Department of  Health and Human Services 
OFFICE  OF 
INSPECTOR  GENERAL 
SPIT  TOBACCO  AND  YOUTH 
OEI  06-92-00500 
I EXECUTIVE  SUMMARY 
PURPOSE 
This  study describes  the present  status of youth use of spit tobacco  in six areas: 
prevalence  and patterns  of use,  health effects,  environmental  influences  on use, product 
promotion  and sales,  regulation  and enforcement,  and educational  efforts. 
BACKGROUND 
This report,  requested  by the Surgeon General,  is the second on spit tobacco  (snuff and 
chewing tobacco)  by the Office of Inspector  General.  The fust,  in 1986, concluded  spit 
tobacco use by young people  was a national problem  with serious potential  health 
consequences.  The current  inspection  focused on data developed  after  1985 for users 
under age  19 and found spit tobacco use persists  as a national  health problem. 
Information  came from four major  sources:  literature  review,  national  and regional  data 
on prevalence  and use patterns,  experts  in spit tobacco  issues,  and young users. 
FINDINGS 
Under-Age Spit  Tobacco  Use Is High,  Wide-Spread And Begun Early. 
In 1990 and  1991, nearly  one in five high school males used spit tobacco.  However,  high 
spit tobacco  use is not confiied  to one region  or group;  northeastemers,  urban  dwellers, 
and Native American  children  use spit tobacco.  Age 11 or  12 is typical  for starting use. 
Ofien Atiicted  To Spii Tobacco,  Under-Age  Users Are Seriously  Endkngeting  Their 
Heallh. 
Spit tobacco  contains  cancer-causing  and addictive  substances.  Short term  spit tobacco 
use often causes leukoplakia  (white,  wrinkled,  skin patches  inside the mouth) which can, 
over time,  become  malignant  in a significant percentage  of cases.  Long term  use greatly 
increases  the risk for oral cancer  which may become  epidemic  if young people  continue 
frequent  use into their adult years.  Use is intense among young people  who frequently 
admit they are addicted  to nicotine. 
Family,  Friends And  Other Incentives  Strongly  Contribute  To Under-Age  Use. 
Perceived  social support from fathers,  other male relatives  and friends  is the most 
influential  reason  youth fwst try spit tobacco.  The baseball  connection,  product  placement 
in stores and  look-alike  items further  enhance  acceptability  of use. 
i  Extensive  And Success@  fiomotion  Of Spit Tobacco  VictimiWs Susceptible  Youth. 
Moist  snuff consumption  has nearly tripled  since  1972, making it a very profitable 
business.  The industry  intensively  promotes  spit tobacco through  sponsorship  of sporting 
events,  entertainment  and distribution  of free samples.  These activities,  and the associated 
images of athleticism  and masculinity,  have strong appeal for many males under age 18. 
Spit  Tobacco Laws And  Their Enforcement  Are  Weak And Ineffective. 
While many other countries  prohibit  spit tobacco,  American  regulatory  policy  is 
inconsistent  with other tobacco products.  The Comprehensive  Smokeless Tobacco  Health 
Education  Act of 1986 has not been an effective  deterrent  to spit tobacco use by young 
people.  State and local tobacco  control  and access laws have loopholes  and lack 
enforcement. 
Under-Age Spit Tobacco  Use Is A Community  Problem,  Requiting  Broad Interventions. 
Spit tobacco use is often socially acceptable  within a community,  including  schools. 
Effective  measures  for change and better  enforcement  include  heightened  community 
consciousness,  tobacco-free  schools,  screening  and counseling  by health professionals, 
disassociation  of sport from  spit tobacco use, and improved  spit tobacco  curricula. 
CONCLUSIONS 
The responsibility  for addressing  the problem  of spit tobacco  use by young people  rests 
with many groups at the national,  State and local levels.  We encourage  responsible 
groups to take action in four broad areas: 
F  Promote  community  awareness  and action. 
F  Support improved  State and local tobacco  control. 
F  Seek the support and involvement  of health care providers  and organized  athletics. 
F	 Re-examine  national  tobacco  control  and access policy  and coordinate  a plan for 
deterring  youth use of spit tobacco. 
ii  TABLE  OF  CONTENTS 
EXECUTIVE  SUMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

Prevalence  AndPatternsOfUse  . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

Health Effects  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5

EnvironmentalInfluences  On Use  . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

Product  Promotion  And Sales.  . . . . . . . . . . . . . . . . . . . . . . . . . . . ...9

Regulation  And Enforcement  . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11

Education  AndIntervention  Strategies  . . . . . . . . . . . . . . . . . . . . . . . . .  13

CONCLUSIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...17

ENDNOTES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...19

BIBLIOGRAPHY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...21

APPENDICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-l

A:  Profdes  0f1992Spit  Tobacco Users  . . . . . . . . . . . . . . . . . . . . . .  A-1

B:  Current  Use Rates InTwentyStates  . . . . . . . . . . . . . . . . . . . . . . ..B-l

