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Topics in Minority Health -- Prevalence of Oral Lesions and Smokeless Tobacco Use in Northern Plains Indians

An estimated 22 million persons in the United States have used smokeless tobacco (1). According to the Office on Smoking and Health's 1986 Adult Use of Tobacco Survey, the current prevalence of smokeless tobacco use in adults greater than or equal to21 years of age is 2.2% for men and 0.5% for women (2). In addition, the prevalence varies by geographic region, ranging from 0.4% in Massachusetts and New York to 10.2% in West Virginia (3). Regional surveys indicate that 3%-26% of adolescent males andless than 3% of adolescent females currently use smokeless tobacco (4).

Surveys of American Indian/Alaska Native schoolchildren have reported prevalences of regular smokeless tobacco use* ranging from 24% to 64% (5-7; Aberdeen Area Indian Health Service (IHS), unpublished data). Preliminary results from the four studies discussed below confirm a greater prevalence of smokeless tobacco use in Indian adolescents than in Indian adults.

ROSEBUD SIOUX RESERVATION In March 1986, 1776 students in grades K-12 were surveyed at eight schools on the Rosebud Indian Reservation in rural South Dakota. All students in attendance the day of the survey completed the anonymous, self-administered questionnaire; 1581 (89%) were American Indians, and 195 (11%) were non-Indians.

Rates of smokeless tobacco use for the Indian students were higher than those for non-Indians (25% compared with 14%; p=0.03, chi-square). Over one third of Indian boys and girls in grades 7-12 reported regular use of smokeless tobacco (Table 1). In addition, 21% of kindergarten children reported using smokeless tobacco.

The most popular tobacco product was snuff (58%), which was dipped, followed by rough-cut chewing tobacco, or chew (25%). Among regular users of smokeless tobacco, the duration of use was 1-3 years, with a mean frequency of 3.5 times per day, each dip or chew being held in the mouth an average of 30 minutes.

Of the 184 regular users in grades 7-12, 37% had oral lesions (defined as any white or red wrinkled area in the mouth or buccal mucosa) detected by a subsequent dental examination. The lesions were thought to be associated with use of smokeless tobacco. The student user with lesions had a mean duration of use of 3.4 years, with a mean frequency of use of 6.6 times per day, each dip or chew being held an average of 40 minutes. For students without lesions, the mean duration was 2.5 years, with a mean frequency of 2.9 times per day, and each dip or chew being held an average of 30 minutes.

MINNESOTA ADOLESCENT HEALTH SURVEY During 1986-87, the University of Minnesota administered an anonymous health survey to over 36,000 Minnesota adolescents; 12,590 lived outside metropolitan areas, and the remainder lived in St. Paul, Minneapolis, and Duluth. In addition, 1056 adolescents from four rural South Dakota Indian reservations were surveyed.

The prevalence of smokeless tobacco use in South Dakota Indian adolescents (34.2%) was 10 times that of nonurban Minnesota non-Indian youth (3.4%) (pless than 0.01, chi-square) (Table 1), although both groups lived outside urban areas and would be expected to share certain characteristics. In addition, Indian adolescents reported that only 14% of their fathers and 3% of their mothers had ever used smokeless tobacco, suggesting that this behavior is not necessarily learned from parents.

CHEYENNE RIVER SIOUX PLANNED APPROACH TO COMMUNITY HEALTH STUDY In 1986, 417 randomly selected Tribal members greater than or equal to18 years of age completed the CDC Behavioral Risk Factor Surveillance Survey (BRFSS) as part of a Planned Approach to Community Health (PATCH) study conducted cooperatively by the Cheyenne River Sioux Tribe, the IHS, the South Dakota Department of Health, and CDC. Seventeen percent of men and 3% of women reported using smokeless tobacco regularly, and rates were higher in the younger age groups (Table 2).


