As television cameras explored the raucous locker rooms of the victors in last year's world series and superbowl, they depicted a quiet kind of drug use that the media have largely overlooked. Alcohol, of course, was clearly there, as delighted sports heroes sprayed champagne all over one another. But another kind of drug was in use there too, and viewers, whether they realized it or not, were being influenced.
This other drug was quietly evident in the lumpy lower lips and sagging jaws of the players who are users of smokeless tobacco. And sadly, these athletes were sending the dangerous signal to TV viewers, especially younger ones, that using smokeless tobacco is an important part of being an athlete.
Young people all too readily pick up this message. When 13-year-old Scan Marsee accepted a free sample of smoke less tobacco at an Oklahoma rodeo, it seemed very natural for him to do so. Many of the other athletes he went to school with already used the stuff. Sean didn't know it, but he was starting down a path of pain, disfigurement, and death. Contracting cancer of the tongue after using smokeless tobacco only five years, he fought a courageous battle for another year before he finally succumbed.
Just before the end, one of Sean's friends asked him if he had any message for his schoolmates. Unable to speak, Sean first scribbled a simple declaration of Christian faith and then wrote three heartfelt words: "Don't dip snuff!"
This message is especially relevant today, because use of smokeless tobacco is mushrooming in the population generally, and especially among youth. The total number of those who currently use smokeless tobacco is unknown, but estimates range from 7 million1 to 22 million. 2 In a report to a consensus development conference at the National Institutes of Health in January 1986, National Institute on Drug Abuse epidemiologist Beatrice A. Rouse pointed out that although smokeless tobacco use was prevalent mostly in the Southern states before 1980, since that time it has spread all over North America.
According to an article in the health publication News and Features: "Chewing tobacco in the United States comes in three forms—plug, twist, or looseleaf. The tobacco can be plain or flavored. Plug chewing tobacco is made of stemless tobacco leaves and flavoring agents that have been pressed into cakes. A portion of the cake is bitten off and held in the mouth or chewed for several hours. . . .
"Snuff is powdered tobacco that can be dry or moist, coarse or fine. In Britain, it is sniffed through the nose. In the United States and Scandinavian countries, snuff is put in the mouth, or 'dipped.' A small portion, or 'pinch,' of a finely ground tobacco is placed in the mouth and held between the lip and gum or cheek and gum." 3
A growing problem among youth
Although the use of smokeless tobacco had not been a pervasive problem among youth in the past, since 1980 the number of adolescent users has grown alarmingly. In Louisiana, for example, the number of White male teenagers who use smokeless tobacco tripled between 1976 and 1981. 4
In a review of eight surveys published between 1981 and 1983, Glover reported that 8 to 10 percent of young males used smokeless tobacco regularly. 5 And another study, of Oklahoma students, found that 13 percent of third-grade males and approximately 22 per cent of fifth-grade males use smokeless tobacco. Thirty-nine percent of eleventh-grade males report the use of smokeless tobacco. 6 A nationwide collegiate survey, which found that 22 percent of college and university males use smokeless tobacco, pointed out that this "indicates that smokeless tobacco is not a rural phenomenon, as initially reported." 7
Whether it is an urban or a rural problem, researchers suggest that peer influence, use of other drugs, and media advertising lie behind the sudden rise in smokeless tobacco use among today's adolescents. Ary and others reported that the primary correlates for smokeless tobacco use were having tried smoking, having a best friend who chewed, and having a number of friends who chew. 8 Dent and others reported that other variables related to the onset of smoke less tobacco use include previous cigarette and alcohol use, having been drunk on liquor, and current marijuana use. 9
One of the most important factors influencing young people to try smoke less tobacco, researchers add, is advertising's use of heros with whom adolescents identify. The list reads like a Who's Who in sports and entertainment. Joe Namath, Catfish Hunter, Carlton Fisk, Tom Seaver, Earl Campbell, Ralph Houk, Shep Messing, Bobby Murcer, Charlie Daniels, George Brett, Terry Bradshaw, and Sparky Lyle have all shilled for the smokeless tobacco industry. At the same time that cigarette advertising has been banned from the electronic media, these stars have been using their influence to persuade children and teenagers—boys especially—to use smokeless tobacco.
