S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 
;; U.
1. " 
OFFICE OF INSPECTOR GENERAL

YOUTH USE OF SMOKELESS TOBACCO: 
MORE THAN A P INCH OF TROUBLE 
NAT IONAL PROGRAM INSPECT ION 
OFFICE OF

ANALYSIS AN D INSPECTIONS
 YOUTH USE OF SMOKELESS TOBACCO:

MORE THAN A P INCH OF TROUBLE

NATIONAL PROGRAM INSPECTION 
January 1986

Control Number P-06-86-0058

Lead Region: 
Region VI Dallas, Texas  Office of Analysis and Inspections

Support Regi ons:  Office of Inspector General 
Region IV , Atlanta, Georgia  Department of Health and Human

Region VII, Kansas City, Missouri  Servi ces

Region IX , Seattle, Washington
 _..

, "

MAJOR FINDINGS 
o Youth start dipping  ages. 
and chewing at very young  The average age of 
first use is only 10 years, in fifth grade, and regular or daily use

begins at only 12 years.

o This study and state use prevalence surveys confirm that use of smokeless

tobacco by secondary and even p imary school students has increased at a 
rapid rate in recent years. 
o Smokeless tobacco advertising does  dipping 
encourage youth to try  and 
chewing according to a strong majority of study respondents. 
o Many heal th provi ders and educators say youth are unaware of the heal th 
and chewing. 
risks of dipping  Abou'" 0 of 10 junior high users and 4 of
10 senior 
high users say there is either no risk or only a slight risk-
from regular smokeless use. 
o There is a considerable amount of 

inaccurate information on the risks of 
For 
smokeless tobacco among users.  example, 81 percent of users see 
safer 
than cigarettes, about 5 of 10 users believe 
smokeless use as much 

gum and mouth problems  among dippers are rare, and 25 percent think snuff 
does not contain nicotine. One-fourth of junior high users say regular 
not  third do 
use is  addictive and one- not think it may lead to mouth 
cancer. 
o Based on self-reports, many young dippers are experiencing serious health

effects. 
specific 
About 4 of 10 users have had site  leukoplakia, 37 
lips,
percent have experienced sores, blisters and ulcers on their gums, 
and tongue and 20 percent have recedi ng gums. 
o Addiction is a very serious problem for many users. Many (70%) say
they	 ve tried to quit, often many times, but most (78%) fail due to
addiction  craving " or "habit" 
o The study 
concludes that youth use of smokeless tobacco is a growing 
nat i ona 1 prob 1 em wi th ser i ous current and future health consequences and 
recommends that the Surgeon General: 
- Launch an educational public media campaign on the risks of use. 
- Support school health educational efforts.

risks. 
Seek funding for basic research on smokeless tobacco use and 
- Provide strong national leadership on the smokeless tobacco issue.  .... 
TABLE OF CONTENTS

PAGE 
iii 
SUMMARY OF FINDINGS AND RECOMMENDATIONS

BACKGROUND 
METHODOLOGY 
FINDINGS 
Who ' Are The Users?

What Is The DurOatiofn  ,U Frseqeue?ncy ,
 

And Quant i ty 
What Is The Overall Trend In Use?

Why Do Youth Start Dipping And Chewing?

Social Acceptability Of Smokeless Use

Why Do Youth Cont i nue Us i ng Smoke less Tobacco?

Schoo 1 Usage Of Smokeless Tobacco

State Law Restrictions

How Aware Are Youth Of Health Risks?

Inaccurate Knowledge Of Risks

Improved Health Educat i on Needed 
What Are The Health Effects On Users?

Smokeless Use And Smoking

What Are States Doi ng About Use?

RECOMMENDAT IONS

APP END ICES 
Append i x A .... Study Respondents

Appendix B .... Organizations Opposing Use of

Smokeless Tobacco

Appendix C .... Surveys of Prevalence of Use Data 
Supplementary Tables and Graphs 
Appendix 
Table I Intensity of Use 
Table II Reasons for Use Initiation 
Table III Reasons for Use Continuation 
IV 
Tab 1 e  Strength of Habi t Among Users 
Family Occupational Background 
Appendix E .... Profi les of Current and Former Users
 SUMMARY OF FINDINGS AND RECOMMENDATIONS

it. 
Then they 
They try it because their friends are using 
the fl 
learn to 1 i ke  avor and taste and pretty soon they 
hooked.  A smokeless user 
o Users are predominately white males 
and include both athletes and ncr.
athletes, youth of urban and rural origins, and white and b ue collar 
f ami ly occupat i ona 1 backgrounds. 
o Moist snuff is, by far, the smokeless product of choice among youth. 
Skoal and Copenhagen, products of U. S. Tobacco, the major advertiser 
dominate as the brands of initial and current use. 
o Over 9 of 10 junior 
and senior highl tuyse.r s report buying their own snuff

and chewing tobacco without diffic  State laws restricting sale to 
minors are not well-known , are very poorly enforced , and do not provide 
an effect i ve deterrent to use. 
ages. 
0 Youth start dipping and chewing at very young  The average age of 
grade. 
foirr sdt auisley  iuss oen lbye g1i0n sy eiarss ,o ninly f 1if2t hy ears. MTahne ya vyeoruangge  uagsee rwsh ewn irlelg uhlaavre  
regularly dipped at least 5-8 years before leaving high school. 
o Young users are consuming 
considerable amounts of snuff and are dipping 
intensity. 
at high levels of frequency and  Most (70 percent) dip every 
day, average 5 or more dips per day, and normally keep each dip in their 
mouth for 30 mi 1utes or more. 
o Youth use of smokeless tobacco in junior and senior high, and even 
years. 
This
eilse mentary schools, has increased at a rapid rate in recent 
the  study 
confirmed  perceptions of  respondents and by a
both  by 
growing body of prevalence of use studies.

reasons: 
o Youth say they start dipping and chewing for 3 main  1) peer 
pressure or social acceptance by using friends, 2) curiosity or desire to 
experience the taste anc effects, and 3) use by fami ly memebers and 
uncles. 
relatives, such as fathers, brothers, cousins and 
o Smokeless users are much more likely to have family members, relatives 
n non-users. 
Users 
and close friends and associates who dip or chew th 
receive much more approval , or at least acceptance, of their dipping and 
chewing habits from parents, siblings , friends and associates than would 
non-users were they to dip or chew. 
o Smokeless tobacco advertising does encourage youth to try dipping and 
users (62 percent), non-users 
chewing according to a strong majority of 
(79 percent) and key informants (98 percent).  o Dipping and chewing are enjoying fairly broad and growing social 
acceptance among youth. Most or some students at their school approve of 
use accord i ng to 86 percent of users and 70 percent of non-users. 
o About 7 of 10 users, non-users and key informants say students generally
at 
regard dipping and chewing as more acceptable, or  least equally 
acceptable to smoking. 
o Youth say they continue using smokeless tobacco for four main reasons: 
1) they enjoy the flavor and taste (64 percent), 2) they have become 
addicted or "hooked" (37 percent), 3) they 1 i ke the effects e. g.,
relaxation  , or "a buzz  (22 percent) and 4) peer pressure from using 
friends and associates (15 percent). 
o Officially, schools prohibit dipping and chewing in their classrooms, yet 
30-40 percent of users say they dip in class and often put in a pinch 
starts. 
just before class  Quite a few schools allow dipping and chewin9
on campus. About one-third even had designated or well-known dipping 
areas , such as the "Skoal Pole" or "Scrounge Lounge 
o Youth are very to 
somewhat unaware of the health risks of dipping and 
chewing, according to 59 percent of health providers and educators. 
Eighty-six (86) percent of these respondents say many youth regard 
smokeless use as " safe 
o Whi le 
many smokeless users (89 percent) acknowledge dipping and chewing

can be harmful to a person s health they are much less likely to believe 
use. 
the re-is much risk of physicial harm in  For example, about 6 of 10 
senior high users say there is. either 
junior high users and 4 of 10 
risk or only a slight risk from regular smokeless use. 
o There is a considerable amount of 
inaccurate information on the risks of 
smokeless tobacco amrng users. In generQl, non-users are somewhat better 
informed. 
informed than users and junior high users are the worse  For 
example, 81 percent of users see  Qke1ess use  safer  than
cigarettes. About 5 of 10 users mistakenly beliaes vmuceh   and mouth 
problems arteo v tehrye  rare among dippers. 2S5n uff does not ucosnetarisn .n icotine 
accord i ng  error.  ous vi ews of  percent of  Regu 1 ar 
not  junior 
smokeless use is  addictive according to one-fourth of  high 
users and one-third of them disagree that it may lead to mouth cancer. 
o Improved health education on smokeless tobacco is clearly needed. A 
large majority of both users (70 percent) and non-users (65 percent) say
their school has provided no health information on smokeless tobacco. 
One-th i rd of key informants admi t no efforts have been made and many say 
i on that 
the educat  is offered is often very cursory. 
i i
 o About one-fourth of key informants say school officials are very 
risks of smokeless tobacco. Twenty-seven (27) 
somewhat unaware of the 
teachers, nurses and coaches, 
percent, including some principals, health 
say they have never viewed or heard any educational materials on 
smokeless. 
o Many young dippers report they are experiencing serious health effects.
le more pronounced among older youth, health problem  are also 
Wphir  evalent among junior high users. About 4 of 10 users have had 
in their mouths. Thirty-
leukoplakia at the site where snuff is held 
seven (37) percent have experienced sores, blisters, ulcers or other 
lesions on their gums, lips, tongue and mouth. Twenty (20) percent have 
reced i ng gum 1 i nes. 
o Addiction is a very serious problem for many users, including 28 percent

users. 
of junior high and 40 percent of senior high  Many (70 percefnati l. 
but most (78 percent) 
say they ve tried to quit, often man.y times, 
The majority (57 percent) of those unable to quit blame "addiction 
craving " or " habit" as the main reasOn. 
o The study 
concludes that youth use of smokeless tobacco is a growing 
national problem with serious current and future health consequences.
avert a potential epidemic of oral cancer and other serious health 
Federal actions are 
problems among youth in future years strong state and 
needed now. 
o The study recommends that the Surgeon General: 
smokeless 
- Launch an educational public media campaign on the risks of 
tobacco use. 
- Support school health educational efforts.

risks. 
- Seek funding for basic research on smokeless tobacco use and 

issue.
- Provide strong national leadership on the smokeless tobacco 

i i i  , "

YOUTH USE OF SMOKELESS TOBACCO: 
MORE THAN A P INCH OF TROUBLE 
BACKGROUND 
Smokeless Tobacco Use Defined 
Smokeless tobacco 'includes two main types: chewing tobacco .and tobacco 
snuff. Snuff " dippers " pl ace a small amount or a "pinch" of loose shredded 
or finely ground tobacco or a tea bag like pouch of tobacco between their 
cheek and gum. Tobacco " chewers " place a wad or " chaw" of loose leaf 
tobacco or a " plug " of compressed tobacco in their cheek. Both chewers and 
dippers suck on the tobacco and spit out the tobacco juices and s.aliva 
generated.  and flavorings 
Smokeless users savor the tobacco taste  and 
achieve the tobacco effect through rapid absorption of nicotine through the
sensitive tissues 'lining 
the mouth.' These practices of "going smokeless
have experienced a dramatic resurgence in popularity and social 
decade. 
acceptability in the last 
Growi ng Pub l i c Concern Over R is i ng Use 
Unfettered by a Federal excise tax  which was dropped in 1966  and 
unrestricted by the  advertising ban 
electronic media  applied to smoked 
in recent years. 
tobacco, sales of smokeless tobacco have skyrocketed  The 
most dramatic increase has been in sales of moist snuff. The U. S. Tobacco 
Company, which controls about 90 percent of this market, saw its sales more 
than quadruple from $94 million in 1973 to $444 million in 1984. 
Although no national surveys of the incidence and prevalence of smokeless 
years, est 
tobacco usage have been conducted in recent  imates of the numbers 
of users are substantial - ranging from an estimate of 11 million by the
National Cancer Institute to a high of 22 million by the Centers for 
Disease Control. Numerous experts, educators and health professionals say 
teens. 
many of these growing numbers of users 3re young males in their 
fact 
, a growing number of state and local surveys are confirming the rapid
and extens i ve growth in use of smoke 1 ess tobacco by ch i 1 dren and 
adults. 
adolescents, as well as yaung 
Concerns over rising use of snuff by youth were dramatized by the death 
from oral cancer in February 1984 of Sean Marsee, an Oklahoma track star 
dipping.  this 
following six years of regular snuff  Ensuing coverage of 
tragic event and the smokeless tobacco issue by national network television 
programs, such as " Sixty Minutes  20-20" , and "Hour Magazine , as well as 
extensive print media coverage in newspapers, Time Magazine, Readers 
Digest , and scholarly journals have further stimulated public concern. 
growing and extensive list of health professional and public health 
associations, public interest groups and government agencies have adopted
position statements or resolutions opposing the use of smokeless tobacco. 
Included are such groups as the An:er'ican Dental Association, The American 
Medical Association , The American Public Health Assocjation, the National 
- 1 
 The World Health Organization and the American 
Cancer Institute, 
Assigsonciifaictaionnt  hofe aDltehn rtaisl kSsc hasosoolcsia. tIend  gwenietrha lu set,h seuspep sotratt ehmeeanltths  cwaatranliongg  
labels, favor a ban or restriction on television and other industry 
public, and 
advertising, promote health education to discourage use by the 
well as restrictions on 
support increased taxation of smokeless tobacco, as 
its sale to minors. 
Appendix B lists some of the many organizations now on 
record against the dangers of smokeless tobacco. 
Significant health risks are associated with use of smokeless tobacco. A

growing body of scientific research links smokeless tobacco use with oral 
cancer. 
extremelySm hokigelhe scso ntcoebnactcroast,i opnasr toifcu lnairtlryo stahmei npoepsu,l aar  vmeoirsyt  psonuteffnst, g croonutpa ionf 
carcinogens known to cause cancer in over 40 different animal species. 
Continued exposure to tobacco juices produces lesions in sensitive mouth 
tissues. 
The white; leathery patches, or leukoplakia, whicuh sdeevresl.o p at the 
Evidence 
site where tobacco is held are common among smokeless 
suggests that the long-term risk of malignant transformation of smokeless 
significant. 
tobacco associated leukoplakia may be 
Periodontal diseases are also common among smokeless tobacco users, 
held. 
teeth at the site where tobacco is 
particularly gums receding from 
dental caries, tooth abrasion and bad 
Discoloration of teeth and fillings,  use. 
Another serious health risk 
breath have also been associated with 
since regular snuff dippers often achieve nicotine
nicotine addiction

smokers.
blood levels that equal or even exceed those of heavy 

Study Origin and Purpose

the 
In January of 1985 the Federal Trade Commissiont hreeq uheesateltdh   Surgeon 
General to conduct a comprehensive review of  effects of 
smokeless tobaccof otro  haieda litth  iwna rpnrioncgesss ionng  sam oPkueblliecs sC ittoibzaecnc oH epaaltchk aRgeisnega racnhd  
Group petition 
advertising. In  Surgeon General established scientific 
response, the 
, and
review panels to advise him regarding the carcinogenic, oral or dental 
Additionally, he asked the 
addiction effects of smokeless tobacco use. 
DHHS Inspector General' s office to conduct a qualitative field survey on 
smoke 1 ess tobacco use among youth.