C:  Summary  OfPrevalence  Studies  . . . . . . . . . . . . . . . . . . . . . . . . ..C-l 
D:  Key Informants  Interviewed.  . . . . . . . . . . . . . . . . . . . . . . . . . ..D-l   INTRODUCTION 
PURPOSE 
This study describes  the present  status of youth use of spit tobacco  in six areas: 
prevalence  and patterns  of use, health effects,  environmental  influences  on use, product 
promotion  and sales, regulation  and enforcement,  and educational  efforts. 
BACKGROUND 
Spit tobacco  includes  two main types:  snuff and chewing  tobacco.  Snuff dippers place 
a small amount  of shredded  or fiiely  ground tobacco  (loose or encased in a paper  pouch) 
between  their cheek and gum.  Tobacco  chewers place a wad of loose leaf tobacco  or a 
plug of compressed  tobacco  in their cheek.  Both dippers  and chewers  suck on the tobacco 
and spit out the tobacco juices  and saliva generated.  Previously  termed  smokeless 
tobacco,  snuff and chewing  tobacco are now sometimes  called  spit or spitting 
tobacco to more accurately  describe  how they are used and to counteract  the 
misconception  that they are safe to use.  This  study,  requested  by the Surgeon General, 
uses the newer  nomenclature  of spit tobacco. 
Youth use of spit tobacco  is a serious public  health concern.  In January  1986 the OIG 
released  a national  study entitled,  Youth Use of Smokeless Tobacco:  More  Than a Pinch 
of Trouble.   This report  concluded  that increasing  use of smokeless  (spit) tobacco  by 
young people  was a national problem  with serious potential  health consequences.  Young 
users were already  experiencing  health effects and were unaware  of the risk for others. 
Subsequently,  offices within the Public Health  Service  (PHS),  i.e.,  the Centers  for Disease 
Control  (CDC),  National  Cancer  Institute  (NCI),  National  Institute  of Dental  Research 
(NIDR),  National  Institute  on Drug Abuse (NIDA),  OffIce of the Surgeon  General,  and 
the Indian Health  Service,  compiled  a growing  body of completed  and developing 
scientit3c research  information  that shows youth use of spit tobacco persists  as a national 
health problem.  The American  Dental  Association  and the American  Academy  of 
Otolaryngology,  among others,  promote  practices  that actively  seek to deter  youth use. 
In  1986, to deter  spit tobacco  use,  Congress  enacted the Comprehensive  Smokeless 
Tobacco  Health  Education  Act (CSTHEA)  of 1986 (P.L.  99-252).  The Act required  the 
Secretary  to inform the public  of any health dangers  of smokeless  (spit) tobacco  use. 
Smokeless  (spit) tobacco packaging  and advertising  had to include  warning  labels with the 
exception  of outdoor  billboard  advertising.  Advertising  on radio or television  was banned. 
The Act also encouraged  States to establish  18 as the minimum  age for the purchase  of 
smokeless  (spit) tobacco,  currently  the standard  in all but three  States.  In July  1992, the 
Congress  further  strengthened  national  law when it passed the ADAMHA  Reorganization 
Act which required  all States to ban the sale and distribution  of tobacco products  to 
everyone  under age  18 by October  1, 1994.  It also requires  States to enforce  their laws 
1
 in a manner that can reasonably  be expected  to reduce  the extent to which tobacco
products  are available  to under-age  youths.  
METHODOLOGY 
This inspection  focused  on spit tobacco  use by people  under age 19 with an emphasis  on 
trends  and data developed  after  1985.  Information  came from four major  sources: 
research  and professional  literature,  national  and regional  survey data on prevalence  and 
patterns  of use,  key informants  considered  experts  in spit tobacco  issues,  and a purposive 
sample of current  and former  young users. 
We completed  a content  analysis of research  and professional  literature  published  after 
1985 (see Bibliography).  This literature  analysis and synthesis covers the six areas 
enumerated  in the Purpose.  The literature  review  serves as the basic  study framework 
supplemented  by national  survey data from the National  Center  for Health  Statistics, 
NIDA and CDC,  and by State and regional  survey data collected  from a variety  of sources 
(see Appendices  B and C).  Numbers  in parentheses  appearing  within the report  text,  e.g. 
(4), reference  the literature  or survey data source.  Superscript  letters,  e.g.  (m) refer  to 
endnotes. 
Using in-depth,  structured  interviews,  we collected  data from  34 key informants 
knowledgeable  in spit tobacco  issues (see Appendix  D).  We selected these key informants 
based on their participation  in Departmental  programs  and/or  research  dealing  with spit 
tobacco  issues,  their prominence  in professional  or research  literature,  their professional 
afftiations  or recommendations  by other key informants.  Their  areas of expertise  are 
preventive  medicine,  dental health and education,  psychology,  psychiatry,  epidemiology, 
clinical pharmacology,  cancer  research  and tobacco  use control policy.  Seventy-five 
percent  have done original  research  on spit tobacco  issues. 
We also collected  detailed  data on use patterns  and motivations  from 54 spit tobacco 
users.  Using a structured  questionnaire,  we interviewed  users either  in person  or by 
telephone.  In some cases,  dental professionals,  using our questionnaire,  conducted  the 
interviews  on-site in their clinics.  The 54 users,  selected judgmentally,  met four criteria: 
1) initiated  use before  age 18, 2) were age 21 or younger  at the time of the interview,  3) 
had used spit tobacco  regularly  for two years or more,  and 4) had used spit tobacco  nearly 
every day in their last year of use.  Beyond the stereotypical  white male and athlete users, 
we also included  females  and members  of other ethnic  groups  such as Native  Americans, 
and Hispanics.  The users come from  15 States,  and from urban and rural  areas. 
The user data,  coupled  with more in-depth  data from our  1986 report  on spit tobacco, 
supplements  and complements  descriptions  of motivations  and consequences  of spit 
tobacco  use from our literature  review.  However,  we could not make general  statements 
about all young  spit tobacco  users since the sample is limited.  Quotes from these users 
are scattered  through  the report  text.  Proffles  of some of the young users are presented  in 
Appendix  A, 
2  FINDINGS