In a magazine advertisement, for example, former football and rodeo star Walt Garrison told beginners how to use smokeless tobacco: "just take a small pinch in your thumb and forefinger, and put it between your cheek and gum. Leave it there. No need to chew. The tobacco slowly releases its great flavor, giving you real satisfaction. ... At first you could feel a slight irritation on the gum, and the tobacco may move around your mouth more than it should, and you might work up too much saliva. But learning is part of the fun, and these things pass with practice. Two weeks should make you a pro." 10
The smokeless tobacco industry has often claimed that its major marketing goal was simply to get existing users to switch brands. But this advertisement shows the industry's early emphasis on enlisting new users.
Recently, smokeless tobacco advertising has shifted its emphasis, at least in part because of the reporting of stories such as Scan Marsee's in such popular media as Reader's Digest, Saturday Evening Post, and TV's 60 Minutes. In July 1985 the industry announced a program to dissuade youth from chewing and dipping. It includes public-service announcements to parents, urging them to tell their children not to use smokeless tobacco, supporting making 18 the legal age for smokeless tobacco use, and encouraging retailers to comply more uniformly with age restrictions.
The harmless alternative?
Yet advertising is only one of the reasons for smokeless tobacco's sudden rise in popularity. One of the greatest reasons people are using it more is that they consider it a safe alternative to smoking. A Texas-Oklahoma study of college students found that more than half of them believed that dipping and chewing were less harmful to a person's health than smoking,11 and other studies have indicated the same general attitude among adults. 12
The belief that smokeless tobacco is not as big a health threat as cigarettes may also lie behind the fact that parents seem to be more accepting of their children's use of the former than of the latter. L. Chassin and others reported that only 41 percent of young smokers said their parents were aware of their smoking, whereas 71 percent of chewers said their parents knew of their use of snuff. 13 Clearly, young people don't seem to feel the need to hide their use of smokeless tobacco from their parents.
Yet increasingly, research is finding that smokeless tobacco has effects on the user just as alarming as those of cigarettes. P. J. Marty and others point out, in fact, that "health gains achieved through the decline in the prevalence of cigarette smoking (in recent years) could be negated partially by increased use of smokeless tobacco." 14
In June 1985, U.S. surgeon general C. Everett Koop impaneled a group of medical experts to assess the risks of smokeless tobacco. Such organizations as the American Cancer Society, the American Dental Association, the Coalition on Smoking or Health, and the American Medical Association have been calling for warning labels on smokeless tobacco packages and a ban on advertising these products on television.
At the fifty-fourth annual session of the American Heart Association, W. G. Squires reported that in "men younger than 20 years of age, within 20 minutes of oral snuff usage, heart rates increased from 69 to an average of 88 beats per minute. Average blood pressure readings increased significantly (118/72 to 126/78) during the same period." 15 Furthermore, snuff slows reaction time and "decreases the user's ability to taste and smell bitter, salty, and sweet foods." 16
Arden Christen, chairman of the Preventive Dentistry Department at Indiana University, said that smokeless tobacco causes visible damage in the mouth "in as little as three to four months." 17 For some time dentists have been seeing receding gums, loosened teeth, roughened biting surfaces, and the forrnation of precancerous white patches and lesions in the gums.