The purpose of this study is to provide the Surgeon General with a broad-
school and junior 
based , geographically diverse survey of a sample of high 
high school current or former regular users of smokeless tobacco. The 
structured to 
study, which also includes non-users and key informants, is 
learn more about the types and levels of smokeless tobacco use, use 
patterns and infrleuseunlctiensg,  yforoumth  uawsaree.n eTssh iosf s ttuhdey h weaalst hn orit sdkess iogfn euds ea sa nda  
health effects 
use  data. 
statistically valid sample for developing prevalence of 

METHODOLOGY 
The study included a total of 525 respondents, of which 290 or 55 percent 
were current (251) or former (39) regular smokeless tDbacco users; 109 or 
percent were key i nformaots. See 
21 percent were non-users and 126 or 24 
Appendix A for additional details on study respondents. 
- 2 
 Users were defi ned as youth havi ng dipped or chewed over 100 times, who 
presently or formerly either used dai ly or at lueasset .3  days per week and who 
dipped or chewed at least 3 times on days of  Non-users were defined 
as those who had never dipped or chewed or who had only tried it a few 
times. 
Key informants were individuals 
times or who had used less than 100 
with knowledge of youth use of smokeless tobacco such as school principals, 
nurses, and coaches, dentists, or hygienists, American Cancer 
r teachers, 
Society representatives and state public and dental health and.educatior.al 
off i cia  and researchers. 
1 s 
Field work was conducted in 16 states: Massachusetts, Pennsylvania, West 
Virginia, North Carolina, Georgia, Alabama, Louisiana, Texas, Oklahoma, 
Indiana, Iowa, Colorado, Arizona, Idaho, Oregon, and Washington. :rhese 
geographical areas 
states were chosen to provide representation of diverse 
of the nation, because their reported high smokeless user populations , and 
activities. 
because of their research, educational or regulatory 
Within each state two schools were selected after consultation wit 
informed researchers, state public health and educational officials and 
school administrators. The study included 31 different schools, 11 junior 
high or middle schools and 20 senior high schools. At each school we 
interviewed an average of 8-10 users, 2-4 non-users and 3-5 key informants. 
Users and non-users were identified for us by school officials, such as 
principals, school nurses, health teachers, counselors and coaches, in 
balanced 
accordance with the above definitions and attempting to draw a 
sample from each appropriate grade level. Key informants were selected 
from with i n the schoo 1 sys tem, the commun ity-at - arge or from the state 
1 eve 
Structured questionnaires, focused on the study aims, were developed to 
guide discussions with respondents. The guides were reviewed extensively 
by PHS and HHS officials, and selected state and local officials and 
researchers.  and revised 
use.  They were also pretested  again prior to field
Study staff administering the guides were all experienced 
interviewers and received two dayst oof  ;f ietelnd   iwve otrrkai.n iAngl lo n the guides and 
smokeless tobacco issues prior  interviews were 
conducted on a voluntary, one-to-one basis, in a private setting with a 
full pledge of confidenti  llty to respondents. 
STUDY FIND INGS 
Who Are The Users?

Smokeless users are predominately males according to users (96 percent) 
non-users (93 percent) and key informants (98 percent). About 6 of 10 of 
these respondents say users of smokeless include both athletes and non-
athletes, although quite a few (28 percent) note a tendency toward higher 
use among athletes, particularly football and baseball players. About two-
thirds of our respondents say smokeless users come from both urban and 
rura 1 areas. However, about 30 percent of them thi nk usage is greater 
those with 
among youth with rural backgrounjs, especially  farming and 
roots. 
ranch i ng  Our respondents do not normally ass6c i ate smoke less use 
- 3 
 , "  , "

with any particular racial group; however, when they do, they overwhelmingly say 
Blacks, Hispanics or others. 
Whites are much more likely to dip or chew than 
Users and key informants consistently state that certain youth groups, such 
FFA , 4H, rodeo club, hunting and fishing clubs contain relatively more young 
users. 
smoke 1 ess 
Asked which youth are least likely to dip or chew, users, non-users and key 
informants frequent  y mention girls, e.g., "girls think it' s gross  girls
say it'  honor students 
s disgusting and nasty.  They also single out " " or 
smart kids  preppies " and kids having strong parental guidance or strict
religious backgrounds. They say Blacks, Hispanics and Asian Americans 
rarely dip or chew, in contrast to Whites and Native Americans. However 
informant said  It' 
there are exceptions to all these patterns. One key 
hard to say who s least likely to dip or chew since most of the kids are 
it." 
do i ng 
profiles of-
For more insight into what smokeless users are like see the 
current and former users in Appendix E. 
What Smokeless Products Are Most Used And How Easily Are They Acquired?

By far, the most popular smokeless tobacco product used by youth is moist
snuff. 
Nine of ten users say they most often dip snuff from tins (84 
percent) or use snuff pouches (6 percent). On ly 10 percent of users chew
loose 1 eaf ,o tfwtie sn t,.  or plug chewi ng tobacco, and even some of these dip 
snuff more  None report sniffing dry, powdered snuff through their 
noses. 
Unfortunately, the more popular moist snuff is also the most potent 
nitrosamines 
form of tobacco in terms of its high content of carcinogenic 
and nicotine. 
Tthhee  dmomaijnoarn aced voefr ttisheer  smoiksel ersesf lteocbtaeccdo  imna rtkeeet nb yp rtohde uUc.t Sp. rTeofbearcecon cCoemsp.a nTyh,e
 
overwhelming brand of first use among youth is Skoal , either in tins or in

the tobacco pouch "Skoal Bandit" form so prominently advertised under the

slogan implying health safety, "take a pouch instead of a puff"  Another 
S. Tobacco product, Copenhagen, its strongest, is the brand most youth 
use. 
say they currently  Copenhagen and Skoal account for the lion s share 
of currently used snuff brlaendsss, .w i th Hawken and Kodi ak also enjoyi ng some 
popularity, although far  Among tobacco cr\e jers, the Redman , Levi 
Garrett, and Beechnut brands are the most popul ar. 
Nine of ten users, among both junior and senior high students, say they 
personally buy their smokeless tobacco. Ninety-five percent of senior high 
users say it is never difficult or only slightly difficult for them to 
minor. 
purchase smokeless tobacco as a  Comparable junior high figures are 
only slightly lower, with 90 percent saying it is never difficult or only 
as a minor.  indicates that 
slightly difficult to buy  This clearly  , even 
where state laws restrict sales of tobacco to minors, they are very weakly
enforced. 
Teens make 55 percent of their purchases from convenience stores 
1 i ke "  11" and 31 percent from supermarkets or groc ry stores with the 
remainder coming mai  ly from gas stations, drug stores and tobacco shops. 
- 4 
 ... ,...

What Is The Duration, Frequency, Intensity, And Quantity Of Smokeless Use?

Youth areu sstearrst isnogo nus teh oefr esamfotkeerl easnsd t obacco at very young ages, becoming

regul ar  consuming cons iderab le amounts of

smokeless tobacco at fairly high levels of frequency and intensity. 
See

Table I of Appendix 

The overall average age when youth report first trying smokeless tobacco 

only 10.4 years, or in the fifth grade. The reported age of i  itiation is

lowest in the South Central (8. 9 years) and the Southeastern U. S. (9.

years) and averages 11 years in other areas. 
reports 
Samfotkeerl ess user  indicate that regular or daily use follows soon

in it i at i on. The overa 11 average age when regu 1 ar use begi ns

grade. 
reported to be only 12. 0 years old, or seventh  In the South East

and South Central regions it is only 10.7 and 11. 2 years, respectively,

wh i 1 e other areas average 13 years. 

users. 
It appears there may be a trend toward even younger  For examp le ,

junior high users say they tried smokeless an average of 3 years earl ier

than senior high students. 
daily basis 3  Likewise, they begin using on a regular or

years earlier. As a result , the average total years of

regular dipping for junior high users of 3. 
8 years even exceeds the total 
. years dipped by older students (3. 5 years). Based on these facts and the 
average ages of the users in our study, it is clear that many of these 
young users wi 11 have dipped regul arly at least 5 to 8 years by the time 
they leave high school! 
Mthosety  udsieprpse (d7 0o rp ecrhceewnte)d,  7i nocluutd ionfg  7a  mdaajyosri tiyn  otfh jeu nwieoerk  hpigrhi ours etros,  bseainigd


interviewed. 
Even more (81 percent),  said they usually dip or thew every

day in another question series on strength of habit. 
. Initiation S Duration Of Use

Days Dipped Or Chewed Last Week

(Junior G SenIor HIgh Use Compared)

V..r.  Perc.nt Respondent. 
101 
.J H111
 1?.J H111 
1'. 7 AVI A8  178'
1'.  !I H111  SR H1gh

18. 2 AVI A8  121 
st. 
'\ 't 
:; B:  I 8M  lppld 1-3 DaJ.  DaJa  7 DaJ.
10.  12.  141  701  . '
Sixty-one percent of users take 5 or less dips per day. About one of four 
(26 percent) take 6-10 dips and 13 percent say they take as many as 10 to 
day. 
20 or more dips each  Senior high users tend to take more dips than 
users. 
junior high  The majority of users (58 percent), both junior and
senior 
high, hold each dip in their mouths over 25 minutes, with most 
keep i ng it in over 30 mi nutes and often ' for up to 1 hour. 
Minutes Each Dip Held In Mouth' 
Dips Dr Chews Per Day 
Uee... 
Percent RespDndent.  itO 
tiO 
101  .. H111 
171' 
100 
!I H111 
I2t41 
""n: 24 M1n.. 
Node 3D+ M1nt.. 
!l0 
S-I 
S-I  ..to  11-18  ..20+  ..SO it-il S..2D 2S-21 283D 3D 
Mn Iii  IUnute. 1n Mauth
As indicated by the graphs on the following page, these rates and durations 
of dips result in rather high amounts of snuff consumption, as well as high
rates of daily  the 
exposure of  sensitive tissues of the mouth to the 
harmful effects of tobacco juices. Two-thirds of our users consume 2 or 
more cans of snuff or pouches of tobacco each week, with 12 percent using 
more. 
as much as 6 to 10 or  Even those dippers who average only 5 or 8 
dips per day usually hold the tobacco in their mouths from 3-4 hours each'
day. 
For the 13 percent of users who take 11 to 20 or more dips each day, 
day! 
tobacco exposure times may be as high as 6 to 9 hours each  Thirty
(30) users 
said they sometimes even sleep with a dip or chew in their 
mouth. 
- 6 
 , ,  . . 
Daily Tobacco Exposure Time

Cans Or Pouches Used Last Week

HDIr. 
Pec.nt AI.pDnOtnt. 
SOl  H1'" 
.. H1'" 
l2i41 
li 13 -
1 II lN  DiP' Pe DI,

a T. I	 Iii
I Of \I...