Under-Age  Spit  Tobacco  Use  Is High,  Wide-Spread  And  Begun  Early. 
  Currently,  nearly 1 in 5 high school males uses spit tobacco;  some St&e rates are 
constierably  higher. 
A 1990 and 1991 school-based  survey in 22 
percent use duringpreced~  30 days  select States (Youth Risk Behavior  Survey -
Grades 9 to 12 
YRBS) shows that nearly  20 percent  of 
Males  Females 
males in grades  9 to 12 were current  users 
m  White  Total  Wite  Total 
of spit tobacco  (1-3).a  Among white males, 
1990  23.9%  19.1%  1.5%  1.4% 
an even higher  1 in 4 currently  use spit 
1991  23.6%  19.2%  1.4%  1.3% 
Source:  YRBS,  1990  (N  =  11,631)  tobacco  (see Table  1).  Use among  white 
& 1991  (N  =  12,272)  male  12th graders  in 1990 was 26 percent. 
Table 1  Rates for Hispanic  and Black teens are 
notably lower,  as are female  use rates. 
In some States,  current  use by high school 
males is much higher than the composite  Current UseBy Grade 
Grade  Alabama  Tennessee 
YRBS rate.  Overall  male usage rates in 
9th  36.6%  35.2% 
grades 9 to 12 are as high as 34 percent  in 
Ml  26.7%  37.1% 
Tennessee  and 33 percent  in Montana  (3). 
1Ith  26.9%  30.7% 
Other States with high overall prevalence  12th  31,1%  33.7% 
among high school males are Colorado  Source: YR13S1991(109, 1Ii) 
(32%),  Alabama  (31 %) and Wyoming  (31%) 
Table 2

(2).  Further,  in States with hkh  use rates,

more 9th or 10th grade  males ~harisenior males may currently  use spit tobacco  (see Table

2).  For additional  States with high spit tobacco use rates,  see Appendix B.

