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The prevalence of smokeless tobacco use among adolescent male athletes
A R T I C L E S
Smokeless tobacco currently presents a health problem for millions of Americans, and its use appears to be continually growing in popularity. The purpose o f this study was to determine the prevalence of smokeless tobacco m e among adolescent athletes, the charac teristics of its use, and the prevalence of associated abnormal mucosal findings. Study results indicate that health care providers—in particular, dentists—m ust take a more active role in educating and monitoring patients who use smokeless tobacco.
The prevalence of smokeless tobacco use among adolescent male athletes Curtis J. Creath, D M D Whitney O. Shelton, D D S J. Timothy Wright, DDS, M S
Dorothy H. Bradley, M S Ronald A. Feinstein, M D John F. Wisniewski, D M D
m okeless tobacco—b o th chew ing to b a c c o a n d s n u f f — c o n t a i n s tobacco leaf plus sweeteners, scents, and flavorings. In chew ing tobacco, the leaf m ay be shredded (loose leaf), pressed in to bricks or cakes (plugs), o r dried an d tw isted in to strands (twists). A portion is either chewed or held in place in the oral vestibule. Snuff is purchased in a sm all ro u n d can or tin, and is supplied in dry an d m oist form s of pow dered or finely cut tobacco leaves. Both types are used in the m o u th (“d ip p ed ”) by holding a sm all am o u n t between the gingiva and lip or cheek. T h e tobacco m ixes w ith saliva, r e s u ltin g in a b s o rp tio n of n ic o tin e th r o u g h th e o r a l m u c o sa in to th e bloodstream .1 F req u ent users of smokeless tobacco have a n increased risk of developing local ized gingival recession, oral leukoplakia, an d oral cancer.2 L eukoplakia can trans form in to oral cancer in about 3% to 5% of cases.3 O ropharyngeal cancer accounts for 3% of all cancers in the U nited States and is the seventh m ost com m on form of cancer. In the U nited States, 11 of every 100,000 people eventually have some form
of o ral cancer. In 1985, new cases of oral cancer totaled 28,500, w ith 9,500 people d ying from oropharyngeal cancer.4 Smok in g is the cause for m ost of these cases; however, an increased risk for smokeless tobacco users has been established.5 C ur ren t data are insufficient to su p p o rt an association of smokeless tobacco use w ith gingivitis, perio d o n tal disease, or dental caries.2 O ther health problem s related to smoke less tobacco use are associated w ith the n icotine levels found in the bloodstream . A ssum ing a daily co n su m p tio n of 10 g of smokeless tobacco, the h ab itu al user can be exposed to 130 to 250 m g of nicotine per day. Sim ilarly, a person sm oking one p ackage of cigarettes daily w o u ld be exposed to 180 m g n ic o tin e per day (assum ing 9 m g of nicotine per cigarette).2 In bo th types of tobacco use, sim ilar lev els of nicotine can be delivered to the cen tral nervous system. It is likely th a t those h ealth consequences of sm oking caused by n ico tin e w o u ld also be associated w ith smokeless tobacco use, as nicotine expo sure from smokeless tobacco is sim ilar in m a g n itu d e to n ico tin e exposure from
S
sm oking. Studies are b eg in n in g to dis close som e of the m ore acute effects of sm okeless tobacco use. T h e p ro b lem s in clu d e sig n ifican tly decreased cardiac stroke volum e and cardiac o u tp u t,6 in creased h eart rate an d blood pressure,7 a n d in c re ase d ep iso d es of d izzin ess.8 C h ro n ic consequences of possible coro nary artery disease, p erip h eral vascular disease, an d p eptic ulcer disease as w ell as developm ent of tolerance psychological d ep endence, a n d phy sical dependence sh o u ld also raise serious h ealth concerns regarding the use of smokeless tobacco.2 C hem ical analysis of various types of smokeless tobacco has show n the presence o f p o lo n iu m -2 1 0 , a rad io a ctiv e alp h a em itter an d k now n rad iatio n carcinogen. Also, two other classes of chem ical car cinogens have been detected—the polycyclic arom atic hydrocarbons an d the nitro sam in es.9 T h e total co n cen tratio n of tobacco-specific nitrosam ines in com m er cial snuff ranges from 5,280 to 141,000 p arts per b illio n .10,11 T h ese levels are ten to 100 tim es h ig h er th a n levels in the in h a led sm oke of one cigarette, an d 500 o r m o re tim es h ig h e r th a n th e level JADA, Vol. 116, Ja n u a ry 1988 ■ 43
ARTICLES
allow ed in some consum er products by the US Food and D rug A dm inistration a n d th e D e p a rtm e n t of A g ric u ltu re .5 Congress has restricted both agencies from r e g u la tin g th e p ro d u c tio n o f tobacco products, however. In spite of these h ealth risks, chew ing tobacco an d snuff have recently em erged as p o p u la r products for the first tim e since the tu rn of the century. In the U n it ed States, smokeless tobacco production declined steadily from 1930 u n til the late 1960s. However, since 1968, production has increased 42%, reaching 135.6 m illion lb in 1985.2 M uch of this increase has occurred d u rin g the past decade, a period in w hich smokeless tobacco products have been p rom oted by fam ous athletes and m u sic ia n s. T h e to b a cc o in d u stry h as ap p aren tly been successful in establishing a m o re p o s itiv e im a g e for sm okeless tobacco th ro u g h skillful advertisem ent.3 T h e steadily increasing use of sm oke less tobacco am o n g y o u n g males has recently becom e a subject of national investigation. For instance, the Bogalusa H eart S tu dy12 found 11.3% of w hite 8- to 9-year-old m ales u sin g smokeless tobacco in 1976-77 as com pared w ith 23.8% in 1981-82. For 14- to 15-year-old males, the rate changed from 23.9% to 43.4% in 198182. O ther local surveys have found that 8% to 36% of m ale hig h school and college students th ro u g h o u t the U nited States are reg u lar users of smokeless tobacco.12 21 T h e 1985 N atio n al H ousehold Survey on D ru g Use provides the only n atio n al p ro b ab ility data on the use of smokeless tobacco by y o u th .22 T h e results of this study indicate that 16% of males between the ages of 12 a n d 25 used som e form of smokeless tobacco in the preceding year, an d 5% to 8% used it at least once a week. Fem ales of all ages reported less use than m ales, w ith ab o u t 2% h av in g used sm oke less tobacco d u rin g the previous year.22 If these estim ates are ap p lied to current p o p u la tio n figures,23 m ore th an 12 m il lio n people aged 12 or older in the U nited States used some form of smokeless tobac
co last year, an d ab o u t 6 m illio n people used it regularly (at least weekly).22 T h e highest user rates have been reported in the South and West, an d the lowest in the N ortheast. Inform ation ab o u t smokeless tobacco use by eth n ic an d racial back g round indicates th a t rates for youth are sim ilar am o n g w hites an d H ispanics. N ative A m erican rates are consistently higher th an those for w hites, an d in m ost locales use appears less am o n g Asians and blacks.5 Smokeless tobacco use is believed to be m ore prevalent in rural p o p u la tio n s, sm all co m m u n ities, an d areas where smokeless tobacco use is co n sidered trad itio n al.5,24 Peers an d fam ily members are consistently cited as im p o r tant influences on smokeless tobacco use by children and adolescents.25 T h e purpose of this study was to survey adolescent football players in the B irm ing ham , AL, area regarding experience w ith and perceptions of smokeless tobacco use, and to determ ine the prevalence of asso ciated oral lesions. Methods and materials A total of 995 adolescent m ale football players, representing 24 local h ig h schools and two ju n io r h ig h schools, p articipated in a preseason m edical an d dental screen in g conducted at the Adolescent Medicine C linic in the C h ild re n ’s H o sp ital of A la bam a. T h e p u rp o se of the dental screen in g was to exam ine each player for the presence of caries, dental fractures, or other oral disease th a t could com prom ise the a th le te ’s p erfo rm an ce d u rin g the upcom ing play in g season. Before the d en tal e x a m in a tio n , each participant was confidentially interviewed by one of six dentists u sin g a standardized questionnaire. T h e questionnaire included 11 m ultiple-choice an d open-ended ques tions regarding his experience w ith smoke less tobacco. E ach ath lete was asked whether he ever dipped or chewed tobacco, if any fam ily mem bers dipped, an d if he was aw are of any h a rm fu l effects of
smokeless tobacco. T hose w ho had tried smokeless tobacco were also asked ad d i tional questions p ertain in g to its use, in c lu d in g w hen they had first tried it, how lo n g they had used it, an d the am o u n t they had used. After the interview, each athlete was exam ined, u sin g a tongue blade an d a floor light. Any m ucosal alterations were exam ined by a second dentist. O nly c lin i cally evident m ucosal changes were re corded. T h e questionnaires were tabulated and the results statistically analyzed using X2 tests.
Results T h e 26 schools p articip a tin g in the study represented a cross section of backgrounds in term s of predom inantly black, predom in a n tly w h ite , a n d ra c ia lly b alan ced schools, ru ral an d u rban schools (mostly urban), an d low, middle, an d h ig h income areas. T h e p articip an ts ranged in age from 11 to 18 years, w ith a m edian age of 15.25 years. T h e racial d istrib u tio n was: white, 469; black, 521; an d other, 5 (for exam ple, Asian). T h e prevalence of smokeless tobacco use is sum m arized in T ab le 1. T h e survey indicated 300 of the total sam ple (30.2%) h ad tried u sin g some form of smokeless tobacco w ith 83 (8.34%) of the athletes being cu rren t users. T h e racial difference is rem arkable w ith 55.6% of the w hite a th letes having tried smokeless tobacco and 16% being cu rren t users. In contrast, 7.3% of the black athletes h ad tried smokeless tobacco an d only 1.5% were current users. R egarding the d u ratio n of tobacco use, 197 of the 289 dippers (68.2%) d id so for less th an 6 m onths. M any people in this category had experim ented o nly once or twice (Table 2). T ab le 3 describes the age d istrib u tio n of in itial smokeless tobacco use. T ab le 4 sum m arizes the frequency of sm okeless tobacco use. O f those w ho dipped, 229 (79.2%) dipped less th an 1
Table 1 ■ Use of smokeless tobacco.