MoOt 
II.. 
. !XDII U..  .f aU, 
1. ti av..... 
.1p. IUlt1p11.. b, ..al length 1n .1nut.. If 
lid! d1p. 
Other Aspects of Usage

The vast majority of users (81 percent) say dipping or chewing is something 
they do both alone and with their friends, rather than mostly with friends 
or mostly alone. The most mentioned sites where youth dip or chew are: 
Setting	
Percent Respondents 
A t Home	 87% 
Rel axing With Friends	
85% 
Watching Sports  73%

At Work  49%

At Parties 
48% 
Studying 
Whi le  47% 
In The Classroom  30% 
few also said they dip or chew while hunting and fishing or, while 
driving around - sometimes in pick-up trucks equipped with spittoons - but 
only 4 percent dip while on dates. 
- 7 
 The great majority of users dispose of the tobacco juices by spitting. 
When indoors, they often use styrofoam cups and soft drink cans as portable 
spittoons. They also spit in rest rooms, water fountains, plants and some
halls. 
times on the floors, carpets and  When outdoors, its easiest to just 
spi t  in the grass or shrubs, on the ground , s i dewa 1 ks or out the wi ndow of 
an automobile . 
Suprisingly, a significant number (37 percent) say they swallow  he tobacco 
juices when they are dipping indoors and have no place to spit , as in the
classroom. 
School nurses confirm that such swallowing occurs based on the 
flu 
numbers of young males they see with upset stomachs, or " " symptoms.
The extensive amount of swallowing users report may pose a significant 
future risk of stomach and throat cancers, in addition to the risk of . oral 
cancer. 
What Is The Over a 11 Trend In Youth Use Of Smokeless Tobacco? 
Use of smokeless tobacco by young people has increased at a rapid rate 
the 
recent years. This is confirmed both by  perceptions of our study 
ng body of prev 
respondent s and by a growi  ence of use surveys around the
a 1 
nation. 
Greatly increased use of smokeless tobacco by adolescents and children 
being reported by numerous state and local surveys of school populations by 
scientific researchers and public health officials. These surveys, many of 
wh i ch are state-wi de in scope and number thousands of respondents, have
the 
been conducted in many different geographical areas of  nation. 
Commonly, they show about 8 percent to 15 percent of junior and high school 
regularly. 
students use smokeless tobacco  Among males, where use tends to 
predomi nate, the proport i on who dip or chew often ranges from 20 percent to 
levels. 
See Appendix C for 
as high as 40 percent of all boys in some grade 
additional highlights of these survey findings. 
12 percent of 
Several recent or on-going college surveys show about 11-
college students dipping snuff or chewing tobacco. One such study reported 
average use of 8 percent , rangi ng from a low of 8 percent (about 16 percent 
for males) at northeastern region colleges to a high of 15 percent (about 
central colleges. 
30 percent for males) at south  Studies show even higher 
athletes. 
smokeless tobacco usage among male college 
Smokeless tobacco use is expanding not only on college campuses and 
secondary schools, but al so among elementary school students. One state 
found 14 percent of fifth graders and 7 percent of third graders using 
smokeless tobacco. Two southeastern states reported over one-fourth of 
tobacco. 
fifth and sixth grade white males use some form of smokeless 
- 8 
 shown by the accompanyi ng graph

substantial majorities of smokeless

Perceived 5-Year Trend In S okeless Tobacco Use

uasreers , non-users and key informants

reporting increaosedr  use of
smokeless tobacco  stable 
use - often at rather high levels.  Plrc8nt RepDrting

1J. 
Our key informants are particularly 
cpoenrccerennetd  osaabryo ui tn gt huiss eri shea, sw ieti ht h8e5r  B311. 
great ly  moderately increased  711  o It Jnflltl 
years. 
during the past five  Among 
the reasons key informants and non
users frequent ly gia ver teo: exp 1 ai n 
this increasing use 
1) 
Peer pr2es)su rteh aned  friends
influence, 
faddish 
popularity  ' of the trend and its 
associated " cowboy" culture, 3) the 
influence of the media, especially
television advertising and 
the 
macho  image it projects 
endorsement by popular role models
c1e i lkeeb prriotfieesss, i  o5n)a  1t haeth letes and dllI DI_ud 
widespread  In_u.,I 
RtpDrt8d Tr8nd In P8rc8ntlg8.

misconception that smokeless is 
maunchd  s6af)er  tthhaen  smoki ng ci garettes,
ease of obtaining
smokeless tobacco and using it
without detection. 
Youth  Start  Dippi ng 
Chewi ng? 
Reasons For Initiating Smokeless Use

Users say 
they first tried 
rsmeoakseloesns tso.b aFccior sfotr,  tahnrede  main tlnl 
is  most  PeClft AlapDn48t8 Cl 
influential  peer pressure. LI... r7 
Their friends use it and push it  PQ" Hi'" 
and they iwtan.t  to be accepted , so  0co :II:....  rz41

they try  Many youth sai d they 11111 
started "
because my friends were 
doing it and offered it" or because
they see other people doing it" 
The second most ment i oned reason is 
curiosity or desire to experience 
taste. 
the effects and  The third 
reason is that other fami ly members
or relatives' use smokeless. 
Other
less 
mentioned reasons include: 
someth i ng to do or to avoi d boredom 
(8 percent), enjoyed the fl 
taste (6 percent),  avor or
and to avoid 
smoking or to change from smoking 
(4 percent). 
'.11,
II  Pr..18  art D' it, 
tll 
",,1\8: 801 
- 9  As shown by Table II in Appendix D, non-users and key informants agree with 
users on the important role that peer pressure and family or relative use 
play in initiation. However, many more key informants (55 percent) blame
the  industry  getting kids 
influence of  advertising for  started on 
smoke 1 ess. A 1 so, more non-users iatnsd  key informants cite the "macho or 
grown-up  image of smokeless and  appeal as a " safer alternative to 
smok i ng  , than do users. 
Reflecting the strong influence of peers and relatives, 58 percent of users 
with 
say they were  another youth or friend, usually their own age or a 
little older, when they first tried smokeless and 38 percent say they were
relative. 
with a 
family member or  Usually this was their brother (28 
percent), cous i n (25 percent), father (23 percent), unc 1 e (15 percent), or 
percent). 
a grandparent (7  The tobacco for their first dip or chew was 
given them by these individuals most of the time (77 percent). However, 14 
percent said they personally bought .their first dip or chew. 
Smokeless users are somewhat more  ikely to have fami ly members or 
relatives who dip or chew than non-users. 
USERS  NON-USERS 
(290)  (l09) 
ather Uses  23%  16% 
Brother Uses  32%  15% 
Other Re 1 at i ves Use *  73%  57% 
No Re  ves Use  16% 
1 at i 
Uncles, cousins, grandparents.  (Mothers and sisters  of both use on ly 
2 percent of time. 
- 10 
 , "  , ," 
 "

t '  likely than 
Smokeless users are also much more  non-users to have daily 
chew. 
close friends and associates who also dip or  For example, 78% of 
users say the i r best male fr i end uses, wh i 1 e th is is reported by on ly 32% 
of non-users. 
USERS  NON-USERS 
Best Male Friend
 78%  32% 
Other Male Friends
 97%  80% 
t , All 
- Many, Mos  ( 74%)  ( 28%)

- A Few
 ( 23%)  ( 52%)

o -
- Coaches  59%  38% 
- Many, Mos t , All
 ( 28%)  ( 13%) 
- A Few
 ( 31 %)  ( 25 %) 
Teammates  98%  43% 
t , All 
- Many, Mos  ( 57%)  ( 23%) 
- A Few
 (41 %)  ( 20%) 
Smokeless tobacco advertising does 
encourage young people to try 
dippi ng and chewi ngo acfc ordi ng to a
strong majority  users 
(62 
non-users (79 percent) 
percent) , 
percent). 
. and key informants (98 
Smokeless TobaccD Ads EncDurage Teen Use

About 8 of 10 users and non-users 
say these 
ads exert a moderate to 
strong effect, whi le 96 percent of
key  strong to  Perc1ln0t A0ll1pDn sl1

informants report a 
181  Uall 
moderate effect.  I2DJ 
PQ Nan 
of users  DO Uall ItD91 
maj or ity  (77 percent)  Key It28J
professional  791  78 Infarllt. 
say commercials using 
i gned to appeal to 
ath 1 etes are des 
teens (45 percent) and young adu

(32 percent). Non-usars closely  821

1181

agree with this view.

The users in our sample report
viewing smokeless T. V. commercials 
were able 
fairly frequently. They 
to accurately identify thseu tcyphe  of  281m 
portrayed, 
peop 1 e  etes, 
profess i onal  cowboys,  171 
ath 1 
outdoorsmen, musicians, and race 
car dr i vers . They des cr i be them as 
II , "
popular or well known  tough or  EncuaL.l..g . IIlIk MEa!df..rc.Ut  Strang
moachro  II , "strong or mraonllye   casual Ef Itct  Eff.ct 
Effectl Df Advlrt111..nt

models " 
laid back "l ike to be like 
people I'd 
people you look up to  Some also 
raespe ated the message ads give, such
II anyone can use it "  it' 
better or 
safer than smoki ng " and 
II it rel axes you " 
- 11 
 , , . .
Social Acceptability of Smokeless Tobacco Use

Dipping and chewing are enjoying fairly broad and growing social approval

and acceptance, part icul arly 
among students.

About 7 of 10 users, non-users and key informants say students generally

eregqarud adilplpiyng  aancd ccheewpingt aasb mloere  atcoce pstamble othkan isnmogkin.g  or at least

. Eighty-six 
(86) percent of users say most (38 percent) or some (48 percent)
students at their school approve of smokeless use. Even among non-users 70
percent say most (32  percent) students 
percent) or some (38  approve.
However , about twi ce as many non-users (29 percent) as users (13 percent)
say only a few approve. Eighty-two (82) percent of key informants report
that dipping and chewing is. acceptable to students in their schools or 
communities. 
However , 9u5 spee rcent of key informants personally  o not " think it' s ok foF

youth to  smokeless tobacco , primarily because of associated health

the  habit. 
risks and  nasty, unsanitary nature of this  An even larger

majority (99 percent) say parents and schools should do their best to

discourage youth from starting or continuing use of smokeless. Yet, it 

noteworthy that 20 key informants or 16 percent admit they personally dip

or chew. 
Unfortunately, most of these are coaches, who serve as important

role models for many young men.

DiupprDval Of Use By Significant Others  DlsapprDval Of Use By S1gn1 f 1cant Others 
Plrc.nt Atlpondtntl  Plrclnt Atlpondlntl

1001  Ut.r.  1001  Uura 
Iii  1201  121
Non-.ra 
Non-l.ra 
11011  11091 
721 
J71 
301 
Fath..  IIthar  Broth..  SI.t..  Bllt  Bllt  Coachll
8or'rl.nd  11r1lrl11d 
- 12 
 , "  , "

, "
It is significant that parents, siblings and friends of non-users are much 
more likely to disapprove of their use of smokeless tobacco than are the 
comparab le re 1 at i ves and friends of users. Many users report their fathers 
(68%), mothers (45%), brothers (91%), sisters (71%), best boy friends (98%) 
and coaches (51%) either approve or are neutral toward their dipping and 
chewing habits. Apparently, parental approval, or at least acceptance, of 
I dipping or chewing 
their sons  is actually even higher, for 93 percent of 
users 
tuhseerisr  say their parsenettst inkngo w they dip or chew and 8u7 spee rcent ot  1 i
home as a  where they regularly  smokeless tobacco. 
their preferences. 
Obviously, many parents are not enforcing  Quite a few
key informants point out that parents would rather see their kids dip or 
chew than have them smoke. 
Why Do Youth Continue Using Smokeless Tobacco?

Enjoyment of the fl avor and taste 
reason users give for
is the main their 
continuing  dipping 
and 
chewing habits. However

percent of users (28 percent of Jr.

High and 40 percent of Sr. High) 
Reasons For Continuing Smokeless Use

" tshaye tihre yh ahabviet  baencodme  addicted by
quit. 
can I 
Twenty-two percent say they keep 
Percent Respondents 
using for the effects they achieve,
e.g., " relaxation  buzz  peps 1001  Ii  U\2sO.,J. 
Peer pressure remains  Non-... 
important infl uence on cont i nued  Uo9! 
use,  their friends 
since many of 
are us i ng smoke less around them and 
in 
offering it to them. Sfeeo Trab le III 
141
Appendix  other 
reasons and for 
cont inuat ion 
comparison of junior and senior 
hi gh , responses. 
Permissibility  alit 
And 
Smokeless Use

Schoo l Usage

not officially 
Schools do  permit 
Pe.. 
daicpcpoirndgi  nogr  tcoh eawi nmg aijno rtihtye  oclfa usssreorosm,   FThuvotsr Addiction  Jluur EftlelelU 
non-users and key informants.  ..t.  HH  lliinnnn::  7105S   40S  tIS  241
Schoo 1 offi cia 1 s real i ze that some

kids dip 
vienr ycl aesass ayny way because
 . The Effech Category Include. "Help Aelu 
it'  to hide  Give. a Buzz  PeP. li 
keep dips in 
especially when they 
for long periods and swallow the

- 13 
 , "

juices. 
In fact, 30 percent of users say they dip in class and 41 percent 
say they often put in a pinch just before class starts. 
Some schools allow dipping and chewing at other places on campus according 
to users (42%), non-users (26%) and key informants (30%). Places where 
dipping often occurs are parking lots, anywhere on outside grounds, and 
field houses or athletic practice fields. Spitting areas, designated or at 
visited. 
least commonly known, were reported at 10 school campuses  These 
sometimes even have names like the li The Skoal Pole  Scrounge Lounge" or 
Cowboy Corner  Sometimes the . smoking area doubles as a dipping area or 
the dipping area may be _something like an old hollow tree stump where 
di ppers congregate. 
Dipping and chewing also goes on at school functions like ball g.ames, 
dances, and pep rall ies 
according to 38 percent of users, and 29 percent of 
non-users. 
School officials acknowledge it is much more difficult to 
settings. 
enforce non-use rules in these 
School Pol icies and Enforcement Vary Widely 
considerably. 
School policies regarding smokeless usage vary  Some address 
smoking but do not touch on dipping or chewing, some requuisree .p ermits to use 
smokeless 
smokeless, others outlaw  and other tobacco  Some restrict 
campus. In 
use but allow possession of smokeless on  some schools where 
even possession is prohibited the telltale white rings on jean pockets are 
fade  tins 
beginning to  as boys conceal their snuff  inside the front of 
lockers. 
their jeans behind their belts, or keep them in their  Schools try 
to strongly enforce their rules, where they exist, but admit they don 
have the time or desire to be "policemen  . However, some schools employ 
suspensions, remedial education and even transfer to alternate schools for
in 
repeat offenders and appear to be havi ng some effect  imit i ng use. 
About 25 percent of our respondents say school rules are only weakly 
enforced. The attitude and leadership of school principals appears to be a 
schools 
key variable in determining how actively  attempt to control or 
restr i ct use. 
State Law Restrictions

users, 
In general , we found mass confusion and/or ignorance on the part of 
non-users and even key informants regarding the legality in their states of 
gift
use ard purchase of smokeiess tobacco products by minors, the sale or 
of 
such products to minors and any legal age limits on use, purchase or
sale. 
Several of the states in our sample do have such laws. However, the 
existence of their 
majority of respondents either are not aware of the 
state  them. 
s laws or have an incorrect understanding of  Many respondents 
incorrectly think their state has legal restrictions on use, purchase and 
sale when, in fact, it does not. Time and again when asked about such 
legal provisions, key informants would say, " I should really know that, but 
I don  . Two-thirds (66 percent) of key informants said state laws 
restricting sale or use of 
smokeless tobacco are only weakly enforced; 30 
know. 
percent di dn I t  These responses, together with the fact that 94 
percent of users report it is never diiftf icult or only rarely difficult for 
state 
them to purchase as a mi nor , make  abundant ly clear that  1 aws 
restricting use of smokeless tobacco products are not being enforced and do 
not provide an effective deterrent to use by minors. 
- 14 
 , . 
How Aware Are Youth of the Health Risks of Smokeless Tobacco?

