Current Trends Use of Smokeless Tobacco - Wisconsin

The recent marked increase in smokeless tobacco use, predominantly by pre-adolescent and adolescent males, has prompted action on local, and Federal level. Smokeless tobacco product have apparantly bacome popular among student in school across tho United States. Data from various regions of the country indicate that 8%-36% of main high school- and colleqe-age student use smokeless tobacco products regularly (1). One study reported on 11% usage rate among 8 to 9-year-olds (2) and a recent U.S. Inspector General's national survey reported the overall average age at first use to be 10.4 years of age-in the 5th grade (3). Two other recent surveys reported 35% and 36% smokeless tobacco use in male adolescent populations in Pittsburgh, Pennsylvania (4), and Arkansas (5), respectively.

Data on smokeless tobacco usage among Wisconsin school-age children reflect national trends. A 1985 Dane County youth survey (6) of students in grades 7-12 showed that more males used smokeless tobacco than smoked cigarettes. For example, 45% of 8th-grade boys reported that they had tried smokeless tobacco at least once. Regular use of smokeless tobacco products increased from 9% of 7th-qrade boys to 22% of 12th-grade boys (Table 1). Fifteen percent of 12th-grade boys were daily users.

Other praliminary data from the Wisconsin Division of Health for Project Model Health for rural Wisconsin schools demonstrate the following: 22% of 8th-grade boys in specific schools are regular users of smokeless tobacco; 35% of 8th-grede girls have triod amo~olaaa tobacco; 12 years is the mean age of initiating smokeless tobacco use; among regular users, the students chew or dip smokeless tobacco an avarage of 6 times/day, with 25% chewing or dipping over 10 times/day; the average duration time per dip or chew is 1 hour. On the basis of these data, the Wisconsin Division of Hearth has projected that one in five pre-adolescent and adolescent males Ia a regular smokeless tobacco user in specific Wisconsin communities.

Reported by RB Jones, DDS, DP Moberg, PhD, HA Anderson, MD, Bureau of Community Health and Prevention, JP Davis, MD, State Epidemiologist, Wisconsin Div of Health; Dental Disease Prevention Activity, Center for Prevention Services, Div of Health Promotion and Education, CDC.

Editorial Note

Editorial Note: Smokeless tobacco products include both snuff and chewing tobacco. Moist snuff, packaged in small tins, is most commonly used by young people in the United States (7). Sales of moist snuff have increased substantially in recent yeare, possibly as a result of successful tobacco company marketing strategies. For example, sales rose 55% during the period 1978-1 984, while cigarette sales were decreasing (8). A bill to ban electronic media advertising passed Congress and bacame law, the Comprehensive Smokeless Tobacco Health Education Act of 1986 (P.L. 99-252), in February 1986. The ban took effect in August 1986; bafore that time, smokeless tobacco products were advertised without restriction on television and radio and had no health-warning labels. (P.L. 99-252) also requires that by February 1987 all smokeless tobacco products and print advertisements bi accompanied by one of the following three health warnings that att to be rotated every 4 months: (1) WARNING: THIS PRODUCT MAY CAUSE MOUTH CANCER, (2) WARNlNG: THIS PRODUCT MAY CAUSE GUM DISEASE, and (3) WARNING: THIS PRODUCT IS NOT A SAFE ALTERNATIVE TO CIGARETTES. Outdoor advertisements are exempt from this law.

Several factors may have contributed to passive acceptance of smokeless tobacco in schools and work-place settings, even where smoking restrictions and prohibitions are strictly enforced. For example, marketing campaigns have frequently used active and retired professional athletes and entertainers to promote the use of smokeless tobacco. Smokeless tobacco products are usually displayed in locations removed from smoking tobacco in convenience stores, grocery stores, end other retail outlets, often close to candy ind other fast-food products. The image of smokeless tobacco also has bien enhanced by promotional give-away on college campuses, at state fairs, ind at sporting events; free samples through printed advertising coupons; and mail-order, product-identified clothing and accessories.

Health professionals ind the general public are well aware of the causal link batween cigarette use ind a multitude of detrimental health conditions. In contrast, the health effects of smokeless tobacco are not so well recognized. Smokelesa tobacco products, especially moist snuff, contain potent carcinogens. Studies have consistently demonstrated a strong association between snuff use and oral cancer (7). Carcinogors in the five most popular U.S. snutt brands include polynuclaar aromatic hydrccarnons, radiation-emitting polonium, and a variety of tobacco-specific nitrosamines. Levels of nitrosaminas in commercial snuff range from 9,800-289,000 parts/billion (ppb) (9), which are hundreds of times higher than the levels allowed in foods ind commercial products (1). Nitrosamines are strictly limited in these products. Bacon and bear, for example, are each limited to 5 ppb, and rubber nipples of baby bottles are limited to 10 ppb of nitrosamines.