Race
Sam ple size
W hite Black O ther T o ta l P ercent o f total sam ple
44 ■ JA DA, Vol. 116, Ja n u a ry 1988
469 521 5 995
H ave tried d ip p in g smokeless tobacco
Are currently chew ing, b u t have never d ip p ed
T o ta l users (dippers an d chewers)
C urrently d ip p in g o r chew ing or both
255 (54.37%) 33 (6.33%) 1 (20.00%) 289 29.05
6 (1.28%) 5 (0.96%) 0 (0.00%) 11 1.11
261 (55.65%) 38 (7.29%) 1 (20.00%) 300 30.15
75 (15.99%) 8 (1.54%) 0 (0.00%) 83 8.34
ARTICLES
h o u r per day. A gain, m ost of these were one- or tw o-tim e users. R egarding the q u an tity of tobacco, 226 (78.2%) of the dippers used less th an one tin per week (Table 5). Some athletes reported heavy usage of u p to 6 hours per day or five tins per week. T h e influence of smokeless tobacco use by fam ily m em bers show ed 31.4% of the users reported fam ily mem bers w ho also dipped, and 68.5% w ith no fam ily users. O f the n o n d ip p e rs, 20.5% h ad fam ily dippers an d 79.4% w ith no fam ily dippers. W hen asked w h at was the m ost in flu e n tial reason they started d ip p in g , the a th letes cited: friends (59.9%), family members (9.7%), advertisem ents (4.5%), coaches (1.4%), to stop sm oking (1.4%), an d other (24.6%). W hen the athletes were asked if they believed d ip p in g tobacco could be h arm ful to their health, 53.9% strongly agreed, 39.8% agreed, 5.5% disagreed, an d 0.8% strongly disagreed. Therefore, 93.7% be lieved smokeless tobacco could be h arm ful an d 6.3% did n o t believe it could be harm ful. Cancer was the answer given by m ost respondents w hen asked w h at the harm ful effects were. In com paring the current use of smokeless tobacco w ith the u ser’s aw areness of harm ful effects, 49 (92.5%) of the current users were aw are of possible harm ful effects from smokeless tobacco and four (7.5%) were not. T he students were also asked if they had heard, seen, or read ab o u t possible h arm fu l effects of smokeless tobacco. Of the entire sam ple, 77.8% reported they had heard som ething about harm ful effects b u t 22.2% had not. T hose w ho had heard of the ill effects were asked w hat was their source of in fo rm atio n (T able 6). T elevision, school, friends, an d magazines were the top four sources of inform ation cited. E x am in atio n for ab n o rm al m ucosal findings disclosed 69 abnorm al co n d i tions, 34 of w hich were found in dippers at the site of tobacco placem ent. L euko p la k ia, g ingival recession, and rolled gingival m argins were the specific altera tions b eing evaluated. T h e prevalence of o ral m ucosal changes is rep o rted in T ables 7 and 8.
Table 2
■ Duration of dipping smokeless tobacco.
T im e < 6 mo 6 to 12 m o 1 to 2 yr > 2 yr
D ippers (no.)
All d ip p ers (%)
197 29 23 40
68.2 10.0 8.0 13.8
Table 3 ■ Age at which dipping smokeless tobacco was first tried.
(yr)
R espondents (no.)
D ippers (%)
C um ulative dippers (%)
< 11 11 12 13 > 13
37 19 46 62 125
12.8 6.6 15.9 21.5 43.2
12.8 19.4 35.3 56.8 100.0
Age
T ables 9 and 10 com pare the prevalence of specific m ucosal fin d in g s w ith the d u ratio n an d am o u n t of tobacco use. T h e m ost notable associations are th at leukoplakic areas occurred m ost in dippers who used m ore th an three tins per week an d in those d ip p in g longer th an 2 years (Fig 1).
Discussion M any of the findings o btained in this study su p p o rt earlier studies conducted in the U nited States as well as add to the current u n d erstan d in g regarding smoke less tobacco use. T h is investigation found 30.15% of adolescent football players had tried smokeless tobacco at least once and 8.34% of a ll players are still cu rren tly u sin g these products. However, these fig ures do n o t accurately disclose a true de scription of use because they do n ot in d i cate the p rofo u n d racial differences. T h is racial difference was rem arkable w ith 56% of the w hite athletes and only 7% of the b lack a th le te s h a v in g trie d sm okeless tobacco. In ad dition, 16% of whites (one in every six) an d 1.5% of blacks were cur re n t users. A N o rth C a ro lin a stu d y 26 show ed 34.6% of w hite m ale an d 14.9% of black m ale seventh grade students had tried smokeless tobacco, an d 14.4% of the w hite m ale sam ple an d 1.9% of the black males were current users. T w o im p o rta n t p o in ts can be draw n from these reports. First, any investiga tions studying smokeless tobacco use m ust include an exam ination of the differences am o n g racial an d eth n ic g roups to obtain an a c c u ra te a c c o u n t of a c tu a l usage. Second, this study fo u n d th a t m ore than one in four of the athletes w ho tried smokeless tobacco w ould become regular users. In the N o rth C aro lin a report, this rate was alm ost 50%. Direct com parison of this study w ith others is difficult because of differences in survey techniques an d varied com bina tions of race, age, an d gender. Most stud ies are n o t w ell defined racially or do not c o n t a i n s u f f i c i e n t s a m p le sizes of other races to propose conclusions about
this variable. In term s of reg u lar (current) users, the rate of 8.34% isolated in this study is sim ilar to several other studies.13,21,27,28 Many o th er investigations have found higher prevalences of reg u lar users. T h ree repre sentative studies w ith h ig h er user rates from o th er areas of the co untry are 36.7% of m ale tenth- th ro u g h 12th-grade stu dents (A rkansas),15 31% of m ale seventhth ro u g h ten th -g rad e students (O h io ),29 an d 12% to 15% of fifth- th ro u g h sixthgrade students as reg u lar smokeless tobac co users (W ashington).19 O ther studies range from 7% to 33%.14,19,30' 32 T h e age at w h ich athletes first tried smokeless tobacco was usually before start in g h ig h school, w ith 56.8% try in g it by age 13. T h is is sim ilar to a T exas study27 in w hich 55% of reg u lar users began before 13 years of age. A lth o u g h the students were n o t asked specifically ab o u t th eir fam ily incom e, by estim ating com m unity in fo rm atio n su p p lie d by the B irm in g h a m C h am b er of Com merce, schools were assigned as p re d o m in an tly serving either low- (less th an $15,000 per year), m edium - ($15,000 to $25,000), or h ig h - (greater th an $25,000) incom e level families. Many of the schools w ith the h ighest percentage of users were
Table 4
■ Frequency of dipping tobacco.
Frequency < 1 h r/d a y 1 to 2 h rs/d a y 3 to 4 h rs/d a y > 4 h rs/d ay
Table 5
D ippers (no.)
All dippers (%)
229 42 5 10
79.2 14.5 1.7 3.5
■ Amount of tobacco dipped.
T in s (no.) < 1 tin /w k 1 tin /w k 1 to 2 d n s /w k > 3 tin s/w k
D ippers (no.)
All dippers (%)
226 32 19 12
78.2 11.1 6.6 4.1
C reath-O thers : PREV A LEN CE O F SM OKELESS T O B A C C O USE IN A T H L E T E S ■ 45
A R T I CL E S
from m edium an d h ig h incom e areas of prim arily w hite p opulations. Therefore, a low level of fam ily incom e did n o t cor resp o n d to an increased prevalence of smokeless tobacco use am ong adolescent males. In contrast w ith other reports, this study found a sim ilar prevalence of sm oke less tobacco use between u rban and rural schools.5'13’21'31 T h e im portance of peer influence in in itia tin g smokeless tobacco cannot be overem phasized. T h e racial differences (and gender in several studies),19’21’26’31'32 the clusters of d ippers in certain schools, as well as the direct answers from users in this study, p o in t to influence of peers as the m ajo r reason for trying smokeless tobacco. T h is study fo u n d 59.9% began u sing smokeless tobacco because of friends and
Table 6 ■ Sources of information re garding harmful effects of smokeless tobacco. M edium T elevision School Friends M agazines P arents B oo k s/p am p h lets N ew spaper/ad s K now people w ith cancer D entists R elatives C oaches C h u rc h /c a m p P hysicians U nknow n C om m on sense
R espondents (no.)
R espondents (%)
267 225 51 50 44 27 20
34.3 29.1 6.9 6.6 5.8 3.5 2.6
19 17 14 11 8 5 3 1
2.5 2.2 1.8 1.4 1.0 0.6 0.4 0.1
Table 7 ■ Prevalence of abnormal mucosal findings in dippers. F in d in g L e ukoplakia G ingival recession R olled ging iv al m argins O ther T o ta l
Frequency
D ippers (%)
15 1
5.2 0.3
9 9 34
3.1 3.1 11.8
Table 8
■ Prevalence of abnormal mucosal findings in nondippers.
F in d in g L eukoplakia G ingival recession R olled gingival m argins O ther T o ta l
Frequency
N ondippers (%)
1 0
0.1 0
24 10 35
3.4 1.4 4.9
46 ■ JADA, Vol. 116, Ja n u a ry 1988
Table 9 ■ Comparison of mucosal findings to tins per week in dippers. F in d in g L e u k o p lak ia G in g iv al recession R olled gingival m argins O th er
Table 10
< 1 tin /w k
1 tin /w k
2 tin s/w k
> 3 tin s/w k
2 0 7 7
2 0 2 1
3 0 0 1
8 1 0 0
■ Comparison of mucosal findings to duration of use in dippers.