Among key informants like school officials, health providers, and health
educators, 59 percent say  very 
youth are  unaware or at least somewhat 
unaware of health risks of dipping and chewing. When asked if any youth 
regard smokeless use as "safe " 86 percent of these respondents said yes 
with a majority sayitneg  many or most young people share this attitude. 
explanation they c  several factors: 1) even youth who know of r-sks
often think li 
lt can t happen to me ; 2) youth see smokeless as safer than 
cigarettes due to misleading advertising claims and the heavy anti-smoking
emphasis; 3) absence of warning labels on smokeless products; and 4) the 
relative dearth, until quite recently, of smokeless risk information. 
Can Smokeless Use Be Harmful To Health?
 Perceived Extent of Risk of Smokeless Use

1001 
P8rclnt Reapond8nta Perc.nt Respondlnt.

17 18  .1r 1H..iG. h1711  1001	 .1r 1.U..'" 1781 
!I HiGh  !I High 
QQ 11... 12141  QQ 11... 12141 
N1a1n... Ito.  Nln 
11... UOJ)

1t7L lKle yr a1rta2a8t
.
 1tL7  IRno y -Uo2nB)t
. 
31 21

I1tlll 
u... 1111 W  Not t.1..l tlll
 II.. 1111NSU oJ4 Ah1tI8  kA Io8rk  I.I...H.rtl tA.l lTi. 
841 
. lT'uhlp  Naant .H..a lUrl-l Hl IC l- t7.g1a.r yS rI nHc1l u-d ..au  DaNn ot IKIn.raw.  1 DTahn.  tN aK nAlasak /ASluipgahnt sAlIl lUi -C Hlti. -ga.ruy  ISnrc luHd1. .-  a. ' 
21 K.y Intarlantl - Nan-era -.u KlY Int_ant. - UI 
Eighty 
(80) percent of junior high  User  s percept ions of the extent of 
users and 92 percent of senior high physical harm that might actually

users acknowledge that dippi 
ng and  result from regular dipping and

chewi ng can be harmfu 1 to a person I s  chewi ng are much lower. About 6 of 
hrei  as 1k ths .  of MoarnaYl -note the potent i a 1 10 junior high users and 4 of 10

cancer (79 percent) senior high users say they see no

and a few (5-
15 percent) mention  risk or only slight risk in regular

use. 
problems like gum disease, tooth  In contrast, about 7 of 10 
damage, mouth sores and stomach non-users and 9 of 10 key informants

problems. 
Yet 1 of 5 junior high  assess the risk of re ular dipping

users and 8 percent of senior high  as moderate to great. It seems very

users say smokeless use is not  likely there is some risk denial by

harmful to health. 
smokeless users who are rationa

lizing habits which they enjoy or

cannot break. 
- 15 
 Inaccurate Knowledge of Health Risks

There is a considerable amount of inaccurate knowledge of the risks of 
part of 
smokeluessse trosb.a cco on the  dippers and chewers, ,especially junior
high  In general , non-users are better informed than users and 
junior high users are worse informed than older users. 
Fully 81 percent of users see smokeless tobacco use as much safer than
cigarettes. 
This widely held  dangerous belief 
perception leads to a very 
that smokeless use is "OK" and a " safe alternative  , which it is not. 
Six of ten junior high users and 4 of 10 senior high users mistakenly
be 1 i eve th at gum and mouth prob 1 ems are very rare among dippers and 
chewers, when , in fact , they are fairly common. Snuff does not contain
nicotine according to the erroneous views of 38 percent of junior high 
users. 
users and 20 percent of senior high  One of four junior high users
and 15 percent of senior high users think regular smokeless use is not 
addictive. One-third of junior high users incorrectly disagreed with tlfe 
statement that regular use of smokeless tobacco may lead to mouth cancer. 
Inaccurate Knowledge Of Risk.	 Inaccurate Knowledge Of Risks

Of Us ing Smokeless Tobacco (ST)	 Of Using Smokeless Tobacco (ST) 
Percent Inaccuratl Reaponae.	 Pecent Inlccurlte Reaponl.1 
90S	 811 IU  .U. .H.rigl hI7SJ  50S  .U. aHeirg.h 1761
High High
Ullrl 1214/  Uaera 12141 
uNo'en	rl 1109/	 NUoaner. II 09) 
101 
i-Sf u.. 11 IUch 80rl "'I than CI'II.tt..	 4-!huff dOli not conhln nlcoUn. 
u.... Ir. 'I'" ,.... 
2-Ql8 8 80uth prob lIu ..on,  IHQU11I ST UI' h' l..d to 80uth canc.r 
.r. iner.... ,.11k I' tooth ltalna. WlIr. lOll  &-QU11I ST Ull 1. not IddlcUn 
I The p.rc.nh,.. Include .don t knn' ,...ponl"  I Th. p.,.clfh,1I lnclud. .don t kno.' ,..ponll.
I aTnhd.  3n aUona8l1 .1. .4n7.1 .l oarn du aU.Sr  rca..tpeg.ocrUl.n. li,..  2- I a1n1d.  8n aIUIo"n l2l !u. .1r2 18 .a.nnad  f1o1r1  C,l.taIp,eorclU.n.l ,4.,  II
- 16 
 . .
Improved School Health Education on Smokeless Risks Is Needed

A large majority of both users (70 percent) and non-user  (65 percent) say 
their school has not provided any health information on smokeless tobacco. 
while more key informants believe schools are providing some educational 
coverage on smoke less tobacco, one-thi is rd  admi t no efforts have.been made. 
the fairly 
Often this lack of school effort  attributed to  recent 
youths, 
discovery of risks to  lack of good educational materials, failure 
priority 
to perceive dipping as a serious problem, competition of higher 
time. 
problems like drugs, alcohol and smoking, and lack of staff and  Many 
school officials admit that health classes, the normal means of conveying 
any smokeless health information, often only provide very cursory treatment 
of smokeless tobacco, perhaps in a tobacco unit heavily focused on smoking, 
or as one small item in a substance abuse unit dominated by drugs. 
Furthermore, since many schools permit senior high students to take only 
one required semester of health at any time during their four years, many-
students may already have formed th  ir dipping habits before receiving 
information. 
health risk 
About one-fourth of key informants say school officials are very or 
somewhat unaware of the risks of smokeless tobacco. Twenty-seven (27) 
percent  including some principals, health teachers, school nurses and 
coaches, say they have  educational materials on 
never viewed or heard 
smokeless tobacco. Many professing knowledge of smokeless risks derived 
from non-school sources, such as the " 60 Minutes" and "20-20" T. V. specials 
article. 
or an occassional newspaper or magazine 
Many schoo 1 respondents recogn i ze they need to do more to educate youth on 
smokeless risks and to discourage them from starting and continuing dipping

and chewing habits. This should be done, they say, both in health classes

and in spec i a 1 programs, wi th hea  th teachers and coaches p 1 ayi ng a vi tal 
role. 
arents should also be educated on

health Threyi sarek qusick  sto opoi ntt ohut ethyat  can work together with schools in discouraging 
seen as 
smokeless use. Parents are  unaware of smokeless risks by 55 
percent of key informants.

Users say the best way to inform youth of smokeless risks is television 
servi ce annoJncements 
-spec i a  documentar i es, pub 1 i c  and 
counteradvert is i ng. The next most effect i ve way is through school 
education in the classroom and special assemblies. Users stress the 
importance of presenting the facts, employing examples of young users with
health problems and use of pictures and audio-visual materials to 
graphically show problems that can occur. 
Key informants and non-users agree on the importance of us ing the 
electronic media, both TV and radio, and school educational efforts, with 
key informants stressing the need to start education early and reinforce it
over time and to train teachers on health risks. Many key informants and 
non-users think product health warning labels are a good way to educate on
risks. 
One non-user said, " I know lots of kids whose o ly reason for using 
it is because it doesn t have a warning label.  Key informants also urge 
- 17 
 . .
of 
banning electronic media smokeless commercials and use  professional 
athlete role models for counteradvertising. They also favor a broad public

media campaign to educate parents, communities and the general population

on smokeless risks.

Fortunately, though most users say they are getting little information on 
smokeless risks at school, they are becoming somewhat aware of risks from 
other sources such as the above noted TV spec i a 1 s (54 percent), word -of
mouth from parents, family and friends (42 percent)  reading 
and 
newspaper or magazi ne art i c les (31 percent). Unfortunately however, 92 
after  they
percent of users say they gained this knowledge of health 
risks 
had already begun dipping or chewing. Asked if they would still have 
started had they known the risks beforehand, 37 percent said they probably 
would not and another 13 percent were not sure. 
Health Warning Labels

Our respondents are not very
Will Warning Labels Discourage Purchase?  optimistic  lacing 
that p, warning
labels on 
containers of smokeless 
tobacco wi 11 deter young dippers and 
perc.nt VII lIapll11 
chewers from buyi ng it. Sixty-two 
701  .. Hi'"  users 
UII'" "II  (62) percent of  and 3 of 4 
IX sUoI .H"l.I h! 2UI
 nnoon-tu msearkse  syaoy uwtahr nliensg sl albikelesl yw ill 
Nan-u. 
regarding the 
purchase. However 
11091 
on 
impact of warning labels  them 
personally, almost 2 of 3 non-users 
it if it 
say they would be less likely to buy
had a warning label. 
of 
Users, many  whom already have 
strong smokeless habit  are much 
ss apt to say warning labels will
deter purchases. Several 
said 
warning labels would have mattered 
more earl ier when beginning use of
smokeless. Junior high 
users are 
than 
somewhat more likely  5erior 
high usefS t.o say warning labels 
will impact on them personally.

All Yautl  Yau PI.an.ll,

- 18 
 t : 
What Are the Health Effects on Users?

Based on user self-reports, many young dippers are experiencing serious 
health effects. While more pronounced among older youth, perhaps due to
their higher volume and more intense use, health problems are also 
prevalent among juni or hi gh users . Although harmful effects run somewhat 
higher in the Southeast and South Central parts of the nation, those areas 
with earliest ages of initiation and highest total years of use, they are 
tudy. 
frequently reported by users from all geographic regions in our 

User Hea 1 th Effects  User Hea 1 th Ef fects 
Peclnt 
Perclnt A8lpandlntl A8partlng  A8lpandent. Rlpartlng 
701  Pf"-
&01  .IaI .H.l.t h II.H.l.t h
1781  P'"  1781
JIth
.. Hlth

1111  IU II... 12141  CI II... 12141
Ka,a 1l1'2u8   Ka,1 1I12t88
  
In f  In f 
1111 
411 
401 
311 
Taath  RecUin.  "'111n.
LUaphkh II Sa,.  Addiction  Shin.  Skin
Uur "'81: 38  371  371  ,,"':: !9  201  tll 
III, Infarnntl I l'art1n. II prall.. II, ,..th 
. KI' Inra,.lnt'l plIclnhge I'r....tl pra
 Ullr. th, knaw. AIclding Ii p.UDI .. MIA
1I1Ia up..ilncU II, 
,auth Ularl thl' lel..