w	 Spit tobacco  use by young  males has increased greatly  since 1970 and has stayed 
high. 
Between  1970 and 1985 spit tobacco  use by young males increased  dramatically  nation 
wide.  The  1970 National  Health Interview  Survey reported  young males age 17 to 19 
were the lowest snuff users while men age 50 and over were the highest  (4).  By 1985, 
the Current  Population  Surve  showed males age  16 to 19 had a snuff usage rate double 
z
that of men age 50 and over.  c 
Other  studies showed high spit tobacco  use among  young people.  In  1989 the NCAA 
replicated  its 1985 national  study of social drug use by college  athletes  (5).  It found use 
of spit tobacco by college  athletes had risen from 20 percent  in 1985 to 28 percent  in 
1989, a 40 percent  increase.  More  importantly,  the NCAA  found the large majority  of 
college users began dipping or chewing  before  they went to college,  i.e.,  either  in junior 
high (21 %) or senior high (54%) school.  Furthermore,  spit tobacco  was the only social 
3  drug in the NCAA  study with a higher reported  prevalence  in 1989 than in 1985.d  From 
1986 to 1989 the NIDA National  High School Senior Survey indicated  current  monthly 
use of spit tobacco  among males ranged  from 22 percent  in 1986 to 16 percent  in 1989 
(6).  Female  use was relatively  low, ranging from  1.6 percent  in 1986 to  1.2 percent  in 
1989, and had stayed low over time (4,6). 
b  High spit tobacco  use is Z@ conjined  to one re~on or population  group. 
Use bv Northeastern  high school males is as high as 10 percent  in States where  it was 
presumed  to be uncommon.  For example,  Con&cticuts  1989-90 Health  Check reported 
male spit tobacco  use in the past 30 days was 7 percent  for both  10th and  1lth  graders 
(7).  Use among that States male seniors increased  25 percent  from  8 percent  in 1987 to 
10 percent  in 1990.  According  to the Tri-Agency  Tobacco  Free Project,  6.6 percent  of 
Maines  9th graders  use spit tobacco  (8).  Maine also experienced  a large  increase  of 23 
percent  in male use of spit tobacco for seniors since  1987, rising from  8.3 percent  to 10.2 
percent  in 1991 (8-10). -
Urban rates of youth use,  although  lower than rural, 
range as high as 16 percent.  A 1987 Illinois  study 
showed 1 in 6 metropolitan  male  1lth  graders  and  1 
in 4 non-metropolitan  males currently  used spit 
tobacco  (see Table 3) (11).  In Missouri,  13 percent 
and 15 percent  of urban  8th and 12th grade  males 
respectively  used spit tobacco  within the last 7 days 
in 1988 (12).  The comparable  prevalence  rates for 
Table3
rural  males were  17 percent  for 8th grade and 31 
percent  for  12th grade  (12). 
Native  Americans  spit tobacco  use rates are the highest for any age group for both males 
and females.  Their  rates of use range from 29 percent  in Washington  to 46 percent  in 
parts of South Dakota  and Montana  (13).  However,  three counties  in North  Dakota, 
which have predominantly  Native American  populations,  reported  even higher  spit tobacco 
use in a 1990 prevalence  survey of their young people.  Ninety-one  percent  of Sioux 
Countys male 7th graders  and 83.3 percent  of 8th graders  currently  used spit tobacco. 
Over 50 percent  of McKenzie  Countys  male 9th,  loth,  and  1lth  graders  and Adams 
Countys  male  1lth  and 12th graders  currently  use spit tobacco  (14).  Native  Americans 
are unique in that female use rates  sometimes  equal,  or even exceed  the high rates of 
males (13). 
k  Youth use spii tobacco  at extremely young  ages. 
Research  on young users indicates the majority  of youth start spit tobacco  use before  the 
age of 12, (11,12,15-18)  with young rural  males starting more than a year earlier 
(19c, 12).  In  1986 we reported  that  average  age of first use was 10 years.  The average 
age of initiation  for our 1992 users was 9.5 years old, with 67 percent  starting  at 12 years 
4
 old or younger.  Twenty-eight  percent  (15 of 54) of them were five years old or younger 
when they first tried  spit tobacco. 
In some regions,  regular  use also occurs at early ages.  For example,  17 percent  of West 
Virginias  5th and 6th grade boys are regular  spit tobacco users  (19b).  Other States are 
experiencing  a smaller,  but significant,  proportion  of their  young children  using spit 
tobacco  regularly:  3.7 percent  of Illinoiss  5th graders  (11), 3 percent  of Oklahomas  (20) 
and Missouris  6th graders  (12), and one percent  of Maines  (8) and Connecticuts  5th 
graders  (7).  In 1986 we reported  the average  age for regular  or daily use was  12. 
Often  Addicted  To  Spit  Tobacco,  Under-Age  Users  Seriously  Endanger  Their  Health. 
+  Spit tobacco  contains  cancer-causing  and addictive  substances. 
Spit tobacco  contains tobacco  nitrosamines  and other proven  carcinogens,  i.e.  cancer-
causing  substances  (21).  Spit tobacco  nitrosamine  levels are hundreds,  or in some cases 
thousands,  of times greater  than what foods and beverages  may legally  contain  (4,22). 
For example,  spit tobacco  has  100 times more nitrosamines  than bacon  (23).  Moist  snuff 
has a much higher nitrosamine  level than looseleaf  chewing tobacco.  While  some 
researchers  have suggested  setting maximum  permissible  levels of nitrosamines  (21), NCI 
has said nitrosarnines  are not safe at any level in tobacco products  (24).  Pinkertons  Red 
Man moist snuff has the highest nitrosamine  level of any snuff sold in the United  States, 
