3%). Most current smokeless tobacco users surveyed were regular rather than merely occasional users.

Smokeless tobacco use was higher among men than among women. For men, prevalence rates of current use ranged from 0.7% in New York and Rhode Island to 21.4% in West Virginia (median = 6.5%). States with male prevalence rates above the median were primarily in the southeastern or northcentral regions (Figure 1). In 19 of the 26 states, more than one-fourth of the male respondents had tried smokeless tobacco. Among women, smokeless tobacco use was much less common, with prevalences ranging from zero in Massachusetts, North Dakota, and the District of Columbia to 4.2% in Georgia (median = 0.3%).

Reported by: R Brooks, Arizona Dept of Health Svcs. F Capell, California Dept of Health Svcs. S Benn, Connecticut State Dept of Health Svcs. R Conn, EdD, District of Columbia Dept of Human Svcs. WW Mahoney, Florida Dept of Health and Rehabilitative Svcs. JD Smith, Georgia Dept of Human Resources. JV Patterson, Idaho Dept of Health and Welfare. D Patterson, Illinois Dept of Public Health. S Jain, Indiana State Board of Health. K Bramblett, Kentucky Cabinet for Human Resources. N Salem, PhD, Minnesota Center for Health Statistics. R Moon, Montana Dept of Health and Environmental Sciences. T Gerber, New York State Dept of Health. R Staton, North Carolina Dept of Human Resources. B Lee, North Dakota State Dept of Health. E Capwell Ohio Dept of Health. J Cataldo, Rhode Island Dept of Health. FC Wheeler, South Carolina Dept of Health and Environmental Control. J Fortune, Tennessee Dept of Health and Environment. GV Lindsay, Utah Dept of Health. R Anderson, West Virginia Dept of Health. DR Murray, Wisconsin Center for Health Statistics. Div of Nutrition, Div of Health Education, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: Although smoking prevalence among adults has declined in the United States (8), the prevalence of smokeless tobacco use among adults has varied only slightly. In 1970, the National Clearinghouse on Smoking and Health reported that 25% of adult men had tried smokeless tobacco and that 6% were current users (unpublished data). In the BRFSS, which surveys adults >= 18 years of age, the median state prevalence for men who had ever used smokeless tobacco was 28.6%, and the median state prevalence for current use among men was 6.5%. Other national surveys, which have studied the prevalence of smokeless tobacco use among younger persons, have shown much higher rates among boys aged 12-17 (range: 10% in the Northeast to 27% in the South {6}).

Long-term smokeless tobacco use may be associated with an increased risk of oral cancer and with peridontal disease (9). Since smokeless tobacco contains nicotine, it may also help promote tobacco addiction among young users. In addition, the increase in policies that restrict smoking in workplaces and other public places may cause smokers to turn to smokeless tobacco products as a source of nicotine.

A 1986 Federal law (10) required that smokeless tobacco products and advertisements carry warning labels about the health hazards of their use. The law also banned smokeless tobacco advertising from television and radio. Congress also added a small federal excise tax to smokeless tobacco products. Increased state efforts, as well as media and health education programs, have focused on the dangers of smokeless tobacco use, especially for youth. Of note, in 1986 the sales of moist snuff by the largest manufacturer of these products declined by 3.7% (11). Prior to 1986, sales had increased steadily from 295 million cans in 1978 to 481 million cans in 1985.

In a recent report to Congress, the Secretary of Health and Human Services made additional recommendations to state and local jurisdictions. These recommendations were 1) to establish a minimum age of at least 18 years for the purchase of smokeless tobacco products, 2) to incorporate curricula against smokeless tobacco use into health education programs in the public schools, and 3) to ban distribution of free smokeless tobacco samples (12).

The more serious adverse health outcomes of smokeless tobacco use may be delayed for many years (13). However, potential nicotine addiction and dental disease are adequate reasons to prevent the use of smokeless tobacco, especially among the young. Additional surveillance of this health-risk behavior will continue to be important.


  1. Connolly GN, Winn DM, Hecht SS, Henningfield JE, Walker B Jr, Hoffmann D. The reemergence of smokeless tobacco. N Engl J Med 1986:314:1020-7.

  2. Glover ED, Johnson R, Laflin M, Edwards SW, Christen AG, Smokeless tobacco use trends among college students in the United States. World Smoking and Health 1986;11(1):4-9.

  3. Schaefer SD, Henderson AH, Glover ED, Christen, AG. Patterns of use and incidence of smokeless tobacco consumption in school-age children. Arch Otolaryngol 1985;111 639-42.

  4. Gritz ER, Ksir C, McCarthy WU. Smokeless tobacco use in the United States: past and future trends. Ann Behav Med 1985;2:24-7.

  5. Berman EJ, Fischer PM, Richards JW, Strickman-Levitas B. Use of smokeless tobacco among adolescents {Editorial}. JAMA 1986;255:3245.

  6. Rouse B. Epidemiology of smokeless tobacco use: a national study. Prev Med (in press).

  7. CDC. Behavioral risk factor surveillance -- selected states, 1986. MMWR 1987;36:252-4. 8 CDC. Smoking and health: a national status report. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (CDC) 87-8396.

  8. Public Health Service. The health consequences of using smokeless tobacco: a report of the Advisory Committee to the Surgeon General. Bethesda, Maryland: US Department of Health and Human Services, 1986; DHHS publication no. (NIH)86-2874.

  9. CDC. Use of smokeless tobacco - Wisconsin. MMWR 1986;35:641-4.

  10. United States Tobacco Company. Annual report, 1986. Greenwich, Connecticut: United States Tobacco Company, Inc, 1987.

  11. US Department of Health and Human Services. Report to the Congress under the Comprehensive Smokeless Tobacco Health Education Act of 1986 (PL-99-252). Washington, DC: US Department of Health and Human Services, 1987.

  12. Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, Fraumeni JF. Snuff dipping and oral cancer among women in the southern United States. N Engl J Med 1981;304:745-9.

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