About 4 of 10 or a total of 113 users say they have had white, wrinkled 
patches, or leukoplakia, develop at the site where they hold the snuff in
their mouths. Thirty-seven (37) percent of users have experienced sores, 
lips and mouth. 
blisters, ulcers or other lesions on their gums,  Receding 
gum 1 i nes are reported by 20 percent of users and 18 percent have 
gums. 
experienced skin sloughing off or peeling from their cheeks or 
reduce these problems many youth frequently shift the tobacco from side to 
heal. 
side in their mouth to allow sores or lesions to  One youth said he 
tloin es his cheeks and gums with plastic to help protect sores and allow him
teeth 
keep dipping. Staining of  and fillings is the most widely
reported oral effect. 
- 19 
 --.
. . , "  , "

Addiction 
users. 
Thirty-seven 
Addiction is a serious problem for many  (37) percent 
of users say the reason they continue using smokeless tobacco is because 
they are addicted or " hooked"  Said a typical user  Itl s a habit. I got 
hooked on it , add i cted to it , 1 i ke smok i ng I guess. II As shown by strength 
of habit, Table IV in Appendix D, many users exhibit numerous indicators of 
addictive behavior. 
For example, 81 percent dip frequently e'1ry day, 68 
special tri 
percent would make d  to the store if they ran out of snuff , 55
percent would have strong cravings and 53 percent would find it li 
quit.  very hard" 
tried to 
if they  Some, 27 percent , say they cannot even go four 
irritable. 
hours without a dip or they will get nervous or 
Many users want to quit and have tried to quit numerous times only to fail 
them. 
due to the strong hold their habit has on  For example, 70 percent of 
users say they ve made a serious attempt to quit dipping or chewing. Many 
who attempt quitting do so out of fear of cancer or other health risks (34 
percent) or because of health problems they are experiencing (15 percent)
For example a former user said li my gums were going down, my teeth were all
stained , it was expensive and I heard it caused cancer.  Quite a few try 
to quit because of the urging of parents and fami ly (18 percent) or their 
girlfriends or other friends (11 percent). Those who ve tried to quit say
it' 
s very hard to do and 78 percent say they failed despite an average of
3 attempts. 
Even those who have stopped report making an average of two 
attempts before successfully quitting. Fifty-seven percent of those unable 
to quit blame " addiction , craviInIg,  habit" as the main reason. Said one 
user  I just had to have it.  Another said, " I was going crazy.
couldn  t concentrate. I was jittery. I couldn t sleep. I would quit if 
I could, if there was a way.  It is very sad to listen to these young 
people recite their health problems and fears and their inability to stop 
doi ng someth i ng they know is hurt i ng them. Many seem to yearn for some 
miracle cure or at least special services or help for those really wanting 
to quit. 
While the user health effects reported above might alarm many health and 
seriousness. 
dental officials, many users tend to uiscount their  They 
usually regard their mouth sores, gum, teeth and stomach problems as only 
harmful. 
slightly to moderately  Perhaps this is due to several factors: 
1d) heaelth prnoblemsi ofaten cllea.r u p after use is curtailed or stopped or may 
be lessened by changing the place where the pinch is placed, 2) oral CJncer 
is a long-term risk which has not yet affected many youth, 3) dental exams 
are not reported as detecting many problems and 4) rationalization and
i st 
It is noteworthy that 40 percent of youth say the dent  was not aware of 
habit. 
their dipping  Among users whose dentist did know about their habit 
43 percent said neither the dentist nor hygienist advised them to quit. 
Smokeless Use and Smoking

The current smoking behaviour of smokeless tobacco users and non-users in 
our sample does not differ substantially. Only slightly more smokeless 
- 20 
 , . 
users (60 percent) than non-users (52 percent) say they ve tried smoking
ci garettes.  arge majority of both users and non-users do not smoke,
with 
somewhat fewer non-smokers among smokeless users (79 percent) than 
non-users (86 percent). Three (3) percent of both users and non-users were 
former dai ly smokers who have quit. Eight (8) percent of users and 6 
smokers. 
percent of non-users are current dai ly  About 6 percent of users 
and 5 percent of non-users say they smoke only occassionally (weekends,
parties). 
are 
Among smokeless users who  also dai ly smokers 45 percent said they 
started smoking after they had been using smokeless. However, the majority 
before  they began dipping or chewing and 56 percent of these
wreree gsmoakirngd 
  smokeless tobacco as a substitute for smoking. Again  among 
less 
smokeless users who also smoke occassionally,  than half started 
before
smoking after using smokeless and of the majority who were smoking 

53 percent regard smokeless as a smoking substitute.

Possibility of Future Cigarette Smoking

USERS  NON-USERS 
Definitely/Probably Not  78%  86% 
50-50 Chance Wi  12% 
Defi ni te ly/Probab ly 
Wi 11 
report a  probability (21.7 percent) of 
Smokeless users  somewhat higher 
smoking in the future than non-users (14.4 percent). However, the majority 
(64 percent) of smokeless users saying they are possible future smokers, 
occassionally. 
already smoke daily, or smoke  Among smokeless users who do 
not smoke and have not smoked only 4 percent say they wi 11 definitely or 
probably smoke in the future and only 7 percent say there is a 50-50 chance 
they wi 11 smoke in the future. 
A large majority of smokeless users in our sample, regard snuff dipping as 
much safer than smok i ng and they do not smoke ci garettes now nor do they 
future. 
intend to smoke in the  Among smokeless users who do smoke the 
majority say they started  before  they began dipping or chewing. 
smoking 
For them, smokeless tobacco is more of a substitute for smoking than a 
precursor of smoking. In summary, our findings provide only weak support 
for the hypothesis held by some public health officials tihna t a nicotine 
addiction developed through dipping will be satisfied  later years 
through smoking. Further research is needed on this important issue. 
What Are States Doing About the Smokeless Tobacco Issue? 
Problem Identification

As indicated by Appendix C, several state health departments have conducted 
states. 
surveys of the use of smokeless tobacco by youth in their  Notable 
among these are Massachusetts, Wisconsin, Iowa, Oklahoma, Utah, and Idaho. 
Significant studies showing prevalence of use have also been conducted by 
(Christen et 
non-state entities in Texas (American Cancer Society), Indiana 
- 21 
 , .  , " 
al), Oregon (Oregon Research Institute), Colorado (Greer and Poulson) and 
Georgia (Offenbacher and Weathers). 
Tshtea tAess odceinattiaoln  doifr eSctatoter sa nidn T eOrkrilathoorimaal , DUenttaahl,  DIidraechtoo,r sa,n pda rMtiacsusalcahrluys ettthse; 

together with the on-going efforts of the CDC Dental Disease Prevention 
Activity 
(DOPA), are helping to raise state and national awareness of the 
serious health threat posed by smokeless tobacco. 
Smokeless Tobacco Education Programs

In a recently completed anaylsis of data offered by 50 state health 
departments by the Centers for Disease Control DDPA, 13 states reported 
offer 
they now  smokeless tobacco educational programs and 7 additional 
states plan to do so in the futurse.ta* tTeh.i rty-three states say there ' is a 
need for such programs in their  The remainder are unsure of the 
need , but none see no need for such educational programs. Only 4 of the 13 
states have developed their own training materials, such as videotapes,
slides , brochures and school health u it curricula. Eight states plan to 
develop materials and 7 states are using materials developed by other-
states or materials such as the 
American Dental Association Smokeles 
Tobacco brochure or the widely used brochure and trigger fi 1m  Everything 
You Always Wanted to Know About Dipping and Chewing , produced by the Texas 
Di vis i on of the Amer i can Cancer Soc i ety. 
Idaho, Oklahoma and Utah have led in developing educational materials which
may include 
brochures, trigger films, slide-tape series for teachers and 
students, posters and  servi ce announcements. Other noteworthy 
pub 1 i c 
smokeless educational materials include "Don  t Take the Risk" , a slide tape
series by the California Dental Association  taundt eli.T he Big Dipper
vi deotape developed by the Oregon Research Inst i  Two states, Texas
and Arizona, assign or make available oral health educators or dental 
hygienists to make school presentations that include smokeless tobacco. 
Regulatory or Legislative Action on Smokeless Tobacco

Warn i ng Labe l s 
The State of Massachusetts recently issued a public health regulation 
requiring the following heJlth warning label on all snuff sold in the State 
after December 1, 1985. "WARNING: Use of snuff can be addictive and may 
cause mouth cancer and other mouth disorders.  According to an October 
Smoking and Health Reporter, bills requiring health warning 
1985 issue of 

1 abe 1 s are now pend i ng in New York, New Jersey, Delaware, Pennsyl van i a, 
Utah and Oregon. Additionally, California 
Illinois, Michigan  and 
Minnesota expect legislation to be filed this winter and Iowa is also 
S. 
considering such action. Both the U.  Senate and the House recently 
passed bills that require health warnings on smokeless tobacco packages and 
in smokeless advertisements. 
Smokeless Tobacco  Programs Offered by State 
Educat ion  Health 
Departments  Cathy L. Backinger, R.  , M.  H". and Margaret 
Scarlett, D.  D. Paper presented at American Public Health Association 
Conf erence in November 1985. 
- 22 
 Excise Taxes

Currently 21 states levy excise taxes on smokeless tobacco products, either 
tobacco. 
snuff or chewi ng  Eight of our samp 1 e states have such exc i se 
taxes, including Alabama, Arizona, Idaho, Iowa, Oklahoma, Oregon, Texas and
Washington. Additionally, the 
Massachusetts legislature is expected to 
cigarettes. All
soon propose a smokeless tobacco excise tax equivalent to 
50 states levy excise taxes on cigarettes. Federal le 
islation to 
reinstate the Federal excise tax on smokeless tobacco is also pending. 
Restrictions on Sale or Gift of Smokeless Tobacco Products to Minors

About 40 states have laws restricting sale or gift of some forms of 
smokeless tobacco, or all tobacco products, to minors - defined as those 
18. 
below age 16, 17 or  All our 16 sample states except Alabama, Georgia, 
Colorado and Louisiana prohibit tobacco sales to minors. However, only 4 
of these states, Idaho, Iowa, Oregon and Oklahoma also restrict the use and 
possession  of smokeless tobacco prodLlcts by minors. UnfortunatelY:most 
state 
laws restricting sale, purchase or possession of smokeless tobacco 
products are not very we ll-
known and appear to be very weak ly enforced. 
restrict the 
None of our sample states  advertising of smokeless tobacco 
products. However, it is noteworthy that in May of 1984 the New York 
Attorney General successfully convi nced the U. S. Tobacco Company to cease 
use of misleading advertisements containing the slogan "Take A Pouch 
Instead Of A Puff" in New York. 
CONCLUS ION 
In light of the foregoing evidence we can only conclude that youth use of 
smokeless tobacco is a growing national problem, with serious current and 
future health consequences. To avert a potential epidemic of oral cancer 
and other serious health problems among.our youth in the years to come, 
strong and decisive state and Federal action is needed now. 
RECOMMENDAT IONS

LAUNCH AN EDUCATIONAL PUBLIC MEDIA CAMPAIGN

The Surgeon General should launch a broad public media campaign to 
educate children and youth, parents, allied health professionals, 
teachers, coaches, school officials and media health specialists on the
health risks of  This 
smokeless tobacco.  campaign might include
television and radio public service announcements and documentaries;
news releases, bulletins and brochures; newspaper and magazine
articles; and counteradvertising, perhaps enlisting 
popular 
professional athletes or celebrities who will tell the "downside " of 
dipping and chewing. 
This campaign should be a coordinated effort involving the Office of

Cancer Communication (OCC) of the National Cancer Institute, the Dental

Disease Prevention Activity (DOPA) and the Center for Health Promotion

and Education of the Centers for Disease Control, the Office of Smoking

and Health and other appropriate Public Health Service organizations.

- 23 
 . " . \..
SUPPORT SCHOOL HEALTH EDUCAT IONAL EFFORTS 
The Surgeon General should direct a coordinated Public Health Service 
effort to develop and/or disseminate smokeless tobacco educational 
information and teaching aids for use in school health education 
classes and programs. This effort might include development of units 
include 
or curricula for clarsissrkoosm,  upsreo,v iudpdinatgi nagn e xinisftoirnmg aclu crrleiacurilnag htoo use for 
smokeless health 
materials, 
smokeless tobacco educational  in-service training programs 
or video tapes for teachers, coaches, and school nurses. States should 
be urged to start education on smokeless risks in primary schools with 
levels. 
on-going reinforcement at the junior and senior high 
for 
This support effort should include the CDC Center  Prevention 
Services, DDPA, the Center for Health Promotion and Education, and the 
NCI Office of Cancer Communication. It should enlist the support of
the State and Territorial Dental Directors, State and Territorial 
Directors for Public Health Education, the National School Health-
Coalition and the National Education Diffusion Network. Assistance 
should also be sought from the American Dental Association the American 
Association of Public Health Dentistry and the Amrican Public Health 
groups. 
Association and other appropriate professional 
SEEK FUNDING FOR BASIC RESEARCH ON SMOKELESS TOBACCO USE AND RISKS

The Surgeon General should seek funding support for basic research on 
smokeless tobacco usage. First, steps should be taken to establish an 
on-going national survey and data base on the incidence and prevalence 
adults. 
of smokeless tobacco use by youth and  This might be achieved 
special national  the 
through a  adolescent survey of tobacco use by 
Office of Smoking and Health, by adding some smokeless tobacco 
questions to NIDA' s Annual Survey of High School Seniors or other on-

go i ng PHS househo 1  or school-based health surveys. Second 
appropriate PHS units such as NCI,  IDA , NIDR should be encouraged to 
target a portion of their research budgets to fund gaps in knowledge
identified by the scientific advisory panel on smokeless tobacco 
Third, 
recently convened by the Surgeon General.  special attention 
should be directed to discovery of effective intervention or treatment

habits. 
methods to help youth who want to stop their smokeless tobacco 
PROV IDE STRONG NAT IONAL LEADERSH IP

The Surgeon General should utilize the great influence of his position 
smokeless tobacco issue. 
to provide strong national leadership on the 
Possible action options:

report on the carcinogenic, oral 
- Issue a comprehensive, special 
health , addiction and other harmful effects of smokeless tobacco as 
soon as possible. 
- 24 
 Urge 
antismoking organizations and coalitions to add 
smokeless tobacco to their agendas, opposing it with the 
same enthusiasm given to smoking. 
Alert the nation s dentists and physicians to screen for 
problems caused by smokeless use during periodic dental 
of health risks.
and medi ca 1 exams and urge them to warn -and inform youth 
Request states to better enforce and strengthen their laws
restricting use,  or sale of 
purchase, gift  smokeless 
products to mi nors . 
aEnn 1 dis  st ttahet es upport of the F edera 1 Department of Educat i on
educational officials to encourage rapid 
timop  1 uermegnet amt oiroen  osfch osom o1k e lteoss  atdoobpatc cpoo  e1du ic ca ti  eiso on fp rnogor aumsse a ondr 
possession of any form of tobacco at school. 
Serve as an advocate and intermediary to important groups

wahso  tchane  help address the smoke less tobacco problem, such

Americaont Dheenrta la Allsiseocdia thioena, lAtmhe rican Medical
Association  professional
associations; national 
associations of school principals,
nurses, high  the 
schoo 1 ath 1 et i cs ;  Amer i can Cancer
Society, Parent and Teacher Associations; and 
youth
organizations such as the Future Farmers of America and