Furthermore, though the tobacco industry refuses to admit the connection between smokeless tobacco use and cancer, researchers feel less and less hesitancy to do so. D. M. Winn linked it to oral and pharyngeal cancer, and pointed out that the risk of developing cancer is four times higher among all snuff users and 50 times higher among long-term chronic users. 18 In an editorial in Archives of Otolaryngology, Dr. Byron J. Bailey noted: "There is a time and dose relationship between the use of tobacco and the spectrum of tissue changes through cellular atypia, dysplasia, and carcinoma. The more tobacco used (number of hours per day and the total years of usage), the greater the probability of developing cancer." 19
An article Arden Christen wrote for the June 1981 issue of Listen magazine reported that "the substance nitrosonornicotine (NNN) is the first organic carcinogen isolated from unburned tobacco. This is found in chewing tobacco and snuff, as well as in smoking tobacco, in high concentrations." 20 Furthermore, a reaction of the nitrites and nicotine in the tobacco when mixed with the saliva during chewing produces additional NNN. Researchers have reported that mixing fine-cut chewing tobacco with saliva increases NNN by 44 percent. And tobacco-saliva mixtures contain 1,000 times more NNN than does mainstream tobacco smoke. 21
In 1982 the surgeon general noted that long-term use of snuff "appears to be a factor in the development of cancers of the oral cavity, particularly cancer of the cheek and gum." The International Agency for Research oh Cancer added in 1984 that there is "sufficient evidence that oral use of snuffs of the types commonly used in North America and Western Europe is carcinogenic to humans" and that "there is a causal relationship between the exposure and human cancer." 22
"This new generation of snuff dippers and tobacco chewers," comments Guggenheimer, "has now become exposed to potential carcinogens which, in con junction with other mediators, particularly alcohol, are considered to be the primary risk factors for cancer of the upper aerodigestive tract. They will also be subjected to the cardiovascular effects from the nicotine in these products." 23
Nicotine's addictive qualities only intensify these problems. Jack E. Henningfield, chief of the biology of dependence laboratory at the National Institute on Drug Abuse (NIDA), reported at the NIH Consensus Development Conference, "A systematic analysis suggests that tobacco. shares the effects that define compulsive use of opioids and other drugs." And recent studies at the Addiction Research Center 24 have found that nicotine meets critical criteria for a dependence-producing drug in that "it was found to be discriminated and/or psychoactive in both humans and animals; it was found to be a euphoriant for drug abusers, with a cocainelike profile of effects; and it was shown to serve as a biologic reinforcer for both humans and animals." 25
Elbert Glover recently conducted two clinics to help smokeless tobacco users quit their habit. Within four hours of their attempting to give it up, all but one of the 41 participants had begun using smokeless tobacco again. "This . . . means that smokeless can be highly addictive," Dr. Glover commented. 26
"Ironically," Dr. Bailey wrote in his editorial, "if the pharmaceutical industry developed a new drug to fight cancer, it would require many years and many millions of dollars to make that drug accessible to the public. The safety of the drug would have to be proved beyond any doubt. By contrast, we have an industry that is being permitted to market tons of carcinogenic tobacco products annually, to focus much of its advertising effort on our youth, and to take the stance that biomedical researchers have not yet brought forth enough evidence to warrant controls and product warning labels." 27
While all of the evidence of the harmful effects of smokeless tobacco use continues to come in, thousands of victims will learn, as Sean Marsee tragically did, that smokeless tobacco is a dangerous substance. As Gregory Connolly, director of the dental division of the Massachusetts Department of Public Health, was quoted in a Time magazine article: "There is a chemical time bomb ticking in the mouths of hundreds of thousands of boys in this country." 28
1 C.A. Squier, "Smokeless Tobacco and Oral
Cancer: A Cause for Concern?" Cancer 34 (1984):
2 S. Harper, "In Tobacco, Where There's
Smokeless Fire," Advertising Age 51 (1980): 85.
3 C. Trotman, "Smokeless Tobacco Use—On
the Rise—and Linked With Oral Cancer," News
and Features 86 (1986): 2, 3.