followed  by U.S.  Tobacco  Companys  (UST) Copenhagen  (21,25,26).  Moist  snuff also 
contains polonium-21 O, uranium-235  and -238, nickel,  cadmium  and formaldehyde,  also 
considered  carcinogens. 
Another  harmful  ingredient  of spit tobacco  is nicotine,  an addictive  drug (27).  Nicotine 
enters the users bloodstream  by being absorbed  through  the lining of the mouth.  In 
normal  use,  a snuff dipper places  a pinch in his mouth and holds it there  for 20 to 30 
minutes.  The amount  of nicotine  absorbed  is 2 to 3 times the amount  delivered  by a 
regular-size  cigarette  (25).  Chewing tobacco  has less available  nicotine  (per gram of 
tobacco)  compared  to moist snuff, but chewers  use more tobacco per  dose.  Thus,  users 
who consume  8 to 10 dips or chews a day receive  a nicotine dose equal to that taken by a 
heavy smoker  who consumes  30 to 40 cigarettes  daily (25).  Nicotine  is absorbed  more 
slowly from  spit tobacco  than from cigarette  smoke.  However,  more nicotine per dose is 
absorbed  from  spit tobacco  and it stays in the bloodstream  longer  (28).  USTs 
Copenhagen  and Pinkertons  Red Man moist snuff have the highest level of available 
nicotine  (21). 
Using spit tobacco  can lead to nicotine  dependence  or addiction  (4,27).  The U.S.  Surgeon 
General,  the World  Health  Organization  and the American  Psychiatric  Association  have all 
recognized  chronic  tobacco  use as dxug addiction  (27).  Further,  the Surgeon General  has 
compared  nicotine  to other addictive  drugs  such as cocaine  or heroin.  While  nicotine  is a 
legal drug and the others  are not, the processes  that determine  nicotine  addiction  are 
similar  to those that determine  addiction  to other drugs. f 
5  	 In the shoti  term,  sp& tobacco  use causes setious,  but generally  not ftial,  health 
effects. 
Leukoplakia  (white,  wrinkled,  skin patches  inside the mouth) and gum recession  at the 
usual site of tobacco placement  are the most frequent  consequences  of short-term  spit 
tobacco  use (4, 29-33).  These conditions  occur  in 40 to 60 percent  of spit tobacco  users. 
Leukoplakia  are a serious concern  because,  over time,  they become  malignant  in a 
sign~lcant,  though unspecified,  percentage  of cases.  A conservative  range  is from 2 to 6 
percent  (33).  However,  leukoplakia  appear  to regress  or resolve  completely  if the spit 
tobacco user quits (33).  Occurring  where the user holds the spit tobacco  in his mouth, 
Ieukoplakia  are significantly  associated  with duration,  frequency,  recency,  type and brand 
of spit tobacco  used.  Fifty-eight  percent  of key informants  agree that the incidence  of oral 
health problems  among  young users are increasing,  with 48 percent  perceiving  a moderate 
rate of increase. 
Other health effects of short-term  spit tobacco  use are mentioned,  but are less certain  in 
research  data.  For pregnant  women,  fetal toxicity  is implicated  in spit tobacco  use (35). 
A concern  is that the nicotine,  sodium and carcinogenic  substances absorbed  from spit 
tobacco  may aggravate  human illness in progress  (36), or for young male athletes  who use 
any form of tobacco,  accelemted  coronary  artery  disease or high-blood pressure  will result 
(28).  A limitation  of data gathered  to describe  the short term to intermediate  effects of 
use is that the study populations  have been young, physically  fit users (36-38). 
}  In the long term,  the consequences  of spit tobacco  use can be deadly. 
The scienttilc  and research  community  is quite certain  of the link between prolonged  spit 
tobacco  use and oral cancer  (4, 39-41).  About 75 percent  of oral and pharyngeal  cancers 
are attributed  to use of smoked and spit 
I 
~!nn~~at  had  tobacco  (40).  Those  who use spit tobacco 
mlm  ram-war  ad  Aiqj.  He 
--- ~=- @-...  _ 
.W..ML  -.u  are at risk for gum and cheek lesions that
used about 40 years.  lT.P.wIJ  ~~u t pati  of his 
in particular  can lead to cancer  (40). 
mouth out, but it got inlto his throat.  
1  Oral cancer  accounts  for 2 to 4 percent  of 
all cancers  diagnosed  annually  in the 
United  States,  but only one-half  of those with oral cancer  are alive five years after 
diagnosis  (40).  Further,  most oral cancers  are advanced  at diagnosis,  so those who 
survive the oral cancer  have an exceptionally  high risk of developing  subsequent  cancers 
(23). 
Young spit tobacco  users who continue  their habit are at risk for oral cancer.  If they 
continue  frequent  spit tobacco  use into their adult years,  94 percent  of key informants 
predict  an increased  incidence  of mouth and throat  cancers  for them.g  The majority 
(64%)  say absolutely  this will happen,  NCI has also expressed  its serious concern 
about  an impending  oral cancer  epidemic  in the young male group  (23). 
Besides oral cancer,  other adverse  health effects are associated  with long-term  spit tobacco 
use.  Oral effects  suggested are dental decay,  tooth abrasion,  and tooth loss (32).h 
6 
  Suggested health problems  under  study are high cholesterol  levels (37,42),  accelerated 
coronary  heart disease  (28,35),  upper digestive  tract cancers  (35,41),  high blood pressure 
(28,35,43),  and cancers  of the throat,  pancreas,  prostate  in males (44) and urinary  tract 
(35). 
  Nicotine  addiction phzys a role in long-term  health consequences. 
Addiction  to spit tobacco  combined  with the serious health effects of long-term  tobacco 