F in d in g L eu k o p lak ia G in g iv al recession R olled gin g iv al m argins O th er
<6 m onths
6 to 12 m onths
1 to 2 years
>2 years
3 0 6 7
2 0 1 1
2 0 0 0
8 1 2 1
9.7% because of family members. O nly 4.5% of the dippers said they started using smokeless tobacco because of advertise m ents. T hese results are sim ilar to those of G uggenheim er an d cow orkers30 who found th a t 63% began th ro u g h peer in flu ence and 4% from advertising, an d M arty a n d cow orkers15 w ho fo u n d th a t 52% began th ro u g h the influence of friends an d 3% from advertisem ents. It does n o t ap p e ar that advertising of smokeless to bacco has in itiated the use of smokeless tobacco by adolescent males, b u t rath er has created an atm osphere in w hich it is acceptable and even desirable to do so. In this study, 30% of dippers had family m em bers w ho d ipped an d 20% of n o n dippers had fam ily members w ho were dippers. It seems th at usage of smokeless tobacco by fam ily members has lim ited value in predicting people at risk for in itiatin g smokeless tobacco use. A study by Chassin an d cow orkers24 exam ined adolescent perceptions of those w ho use smokeless tobacco. T h e respon dents described chewers as less phony, more self-confident, m ore p o p u lar, more h ard w o rk in g , m ore ath letic, m ore relaxed, h ap p ier, braver, h ealth ier, u sin g drugs less, lik in g the co u n try m ore, g e ttin g alo n g better w ith family, d o in g better at schoolw ork, an d being m ore conservative than smokers. T h is points tow ard success ful assim ilatio n of ad v ertisin g -in sp ired ideas. T h e students also said chew ing was m ore acceptable to parents, friends, an d school personnel th an smoking. T h e total weekly co n su m p tio n a n d d u ratio n of smokeless tobacco use in this study appeared m oderate as com pared w ith other investigations. O nly 13.8% of the d ippers h ad co n tin u ed for m ore th an 2 years. T h e C olorado study found th at m ore than 50% an d the A rkansas investi g atio n reported m ore th an 60% of dippers u sin g smokeless tobacco m ore th a n 2
years.15,31 In the present study, m ost regu lar users d ip p ed tobacco 1 to 2 h o u rs per day, an d the average use in the C olorado study was between 2!4 to Vh h ours per day. O ther studies have asked the respondents how m any chews per day o r week they used to determ ine the am o u n t of tobacco exposure.31 T h e present study used hours per day a n d tins per week to ascertain the o ra l m u c o sal e x p o su re to sm okeless tobacco. C h r is te n 33 d escrib ed th e fo u r m o st co m m o n in tra o ra l fin d in g s of ch ro n ic smokeless tobacco users as: gingival reces sion, leukoplakia, breakdow n of the p eri o dontium , an d tooth abrasion. O verall, abnorm al m ucosal findings in this study were found in 22% of the dippers an d in only 6% of the nondippers. T h e incidence of leukoplakia in this study was m uch h igher in dippers th an in nondippers. L eukoplakic lesions were seen in 5.2% of those w ho had ever dipped, b u t o nly 0.1% of n o n d ip p ers had such lesions. T h e re fore, a 50-fold increase of oral le u k o p la kia was seen in dippers as com pared w ith nondippers. O f current dippers, 15% had observable oral leukoplakia. T h is com p are s w ith an 8% rate of le u k o p la k ia found in smokeless tobacco users by Axell an d cow orkers34 an d w ith C hristen an d associates35 w ho found n in e of 14 college athletes u sin g smokeless tobacco had leu koplakia lesions. A relatio n sh ip was found between b oth the d u ratio n an d the q u an tity of sm oke less tobacco exposure w ith the presence of o ral leukoplakia. T h is study fo u n d a greater incidence of leukoplakia in a th letes w ho used m ore th an three tins per week an d in those w ho were users for m ore th a n 2 years. T hese two param eters, tin s per week an d span of use, show ed parallel findings in this study regarding the presence of o ral le u k o p la k ia an d m ig h t provide some guidance in p redict
A R T I C L E S
in g the likelihood of the developm ent of le u k o p lak ia. P o u lso n a n d associates31 found the average exposure of dippers w ith abnorm al m ucosal alterations was greater (205 m in /d ay , 3.3 years of use) th an those in w hom n o alterations were found (110 m in /d ay , 2.3 years of use). T h e increased incidence of leukoplakia in dippers should be of serious concern. T h e fact that males are begin n in g to use smokeless tobacco at a younger age could m ean a longer period of use and oral exposure to tobacco, thus increasing their chances for oral pathological conditions. T h e body of evidence seems to show some level of co rrelation between smokeless tobacco use an d oropharyngeal cancer. Earlier studies35 44 have show n a m alig n an t transform ation rate of oral leuko plak ia of 0.13% to 17.5%, w ith an average of 3% to 5%. C hristen45 cites 646 cases of cancer of the m o u th , pharynx, or larynx in N o rth A m erican smokeless tobacco users between 1915 a n d 1972. O ther more recent cases have also been reported.46' 48 It is im p o rta n t to be cognizant that the h ealth concerns regarding smokeless to bacco are n o t centered aro u n d ju st the long-term consequences of leukoplakia an d oral cancer. C ardiovascular and cen tral nervous system effects described ear lier can be seen d u rin g short-term usage. A th letic coaches sho u ld be concerned about w hat consequences these effects will have on athletes’ perform ance. T h e re la tio n s h ip betw een sm okeless tobacco an d sm oking tobacco cannot be ignored. As noted earlier, m any students believe smokeless tobacco is m ore accept able th an sm oking tobacco. O f the d ip p ers in th is stu d y , 1.4% b eg a n u sin g smokeless tobacco in order to stop sm ok ing. W hen A rkansas students were asked w hy they co n tin u ed to use smokeless tobacco once they began co n su m p tio n , 38.4% said it was because of the relaxation they felt, 17.1% cited enjoym ent, and 15.8% said good taste was the m ajor influence.15 T hese are often the same reasons given by sm okers w ho continue their habit. In a lo n g itu d in al W ashington investigation,19 one th ird of those w ho sm oked also began to chew tobacco after 2 years, an d two thirds of smokeless users began to smoke. T h e use of one type of tobacco does not ap p ear to preclude the use of another type. Because of the sim ilar nicotine lev els of b o th types of tobacco, it is ques tionable w hether smokeless tobacco is a better substitute. As the evidence points to n eith er sm oking nor smokeless tobacco as bein g a safe alternative, the conclusion of Chassin an d cow orkers24 seems appropri-
smokeless tobacco use an d m o n ito rin g any tissue changes th a t m ig h t occur or p ro gress because of p rolonged use. E ducation th ro u g h dental school cu rricula an d co n tin u in g education program s sh o u ld be used to increase the aw areness an d p artic ip atio n of all dental professionals in deal in g w ith sm okeless tobacco use an d its c o n seq u e n ces o n th e o ra l h e a lth of patients. F ig 1 ■ M ild o ra l le u k o p la k ic lesion seen in a 16-
Summary
year-old m ale . T h i s w as typ ica l of the lesions seen in the athletes in th is stud y. A s sa liv a co llects, the tooth becomes discolored.
ate: “ Intervention program s m ust address bo th types of tobacco so th at one is not substituted for an o th er.” Any p ro g ra m s for in terv en tio n an d prevention m ust have specific strategies if there are any real hopes for success. M uch of the info rm atio n gained from this an d other studies h elp identify some of these strategies. First, these program s sh o u ld be targeted at hig h -risk groups. In the Bir m ingham , AL, area, for exam ple, w hite males younger th an 13 years w ould be the m ain target group. In addition, the role of peer influence in the use of smokeless tobacco is considerable an d m ust be taken in to account in any intervention/prevention program . Incorporation of peer-interaction com ponents appears essential. A W ashington stu d y 19 showed some prom is in g results w hen this appro ach was tried. Inform ation ab o u t the harm fu l effects of smokeless tobacco still needs to be dis sem inated to certain segments of the p u b lic. Perceived or actu al acceptance of smokeless tobacco by parents, teachers, a n d coaches w arrants specific inform ation to be shared w ith these people w ho are influential in the lives of adolescent users. An increased role by h ealth professionals, in c lu d in g dentists, m ust be emphasized. H ealth professionals and their respec tive organizations have begun to take a m ore active role, b u t expanded efforts are still needed. W ith smokeless tobacco use rates am ong yo u n g males of 10% to 30% th ro u g h o u t the country, it appears that dentists are treating at least some of these users in their practices. In this study, however, only 1.4% of the dippers were inform ed ab o u t smokeless tobacco’s h arm less effects from dentists an d only 0.6% told by physicians. A lth o u g h dentists cannot m ake patients change their tobacco use habits, as h ealth care providers they are obligated to take active roles in inform in g patien ts of the p o te n tia l risks of