4H. 
GENERAL OBSERVATION

Our study noted a 
fundamental difference in public policy regarding smoked
and smokeless tobacco. Smoked tobaccos  ' are subject to health warning
labels, advertising restrictions and a Federal excise tax , none of which. 
apply to smokeless tobacco. It is important for the Surgeon General to
determine from available evidence whether this basic difference is
justified. 
The Federal Cigarette Labeling and Advertising Act of 1965 mandated health 
Tharzaardde w Caronminmg ilssaiboenl sb oeng acing arreeqttuei rpinacgk wagaersn.i Inng  1m9e71s saandg e1s97 2i nth ec iFgeadreertatle
advertisements as well. The Public Health Cigarette Smoking Act of 1969 
prohibited any cigarette advertisements on television and radio after 1971.
The 
Comprehensive Smoking Education Act  beginning in October 1985 
requires four strong warning labels on both cigarette packages and in
advertisements. 
oUnfl ike the ban on cigarette advertising, radio and television advertising
smokeless tobacco has never been prohibited. Often professional
athletes and celebrities are used to promote smokeless products in ads that 
are targeted toward young audiences and which suggest smokeless tobacco is 
a clean, enjoyable, safe alternative to smoking. 
- 25 
 I. . 
and public health associations, 
Many prominent professional  as well
public interest groups, have strongly endorsed Surgeon General health 
hazard warning labels on smokeless tobacco packages. They have also called
for restrictions on advertisement of these products which range from a 
total advertising ban, to a ban on radio and television ads, to requiring 
that all broadcast or print media ads be accompanied by health warning 
messages. 
Ameri can DAemnotnagl  Atshseo c oi ragt ainoinza,t iTohnse  sAumppeorritcianng M esdu cicha  m1e Aasssuorce i sa t iaoren:,  TThhee  
Association of State and Territorial Dental Directors, The Association of 
State and Territorial Health Officials, The American Cancer Society, The
American Heart Association , The American Lung Association , The National 
Cancer Advisory Board and numerous state medical , dental, and public health
associations. 
A growing number of states are curr ntly assessing whether to follow the
state of 
Massachusetts example of requiring warning labels on smokeless
products. Also,  require 
Federal legislation to  warning labels and 
recently passed. 
advertising restrictions on smokeless tobacco was 
December of 1985 the Senate passed the Comprehensive Smokeless Tobacco 
(S. 1574). 
tEodu cation Act of 1985  This bill calls for the Secretary of HHS
establish a public information program on smokeless health risks, 
prescribes warning labels on smokeless tobacco packages and requires that 
print media advertisements include warning messages. Recently, the House 
passed an amended version of the Senate bill that would also ban television 
and radio advertisements of smokeless tobacco. The Senate approved the 
amended bill, clearing it for Presidential consideration. 
years. 
A Federal excise tax on cigarettes has been levied for many  In 1982 
this tax was raised for the first time in 31 years to 16 cents per pack. 
level of 8 
Last year, to prevent reversion to the 1951  cents per pack 
Congress temporarily extended the tax through March 15, 1986. From 1950 to 
1965 the Federal government imposed an excise tax on smokeless tobacco.
This tax was repealed beginning in 1966 and has not been reenacted. 
the 
Recently however  Senate Finance Committee considered a smokeless 
tobacco excise tax. Several proposals have been offered to reinstitute a 
tax on smokeless tobacco at levels ranging from as low as 2 cents per 
container to a level as high as the cigarette tax. Many professional and
public health experts support reinstitution of a smokeless tobacco excise 
tax comparable to the cigarette tax. It is estimated that enactment of a 
smokeless tobacco tax equivalent to the cigarette excise tax would generate 
approximately $150 million in revenue. 
- 26 
 . . . .. 
APPENDICES 
Append i x A ..... Study Respondents

Appendix B ..... Organizations Opposing Use of

Smokeless Tobacco

Append i x  Surveys of Prev  ence of Use Data 
a 1 
Appendix D ..... Supplementary Tables and Graphs

Table I Intensity of Use 
Table II Reasons for Use Initiation 
Table III Reasons for Use Continuation 
Table IV 
Strength of Habit Among Users 
F ami ly Occupat i ona 1 Background 
Appendix E ..... Profiles of Current and Former Users
 , .
APPENDIX A

PAGE 1 
TOTAL RESPONDENTS

KEY 
USERS 1./  NON -USERS 1/  INFORMANTS 1/  TOTAL 
Mass., Penn., W. Va. 
Ga., N. C., Ala.	 112 
Tx., Okla., La.	 125 
Ind., Iowa, Colo.

I d., Ore., 
Wa., Az.	 110 
TOTALS	 290  109  126  525 
PERCENT	 55%  21%  24% 
JUNIOR HIGHS (11)  SEN lOR HIGHS (20) 
Number  Percent  Number  Percent 
USERS  26%  214  74% 
NON-USERS  30%  70% 
1/ 
Has dipped or chewed over 100 times, presently uses daily or at 
least 3 days per week, dipping at least three times on days of 
use. 
Has never dipped or chewed , or has only tried it a few times or

more than a few times but less than 100 times.

1/ 	 School officials (principals, teachers, coaches, nurses), health 
providers (dentists and physicians), state health and education 
officials, researchers and public interest groups - American 
Cancer Society.  APPENDIX A

PAGE 2 
KEY INFORMANTS

NUMBER  PERCENT 
SCHOOL OFF IC IALS 
65% 
Principals 
(20) 
Teachers  (26) 
Coaches  (22) 
Schoo 1 Nurses  ( 7) 
Counselors and Other 
HEALTH PROVIDERS 
Dentists and Physicians 
AMER I CAN CANCER SOC I ETY 
STATE HEALTH DEPT. OFFICIALS  11% 
STATE EDUCATION AND OTHER 
STATE LEVEL RESPONDENTS 
RESEARCHERS 
Dental  Schoo 1  and Other 
TOT AL  126  100%  APPENDIX A

PAGE 3 
USER AND NON-USER DEMOGRAPH ICS

USERS  NON-USERS 
Number  Percent  Number  Percent 
o SEX:

Ma 1 es  286  98.  74%

F ema 1 es  1.4%  26%

o AG E:

Mean Age  15. 5 years  15. 1 years

Age Range  11-19 years  11-19 years

o ETHNICITY:

Whi tes  263  90. 7%  75% 
Blacks 
1. 7%  14% 
Hispanics 
1.0% 
Native Americans

o GRADE

LEVEL: 
1. 7% 
11. 
10. 
13.  15. 
19.  20. 
22. 
15. 6% 
26. 2%  27. 
o SIZE CITY WHERE RAISED:

Country/Rura 1 Area  27.  26. 6% 
Small City (50 000()  28. 3%  41. 3% 
Medi um Ci ty (51 - 250K)  26. 8%  14. 
Large City (251K - 1M)  13.  14. 
Mixed/Can  t Say  APPENDIX B

ORGAN IZAT IONS OPPOS ING USE OF SMOKELESS TOBACCO

A growing 
and extensive list of health professional organizatiGns, public
health 
associations, public interest groups and government agencies Ii 
\'e 
adopted position statements Qr resolutions on the use of smokeless tobacco. 
In general , these statements catalog significant health risks associated
with use,  favor a 
support health warning labels,  ban or restriction
television and other industry advertising, promote health education to 
discourage use by the public, and support increased taxation of smokeJess
tobacco,  minors. 
as well as restrictions on its sale to  The following 
the 
include some of  organizations that have gone on record against the 
dangers of smokeless tobacco: 
American Dental Association *

Amer i can Med i ca 1 Assoc i at i on 
Association of State and Territorial Dental Directors *

Association of State and Territorial Health Officials *

American Association of Oral and Maxillofacial Surgeons *

American Association of Dental Schools

American Public Health Association

Coalition of Smoking or Health which includes

Amer i can Cancer Soc i ety * 
American Heart Association*

American Lung Association*

World Health Organiz3tion , International Agency

for Research on Cancer *

National Cancer Institute and National Cancer Advisory Board*

Centers for Di sease Control 
as Dental Association 
Oklahoma Dental , Medical and Public Health Associations * 
Organizations stating smokeless tobacco use can cause oral cancer.  APPENDIX C

REPORTED SURVEYS Of ADOLESCENT AND ADULT

USERS Of SMOKELESS TOBACCO IN THE UNITED STATES

JUNIOR-SENIOR HIGH SCHOOL STUDENTS 
1983-1985 
INVEST IGA TORS/LOCA T ION  SAIfLE  AGE/GRADES  USAGE 
1. Schaefer, Hender on,  5392  11-18 yrs  19% Male

Glover, Christen  H-2534 (47",) 0- female

Texas (1985)  f -2858

55% T started at

12 years or less

88% T started at

15 years or less

2. Offenbacher & Weathers	 565
 11-17 yrs  20% Hale

Georgia (1983)  Hale 100%  13. 3'" regular usage 
31% trial

50% 2 years+ usage

20% 4 years+ usage

50%+ started at

age 12

3. Christen, Palenik, Niemann  2226  12-18 yrs 9", T 
eItn .d a1i a.na  grades 6- Grades 6-8 R 0.  42%
(1984)  Avg 15%
Grades 9-12 R 13-47% 
Avg 30% 
4. McCarty & Krakow	 5013  14-18 yrs 15% T

Massachusetts (1984)  H-2406 (48",) grades 9- 28. 2% Hale

f -2607  8% female 
67 schools 
1 class per 
grade 
5. Glover, Edwards	l Tedford 2098  grades 3,  15", T

Oklahoma (1984) H-11l2 (53%) 7, 9, 11  grades 3,  12'"

f -986  grades 9 11-20%

78% started at

12 years or younge

6. Edwards	 3232  10-18 yrs  Ever used

Utah (1984)  H-168l  (52tJ  HaIe-39. 41'

f -1551  female-
Cont . use 
Hale-14. 
Female
7. Greer and Poulson	 1119  14-18 yrs  11% T

Colorado (1983)

8. Jones	 12-18 yrs Daily use

Wisconsin (1985)  grades 7- Hales

female 

Weekly use

Hales-15'" 
female-I'" 
Ever 
Males-45'" 
female-
11% 
T -
Percent of total sample population. 
NA - Not available 
M -
f - Male population 
female population
R -
Range  LONGITUDINAL STUDIES 1976-1984 
INVEST IGATORS/LOCAT ION  SAI4LE  AGE/GRADES  USAGE 
1. I daho Schoo 1 Tobacco 
Program 
Educat  ion  fare, 
Dept. of Heal th & Wel 
Idaho (1982-l98J)  8300  Elementary  14% Elementary

81 schools
 and  males 
Secondary  (2% daily use)

Grades  25", Secondary 
males 
(ll% daily use)

(1983-1984)  2639  Grades 7 8% T

27 districts
 6% 7th Graders

15. 5% 10th Graders 
39% started before 
10 years 
84% started before 
12 years

16% used & quit

2. Bogalusa Heart Study, 
Louisiana State University
Medical Center, 
Louisiana (1976-1977)  30l4  Grades 3 Chew - Hale 13%

H-1556  female 1%

f -1458  20% l4yr. olds chew

15% l5yr. olds chew

(1981-1982)  2I52  Grades 3 26% Male usage D/C

H-1068  21% Male age 8-9 D/C

f -1084  40% Male age 12-15 D/

43% l4yr. olds chew

43% l5yr. olds chew

3. Oregon Research

Institute Studies

Oregon  (1983)  1639  12-16 yrs.  Male daily usage

H-822  Grades 7 range 8.  23. 
f -817  female daily usage

range 0.  1.1% 
Trial by males range

65.  76. 
Trial by females

20", 
(1984)  3165  Grades 7.  55% Male trial by

H-1568  age 12 years

r -1597  60% Male usage

4 school
 68% male trial

distr icts  14% male daily use

trial 
19", female 
7% female daily

use 
T -
Percent of total sample population 
D/C - Combined dipping and chewing  COLLEGE STUDENTS ATHLETES 1984-1985 
INVEST IGATORS/LOCAT ION  SA/oLE  AGE/GRADES  USAGE 
1. Anderson & McKeag  College Studen  18+ years  20% T in last 12 
Hichi  an State University  - Athletes  months 
(1985  2039  17% regular 
H-1407 (69%) 16% started at or 
f -632  below Jr High 
11 Colleges!
Universities  stsrted 
high achool 
2. Noland, Bliss, Geary  College Studen  18+ years  28% dip 
University of Kentucky  - Athletes  (avg. 19.  chew 
(1985)  143  Years)  22% started at 
Hale 100%  15 yrs. or younger 
1 University  11% started at 
12 yrs. or younger 
3. eGlt.o ver, Johnson, Edwards,  5258  12% T, 22  msles 
H-2608  NE Colleges - 16'" M 
East Carolina University  f -2650  SC Colleges - 30% M 
(1984)  8 States 
(regional) 
T - Percent of total sample population.