Tissue changes have bien reported for school-age children who use smokeless tobacco. One study showed thit in rural Colorado, 82.5% of teenagers who used smokeless tobacco had lesions described as alterations in texture, color, or contour of the mucosal lining; localized pariodontal degeneration; or a combination of the two (1O). In the recent Inspactor General's survey (3), 39% of regular users of smokeless tobacco reported that they had a white, wrinkled patch (which characterizes leukoplakia, a precancerous condition), and 37% reported some other form of sore, ulcer, blister, or lesion of the gums, lips, or mouth. It has been estimated that from 1% to 18% of all leukoplakias transform to malignancies (7).

Smokeless tobacco use may also be associated with a number of other corditions including localized gingival recession, tooth loss, tooth abrasion, end stained teeth.

Exposure to nicotine from smokeless tobacco use is comparable with nicotine exposure from cigarette smoking; therefore, nicotine-related health coquences of smokeless tobacco use may be similar to those of smoking in addition to addiction, nicotine may contribute to coronary artery and peripheral vascular disease, hypertension, peptic ulcer disease, and fatal morbidity and mortality (11).

The January 1986 National institutes of Health Consensus Development Conference concerning the health implications of smokeless tobacco use concluded that the use of smokeless tobacco is one of a number of health-endangering behaviors that raise the clear potential for long-term and serious consequences (7).

In 1986, almost 30 years after the Public Health Service's first staternent on the health effects of cigarette smoking, a comprehensive review by the Advisory Committee to the Surgeon General on the health conseouences of using smokelees tobacco concluded the following:

After a careful examination of in relevant epidamiologic, experimental, and clinical data, the committee concludes that the oral use of smokeless tobacco represents a significant health risk. it le not a safe subetitute for smoking cigarettes. It can cause cancer and a number of noncancerous oral conditions and can lead to nicotine addicion and dependence. (11)

The Division of Health, Wisconsin Department of Health and Social Services, a) has suggested that preventive and regulatory actions are needed to offset a trend in smokeless tobacco use that may produce increased oral cancer death rates for this generation of young people, and bi has proposed the following measures (12):

Educational campaigns to increase public oworensss of the possible adverse health effacts caused by smokeless tobacco use. Students, school officials, coaches, and parants should be informed of these health effects.

State laws to prohibit sales to minors. Presently, 14 states have no such law.

Additional excise taxes levied on srnokelesa tobacco products. Presently, 28 states tax smokeless tobacco products.

State laws enacted to prohibit free distribution. Only two states have such a law.

A ban placed on media advertising. A requirement for strong health-warning labels. Increased awareness of health professionals concerning the effects of smokeless tobacco use. Because a subetantial number of pro-adolescent and adolescent males may be regular smokeless tobacco users, oral examinations should be carried out to detect oral lesions.

Primary prevention programs, as well as cessation programs, need to be developed and implemented.

References

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

2. Hunter SMD, Croft JB, Burke GL, Parker FC, Wabber LS, Berenson GS. Longitudinal patterns of cigarette smoking and smokeless tobacco use in youth: the Bogalusa Heart Study. Am J Public Health 1986;76:193-5.

3. Office of the Inspector General and Office of Analysis and Ispections. Youth use of smokeless tobacco: more than a pinch of trouble. Dallas, Texas: US Department of Health and Human Serv- ices, January 1986.

4. Guqqenheimer J, Zullo TG, Kruper DC, Verbin RS. Changing trand of tobacco use in a teenage population in western Pennsylvania. Am J Public Health 1986;76:190-200.

5. Marty PJ, McDermott RJ. Williams T. Patterns of smokeless tobacco use in a population of hich school students. Am J Public Health 1986;76:196-2.

6. Jones RB. Smokeless tobacco: a challenge for the 80's. J Wisconsin Dental Association 1985;10:717-21.

7. National Institutes of Health. Consensus Development Conference statement: health implications of smokeless tobacco use. Bethesda, Maryland: National Institutes of Hearth, 1988: vol.6 No.1.

8. US Department of Agricurture. Tobacco outlook end situation report. Washington, DC: US Department of Agticulture, 1985;1-24. Publication number USDA TS-192.

9. Hoffmann D, Harley NH, Fisenne I, Adams JD, Brunnemann KD. Carcinogenic aqents in snuff. JNCI 1986;76:435-7.

10. Poulson TC, Lindenmuth JE, Greer RO Jr. A comparison of the use of smokeless tobacco in rural and urban teenagers. Ca-Cancer, J Clin 1984;34:248-61.

11. Public Health Service. The health consquences of using smokeless tobacco: a report of the Advisory Committee to the Surgeon General. Bethesda, Maryland: US Department of Hearth and Human Services, April 1988: NIH publication no. 86-2874.

12. Division of Health, Wisconsin Department of Hearth and Social Services. The smokeless tobacco challenge in Wisconsin. Wisconsin Epidemiology Bulletin 1986;8(2):1-3.

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