In assessing the prevalence an d percep tions of use of smokeless tobacco am o n g adolescent m ale athletes, several findings have p u b lic h ealth im plications. A lm ost a th ird of the sam ple h a d tried smokeless tobacco an d 8% were cu rren t users. R acial differences between blacks and w hites were rem arkable. Differences in incom e strata an d u rb a n /ru ra l settings were n o t significant. Peer influence was the m ajor factor th at in itiated smokeless tobacco use. A bnorm al m ucosal findings were m uch m ore prevalent in those w ho had dipped smokeless tobacco th an in those w ho had not. M ost sig n ifican t was a prevalence of oral leu k o p lak ia in 5.2% of those w ho had ever dipped, w hich was 50 times th a t of nondippers. U sin g smokeless tobacco for m ore th an 2 years or u sin g m ore th an three tins per week seemed to be of possi ble predictive value regarding the in c i dence of oral leukoplakia. Fifteen percent of cu rren t users h ad observable leu k o plakia. C o m p o n e n ts necessary for effective in te rv en tio n /p re v en tio n program s were e lu c id a te d w ith an e m p h a sis o n an increased role by dentists an d other health professionals. ----------------------- J A D A ----------------------T h e a u th o rs th a n k Drs. C huck S h a n n o n , T im o th y M cN utt, an d Ken C o ch ran for th eir assistance in ex am in in g the athletes. T h e a u th o rs also th a n k the staff a n d volunteers of the division of adolescent m ed icine, d ep artm en t of pediatrics, U niversity of A labam a B irm in g h am , for th e ir h e lp d u rin g the exam in atio n s, B arbara M ullis for assistance in p re p a ra tio n of the m an u scrip t, a n d the U niversity of A labam a, B irm in g h a m d e p a r tm e n t o f m e d ic a l p h o to g r a p h y a n d graphics. Dr. C reath is resident, d epartm ent of pediatric d e n tistry, School of D entistry, U niversity of A labam a a t B irm ingham . Dr. S helto n is in private practice, p e d i atric dentistry, H u n tsv ille , AL. Dr. W right is assistant professor, d e p artm e n t of pediatric dentistry, School of D entistry, U n iv e rsity o f A labam a a t B irm in g h a m , Box 89, U niversity S tation, B irm ingham , A L 35294. Ms. B radley is in stru c to r, d ep artm e n t of e p id e m io l ogy, School of P u b lic H ealth , U niversity of A labam a a t B irm ingham . Dr. F einstein is a ssistant professor, division of adolescent m edicine, d epartm ent of p e d i
C reath -O th ers : PREV A LEN CE O F SM OKELESS T O B A C C O USE IN A T H L E T E S ■ 47
A R T I C L E S
atrics, U niversity of A labam a H ospitals. Dr. W isniew ski is in stru c to r, d e p artm e n t of op erativ e dentistry, school of den tistry , U niversity of A labam a a t B ir m in g h am . Address requests for re p rin ts to Dr. W right. 1. In te rn a tio n a l Agency for Research on Cancer. T o b acco h a b its o th e r th a n sm oking: betel-q u id an d areca-n u t chew in g , a n d som e related nitrosam ines. I A R C M onogr Eval C arcin o g R isk C hem H u m 37:1291, 1985. 2. C ullen, J.W ., a n d others. H e alth consequences of u sin g sm okeless tobacco: sum m ary of the advisory co m m ittee’s re p o rt to the surgeon general. P u b lic H e alth R ep 101(4):355-373, 1986. 3. S q u ier, C. Sm okeless tobacco a n d o ra l cancer: a cause for concern? CA 34(5):242-261, 1984. 4. A m erican C ancer Society. C ancer facts an d fig ures. New York, A m erican C ancer Society, 1985. 5. C o n nolly , G .N ., a n d others. T h e reem ergence of sm okeless tobacco. N E n g l J M ed 314(16):1020-1027, 1986. 6. Squires, W. C hew ed, sucked o r sm oked tobacco affects the heart. M ed W orld News 24(1 ):53, 1983. 7. S quires, W .G ., J r., an d others. H em odynam ic effects of o ra l sm okeless tobacco in dogs an d you n g adults. Prev M ed 13(2): 195-206, 1984. 8. G ross, J.Y . O ral tobacco: a n o th e r cause for diz ziness. S outh Med J 77(6):772-774, 1984. 9. H offm an , D., an d others. C arcinogenic agents in snuff. JN C I 76(3):435-437, 1986. 10. H offm an , D., a n d others. F o rm atio n an d an aly sis of N -n itro sam in es in tobacco p roducts a n d their endogenous fo rm atio n in tobacco consum ers. IARC Sci P u b l 57:743-762, 1984. 11. H o ffm an , D ., a n d H echt, S. N icotine-derived N -nitrosam ines an d tobacco-related cancer: curren t status a n d fu tu re directions. C ancer Res 45(3):935-944, 1985. 12. H u n te r, S., a n d others. L o n g itu d in a l patterns of cigarette sm o k in g a n d smokeless tobacco use by youth: the B ogalusa H eart Study. Am J P u b lic H ealth 76(2): 193-195, 1986. 13. G reer, R ., an d P o u lso n , T . O ral tissue altera tions associated w ith the use of sm okeless tobacco by teenagers. C lin ical findings. O ral Surg 56(3):275-284, 1983. 14. O ffenbacher, S., a n d W eathers, D .R. Effects of sm okeless tobacco o n th e p e rio d o n tiu m of adolescent males. J O ral P ath o l 14(2): 169-181, 1985. 15. M arty, P .J.; M cD erm ott, R .J.; an d W illiam s, T. P a tte rn s of sm okeless tobacco use in a p o p u la tio n of h ig h school students. Am J P u b lic H e alth 76(2): 190193, 1986. 16. Severson, H .H ., a n d L ich ten stein , E. Analysis of the use of sm okeless tobacco by adolescents. P ro ceedings of the fifth W orld Conference on S m oking
an d H ealth. W in n ipeg, C anada, 1983. 17. G lover, E.D., a n d others. Smokeless tobacco research: an in terd isciplinary approach. H ealth Values 8(3):21 -25, 1984. 18. G ritz, E .R .; Ksir, C.; a n d M cC arthy, W .J. Sm okeless tobacco use in the U n ited States: p ast and fu tu re trends. A nn Behav Med 7(2):24-27, 1985. 19. Schinke, S.P.; Lew ayne, D .G .; and S hillin g , P.F. Sm o k in g an d smokeless tobacco use a m o n g ado lescents: tre n d s a n d in te rv e n tio n results. P u b lic H e alth R ep 101(4):373-378, 1986. 20. Severson, H .W .; L ichtenstein, E.; an d G allison, S. A p in c h o r a p o u c h instead of a puff? Im p licatio n s of c h ew in g tobacco for addictive processes. B ull Psy ch o l A ddict Behav 4(2):85-92, 1985. 21. Jo n es, R. Sm okeless tobacco: a challenge for the 80s. J W is State D ent Soc 10:717-721, 1985. 22. US D ep artm en t of H ealth a n d H u m a n Services. T h e h e alth consequences of usin g smokeless tobacco. N a tio n a l In stitu te s of H e alth p u b no. 86-2874, A pril, 1986. 23. US B ureau of the Census. C u rre n t p o p u la tio n p ro jectio n s of the p o p u la tio n of the U nited States 1982 to 2050. C P Series P 25, no. 922, 1982. 24. C hassin, L., a n d others. Psychosocial correlates o f ad olescent sm okeless tobacco use. A ddict Behav 10(4):431-435, 1985. 25. O ffice o f the Inspector G eneral. Y outh use of sm okeless tobacco: m ore than a p in c h of trouble. C o n tro l no. P-06-86-0058. US D epartm ent of H ealth a n d H u m a n Services, W ashington, DC, 1986. 26. D in g h a m , M .B., a n d others. P revalence of h e alth -risk b eh av io r a m o n g seventh grade students in N o rth C arolina. S o u th M ed J 79(3):295-298, 302, 1986. 27. Schaefer, S.D., a n d others. P atterns of use and incidence of smokeless tobacco c o n sum ption in school age ch ildren. A rch O tolaryngol 111(10):639-642, 1985. 28. N ew m an, I.M ., a n d D uryea, E.J. Adolescent cig arette s m o k in g a n d tobacco chew in g in Nebraska. N ebr M ed J 66(10):243-244,1981. 29. B onaguro, J.A .; B onaguro, E.W.; a n d Sm ith, E.J. Predictors of sm okeless tobacco use. Presented a t the 111th a n n u a l m eeting of the A m erican P ublic H e alth A ssociation, D allas, 1983. 30. G u g g en h eim er, J., a n d others. C h an g in g trends o f tobacco use in a teenage p o p u la tio n in w estern P en n sy lv an ia. A m J P u b lic H e alth 76(2):196-197, 1986. 31. P o u lso n , T .C .; L in d em u th , J.E .; and G reer, R .O ., Jr. A co m p ariso n of the use of smokeless tobacco in ru ral an d u rb a n teenagers. CA 34(5):248261, 1984. 32. B erm an , E .J., a n d others. Use of sm okeless tobacco a m o n g adolescents, (letter). JAM A 255(23): 3245, 1986. 33. C h risten , A .G . T h e four m ost c om m on altera
tio n s of the teeth, p e rio d o n tiu m an d o ral soft tissues observed in sm okeless tobacco users: a literatu re review. J In d ia n a D ent Assoc 64(3): 15-18, 1985. 34. A xell, T .; M ornstad, H .; and S undstrom , B. T h e relatio n of the clinical p icture to the histopathology of snuff d ip p e r’s lesions in a Sw edish p o p u la tion. J O ral P athol 5(4):229-236, 1976. 35. C hristen, A.G.; M cD aniel, R.K.; a n d D oran, J.E . Snuff d ip p in g an d tobacco chew ing in a g ro u p of T exas college athletes. T e x D ent J 97(2):6-10, 1979. 36. Silverm an, S., Jr.; G orsky, M.; and Lozada, F. O ra l le u k o p la k ia an d m a lig n a n t transform ation. A fo llo w -u p study of 257 patients. C ancer 53(3):563-568, 1984. 37. G u p ta , P.C., a n d others. Incidence rates of oral cancer and n a tu ra l history of oral precancerous lesions in a 10-year fo llo w -u p stu d y of In d ia n v illagers. C om m u n ity D ent O ra l E pidem iol 8(6):287-333, 1980. 38. R oed-Peterson, B. C ancer developm ent in oral le ukoplakia: follow -up of 331 patients. J D ent Res 50(3):711, abstract no. 20,1971. 39. E in h o rn , J ., an d W ersall, J. Incidence of oral carcinom a in p a tie n ts w ith leukoplakia of the oral mucosa. C ancer 20(12):2189-2193, 1967. 40. Pindborg, J .J ., an d others. Studies in oral leu koplakia: a p re lim in a ry re p o rt on the period preval ence of m a lig n a n t tran sfo rm a tio n in leuk o p lak ia based o n a fo llo w -u p study of 248 p atients. JAD A 76(4):767-771, 1968. 41. Kram er, I.R . Precancerous conditions of oral m ucosa: a c o m p u te r aided study. A nn R C oll S urg E ngl 45(6):340-356, 1969. 42. Banoczy, J. F ollow -up studies in oral leuko plakia. J M axillofac Surg 5(1 ):69-75, 1977. 43. Silverm an, S., J r., a n d Rosen, R.D. O bserva tions o n the c linical characteristics an d n atu ral h is tory of oral leukoplakia. JADA 76(4):772-776, 1968. 44. Silverm an, S., Jr., a n d others. M alignant trans fo rm atio n a n d n a tu ra l history of oral leukoplakia in 57,518 in d u stria l w orkers in G u jarat, India. Cancer 38(4): 1790-1795, 1976. 45. C h risten , A .G . T h e case a g a in st sm okeless tobacco: five facts for the h ealth professional to c o n sider. JAD A 101(3):464-469, 1980. 46. W inn, A.M ., an d others. Snuff d ip p in g and o ral cancer a m o n g w om en in the southern U nited States. N E ngl J M ed 304(13):745-749, 1981. 47. D uncan, J.M . O ral m anifestations of smokeless tobacco. T e x D ent J 103(6): 10-12, 1986. 48. Fincher, J. Sean M arsee’s smokeless death. Read D ig 61( 10): 1-6, 1985. 49. G reenw ald, P., an d Sondik, E.J. C ancer control ob jectiv es fo r the n a tio n : 1985-2000. D iv isio n of C an c e r P re v e n tio n a n d C o n tro l, N a tio n a l C ancer In stitu te , N a tio n a l In stitutes of H e alth p u b no. 862880, no. 2, 1986.
Self-Assessment Questions 1. A ccording to this study, w hat per cent of all m ale adolescents had tried smokeless tobacco? 2. W hat percent of current users of smokeless tobacco had clinically observ able oral leukoplakia? 3. In regard to receiving inform ation 48 ■ JADA, Vol. 116, Ja n u a ry 1988
ab o u t the h arm fu l effects of smokeless tobacco use, where did m ore athletes receive their in fo rm atio n —from den tists an d physicians or television and friends? 4. W hat was the m ajor factor in itiat in g smokeless tobacco use am ong ado lescent males?
5. F our suggestions were offered re g ard in g possible com ponents of in ter v e n tio n /p re v e n tio n p ro g ram s: w h at were they?