- 3 
 SURVEY REFERENCES

Offenbacher S, Weathers DR. Effects of smokeless tobacco on the 
periodontal , mucosal and caries status of adolescent males. J Oral 
Path 1985:14:169. 
oGrfee r RO, Poulson TC. Oral tissue alterations associated with the use
smokeless tobacco.  Part I Clinical Findings. Oral 
Surg
1983: 56: 275. 
3 )	 Noland M, Bliss R , Geary D. College athletes ' knowledge and practices
regarding smokeless tobacco. HPR Dept  University of Kentucky.
Unpublished (1985). 
FC, 
Hunter SM, Parker  Burke GL, Webber LS, Croft JB, Berenson GS. 
Longitudinal patterns of cigarette smoking and smokeless tobacco use in 
adolescents: Bogalusa Heart Study. National Research and Demonstration 
Center-Arteriosclerosis, Louisiana State University Medical Center. 
Unpub 1 i shed (1985). 
, Berenson GS. 
5 )	 Hunter SM, Webber LS Cigarette smoking and tobacco usage 
behavior in children and adolescents: Bogalusa Heart Study. Preventive 
Medicine 1980:9:701. 
M. 
6 )	 McCarty D, Krakow  More than ' just a pinch' : the use of smokeless
tobacco among Massachusetts hi gh school students. Dept. of Public 
Health , Massachusetts (1984). 
Anderson WA, McKeag DB. The substance use and abuse habits of college 
student athletes. Michigan State University (1985). 
PL. 
Hosokawa MC, Roberts CR  Hansen  Health education in rural
Missouri: 
Phase II. Health Education , March/April 1984  18. 
9 )	 Glover ED, Edwards SW) Christen AG, Finnicum P. Smokeless tobacco
research: An interdisciplinary approach. Health Values. 
May/.une
1984: 8: 21. 
DV. 
10) Lichtenstein E, Severson HH , Friedman LS, Ary  Chewing tobacco use 
by adolescents: Prevalence and relation to cigarette smoking. Oregon 
Research Institute (in press), 1984. 
11) Schaefer SD, Henderson AH, Glover ED , Christen AG. Patterns of use and 
of  in 
i nc i dence  smoke 1 es s tobacco consumpt ion  schoo l-age ch i 1 dren. 
Texas Division , American Cancer Society. Presentation to Fifth Joint 
Mtng of Amer Soc for Head & Neck Surgery and the Society of Hd & Nk
Surgeons, 5/8/85. 
- 4 
 PAGE 2 - SURVEY REFERENCES

12) Jones RB. Smokeless tobacco: A challenge for the 80'  Division of 
Health , Wisconsin. 
H. 
13) Glover ED, Edwards SW, Tedford  Prevalence of smokeless tobacco 
Oklahoma public schools. (In preparation), 1984. 
14) Edwards G. Chalking up the chewers: Utah school-based smokeless tobacco 
survey. 
Dept. of Health , Utah, 1984. 
15) Smokeless Tobacco Publ ic Health Program.  Idaho Dept of Health & 
Welfare, Idaho Cancer Coordinating Committee.  Report 4/85. 
- 5 
 APPENDIX D 
T ABLE I 
INTENSITY Of USE 
Wash 
Massachuset ts  North Carolina  Texas  Indiana  Idaho 
Pennsylvania Georgia  Oklahoma  Iowa  Oregon
West Vir  inia  Alabama  Louisiana  Colorado  Arizona  National 
Per Week 
Mean 
Mode 
Number Di  Per Da 
Mean 
Mode 
Minutes Held In Mouth 
Mean 
30+  30+  30+  30+  30+ 
Mode 
osure Time On Da s Di  (Hours) 
Mean 
Mode 
Numbp  Cans/Pouches Per Week 
Mean 
Mode 
When first Tried  Years) 
Mean  11.  11.  10.  10. 
11
Mode 
When Re ular Use Started (Years) 
12.  10.  11.2  13.  12.  12. 
Mean 
Mode 
TOTAL YEARS DIPPED 
Mean 
Mode  . .
APPENDIX D

TABLE I I 
REASONS . FOR USE IN IT IAT ION 
USERS  NON-USERS  KEY INFORMANTS 
Peer Pressure, Friends
 50%  62%  59% 
Curiosity, To Try It  32%  22% 
Family Members/Relatives Use  18%  15%  36% 
It' 
s Something To Do 
Like Flavor or Taste  21%

Safer Than Smoking  26%

Be Macho or  Grown-up  27%  32%

Advert i sing  I nf 1 uence  55%
 , " , "

APPENDIX D 
TABLE II I 
REASONS FOR CONT INUAT ION OF USE 
JUN lOR HIGH  SENfOR HIGH 
USERS  NON-USERS  ALL OSERS  NON-USERS 
Enjoy Flavor or Taste  75%  60%  64%  31%. 
Addiction , Habit  Hooked"  28%  40%  37%  51% 
F or Effects:  Relax  Buzz  16%  24%  22%  14% 
Peer Pressure, Friends  16%  15%  15%  20% 
Something To  Do,  Avoids  Boredom  12%  10%  N/R 
. Better Alternative 
Than Smoking 
N/R 
Macho or Grown-up" Image  N/R  , .
APPENDIX D

TABLE IV 
STRENGTH OF HAB IT AMONG USERS 
JR. HIGH
 SR . HIGH  TOT AL 
Usually Dip or Chew Every Day  74%  84%  81% 
Would Make a Special Trip To Store If Ran Out  59%  71%  68% 
Wou ld Have Strong Cravi ngs If Tried To Quit  49%  57%  55% 
Would Be Very Hard For Me To Quit  61%  51%  53% 
Often Take A Dip Or Chew Just Before Class  26%  46%  41% 
Hard Not To Use Where Use Is Forbidden  42%  32%  34% 
Want A Dip Or Chew First Thing In Morning  20%  31%  28% 
Get Nervous If Go Four Hours Without It  36%  23%  27% 
Sometimes Sleep With A Dip Or Chew  13%  10%  ::"::::::':::.::: ::.:: ::":,:-,::-.::' .::::'': : , :. : ::: :,,::::, .::..:::::..:::.":",:"":::. :::'::, ":  .::: : ::: :..:".,.::::::.,::::::.::.::::::::::::.::: ::'::~ ::::~'.:::~:,,: :  .:''.:,:, :: ::',:":,:,:
.   -~',:,:,: ~ :::::~"::,::::::.:: ::::::::::::.::::::::::::.:.::~.:::~::::,:~::: :.:.:. ::::":: '::: ::: ::.::::. :::,::,:':: : :~:. ::.~::::.::~::":,":::~ ::  ::.~::,.::~::::::
APPENDIX D

FaMi 1 y  Dc c upa t ion a 1 Bac kg o un d 
COMpared  Non-Users) 
( Use  Wi th 
Per-cen  Responden t:s 
100:. 
Duser-s 
Pt7:  No n

r-s 
LI s e 
70:. 
59:. 
56:. 
0 ,0 , 
S1:. 
49:. 
0 ,0 , 
44:. 
41:. 
0 ,0 ,0 " 
30:. 
0 , 
0 , 
10 
0 ,0 " 
0 ,0 " 
Fa t:her- Ho t: he r.  Fa t:her- Ho t: 'lie r-
d t:  Co I I ar- Blue  Co I I ar
...n'  APPEND IX E

PROF ILES OF CURRENT AND FORMER

SMOKELESS TOBACCO USERS
 . , 
The tall, slender fifteen-year-old (we will call him Don) was clearly eager 
to talk abrouutr ahli s experiences with smokleilvesess  tobacco. Mosst toaf thei.s  life was 
spent in  Virginia, but he now  in another  When Don 
recently moved from the . country to a city of 123 000 he brought aloInIg  his
spittoon with a deodorizer  and what he calls "  nasty habit.  The
10th-grader has regularly dipped snuff - current y Skoal - since he was six 
years old. Don uses about three cans of snuff each week. 
He recalls that his first dip was given to him by a 10-year-old cousin , one 
of many relatives and friends who used smokeless tobacco then or later. He
started dipping li 
to follow the crowd, to be a tough , macho guy.  Among
students, it'  reaction. It " 
s like a chain  starts as a joke but a person 
likes it and keeps doing it.

II and other 
Notably, Don views the " athletes , cowboys  guys II shooting the
rapids " in television commercials for smokeless as IIhappy, self-confident"
and II dependent on tobacco. II He th i n  s such advert i sement s are aimed at
youn g adu lts and teenagers, and that they strongly infl uence young peop 
1 e 
to try smokeless tobacco. 
dipping: 
Don admits having physical effects of  sore gums and "teeth being 
. pushed back by the constant pressure of tobacco" (the  atter was detected 
by a dentist). Additionally , it "ruins the way you feel, think and act." 
It "affects all body functions and it' s not good for your stomach.  This 
ins i ghtfu 1 young man knows, too  ate, the truth about, and consequence of 
using smokeless tobacco.

Unfortunately, the gripping thing about Don s sad experience with snuff 
that he is profoundly addicted to it and genuinely wants to quit dipping. 
He has tried to quit , he says, some 18 times, but the longest he has gone 
without snuff is two days. The " combination of irritability and being 
tempermenta 1" is too much for the youngster. II I get reailt n.e rvous and 
gripey and tense without it. My lip hurts if I don t have  I get the
shakes. 
Though he does not specifically mention the risk of oral cancer, surely he 
knows tlhla ot ni tt'esle vthisei ounl.t imate risk. Like so many others he too saw 11 
Minutes  He thinks that the risks related to smokeless use 
should be publicized more by newspapers, magazines, television, radio - all
public relations situations. 1I Meanwhile, the young man continues taking a 
dozen dips per day.  , .

Jim is 16 years old and in the 12th grade. He dips every day, about 6 times per
day, and uses over 4 cans of snuff per week. 
He leaves the tobacco in his mouth 
longer than 15 minutes per dip. 
Jim first tried dipping when he was 11 years old. His friend/cousin was a
dipper , so Jim asked him for his first dip. Jim- has been a dipper since then. 
Jim  s uncles and and his grandpa also dip, as well as most of hts friends and a 
few of hi 
s coaches. 
After 5 
years of dipping Jim finds himself wanting a dip right away in the
morning. 
He gets nervous if he goes four hours without a dip, usually takes a 
dip just before class, would make a special trip to the store if he ran out of 
snuff , and says he would have strong cravings if he tried to quit. 
Jim has tried to quit, but like most. other high school dippers that have tried 
to quit , he failed. . As Jim put it, " I was going crazy. I couldn t concentrate. 
I was jittery. I couldn t sleep.  JirJl tried to quit because his dad askeahim 
to do so, however the most common reason why a teenage dipper tries to quit 
because he s heard that somehow, or in some way, cancer is connected to dipping. 
Jim has noticed the white wrinkled patches in his mouth and the staining of his
teeth. 
He read about a kid (dipper) who died of cancer. He stated that had he 
heard about the cancer threat before he had started dipping, he probably would 
still have dipped , his reason being that he was so young when he started dipping 
him. 
that it probably would not have mattered to  Jim is probably correct that, 
at age 11 , the fear of cancer would not have overridden the curiousity or peer 
pressure to try dipping. But Jim is unlike over half of the high school dippers
interviewed , in that they stated they would not have gotten started dipping had 
they known then what they know now. 
Jim has never smoked cigarettes. Most of the dippers interviewed were not 
cigarette smokers and all but two of them believed that it was safer to dip than 
to smoke. 
Jim  s last comments were, .. If they gave  a miracle cure where I could take it 
r.1t: 
and it would make me never want to take a dip, I would take it right now.  Fred , who is a regular snuff dicppietry,.  is an 18 year old senior at a high 
schoo 1 in a small southwestern  He is a handsome we ll-groomed young
white male. He doesn  t participate in athletics but is a member of FFA 
Future Farmers of America. 
Fred likes to dress. western , wears boots and -jeans and drives his own 
pickup truck complete with spitton for convenient disposal of -his snuff. 
He is a hard working, self-employed young man. 
He first tried snuff when a young male friend offered him some when he was 
grade. 
eleven years old in the fifth  By sixth grade, he had become a 
the last 6 years. 
regular user and has dipped heavi ly for  Fred star.ted 
has settled on 
with Copenhagen , has tried Skoal , but  Copenhagen as his
preferred brand. 
He buys his snuff at the gas station and has never had 
any difficulty purchasing as a minor.

Fred says he started dipping snuff , mostly because several of his friends-
were using it. Currently , his best male friend and most of his other male 
dips. 
friends dip. His Dad' s brother also  His father doesn t dip but
. neutral toward Fred'  dipping. His mother and one of his sisters 
habit. 
disapprove of his  His girlfriend and another sister are neutral.
He  equally 
views dipping as  acceptable to smoking and says a number of 
students at hi 
s school approve of snuff. 
Fred dips 7 days a week and takes about 15 dips a day, which works out to
about 10 cans of snuff each week. 
Normally, he holds each dip in his mouth
about 45  ess in 
Normally,m ih neu tsesp,i tusn  in his sscphiototo 1o n-  wohre roen  hhee  agvreoruangde s abbuotu t i2n0  mcli ansuste s. 
juices. 
swallows the  He wants a dip right away in the morning, and gets 
nervous if he goes over 4 hours wi thout a dip. 
settings: 
He dips both alone and with his friends in lots of different 
home, at work , while studying, in class, at ball games, at parties, when 
relaxing with friends, and even on dates. He says he likes the taste of 
dipping, that it relaxes him and gives him something to do. 
Fred has a pretty high awareness of the health risks of his snuff habit. 
He knows, for example, that it can cause gum and mouth problems, mouth and 
, that it' 
throat cancer  s addictive and stains your teeth. Nevertheless, he 
says snuff is safer than cigarettes and that young people who regularly dip 
run only a moderate risk of physically harming themselves. 
Fred has experienced sore and irritated gums, gum line recession, 
tleeuektohpl.a kia, skin peeling off his cheeks and gums and staining of his
He also reports having had mouth sores and blisters under his 
tongue and all across hi s gums for about 9 months. These problems prompted 
him to visit the school nurse, which , in turn, led to visits to a dentist 
and oral surgeon. The dentist failed to detect his problem source, but the 
dipping. 
oral surgeon urged him to quit  Fred stopped for 4 days before 
resuming his dipping habit.