In 1987, 222 Great Falls Indians (urban), and 241 Blackfeet Reservation Indians participated in a survey conducted by IHS and CDC, and 691 Montana residents of all races participated in the CDC BRFSS. Persons surveyed ranged in age from 15 to 49 years. Members of both Indian groups were interviewed in person, and the other Montana residents were interviewed by telephone. Rates of smokeless tobacco use were higher for reservation Indians than for urban Indians or the random sample of Montana residents, higher for men than for women, and highest in the youngest age groups (Table 2). Reported by: K Jewett, Cheyenne River Sioux Tribe, Eagle Butte; KA Senger, State Epidemiologist, South Dakota State Dept of Health. L Bergeisen, MD Resnick, PhD, RW Blum, MD, Adolescent Health Program, Dept of Pediatrics and School of Public Health, Univ of Minnesota, Minneapolis. D Pepion, Blackfeet Tribe, Browning; F Buckles, Native American Center, Great Falls; JK Gedrose, MN, State Epidemiologist, Montana State Dept of Health. B Bruerd, MPH, TK Welty, MD, J Bausch, DDS, Aberdeen Area Indian Health Svc; L Oge, Billings Area Indian Health Svc, Health Resources and Services Administration. Office on Smoking and Health, Div of Nutrition, and Div of Reproductive Health, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: Smokeless tobacco use in Indian and non-Indian populations in the Northern Plains differs in at least three important respects: 1) a higher overall prevalence of smokeless tobacco use in Indian adolescents; 2) similar prevalence of use in adolescent Indian boys and girls (Table 1); and 3) younger age of onset of smokeless tobacco use in Indians. In addition, smokeless tobacco use is higher in Indian adolescents than in Indian adults. For both adults and adolescents, rates of use are higher in reservation Indians than in urban Indians (Aberdeen Area IHS, unpublished data) (Table 2).

Smokeless tobacco use has been causally linked with oral cancer and other oral conditions and can produce nicotine addiction similar to that of cigarette smoking (4,8). To address this public health problem in American Indians, IHS and tribal outreach activities could focus on the following areas: 1) education for youth, school administrators, and parents regarding the adverse health effects of smokeless tobacco use; 2) policy interventions to restrict the sale and distribution of smokeless tobacco to children; 3) implementation of tobacco use cessation programs; 4) screening and monitoring of adverse health effects; 5) further research to determine reasons for the high prevalence of smokeless tobacco use and to discover correlations for use by Indian youth; and 6) design, implementation, and evaluation of interventions to reduce smokeless tobacco use in Indian communities. The IHS, in cooperation with CDC and the Bureau of Indian Affairs, will initiate a school-based Indian-specific comprehensive health education curriculum, which includes a section addressing the high prevalence of smokeless tobacco use in Indian adolescents. Through IHS support, the Minnesota Adolescent Health Survey has recently been administered in many schools with a large population of American Indians and Alaska Natives so that base-line prevalence data are available to evaluate the impact of such community-based interventions.


  1. Rouse BA. Epidemiology of smokeless tobacco use: a national study. NCI Monogr (in press).

  2. Novotny TE, Pierce JP, Fiore MC, Hatziandreu E, Davis RM. Smokeless tobacco use in the United States: the Adult Use of Tobacco Surveys. NCI Monogr (in press).

  3. CDC. Smokeless tobacco use in the United States--Behavioral Risk Factor Surveillance System, 1986. MMWR 1987;36:337-40.

  4. 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, Public Health Service, 1986; DHHS publication no. (NIH)86-2874.

  5. CDC. Smokeless tobacco use in rural Alaska. MMWR 1987;36:140-3.

  6. Schinke SP, Gilchrist LD, Schilling RF II, Walker RD, Locklear VS, Kitajima E. Smokeless tobacco use among native American adolescents (Letter). N Engl J Med 1986;314:1051-2.

  7. Wolfe MD, Carlos JP. Oral health effects of smokeless tobacco use in Navajo Indian adolescents. Community Dent Oral Epidemiol 1987;15:230-5.

  8. Public Health Service. The health consequences of smoking: nicotine addiction. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1988; DHHS publication no. (CDC)88-8406. *Use of smokeless tobacco is considered to be regular if respondent answered affirmatively to questions regarding whether he or she used smokeless tobacco products "currently," "now," or "daily," depending upon the survey.

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