Answers are found in the People 8c Meetings Section.
Smokeless tobacco currently presents a health problem for millions of Americans, and its use appears to be continually growing in popularity. The purpose o f this study was to determine the prevalence of smokeless tobacco m e among adolescent athletes, the charac teristics of its use, and the prevalence of associated abnormal mucosal findings. Study results indicate that health care providers—in particular, dentists—m ust take a more active role in educating and monitoring patients who use smokeless tobacco.
The prevalence of smokeless tobacco use among adolescent male athletes Curtis J. Creath, D M D Whitney O. Shelton, D D S J. Timothy Wright, DDS, M S
Dorothy H. Bradley, M S Ronald A. Feinstein, M D John F. Wisniewski, D M D
m okeless tobacco—b o th chew ing to b a c c o a n d s n u f f — c o n t a i n s tobacco leaf plus sweeteners, scents, and flavorings. In chew ing tobacco, the leaf m ay be shredded (loose leaf), pressed in to bricks or cakes (plugs), o r dried an d tw isted in to strands (twists). A portion is either chewed or held in place in the oral vestibule. Snuff is purchased in a sm all ro u n d can or tin, and is supplied in dry an d m oist form s of pow dered or finely cut tobacco leaves. Both types are used in the m o u th (“d ip p ed ”) by holding a sm all am o u n t between the gingiva and lip or cheek. T h e tobacco m ixes w ith saliva, r e s u ltin g in a b s o rp tio n of n ic o tin e th r o u g h th e o r a l m u c o sa in to th e bloodstream .1 F req u ent users of smokeless tobacco have a n increased risk of developing local ized gingival recession, oral leukoplakia, an d oral cancer.2 L eukoplakia can trans form in to oral cancer in about 3% to 5% of cases.3 O ropharyngeal cancer accounts for 3% of all cancers in the U nited States and is the seventh m ost com m on form of cancer. In the U nited States, 11 of every 100,000 people eventually have some form
of o ral cancer. In 1985, new cases of oral cancer totaled 28,500, w ith 9,500 people d ying from oropharyngeal cancer.4 Smok in g is the cause for m ost of these cases; however, an increased risk for smokeless tobacco users has been established.5 C ur ren t data are insufficient to su p p o rt an association of smokeless tobacco use w ith gingivitis, perio d o n tal disease, or dental caries.2 O ther health problem s related to smoke less tobacco use are associated w ith the n icotine levels found in the bloodstream . A ssum ing a daily co n su m p tio n of 10 g of smokeless tobacco, the h ab itu al user can be exposed to 130 to 250 m g of nicotine per day. Sim ilarly, a person sm oking one p ackage of cigarettes daily w o u ld be exposed to 180 m g n ic o tin e per day (assum ing 9 m g of nicotine per cigarette).2 In bo th types of tobacco use, sim ilar lev els of nicotine can be delivered to the cen tral nervous system. It is likely th a t those h ealth consequences of sm oking caused by n ico tin e w o u ld also be associated w ith smokeless tobacco use, as nicotine expo sure from smokeless tobacco is sim ilar in m a g n itu d e to n ico tin e exposure from
S
sm oking. Studies are b eg in n in g to dis close som e of the m ore acute effects of sm okeless tobacco use. T h e p ro b lem s in clu d e sig n ifican tly decreased cardiac stroke volum e and cardiac o u tp u t,6 in creased h eart rate an d blood pressure,7 a n d in c re ase d ep iso d es of d izzin ess.8 C h ro n ic consequences of possible coro nary artery disease, p erip h eral vascular disease, an d p eptic ulcer disease as w ell as developm ent of tolerance psychological d ep endence, a n d phy sical dependence sh o u ld also raise serious h ealth concerns regarding the use of smokeless tobacco.2 C hem ical analysis of various types of smokeless tobacco has show n the presence o f p o lo n iu m -2 1 0 , a rad io a ctiv e alp h a em itter an d k now n rad iatio n carcinogen. Also, two other classes of chem ical car cinogens have been detected—the polycyclic arom atic hydrocarbons an d the nitro sam in es.9 T h e total co n cen tratio n of tobacco-specific nitrosam ines in com m er cial snuff ranges from 5,280 to 141,000 p arts per b illio n .10,11 T h ese levels are ten to 100 tim es h ig h er th a n levels in the in h a led sm oke of one cigarette, an d 500 o r m o re tim es h ig h e r th a n th e level JADA, Vol. 116, Ja n u a ry 1988 ■ 43
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allow ed in some consum er products by the US Food and D rug A dm inistration a n d th e D e p a rtm e n t of A g ric u ltu re .5 Congress has restricted both agencies from r e g u la tin g th e p ro d u c tio n o f tobacco products, however. In spite of these h ealth risks, chew ing tobacco an d snuff have recently em erged as p o p u la r products for the first tim e since the tu rn of the century. In the U n it ed States, smokeless tobacco production declined steadily from 1930 u n til the late 1960s. However, since 1968, production has increased 42%, reaching 135.6 m illion lb in 1985.2 M uch of this increase has occurred d u rin g the past decade, a period in w hich smokeless tobacco products have been p rom oted by fam ous athletes and m u sic ia n s. T h e to b a cc o in d u stry h as ap p aren tly been successful in establishing a m o re p o s itiv e im a g e for sm okeless tobacco th ro u g h skillful advertisem ent.3 T h e steadily increasing use of sm oke less tobacco am o n g y o u n g males has recently becom e a subject of national investigation. For instance, the Bogalusa H eart S tu dy12 found 11.3% of w hite 8- to 9-year-old m ales u sin g smokeless tobacco in 1976-77 as com pared w ith 23.8% in 1981-82. For 14- to 15-year-old males, the rate changed from 23.9% to 43.4% in 198182. O ther local surveys have found that 8% to 36% of m ale hig h school and college students th ro u g h o u t the U nited States are reg u lar users of smokeless tobacco.12 21 T h e 1985 N atio n al H ousehold Survey on D ru g Use provides the only n atio n al p ro b ab ility data on the use of smokeless tobacco by y o u th .22 T h e results of this study indicate that 16% of males between the ages of 12 a n d 25 used som e form of smokeless tobacco in the preceding year, an d 5% to 8% used it at least once a week. Fem ales of all ages reported less use than m ales, w ith ab o u t 2% h av in g used sm oke less tobacco d u rin g the previous year.22 If these estim ates are ap p lied to current p o p u la tio n figures,23 m ore th an 12 m il lio n people aged 12 or older in the U nited States used some form of smokeless tobac
co last year, an d ab o u t 6 m illio n people used it regularly (at least weekly).22 T h e highest user rates have been reported in the South and West, an d the lowest in the N ortheast. Inform ation ab o u t smokeless tobacco use by eth n ic an d racial back g round indicates th a t rates for youth are sim ilar am o n g w hites an d H ispanics. N ative A m erican rates are consistently higher th an those for w hites, an d in m ost locales use appears less am o n g Asians and blacks.5 Smokeless tobacco use is believed to be m ore prevalent in rural p o p u la tio n s, sm all co m m u n ities, an d areas where smokeless tobacco use is co n sidered trad itio n al.5,24 Peers an d fam ily members are consistently cited as im p o r tant influences on smokeless tobacco use by children and adolescents.25 T h e purpose of this study was to survey adolescent football players in the B irm ing ham , AL, area regarding experience w ith and perceptions of smokeless tobacco use, and to determ ine the prevalence of asso ciated oral lesions. Methods and materials A total of 995 adolescent m ale football players, representing 24 local h ig h schools and two ju n io r h ig h schools, p articipated in a preseason m edical an d dental screen in g conducted at the Adolescent Medicine C linic in the C h ild re n ’s H o sp ital of A la bam a. T h e p u rp o se of the dental screen in g was to exam ine each player for the presence of caries, dental fractures, or other oral disease th a t could com prom ise the a th le te ’s p erfo rm an ce d u rin g the upcom ing play in g season. Before the d en tal e x a m in a tio n , each participant was confidentially interviewed by one of six dentists u sin g a standardized questionnaire. T h e questionnaire included 11 m ultiple-choice an d open-ended ques tions regarding his experience w ith smoke less tobacco. E ach ath lete was asked whether he ever dipped or chewed tobacco, if any fam ily mem bers dipped, an d if he was aw are of any h a rm fu l effects of
smokeless tobacco. T hose w ho had tried smokeless tobacco were also asked ad d i tional questions p ertain in g to its use, in c lu d in g w hen they had first tried it, how lo n g they had used it, an d the am o u n t they had used. After the interview, each athlete was exam ined, u sin g a tongue blade an d a floor light. Any m ucosal alterations were exam ined by a second dentist. O nly c lin i cally evident m ucosal changes were re corded. T h e questionnaires were tabulated and the results statistically analyzed using X2 tests.
Results T h e 26 schools p articip a tin g in the study represented a cross section of backgrounds in term s of predom inantly black, predom in a n tly w h ite , a n d ra c ia lly b alan ced schools, ru ral an d u rban schools (mostly urban), an d low, middle, an d h ig h income areas. T h e p articip an ts ranged in age from 11 to 18 years, w ith a m edian age of 15.25 years. T h e racial d istrib u tio n was: white, 469; black, 521; an d other, 5 (for exam ple, Asian). T h e prevalence of smokeless tobacco use is sum m arized in T ab le 1. T h e survey indicated 300 of the total sam ple (30.2%) h ad tried u sin g some form of smokeless tobacco w ith 83 (8.34%) of the athletes being cu rren t users. T h e racial difference is rem arkable w ith 55.6% of the w hite a th letes having tried smokeless tobacco and 16% being cu rren t users. In contrast, 7.3% of the black athletes h ad tried smokeless tobacco an d only 1.5% were current users. R egarding the d u ratio n of tobacco use, 197 of the 289 dippers (68.2%) d id so for less th an 6 m onths. M any people in this category had experim ented o nly once or twice (Table 2). T ab le 3 describes the age d istrib u tio n of in itial smokeless tobacco use. T ab le 4 sum m arizes the frequency of sm okeless tobacco use. O f those w ho dipped, 229 (79.2%) dipped less th an 1
Table 1 ■ Use of smokeless tobacco.