use assure that many young users face an unhealthy  future.  Researchers  agree a 
relationship  between  spit tobacco  and cigarette  use exists,  although the dynamics  and 
sequence are not clear  (45,46).  One researcher  explains  it this way,  It appears  that the 
use of one nicotine product  is associated  with the initiation  of another  nicotine product. 
The use of [spit tobacco]  is far more likely to precede  cigarette  smoking than the other 
way around.  (46)  The majority  of key informants  say many young people  start their 
tobacco use with spit tobacco.  Additionally,  they say many also smoke or will switch to 
cigarettes  in the future.  The First International  Conference  on Smokeless Tobacco,  in 
recognizing  the addictive  nature  of nicotine,  concluded  ..there  is a clear potential  for 
[spit tobacco]  to serve as a gateway  substance  for cigarette  smoking and the use of other 
addictive  substances,  [i.e.  alcohol,  illicit drugs].  (47) 
Therefore,  the probable  course of events is:  1) nicotine  addiction  leads to continuous 
tobacco use,  either as spit tobacco,  cigarettes  or both,  which leads to 2) continuous  intake 
of carcinogenic  or other harmful  substances,  that,  in time,  may lead to 3) cancers  and a 
whole host of other disease processes. 
b	 Dmly,sustained  use is often the p~ern  for  young people;  many admit to nicotine 
addiction. 
Young  spit tobacco  users follow a frequent  and intense use pattern.  One national  study 
found that daily use rates among current  users were 55 percent  for young people  between 
11 and  15 years old,  and 70 percent  for those between  16 and  18 years old (48).  Further, 
regional  and State data show young male spit tobacco users consume,  on average,  between 
one to three  or more cans of snuff per week and one to three  or more pouches  of chewing 
tobacco  (11, 13,49).  Our 1992 users averaged  3.5 cans of snuff or almost  1 pouch  of 
chewing  tobacco  a week.  They averaged  use of over six times per  day,  with over one-
fourth using ten or more times a day -- a nicotine intake equivalent  to 1.5 to 2 packs of 
cigarettes.  Young users also keep each tobacco  dose in their mouths anywhere  from  10 
minutes to one hour,  with more than twenty  minutes  not uncommon  (17,49-51).  Our 
1986 and 1992 users typically  held their dip or thaw  25 to 30 minutes,  with most keeping 
it in over 30 minutes,  and often up to an hour. 
Addiction  continues  to be a problem  for 
young users.  The  1986 OIG report  on spit  Ive quit 4 or 5 times,  but only for a 
tobacco  found 37 percent  of young users  week.  Then 1 think,  using hasnt done 
continued  spit tobacco use because  they were  any damage,  so I go back to it.  
addicted.  Many  wanted to quit and had tried 
7  many times only to fail due to the strong hold their habit had on them.  The majority  used 
spit tobacco  every day,  and believed  it would be very hard for them to quit.  Since 1986, 
other  studies of young users have reported  similar fiidings  (12,48,52).  In  1992, 85 
percent  of our key informants  say more young users are addicted  to spit tobacco,  and all 
agree that quitting  spit tobacco use is difficult  for them.  Sometimes,  a young user may 
not know (s)he is addicted.  One key informant  observed,  Many havent tried to quit. 
But when we tell them the health consequences,  and then they try to quit,  they cant.  
Nearly  75 percent  of our  1992 current  users admit they are addicted.  Forty-two  percent 
have tried to quit,  many two or more times. 
Family,  Friends  And  Other  Incentives  Strongly  Contribute  To Under-Age  Use. 
&  Male relaiives  and peers  gretily  in$luence young peoples  spit tobacco  use. 
Perceived  social support from fathers,  other male relatives  and peers  is the most 
influential  reason youth frost try spit tobacco. i  In fact,  most beginning  tobacco  users are 
given their  first spit tobacco by these  same people  (17,18, 19b,53).  Several  studies have 
found one-quarter  to one-third  of young users have someone in their family who uses spit 
tobacco  (49,54,55).  Family  use is as high as 62 percent  for Native American  populations 
55).  According  to key informants,  use of spit tobacco  by friends and family members 
strongly motivates  young people  to start using.  Nearly  two-thirds  rate friends  as the most 
powerful  influence. 
7  OIG user  studies show the same influences.  In 
Grandfather  got me hooked on it.   1986 and  1992 users said the most influential 
reason for trying  spit tobacco  was peer  pressure 
It keeps  the kids off hard drugs,  and other family members  use.  In fact,  at the 
and they dont use a Iot of candy. w  time when the  1992 users  started their  spit 
-- A users father  tobacco use,  37 percent  had a father using,  and 
33 percent  had a brother  or other male relative 
using.  In both studies,  most users believed  their fathers,  brothers  and best male friends 
either approved  or accepted  their  spit tobacco use.  In 1986, parental  approval,  or at least 
acceptance,  of spit tobacco use was exemplifkd  by the 93 percent  of users who said their 
parents  knew they used and the 87 percent  who listed their  homes as a regular  setting for 
use.  The majority  of our  1992 users felt their parents  would agree that using spit tobacco 
is better  than smoking or using drugs. 
	 The basebaJl connection,  product  placement  in stores and  look-dikes  jkrther 
enhance acceptability  of use. 
Some experts  say the connection  between  baseball