4 S. Mac D. Hunter et al., "Longitudinal
Patterns of Cigarette Smoking and Smokeless
Tobacco Use in Youth: The Bogalusa Heart
Study," American Journal of Public Health 76
5 E. D. Glover et al., "Smokeless Tobacco
Research: An Interdisciplinary Approach," Health
Values: Achieving High Level Wellness 8 (1984):
6 E. D. Glover et.al., "Prevalence of Smokeless
Tobacco Use in Oklahoma Public Schools" (sub
mitted for publication, East Carolina University).
7 E. D. Glover et al., "Smokeless Tobacco Use
Trends in the United States" (submitted for
publication, East Carolina University).
8 D. V. Ary et al., "Concurrent Correlates and
Prospective Factors Associated With Smokeless
Tobacco Use Among Adolescents" (paper pre
sented at the 1985 annual convention of the
American Psychological Association, Los
9 C. W. Dent et al., "Adolescent Smokeless
Tobacco Incidence: Relations With Other Drugs
and Psychosocial Variables" (submitted for publication).
10 Walt Garrison Answers Your Questions
About Moist Smokeless Tobacco, " advertisement
in Parade, Sunday supplement, June 8, 1980.
11 Glover, "Smokeless Tobacco Use Trends."
12 See E. Lichtenstein et al., "Chewing Tobacco
Use by Adolescents: Prevalence and Relation to
Cigarette Smoking," Addictive Behaviors 9,(1984):
351-355; L. Chassin et al., "Psychosocial Corre
lates of Adolescent Smokeless Tobacco Use,"
Journal of Consulting and Clinical Psychology (in
press); and S. Schinke et al., "Smoked and
Smokeless Tobacco Use Among Adolescents:
Trends, Explanations, and Prevention Out
comes," Public Health Reports (in press).
14 P. J. Marty et al., "Patterns of Smokeless
Tobacco Use in a Population of High School
Students," American Journal of Public Health 76
15 A. G. Christen et al., "Smokeless Tobacco: The Folklore and Social History of Snuffing,
Sneezing, Dipping, and Chewing," Journal of the
American Dental Association 105 (1982): 821-829.
16 A. G. Christen, "The Case Against Smoke
less Tobacco: Five Facts for the Health Professional
to Consider," Journal of the American Dental
Association 101 (1980): 464.469.
17 In C. Wallis, "Into the Mouths of Babes,"
Time, July 15, 1985, p. 68.
18 D. M, Winn et al., "Snuff Dipping and Oral
Cancer Among Women in the Southern United
States," New England Journal of Medicine 304
19 B. J. Bailey, "We Must Stop Selling Cancer to
Our Children," Archives of Otolaryngology 111
(1985): 637, 638.
20 A. G. Christen, "The Facts About Smokeless
Tobacco," Listen, June 1981, pp. 9, 10.
22 D. Hofftnan, "The Identification of Carcino
gens in Smokeless Tobacco," Program and
Abstracts, NIH Concensus Development Conference
on Health Implications of Smokeless Tobacco, January
13-15, 1986, p. 48.
23 J. Guggenheimeretal., "Changing Trends of
Tobacco Use in Western Pennsylvania," American
Journal of Public Health 76 (1986): 196, 197.
24 See D. R. Jasinski et al., "Abuse Liability
Assessment in Human Subjects," Trends in Pharmacological
Sciences 5 (1984): 196-200; j. E.
Henningfield, "Pharmacologic Basis and Treat
ment of Cigarette Smoking," Journal of Clinical
Psychiatry 45 (1985): 24-34; and]. E. Henningfield
et al., "Abuse Liability and Pharmacodynamic
Characteristics of Intravenous and Inhaled Nico
tine," Journal of Pharmacology and Experimental
Therapeutics 234 (1985): 1-12.
25 J. E. Henningfield, "Evidence That Smoke
less Tobacco Use May Lead to Dependence,"
Program and Abstracts, NIH Consensus Development
Conference on Health Implications of Smokeless
Tobacco, January 13-15, 1986, pp. 95-101.
26 Quoted in J. Fincher, "Sean Marsee's Smoke
less Death," Reader's Digest, October 1985, p. 111.