What is smokeless tobacco? Does it cause cancer?

Exposure routes: Oral by chewing, sucking, and ingestion

Where found: Sold in the form of snuff, chewing tobacco, and plug tobacco

At risk: Users of smokeless tobacco

Many individuals use tobacco by smoking it in the form of cigarettes or cigars, and in pipes. Other individuals use tobacco by simply chewing it. Some do not even chew it but use it by keeping it inside their mouth, such as in a cheek or between the teeth and lower lip, and absorb it by sucking on it. The tobacco products release their chemicals, like nicotine, and these are absorbed into the body. Relative to cigarettes, three to four times as much nicotine is absorbed into the body per dose with smokeless tobacco. Additionally, because having these substances in the mouth will generate saliva, individuals who use them may frequently be spitting out the saliva and part of these products or their juices in the process of using them. Such products include chew, snuff, and dip.

Chew is a form of shredded tobacco leaves. Snuff is processed tobacco that is fine-grained and smaller particles, similar to prepared spices or tea; it may even be powdery. It is so fine in some cases that users may inhale or sniff it, rather than use it orally. Dip is another term for snuff and refers to how individuals will use the material. For instance, they may dip their finger into a packet or pinch it to get the dose required to place in the mouth. Plug tobacco is similar to chew, but instead of having loose leaves, the tobacco is compressed into a hard plug that is placed in the mouth between the cheek and gums for use. All serve the same function to dispense nicotine to the user and all are classified under the general term of chewing tobaccos.

Etiology and symptoms of associated cancers: Many individuals wrongly believe that because they are not smoking tobacco, they are skirting the normal cancer risks posed by tobacco in cigarettes and cigars. However, this is not true. In fact, chewing tobacco also carries health and cancer risks. Smokeless tobacco contains at least twenty-eight known carcinogens, as of 2010, according to the National Cancer Institute. These cancer-causing agents form in the tobacco while it is being grown, processed, and aged for use. They include substances such as acetaldehyde, arsenic, benzo(a)pyrene, cadmium, formaldehyde, hydrazine, and nitrosamines. Nitrosamines are some of the most dangerous carcinogens in smokeless tobacco.

Oral cancers are commonly associated with such tobacco use and are somewhat of a function of the direct or close contact of the substance with parts of the mouth, such as the bones, cheeks, floor of the mouth, gums, roof of the mouth, and tongue. Further, users sometimes swallow juices from these products, causing them to travel elsewhere into the body. As a result, smokeless tobacco use is associated with cancers of the esophagus, larynx, pharynx, stomach, and bladder. Often problems will show up first as sores in the mouth that will not heal, difficulty swallowing or chewing, ear pain, voice changes, or sore throats that seem to persist. Another sign might be lesions or areas of discoloration, such as white patches or red sores on the gums, tongue, or cheeks. Exposed tooth roots may also begin to have problems.

History: Reports on health problems related to smokeless tobacco use date back to the eighteenth century. Use of these products is worldwide. Approximately 90 percent of individuals with mouth cancers are tobacco users. In the United States in 2012, an estimated 2.6 percent of adults, 6.4 percent of high school students, and 1.7 percent of middle school students were smokeless tobacco users, according to the US Centers for Disease Control and Prevention (CDC). Many high school and middle school students learn about smokeless tobacco through its use by members of professional sports teams, such as baseball players and hockey players. Prevention efforts have focused on sports players who have endured problems related to oral cancers telling their stories and warning students about the risks to dissuade them from starting this habit. Relative to women, men are about sixteen times more likely to use smokeless tobacco, based on responses to the CDC's National Adult Tobacco Survey, United States, 2012–2013. In the United States, 3 percent of smokeless tobacco users are non-Hispanic whites and 4.4 percent of other non-Hispanics, relative to 1 percent of African Americans and 0.6 percent of Hispanics. The American Cancer Society (2014) reports that oral cancers usually occur in individuals over the age of fifty-five; however, they may occur at any age. Tobacco use combined with alcohol use can dramatically increase the risk of cancers related to smokeless tobacco. Oral cancers accounted for only 2.5 percent of new cancer diagnoses in the United States in 2014, according to the National Cancer Institute's SEER database, but they had only a 62.7 percent five-year survival rate.

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