Race
Sam ple size
W hite Black O ther T o ta l P ercent o f total sam ple
44 ■ JA DA, Vol. 116, Ja n u a ry 1988
469 521 5 995
H ave tried d ip p in g smokeless tobacco
Are currently chew ing, b u t have never d ip p ed
T o ta l users (dippers an d chewers)
C urrently d ip p in g o r chew ing or both
255 (54.37%) 33 (6.33%) 1 (20.00%) 289 29.05
6 (1.28%) 5 (0.96%) 0 (0.00%) 11 1.11
261 (55.65%) 38 (7.29%) 1 (20.00%) 300 30.15
75 (15.99%) 8 (1.54%) 0 (0.00%) 83 8.34
ARTICLES
h o u r per day. A gain, m ost of these were one- or tw o-tim e users. R egarding the q u an tity of tobacco, 226 (78.2%) of the dippers used less th an one tin per week (Table 5). Some athletes reported heavy usage of u p to 6 hours per day or five tins per week. T h e influence of smokeless tobacco use by fam ily m em bers show ed 31.4% of the users reported fam ily mem bers w ho also dipped, and 68.5% w ith no fam ily users. O f the n o n d ip p e rs, 20.5% h ad fam ily dippers an d 79.4% w ith no fam ily dippers. W hen asked w h at was the m ost in flu e n tial reason they started d ip p in g , the a th letes cited: friends (59.9%), family members (9.7%), advertisem ents (4.5%), coaches (1.4%), to stop sm oking (1.4%), an d other (24.6%). W hen the athletes were asked if they believed d ip p in g tobacco could be h arm ful to their health, 53.9% strongly agreed, 39.8% agreed, 5.5% disagreed, an d 0.8% strongly disagreed. Therefore, 93.7% be lieved smokeless tobacco could be h arm ful an d 6.3% did n o t believe it could be harm ful. Cancer was the answer given by m ost respondents w hen asked w h at the harm ful effects were. In com paring the current use of smokeless tobacco w ith the u ser’s aw areness of harm ful effects, 49 (92.5%) of the current users were aw are of possible harm ful effects from smokeless tobacco and four (7.5%) were not. T he students were also asked if they had heard, seen, or read ab o u t possible h arm fu l effects of smokeless tobacco. Of the entire sam ple, 77.8% reported they had heard som ething about harm ful effects b u t 22.2% had not. T hose w ho had heard of the ill effects were asked w hat was their source of in fo rm atio n (T able 6). T elevision, school, friends, an d magazines were the top four sources of inform ation cited. E x am in atio n for ab n o rm al m ucosal findings disclosed 69 abnorm al co n d i tions, 34 of w hich were found in dippers at the site of tobacco placem ent. L euko p la k ia, g ingival recession, and rolled gingival m argins were the specific altera tions b eing evaluated. T h e prevalence of o ral m ucosal changes is rep o rted in T ables 7 and 8.
Table 2
■ Duration of dipping smokeless tobacco.
T im e < 6 mo 6 to 12 m o 1 to 2 yr > 2 yr
D ippers (no.)
All d ip p ers (%)
197 29 23 40
68.2 10.0 8.0 13.8
Table 3 ■ Age at which dipping smokeless tobacco was first tried.
(yr)
R espondents (no.)
D ippers (%)
C um ulative dippers (%)
< 11 11 12 13 > 13
37 19 46 62 125
12.8 6.6 15.9 21.5 43.2
12.8 19.4 35.3 56.8 100.0
Age
T ables 9 and 10 com pare the prevalence of specific m ucosal fin d in g s w ith the d u ratio n an d am o u n t of tobacco use. T h e m ost notable associations are th at leukoplakic areas occurred m ost in dippers who used m ore th an three tins per week an d in those d ip p in g longer th an 2 years (Fig 1).
Discussion M any of the findings o btained in this study su p p o rt earlier studies conducted in the U nited States as well as add to the current u n d erstan d in g regarding smoke less tobacco use. T h is investigation found 30.15% of adolescent football players had tried smokeless tobacco at least once and 8.34% of a ll players are still cu rren tly u sin g these products. However, these fig ures do n o t accurately disclose a true de scription of use because they do n ot in d i cate the p rofo u n d racial differences. T h is racial difference was rem arkable w ith 56% of the w hite athletes and only 7% of the b lack a th le te s h a v in g trie d sm okeless tobacco. In ad dition, 16% of whites (one in every six) an d 1.5% of blacks were cur re n t users. A N o rth C a ro lin a stu d y 26 show ed 34.6% of w hite m ale an d 14.9% of black m ale seventh grade students had tried smokeless tobacco, an d 14.4% of the w hite m ale sam ple an d 1.9% of the black males were current users. T w o im p o rta n t p o in ts can be draw n from these reports. First, any investiga tions studying smokeless tobacco use m ust include an exam ination of the differences am o n g racial an d eth n ic g roups to obtain an a c c u ra te a c c o u n t of a c tu a l usage. Second, this study fo u n d th a t m ore than one in four of the athletes w ho tried smokeless tobacco w ould become regular users. In the N o rth C aro lin a report, this rate was alm ost 50%. Direct com parison of this study w ith others is difficult because of differences in survey techniques an d varied com bina tions of race, age, an d gender. Most stud ies are n o t w ell defined racially or do not c o n t a i n s u f f i c i e n t s a m p le sizes of other races to propose conclusions about
this variable. In term s of reg u lar (current) users, the rate of 8.34% isolated in this study is sim ilar to several other studies.13,21,27,28 Many o th er investigations have found higher prevalences of reg u lar users. T h ree repre sentative studies w ith h ig h er user rates from o th er areas of the co untry are 36.7% of m ale tenth- th ro u g h 12th-grade stu dents (A rkansas),15 31% of m ale seventhth ro u g h ten th -g rad e students (O h io ),29 an d 12% to 15% of fifth- th ro u g h sixthgrade students as reg u lar smokeless tobac co users (W ashington).19 O ther studies range from 7% to 33%.14,19,30' 32 T h e age at w h ich athletes first tried smokeless tobacco was usually before start in g h ig h school, w ith 56.8% try in g it by age 13. T h is is sim ilar to a T exas study27 in w hich 55% of reg u lar users began before 13 years of age. A lth o u g h the students were n o t asked specifically ab o u t th eir fam ily incom e, by estim ating com m unity in fo rm atio n su p p lie d by the B irm in g h a m C h am b er of Com merce, schools were assigned as p re d o m in an tly serving either low- (less th an $15,000 per year), m edium - ($15,000 to $25,000), or h ig h - (greater th an $25,000) incom e level families. Many of the schools w ith the h ighest percentage of users were
Table 4
■ Frequency of dipping tobacco.
Frequency < 1 h r/d a y 1 to 2 h rs/d a y 3 to 4 h rs/d a y > 4 h rs/d ay
Table 5
D ippers (no.)
All dippers (%)
229 42 5 10
79.2 14.5 1.7 3.5
■ Amount of tobacco dipped.
T in s (no.) < 1 tin /w k 1 tin /w k 1 to 2 d n s /w k > 3 tin s/w k
D ippers (no.)
All dippers (%)
226 32 19 12
78.2 11.1 6.6 4.1
C reath-O thers : PREV A LEN CE O F SM OKELESS T O B A C C O USE IN A T H L E T E S ■ 45
A R T I CL E S
from m edium an d h ig h incom e areas of prim arily w hite p opulations. Therefore, a low level of fam ily incom e did n o t cor resp o n d to an increased prevalence of smokeless tobacco use am ong adolescent males. In contrast w ith other reports, this study found a sim ilar prevalence of sm oke less tobacco use between u rban and rural schools.5'13’21'31 T h e im portance of peer influence in in itia tin g smokeless tobacco cannot be overem phasized. T h e racial differences (and gender in several studies),19’21’26’31'32 the clusters of d ippers in certain schools, as well as the direct answers from users in this study, p o in t to influence of peers as the m ajo r reason for trying smokeless tobacco. T h is study fo u n d 59.9% began u sing smokeless tobacco because of friends and
Table 6 ■ Sources of information re garding harmful effects of smokeless tobacco. M edium T elevision School Friends M agazines P arents B oo k s/p am p h lets N ew spaper/ad s K now people w ith cancer D entists R elatives C oaches C h u rc h /c a m p P hysicians U nknow n C om m on sense
R espondents (no.)
R espondents (%)
267 225 51 50 44 27 20
34.3 29.1 6.9 6.6 5.8 3.5 2.6
19 17 14 11 8 5 3 1
2.5 2.2 1.8 1.4 1.0 0.6 0.4 0.1
Table 7 ■ Prevalence of abnormal mucosal findings in dippers. F in d in g L e ukoplakia G ingival recession R olled ging iv al m argins O ther T o ta l
Frequency
D ippers (%)
15 1
5.2 0.3
9 9 34
3.1 3.1 11.8
Table 8
■ Prevalence of abnormal mucosal findings in nondippers.
F in d in g L eukoplakia G ingival recession R olled gingival m argins O ther T o ta l
Frequency
N ondippers (%)
1 0
0.1 0
24 10 35
3.4 1.4 4.9
46 ■ JADA, Vol. 116, Ja n u a ry 1988
Table 9 ■ Comparison of mucosal findings to tins per week in dippers. F in d in g L e u k o p lak ia G in g iv al recession R olled gingival m argins O th er
Table 10
< 1 tin /w k
1 tin /w k
2 tin s/w k
> 3 tin s/w k
2 0 7 7
2 0 2 1
3 0 0 1
8 1 0 0
■ Comparison of mucosal findings to duration of use in dippers.