Fred 
knows, first-handi s,  that snuff is addictive and that dipping is a
break. 
strong habit , which  very difficult to  He has made twelve 
attempts to stop dipping snuff; unfortunately, all have ended in failure.  I was born to chew " Johnny said proudly as he described why he began using
smokeless tobacco. He" took his first pinch of smokeless at age 15, when he 
took a can of Copenhagen from a store. "I was-
looking for a bad habit " he
continued. 
Now 19 and a high school senior
, Johnny has been chewing regular  ly  for two 
syneaurfsf. e aHec hc hwewese ekver.y  dHay, e  mostly  alone, adndi ffuisceus lta btoou t four cans of moist
said it is never  purchase smokeless 
especiaJJy because he is an  older  teen and can buy it at the tribal smokeshop. 
He recently moved to a smaJJ Indian reservation, where his chewing influence
among students has been noticed by . Chewing among students has
the  elders. 
noticeably increased since Johnny and a couple of other chewers moved to the
reservation. 
As an athlete, playing both footbaJJ and  basketbaJJ, he doesn t chew while
playing sports because the coach is strict.  If caught, he would be kicked off 
the team. He noted, however, that he had moved from basebaJJ country where
his previous coaches had chewed. 
He displayed some disdain for kids who don t chew, describing them as either
honor 
roJJ gir  Is  or nerds. 
He said he had seen about 24 television commercials for smokeless tobacco in 
the past month and describes the people shown using smokeless as "outdoor 
dudes." He believes TV ads have a strong effect in encouraging young people
especiaJJy preteens , to try smokeless. 
He admits it would be hard to quit chewing, and sometimes even sleeps with a 
pinch in his mouth. He doesn t believe smokeless tobacco is addicting, saying
it does not contain nkotine. 
He does admit, however, that chewing  lead 
to mouth or lip cancer, but says that the risk depends on how much aca nc  hewer
uses and whether he brushes his teeth. 
He has no plans to quit.  . .
yecr-old junior 
Richmond is a l6- years.  who has been a regular snuff 
dipper for the past 3  He is a rather heavy user, going 
through about 6 cans of  he dips an ave age of 6 to 
Skoal a week  week. 
10 times a day evaerrye ada. y of the  Rich has spent all of his 
life in a rural  He is a member of his high .school football 
and track teams. 
firs t 
Like many other young men who use smokeless tobacco, Ri ch 
just 
tried snuff because so many of his peers used and he " 
wanted to see what it was like.  He admits to naving a 
dependency on snuff, but describes it as being more 
psychological than physical. Often, he says, he does it
because there 
s nothing else to do.  Rich did try 
unsuccessfully to quit 6 months ago because his girlfriend
di sapprovcd of  he retur 
ed to snuff after 3 weeks of 
the habi t 
abstinence, he says, because of lack of willpower. He 
convinced he could qui t for good if he "really had to. 
\':hen asked about use of smokeless tobacco by relatives, Richmond 
stated that his father switched from smoking cigarettes to 
dipping snuff because of his son s influence. Rich is strongly 
anti-smoking, citing his father s improved health since stopping 
smoking as evidence for his argument that dipping is much snfer 
than smoking. He acknowledges that smokeless use can lead to 
such problems as lip cancer and deterioration of the teeth, but 
stating, " 
qualifies this by  The way mE' and my friends look at 
tr.eir lives, 
it, we know people who ve rubbed (dipped) all  and 
some people it affects and some it doesn  But he is quick to
add, " It' s not something I want to do all my life. 
Rich mentioned that his mOM h d pp.rsuaded him to watch the GO 
Minutes  episode on smokeless tobacco, and this seemed to have 
had a strong impact on hiJT. He said, ""fuen I first started
(using snuff), I' 
d never heard about lip cancer and all that 
d knoWn before, it may have had some jnfluence (on my deci  ion
to use).  60  utes  thi nk about it
lot more.S ince the  M.r; lI.e n  s waetpic hseodd et,h cI   show. 
A lot of my 
Rich felt that the best way to Educate youth about the peal 
risks of smokeless tobacco use is to " just advprtise it more. 
You see a lot of warnings against smoking but not against
smokeless. I' ve seen and not iced 8urgeon General warnings for
cigaret te  it' 
s probably not a bad idea to put warnings on 
snuff cans. 
Although Pich himself has experienced only relatively mild 
heal th side-effects from usage such as occasional leukoplaki a, 
final 
peeling of mo th tissue and tooth staining, in hLs 
comments he expressed a good deal of concern over contracting  cancer. 
60 Minut(-s episode again, he said, " 
friends anCitidng  tIhe   f'1y 
have been worr  ed about getting lip cenccr and
hfaovre i tt2.  J ked about \lhether or not there s some way to get checked
He inqu ired 2.S to wr,ether or not there exi sted some 
quick and inexpensivt way to get tested 
for cancer.

his 
I'espi te  commer.ts that some people are simply immun.e from 
health problems resulting from use of snuff or chewing tobacco,
oRifc hc ains coebrv.i C'usly very aH re of and very worr ied about the risk
He is an eXQmple of a young person who could greatly 
benefit fron a greater understanding of the 2ctual risks
involvrd. 
He and his friends ' concern points up the need for
informutional camp igns and the availability of informed health 
professionals to anSWPT questions and check 
for existing or
developing heal 
th pToblpms.  , "

A 17-year old high school senior in a small Southeastern textile city says,
I wish li d never started. 1I Stanley, the son
of his experience with snuff

of a computer programmer "and a teacher , first tried snuff at the age of 12.

ly for the 
He has used it regu 1 ar  ast two years.

The six to ten dips he takes dai ly adds up to about seven cans of 
Copenhagen per week, and he keeps a dip in his mouth about 30 minutes. 
When and where does he dip snuff? It runs the gamut, for he uses it whi le 
alone and when with his friends; he dips at home, at work, in class, 
sports. 
parties, and at spectator  Stanley, a wrestler and football player 
sports. 
also uses snuff when playing  Smokeless tobacco is widely used by 
his friends (most of his buddies and teammates dip or chew, as does his 
very best friend). The use of smokeless is further reinforced, since 
several of the school' s coaches also use the products.

Incidentally, a female physical education instructor and coach at Stanley 
reason for 
school feels that the use of smokeless by male coaches is the 
laxity in enforcement of the school' s tobacco policy. She says the other 
- coaches condone the use of smokeless by students. Stanley says that
1I adding 
dipping and chewing are permitted at the campus II smoking block 
that school restrictions on dipping and chewing are II somewhat weakly
enforced. 
Like so many young smokeless victims, Stanley started dipping 
due to what he calls II peer pressure. II He was with a pal of the same age 
his first dip. 
when he took  His young friend supplied that first dip, and 
perhaps an adequate dose of peer pressure. 
Although his best girl friend and both his pairte nts disapprove of his 
dipping, hei cto.nt inues to dip because he likes  and his friends have 
his 
encouraged  In fact, he believes that most students at  school 
approve of the use of smokeless and that " it is certainly more acceptable 
than smoking.

H av i ng read newspaper art i c 1 es about the potent i a 1 hazards of us i ng snuff 
and having seen a thought-provoking expose on television (Ii Sixty Minutes 
risk of  problems. 
Stanley is well aware of the  oral cancer and other 
has already experienced lellkoplakia, peeling cheeks and gums, and stained
teeth.  dipping. 
But he is, so far, unable to quit  He has made thi;2 or
four attempts to gi ve it up, but has resumed use each time after no more 
than two weeks. 
years, itl 
So, after dipping snuff regularly for two  s clearly a powerful 
habit he can  subdue. Sadly, Stanley says, II I wish li d never started 
that' s all.lI  . .
..  .. 
Jack is a 17-year old senior whose cousin encouraged him to take his first 
13. 
chew of Redman when he was  He has been chewing dai ly for two years and 
week.  spit 
uses three cans of Copenhagen a  He carries a cup to  in when
indoors. 
Besides his cousin, both his grandpa  nd uncle chew. ALL of his 
male friends chew  On the other hand , none of his soccer coac es-nd only
a few of hi 
s soccer teammates chew. 
Although he has seen about five TV ads for smokeless during the past month
he says he 
pays more attention to the radio commercials which he hears
frequently. 
He continues to chew because, II I like the taste. It relaxes me. 
friends do it. And it' s something to do. 1I He has never tried to quit.
are not likely 
described kids who  to chew as " brainy, straight kids and
nerds. 
He  be 
acknowledges that dipping or chewing can  harmful to a person
health , citing potential problems such as lip cancer, stomach and throat 
problems if you swallow it , and teeth or gum problems. He admits he 
doesn  t know the extent to wh i ch young peop le ri sk harm by regu 1 ar use and 
argues that it depends on a person s usage pattern and other health habits 
such as how frequently he brushes his teeth or goes to the dentist.

Jack bel ieves that smokeless is much more safe than cigarettes and that 
users rarely experience gum and mouth problems. He does not know whether 
snuff contains nicotine. He agrees, however, that regular use is addicting 
and may lead to mouth cancer. Although he denies that dipping has been 
harmful to his own health , he admits he personally has experienced white, 
wrinkled patches where he keeps the tobacco. 
I t 
He doesn  bel ieve there is any way to inform students about the health
risks of 
smokeless tobacco, saying II I don t know how anyone can stop kids 
from using it. They aren  t going to listen anyway. We re told by adults 
that everything is harmful, even water, so why listen when they tell us 
smokeless is bad?1I  . .
Bill is athletic looking, to go along with his interests in four sports. 
says, 
He was 14 years old when he first tried smokeless tobacco, and he 
Now I' m hooked.  He has become more concerned about the health risks 
20/20. " Unfortunately, " he said, " I did not see 
since he saw a program on  it. 
it before I started.  He would like to quit but he can t seem to do 
stop. li 
But I'  it.  ve tried to stop, but
ve never asked anyone to help me to 
, II he
ve never had the strong urge to qu  I know you can get cancer now
added. But, in fact, he wanted to dip snuff while we were tal-ing about 
the effects it had 011 him: 
lt kind of calms me down. It seems to help me settle down to do 
now. I 
homework. Isn  t it funny, I feel like having a dip right 
feel nervous. 
Is this really confidential?" 
He is not a 11 owed to dip or chienw .a t his schoo 1 .  ISIm Iofk ers have a designated
area at the school to smoke  He ' comp 1 a i ned  the smokers can throw 
It makes me mad. 
cigarette butts everywhere, why can t we spit?  I don 
unders tand it. 
le 
He says to young peop 
it. 
II It is worse than smoking. You should never ever try  I wi sh

kids: 
they had a commercial like they have for little 
, Slam the door to a stranger I S face,

tobacco,

Say no to smokeless 
Be smart,

Chew gum. ' II 
He would like to talk to someone who has quit, so he could quit.
 , '
Har ley grew up among dippers and chewers. His gr andf ather , uncle and cousin all 
used smokeless tobacco.  Being curious and wanting to act grownup, he tried 
some dip. He was four years of age at the time. He said he began regular use 
five with 
of snuff at age  brother buying it for him. 
his  older 
Before quitting, he was dipping Copenhagen 20 times every day. He used six 
cans of snuff a week. He was dipping alone and with friends. Dipping 'was a 
favorite thing to do  motorcycle.
when riding  his 
Har  ley  thinks television commercials have a strong influence on teenag rs by 
depicting users as "rough , tough outdoor types. 
Harley, now 16 years old , adumistete.d  the difficulty he had trying to quit dipping 
years of regular  He had the strong cravings caused by the 
after  I I 
nicotine. He had to cut back gradually, chewing sunflower seeds as a substitute 
for dipping. He wanted his second attempt to succeed. 
quit. 
He stated several reasons for deciding to  His mother disapproved. His 
uncle had gotten throat cancer probably as a result of tobacco use. He had read 
about the Oklahoma athlete who had died from oral cancer. And his sponsors 
who funded his motor cross racing didn t think dipping was the image they wanted 
their  riders  to project. 
He quit dipping two months ago and hopes dipping is a thing ' of the past.  , "  , " , "

He wore a Copenh agen hat and  1 i ke he wou 1 d be more comfort ab 
look  ed  1 e 
idling time away on a street corner than in school. He was sixteen and in
the ninth 
grade, a user of smokeless tobacco since he was five.
started 
, he recalled, when his cousin took a dip. " I asked him what 
a chew. I said, let 
was , and he said , it was.  me have a taste. 
it. 
Like so many of today s youths who use smokeless-tobacco, he plays sports.
' He says, " Ii tn.e eId'   If 11 m playing football  I almost get shakey if
don  t have  ll yell at my teammates if they are not doing everything
just righL" 
On the other hand , he does not smoke since it would affect his wind.
said 
I have to be able to run and not have my chest hurt." 
He was using over two cans of snuff a day until he read the article on Sean 
Marsee in  Readers Digest.  Now  " he" said  m trying to quit, because 
it took to kill him. 
saw that Sean guy s face and how short a time  It made 
me want to qu it. 
When asked what recommendations he had for young people concerning the use
of 
smoke 1 ess tobacco, he responded  I th i nk they shou 1 d out 1 aw it jus 
like they should cigarettes.  ! -' -
- t 
Roy was introduced to smokeless tobacco at the age of eight when a friend 
offered him a pinch of moist snuff. Five years later , at age 13  he began 
dipping regularly. What started as mere curiosity became a habit. 
1I he explained.  I like 
something harsh in my lip, 
Roy, 
at. 17 years of age, dips every day, consuming as many as sev..n  cans of 
Copen1haI gheen  cao nwfeeesks.e dH.e  dips with friends or alone. II I have some in a 11 the
time, 
He can buy the snuff at any convenience store wi thout 
ty. 
d iff i cu 1 
Like many of his peers he is aware of the potent i a 1 health consequences of
dipping snuff 
the least of,  wbhuitc hh ei sha sh abbouigtuhta tiinotno .t Theo  ahcitmi vtithye  fhoera lmtahny  rriesaks oinss , o.nnolyt
moderate  despite experiencing stained teeth  irritated gums, and 
leukoplakia. He considers dipping much more safe than smoking. 
Roy thinks television commercials are designed to appeal to young adults-
and have only a moderate effect on teenagers to try smokeless tobacco. He
feels that II 
jocks like to dip because they can t smoke when training. 
Roy believes that dipping snuff is in line with the tough cowboy image.
labeled nondippers as ll 
mommy  s boys. 
He said he tried to quit dipping twice because of the growing expense and 
the disapproval of his parents and girlfriends. In fact, he stopped one
time for over a year only to begin again. II  ll he said. 
I missed it,
Roy will continue dipping.