and spit tobacco use is a powerful  influence  on

Famous athletes  use dip.  One

shaping youthful behavior  (26).  That is, many 
of the things that goes along with

baseball  players  use spit tobacco,  and young people 
p~y~g  ball is taking  a dip. 

are aware they do.  Researchers  studied  1109 
8  members  of major  and minor league professional  baseball  during  spring training  of 1988. 
Thirty-eight  percent  of the players  currently  used spit tobacco.  Most used moist snuff, 
Copenhagen  and Skoal being the most preferred  brands  (37).  By 1991, current  use by 
baseball players  reached  45 percent  -- unprecedented  in the history  of baseball  and the 
nation. (26) 
Product placement  in stores and spit tobacco  imitations  also influence  young people. 
Local  studies have found distributors  locate moist snuff in stores that youth visit 
frequently,  and they often place it next to cigarettes,  candy and snacks (26,56-58). 
Chewing  gum manufacturers  have a shredded  gum called  Big League  Chew and a tape-
shaped bubble  gum rolled to fit into a flat,  round metal container,  similar to a snuff tin 
(59).  Sunflower  seeds are marketed  as Dugout Chew and other products  resembling 
snuff,  such as beef jerky,  have been marketed  to youth.  The National  Dental  Tobacco 
Free  Steering  Committee  took exception  to this marketing  technique  and has resolved  to 
condemn the manufacturing  and marketing  of candy and gum packaged  to look like 
tobacco products.  (60) 
Extensive  And  Successful  Promotion  Of  Spit  Tobacco  Vktimizes  Susceptible  Youth. 
	 Moist snuff  consumption  has nearly tripled  since 1972,  making  it a very profitable 
business. 
Moist  snuff and looseleaf  chewing tobacco  are the two most popular  forms of spit 
tobacco,  but their growth patterns  have been quite different  (61).  Since  1972, pounds of 
moist snuff consumed  has grown steadily until,  in 1991, it was nearly  3 times the  1972 
level.  Consumption  has increased  by 24 percent  since  1986.  On the other hand, pounds 
of looseleaf tobacco  consumed  grew until  1980, when it peaked,  and then declined  12 
percent  by 1991.  The U.S.  Department  of Agriculture  predicts  that moist snuff 
production  in 1992 will increase  from the  1991 level (62).  As mentioned  earlier,  in 1970 
men over the age of 55 were the heaviest users of snuffi by 1985, males under the age of 
19 had replaced  them.  Seventy-eight  percent  of our  1992 users prefer  moist snuff, 
particularly  once they became  regular  users. 
One company,  U.S.  Tobacco  Company  (UST),  dominates  the spit tobacco  industry  with 
its moist  snuff products,  the most popular  being Copenhagen  and Skoal (61).  In fact,  key 
informants  and our  1992 users named Copenhagen  and Skoal as top choices  among  spit 
tobacco  options.  In  1991, UST produced  87 percent  of the moist snuff consumed  and 
held the largest  market  share of all spit tobacco produced.  In a 1991 Annual Report,  UST 
said net sales for the tobacco  segment rose  18 percent  to $773.2  million;  net earnings 
reached  $265.9  million,  a 19 percent  increase  from the prior  year due primarily  to the 
tobacco  segment  (63).  A July  1992 Kidder  Advisory  on stock market  investments 
characterized  UST as very well positioned  in a high-growth,  highly profitable  industry.  
The growth  in moist snuff sales is remarkable  considering  the publicity  surrounding  the 
death of Sean Marsee  eight years ago (64).  Marsee  started using Copenhagen  at age 13 
9  when he received  a free sample at a rodeo.  Six years later he died of oral cancer,  and his 
family fded a $147 million product  liability  suit against UST in 1986.  The company  won 
the Marsee  case in 1989 after an appeals court upheld the lower court verdict.  Despite 
the negative press,  USTs profits  increased  steadily.  Further,  in 1990 pinkerton 
introduced  Red Man moist snuff to compete  against UST (26). 
w  Spit tobacco  companies  achvelymarket products  in selective  venues. 
Most of the industrys  intense and well-funded  marketing  efforts take place outside media 
centers.  Radio and television  advertising  ended by law in August  1986 while advertising 
expenditures  for newspapers,  magazines  and billboards  declined  in both  1988 and 1989. 
Entertainment  and distribution  of free samples have been the largest  expenditure  categories 
in recent  years.  Public entertainment  has been the largest  single advertising  and 
promotion  spending category  every  year from  1986 to 1989.  In  1989 it accounted  for 24 
percent  of the total  spending on advertising  and promotion,  and equalled  nearly $20 
miLlion (65).  Expenditures  on distribution  of free samples exceeded  $15 million  in 1989 
and were the second largest category  of promotion  and advertising  that year (65).  Under 
the categories  of public  entertainment  and endorsements,  the five major  spit tobacco 
companies  spent a total of $17.6  million on sports and sporting events in 1988, and $19.6 
million  in 1989 (65). 
~  Intentional  or not,  spit tobacco promotions  do appeal to people  under age 18. 
The activities  and images portrayed  in spit tobacco promotions  are attractive  to young 
people.  Researchers  and key informants  point,  for example,  to the industrys  sponsorship 
of sporting  and entertainment  events -- auto racing,  rodeos,  monster truck  shows, tractor 
pulls and country/western  concerts.  Typical  of the industry,  UST and others  spent 
millions to sponsor  such events;  Pinkerton  has acted as a promoter  to organize  country 
western concerts  (64).  Experts  also reference  young-appearing  or macho  models in 
magazine  or bill board advertisements,  free 
samples,  advertising  in magazines  that young
Walt Garrison  talked about Skoal. 
people  read,  and give-sways  of caps,  clothing or 
I wanted to be li%e him.  Hes a 
other items that bear the brand logo.  The spit
hero.  I wanted to be one also.  
tobacco image  strongly  appeals to young males. 
Typical  descriptions  used by researchers  and key 
informants  are a macho,  masculine  or grown-up  image;  a context  of vitality,  popularity 
or excitement;  a strong association  with sports,  hunting or the outdoors,  or with sport or 
entertainment  heroes;  and themes of rebellion  and independence. 
The intended  audience  of spit tobacco promotions  is a controversial  issue.  Some