F in d in g L eu k o p lak ia G in g iv al recession R olled gin g iv al m argins O th er
<6 m onths
6 to 12 m onths
1 to 2 years
>2 years
3 0 6 7
2 0 1 1
2 0 0 0
8 1 2 1
9.7% because of family members. O nly 4.5% of the dippers said they started using smokeless tobacco because of advertise m ents. T hese results are sim ilar to those of G uggenheim er an d cow orkers30 who found th a t 63% began th ro u g h peer in flu ence and 4% from advertising, an d M arty a n d cow orkers15 w ho fo u n d th a t 52% began th ro u g h the influence of friends an d 3% from advertisem ents. It does n o t ap p e ar that advertising of smokeless to bacco has in itiated the use of smokeless tobacco by adolescent males, b u t rath er has created an atm osphere in w hich it is acceptable and even desirable to do so. In this study, 30% of dippers had family m em bers w ho d ipped an d 20% of n o n dippers had fam ily members w ho were dippers. It seems th at usage of smokeless tobacco by fam ily members has lim ited value in predicting people at risk for in itiatin g smokeless tobacco use. A study by Chassin an d cow orkers24 exam ined adolescent perceptions of those w ho use smokeless tobacco. T h e respon dents described chewers as less phony, more self-confident, m ore p o p u lar, more h ard w o rk in g , m ore ath letic, m ore relaxed, h ap p ier, braver, h ealth ier, u sin g drugs less, lik in g the co u n try m ore, g e ttin g alo n g better w ith family, d o in g better at schoolw ork, an d being m ore conservative than smokers. T h is points tow ard success ful assim ilatio n of ad v ertisin g -in sp ired ideas. T h e students also said chew ing was m ore acceptable to parents, friends, an d school personnel th an smoking. T h e total weekly co n su m p tio n a n d d u ratio n of smokeless tobacco use in this study appeared m oderate as com pared w ith other investigations. O nly 13.8% of the d ippers h ad co n tin u ed for m ore th an 2 years. T h e C olorado study found th at m ore than 50% an d the A rkansas investi g atio n reported m ore th an 60% of dippers u sin g smokeless tobacco m ore th a n 2
years.15,31 In the present study, m ost regu lar users d ip p ed tobacco 1 to 2 h o u rs per day, an d the average use in the C olorado study was between 2!4 to Vh h ours per day. O ther studies have asked the respondents how m any chews per day o r week they used to determ ine the am o u n t of tobacco exposure.31 T h e present study used hours per day a n d tins per week to ascertain the o ra l m u c o sal e x p o su re to sm okeless tobacco. C h r is te n 33 d escrib ed th e fo u r m o st co m m o n in tra o ra l fin d in g s of ch ro n ic smokeless tobacco users as: gingival reces sion, leukoplakia, breakdow n of the p eri o dontium , an d tooth abrasion. O verall, abnorm al m ucosal findings in this study were found in 22% of the dippers an d in only 6% of the nondippers. T h e incidence of leukoplakia in this study was m uch h igher in dippers th an in nondippers. L eukoplakic lesions were seen in 5.2% of those w ho had ever dipped, b u t o nly 0.1% of n o n d ip p ers had such lesions. T h e re fore, a 50-fold increase of oral le u k o p la kia was seen in dippers as com pared w ith nondippers. O f current dippers, 15% had observable oral leukoplakia. T h is com p are s w ith an 8% rate of le u k o p la k ia found in smokeless tobacco users by Axell an d cow orkers34 an d w ith C hristen an d associates35 w ho found n in e of 14 college athletes u sin g smokeless tobacco had leu koplakia lesions. A relatio n sh ip was found between b oth the d u ratio n an d the q u an tity of sm oke less tobacco exposure w ith the presence of o ral leukoplakia. T h is study fo u n d a greater incidence of leukoplakia in a th letes w ho used m ore th an three tins per week an d in those w ho were users for m ore th a n 2 years. T hese two param eters, tin s per week an d span of use, show ed parallel findings in this study regarding the presence of o ral le u k o p la k ia an d m ig h t provide some guidance in p redict
A R T I C L E S
in g the likelihood of the developm ent of le u k o p lak ia. P o u lso n a n d associates31 found the average exposure of dippers w ith abnorm al m ucosal alterations was greater (205 m in /d ay , 3.3 years of use) th an those in w hom n o alterations were found (110 m in /d ay , 2.3 years of use). T h e increased incidence of leukoplakia in dippers should be of serious concern. T h e fact that males are begin n in g to use smokeless tobacco at a younger age could m ean a longer period of use and oral exposure to tobacco, thus increasing their chances for oral pathological conditions. T h e body of evidence seems to show some level of co rrelation between smokeless tobacco use an d oropharyngeal cancer. Earlier studies35 44 have show n a m alig n an t transform ation rate of oral leuko plak ia of 0.13% to 17.5%, w ith an average of 3% to 5%. C hristen45 cites 646 cases of cancer of the m o u th , pharynx, or larynx in N o rth A m erican smokeless tobacco users between 1915 a n d 1972. O ther more recent cases have also been reported.46' 48 It is im p o rta n t to be cognizant that the h ealth concerns regarding smokeless to bacco are n o t centered aro u n d ju st the long-term consequences of leukoplakia an d oral cancer. C ardiovascular and cen tral nervous system effects described ear lier can be seen d u rin g short-term usage. A th letic coaches sho u ld be concerned about w hat consequences these effects will have on athletes’ perform ance. T h e re la tio n s h ip betw een sm okeless tobacco an d sm oking tobacco cannot be ignored. As noted earlier, m any students believe smokeless tobacco is m ore accept able th an sm oking tobacco. O f the d ip p ers in th is stu d y , 1.4% b eg a n u sin g smokeless tobacco in order to stop sm ok ing. W hen A rkansas students were asked w hy they co n tin u ed to use smokeless tobacco once they began co n su m p tio n , 38.4% said it was because of the relaxation they felt, 17.1% cited enjoym ent, and 15.8% said good taste was the m ajor influence.15 T hese are often the same reasons given by sm okers w ho continue their habit. In a lo n g itu d in al W ashington investigation,19 one th ird of those w ho sm oked also began to chew tobacco after 2 years, an d two thirds of smokeless users began to smoke. T h e use of one type of tobacco does not ap p ear to preclude the use of another type. Because of the sim ilar nicotine lev els of b o th types of tobacco, it is ques tionable w hether smokeless tobacco is a better substitute. As the evidence points to n eith er sm oking nor smokeless tobacco as bein g a safe alternative, the conclusion of Chassin an d cow orkers24 seems appropri-
smokeless tobacco use an d m o n ito rin g any tissue changes th a t m ig h t occur or p ro gress because of p rolonged use. E ducation th ro u g h dental school cu rricula an d co n tin u in g education program s sh o u ld be used to increase the aw areness an d p artic ip atio n of all dental professionals in deal in g w ith sm okeless tobacco use an d its c o n seq u e n ces o n th e o ra l h e a lth of patients. F ig 1 ■ M ild o ra l le u k o p la k ic lesion seen in a 16-
Summary
year-old m ale . T h i s w as typ ica l of the lesions seen in the athletes in th is stud y. A s sa liv a co llects, the tooth becomes discolored.
ate: “ Intervention program s m ust address bo th types of tobacco so th at one is not substituted for an o th er.” Any p ro g ra m s for in terv en tio n an d prevention m ust have specific strategies if there are any real hopes for success. M uch of the info rm atio n gained from this an d other studies h elp identify some of these strategies. First, these program s sh o u ld be targeted at hig h -risk groups. In the Bir m ingham , AL, area, for exam ple, w hite males younger th an 13 years w ould be the m ain target group. In addition, the role of peer influence in the use of smokeless tobacco is considerable an d m ust be taken in to account in any intervention/prevention program . Incorporation of peer-interaction com ponents appears essential. A W ashington stu d y 19 showed some prom is in g results w hen this appro ach was tried. Inform ation ab o u t the harm fu l effects of smokeless tobacco still needs to be dis sem inated to certain segments of the p u b lic. Perceived or actu al acceptance of smokeless tobacco by parents, teachers, a n d coaches w arrants specific inform ation to be shared w ith these people w ho are influential in the lives of adolescent users. An increased role by h ealth professionals, in c lu d in g dentists, m ust be emphasized. H ealth professionals and their respec tive organizations have begun to take a m ore active role, b u t expanded efforts are still needed. W ith smokeless tobacco use rates am ong yo u n g males of 10% to 30% th ro u g h o u t the country, it appears that dentists are treating at least some of these users in their practices. In this study, however, only 1.4% of the dippers were inform ed ab o u t smokeless tobacco’s h arm less effects from dentists an d only 0.6% told by physicians. A lth o u g h dentists cannot m ake patients change their tobacco use habits, as h ealth care providers they are obligated to take active roles in inform in g patien ts of the p o te n tia l risks of
In assessing the prevalence an d percep tions of use of smokeless tobacco am o n g adolescent m ale athletes, several findings have p u b lic h ealth im plications. A lm ost a th ird of the sam ple h a d tried smokeless tobacco an d 8% were cu rren t users. R acial differences between blacks and w hites were rem arkable. Differences in incom e strata an d u rb a n /ru ra l settings were n o t significant. Peer influence was the m ajor factor th at in itiated smokeless tobacco use. A bnorm al m ucosal findings were m uch m ore prevalent in those w ho had dipped smokeless tobacco th an in those w ho had not. M ost sig n ifican t was a prevalence of oral leu k o p lak ia in 5.2% of those w ho had ever dipped, w hich was 50 times th a t of nondippers. U sin g smokeless tobacco for m ore th an 2 years or u sin g m ore th an three tins per week seemed to be of possi ble predictive value regarding the in c i dence of oral leukoplakia. Fifteen percent of cu rren t users h ad observable leu k o plakia. C o m p o n e n ts necessary for effective in te rv en tio n /p re v en tio n program s were e lu c id a te d w ith an e m p h a sis o n an increased role by dentists an d other health professionals. ----------------------- J A D A ----------------------T h e a u th o rs th a n k Drs. C huck S h a n n o n , T im o th y M cN utt, an d Ken C o ch ran for th eir assistance in ex am in in g the athletes. T h e a u th o rs also th a n k the staff a n d volunteers of the division of adolescent m ed icine, d ep artm en t of pediatrics, U niversity of A labam a B irm in g h am , for th e ir h e lp d u rin g the exam in atio n s, B arbara M ullis for assistance in p re p a ra tio n of the m an u scrip t, a n d the U niversity of A labam a, B irm in g h a m d e p a r tm e n t o f m e d ic a l p h o to g r a p h y a n d graphics. Dr. C reath is resident, d epartm ent of pediatric d e n tistry, School of D entistry, U niversity of A labam a a t B irm ingham . Dr. S helto n is in private practice, p e d i atric dentistry, H u n tsv ille , AL. Dr. W right is assistant professor, d e p artm e n t of pediatric dentistry, School of D entistry, U n iv e rsity o f A labam a a t B irm in g h a m , Box 89, U niversity S tation, B irm ingham , A L 35294. Ms. B radley is in stru c to r, d ep artm e n t of e p id e m io l ogy, School of P u b lic H ealth , U niversity of A labam a a t B irm ingham . Dr. F einstein is a ssistant professor, division of adolescent m edicine, d epartm ent of p e d i
C reath -O th ers : PREV A LEN CE O F SM OKELESS T O B A C C O USE IN A T H L E T E S ■ 47
A R T I C L E S
atrics, U niversity of A labam a H ospitals. Dr. W isniew ski is in stru c to r, d e p artm e n t of op erativ e dentistry, school of den tistry , U niversity of A labam a a t B ir m in g h am . Address requests for re p rin ts to Dr. W right. 1. In te rn a tio n a l Agency for Research on Cancer. T o b acco h a b its o th e r th a n sm oking: betel-q u id an d areca-n u t chew in g , a n d som e related nitrosam ines. I A R C M onogr Eval C arcin o g R isk C hem H u m 37:1291, 1985. 2. C ullen, J.W ., a n d others. H e alth consequences of u sin g sm okeless tobacco: sum m ary of the advisory co m m ittee’s re p o rt to the surgeon general. P u b lic H e alth R ep 101(4):355-373, 1986. 3. S q u ier, C. Sm okeless tobacco a n d o ra l cancer: a cause for concern? CA 34(5):242-261, 1984. 4. A m erican C ancer Society. C ancer facts an d fig ures. New York, A m erican C ancer Society, 1985. 5. C o n nolly , G .N ., a n d others. T h e reem ergence of sm okeless tobacco. N E n g l J M ed 314(16):1020-1027, 1986. 6. Squires, W. C hew ed, sucked o r sm oked tobacco affects the heart. M ed W orld News 24(1 ):53, 1983. 7. S quires, W .G ., J r., an d others. H em odynam ic effects of o ra l sm okeless tobacco in dogs an d you n g adults. Prev M ed 13(2): 195-206, 1984. 8. G ross, J.Y . O ral tobacco: a n o th e r cause for diz ziness. S outh Med J 77(6):772-774, 1984. 9. H offm an , D., an d others. C arcinogenic agents in snuff. JN C I 76(3):435-437, 1986. 10. H offm an , D., a n d others. F o rm atio n an d an aly sis of N -n itro sam in es in tobacco p roducts a n d their endogenous fo rm atio n in tobacco consum ers. IARC Sci P u b l 57:743-762, 1984. 11. H o ffm an , D ., a n d H echt, S. N icotine-derived N -nitrosam ines an d tobacco-related cancer: curren t status a n d fu tu re directions. C ancer Res 45(3):935-944, 1985. 12. H u n te r, S., a n d others. L o n g itu d in a l patterns of cigarette sm o k in g a n d smokeless tobacco use by youth: the B ogalusa H eart Study. Am J P u b lic H ealth 76(2): 193-195, 1986. 13. G reer, R ., an d P o u lso n , T . O ral tissue altera tions associated w ith the use of sm okeless tobacco by teenagers. C lin ical findings. O ral Surg 56(3):275-284, 1983. 14. O ffenbacher, S., a n d W eathers, D .R. Effects of sm okeless tobacco o n th e p e rio d o n tiu m of adolescent males. J O ral P ath o l 14(2): 169-181, 1985. 15. M arty, P .J.; M cD erm ott, R .J.; an d W illiam s, T. P a tte rn s of sm okeless tobacco use in a p o p u la tio n of h ig h school students. Am J P u b lic H e alth 76(2): 190193, 1986. 16. Severson, H .H ., a n d L ich ten stein , E. Analysis of the use of sm okeless tobacco by adolescents. P ro ceedings of the fifth W orld Conference on S m oking
an d H ealth. W in n ipeg, C anada, 1983. 17. G lover, E.D., a n d others. Smokeless tobacco research: an in terd isciplinary approach. H ealth Values 8(3):21 -25, 1984. 18. G ritz, E .R .; Ksir, C.; a n d M cC arthy, W .J. Sm okeless tobacco use in the U n ited States: p ast and fu tu re trends. A nn Behav Med 7(2):24-27, 1985. 19. Schinke, S.P.; Lew ayne, D .G .; and S hillin g , P.F. Sm o k in g an d smokeless tobacco use a m o n g ado lescents: tre n d s a n d in te rv e n tio n results. P u b lic H e alth R ep 101(4):373-378, 1986. 20. Severson, H .W .; L ichtenstein, E.; an d G allison, S. A p in c h o r a p o u c h instead of a puff? Im p licatio n s of c h ew in g tobacco for addictive processes. B ull Psy ch o l A ddict Behav 4(2):85-92, 1985. 21. Jo n es, R. Sm okeless tobacco: a challenge for the 80s. J W is State D ent Soc 10:717-721, 1985. 22. US D ep artm en t of H ealth a n d H u m a n Services. T h e h e alth consequences of usin g smokeless tobacco. N a tio n a l In stitu te s of H e alth p u b no. 86-2874, A pril, 1986. 23. US B ureau of the Census. C u rre n t p o p u la tio n p ro jectio n s of the p o p u la tio n of the U nited States 1982 to 2050. C P Series P 25, no. 922, 1982. 24. C hassin, L., a n d others. Psychosocial correlates o f ad olescent sm okeless tobacco use. A ddict Behav 10(4):431-435, 1985. 25. O ffice o f the Inspector G eneral. Y outh use of sm okeless tobacco: m ore than a p in c h of trouble. C o n tro l no. P-06-86-0058. US D epartm ent of H ealth a n d H u m a n Services, W ashington, DC, 1986. 26. D in g h a m , M .B., a n d others. P revalence of h e alth -risk b eh av io r a m o n g seventh grade students in N o rth C arolina. S o u th M ed J 79(3):295-298, 302, 1986. 27. Schaefer, S.D., a n d others. P atterns of use and incidence of smokeless tobacco c o n sum ption in school age ch ildren. A rch O tolaryngol 111(10):639-642, 1985. 28. N ew m an, I.M ., a n d D uryea, E.J. Adolescent cig arette s m o k in g a n d tobacco chew in g in Nebraska. N ebr M ed J 66(10):243-244,1981. 29. B onaguro, J.A .; B onaguro, E.W.; a n d Sm ith, E.J. Predictors of sm okeless tobacco use. Presented a t the 111th a n n u a l m eeting of the A m erican P ublic H e alth A ssociation, D allas, 1983. 30. G u g g en h eim er, J., a n d others. C h an g in g trends o f tobacco use in a teenage p o p u la tio n in w estern P en n sy lv an ia. A m J P u b lic H e alth 76(2):196-197, 1986. 31. P o u lso n , T .C .; L in d em u th , J.E .; and G reer, R .O ., Jr. A co m p ariso n of the use of smokeless tobacco in ru ral an d u rb a n teenagers. CA 34(5):248261, 1984. 32. B erm an , E .J., a n d others. Use of sm okeless tobacco a m o n g adolescents, (letter). JAM A 255(23): 3245, 1986. 33. C h risten , A .G . T h e four m ost c om m on altera
tio n s of the teeth, p e rio d o n tiu m an d o ral soft tissues observed in sm okeless tobacco users: a literatu re review. J In d ia n a D ent Assoc 64(3): 15-18, 1985. 34. A xell, T .; M ornstad, H .; and S undstrom , B. T h e relatio n of the clinical p icture to the histopathology of snuff d ip p e r’s lesions in a Sw edish p o p u la tion. J O ral P athol 5(4):229-236, 1976. 35. C hristen, A.G.; M cD aniel, R.K.; a n d D oran, J.E . Snuff d ip p in g an d tobacco chew ing in a g ro u p of T exas college athletes. T e x D ent J 97(2):6-10, 1979. 36. Silverm an, S., Jr.; G orsky, M.; and Lozada, F. O ra l le u k o p la k ia an d m a lig n a n t transform ation. A fo llo w -u p study of 257 patients. C ancer 53(3):563-568, 1984. 37. G u p ta , P.C., a n d others. Incidence rates of oral cancer and n a tu ra l history of oral precancerous lesions in a 10-year fo llo w -u p stu d y of In d ia n v illagers. C om m u n ity D ent O ra l E pidem iol 8(6):287-333, 1980. 38. R oed-Peterson, B. C ancer developm ent in oral le ukoplakia: follow -up of 331 patients. J D ent Res 50(3):711, abstract no. 20,1971. 39. E in h o rn , J ., an d W ersall, J. Incidence of oral carcinom a in p a tie n ts w ith leukoplakia of the oral mucosa. C ancer 20(12):2189-2193, 1967. 40. Pindborg, J .J ., an d others. Studies in oral leu koplakia: a p re lim in a ry re p o rt on the period preval ence of m a lig n a n t tran sfo rm a tio n in leuk o p lak ia based o n a fo llo w -u p study of 248 p atients. JAD A 76(4):767-771, 1968. 41. Kram er, I.R . Precancerous conditions of oral m ucosa: a c o m p u te r aided study. A nn R C oll S urg E ngl 45(6):340-356, 1969. 42. Banoczy, J. F ollow -up studies in oral leuko plakia. J M axillofac Surg 5(1 ):69-75, 1977. 43. Silverm an, S., J r., a n d Rosen, R.D. O bserva tions o n the c linical characteristics an d n atu ral h is tory of oral leukoplakia. JADA 76(4):772-776, 1968. 44. Silverm an, S., Jr., a n d others. M alignant trans fo rm atio n a n d n a tu ra l history of oral leukoplakia in 57,518 in d u stria l w orkers in G u jarat, India. Cancer 38(4): 1790-1795, 1976. 45. C h risten , A .G . T h e case a g a in st sm okeless tobacco: five facts for the h ealth professional to c o n sider. JAD A 101(3):464-469, 1980. 46. W inn, A.M ., an d others. Snuff d ip p in g and o ral cancer a m o n g w om en in the southern U nited States. N E ngl J M ed 304(13):745-749, 1981. 47. D uncan, J.M . O ral m anifestations of smokeless tobacco. T e x D ent J 103(6): 10-12, 1986. 48. Fincher, J. Sean M arsee’s smokeless death. Read D ig 61( 10): 1-6, 1985. 49. G reenw ald, P., an d Sondik, E.J. C ancer control ob jectiv es fo r the n a tio n : 1985-2000. D iv isio n of C an c e r P re v e n tio n a n d C o n tro l, N a tio n a l C ancer In stitu te , N a tio n a l In stitutes of H e alth p u b no. 862880, no. 2, 1986.
Self-Assessment Questions 1. A ccording to this study, w hat per cent of all m ale adolescents had tried smokeless tobacco? 2. W hat percent of current users of smokeless tobacco had clinically observ able oral leukoplakia? 3. In regard to receiving inform ation 48 ■ JADA, Vol. 116, Ja n u a ry 1988
ab o u t the h arm fu l effects of smokeless tobacco use, where did m ore athletes receive their in fo rm atio n —from den tists an d physicians or television and friends? 4. W hat was the m ajor factor in itiat in g smokeless tobacco use am ong ado lescent males?
5. F our suggestions were offered re g ard in g possible com ponents of in ter v e n tio n /p re v e n tio n p ro g ram s: w h at were they?
Answers are found in the People 8c Meetings Section.