researchers  (25 ,26,58, 66-68) and 97 percent  of key informants  said spit tobacco

promotions  definitely  target  young people,  including  those under age  18.  In addition to

the activities  and image already  mentioned,  they cite print  ads that provide  instructions  on

how to use spit tobacco  (67) and moist snuff products  with added flavorings  and

sweeteners.  UST has admitted  to the intended  graduation  process  for consumers  using its

products. (67)  Critics  assert the  graduation  is in terms  of nicotine  content  so that a

10  young user can build up a nicotine tolerance  (12,25,26,67).  Another  example  comes from 
a key informant  who,  at a spit tobacco  sponsored  event,  saw imprinted  hats and jackets  in 
small sizes that would not fit adults.  The indust~  has repeatedly  disavowed  the charge 
that they intend to sell their products  to minors  (69-71).  They also remind  their critics 
that the use of tobacco products  for people  age 18 or older is legal and that manufacturers 
have a right to promote  them at events designed for adult audiences. 
Even if the spit tobacco companies  are successful in portraying  spit tobacco  use as an 
adult behavior,  their promotions  may still influence  many under-age  youth to use their 
products  (45).  Emulating  adult behavior  or adopting an image of masculinity,  athleticism 
or toughness  are very attractive  to young people,  especially  boys (45).  Whether  they are 
the intended  consumers  or not, large numbers  of young people  from many backgrounds  do 
obtain and use spit tobacco.  Many become  nicotine  addicts before  they finish school,  and 
many are seriously  endangering  their future health. 
Spit  Tobacco  Laws  And  Their  Enforcement  Are  Weak  And  Ineffective. 
	 Amencanpublic policy  on spit tobacco  control is inconsistent  with other tobacco 
products. 
Unlike the United  States,  many other developed  countries  totally ban spit tobacco  sale and 
use.  In  1987 the Study Group on spit tobacco  of the World Health  Organization 
recommended  that countries  with no history of spit tobacco  use should ban it (26).  By 
1990 New Zealand,  Australia,  Hong Kong, Ireland  and Belgium  had banned  spit tobacco. 
By 1992 the European  Economic  Community  had given preliminary  approval  to a ban on 
these products  in its 13 member  nations  (26).  The Secretary  of Health  and Human 
Services,  has openly criticized  American  policies  that permit  the promotion  of spit 
tobacco,  a product  which is so harmful  to good health  (72). 
American  policy  for the regulation  and taxation  of substances  intended  for adult use only, 
such as spit tobacco,  cigarettes  and alcohol,  is internally  inconsistent.  Twenty-one  is the 
national  legal age for purchasing  alcohol;  18 is the age for tobacco.  As late as 1990,  16 
States had no excise tax on spit tobacco  while all States had excise taxes on cigarettes 
(73).  In  1989 Federal  excise tax on cigarettes  was  16 cents per pack,  but only  1.8 cents 
on a tin of snuff and  1 cent on a pouch of chewing tobacco  (74).  The Federal  excise tax 
on spit tobacco  was only recently  restored  in 1985 (26).  Finally,  all States require  retail 
alcohol vendors  to be licensed;  only 22 States require  the same for tobacco  (75). 
w	 The Cornprehensive Smokeless  Tobacco Heai2h Educ@on Act  of 1986 has not 
worked as intended. 
The  1986 Act placed  advertising  and packaging  restrictions  on spit tobacco  products. 
Three-fourths  of key informants  agree the Act has not been an effective  deterrent  to spit 
tobacco  use by young people.  Criticisms  from the key informants  and some 
research/policy  data are:  1) young people  dont read or dont heed the warning  labels on 
11  spit tobacco  containers,  the labels are too small or the wording  isnt strong enough 
(27,35,76);  2) the Act had no effect on State or local laws or their enforcement,  and 
youth still have easy access to spit tobacco  (18,35,56-58,68,77,78);  3) the Act has not 
been enforced  and some provisions  are weak,  thus allowing the industry  to circumvent 
restrictions  on advertising  via electronic  media (26,34,69,75,79);  4) no funds were 
appropriated  to support the educational  provisions  of the Act; and 5) the powerful  appeal 
of industry  advertising  is difficult  to overcome  (24,35,43,72). 
A recent  exception  has been the Federal  Trade  Commissions  (FTC) enforcement  of some 
provisions.  The FTC  has given final approval  to a consent agreement  with Pinkerton 
(Red Man spit tobacco products),  settling charges  that the company violated  the  1986 Act, 
by among other things,  advertising  its tobacco products  at live truck and tractor  pulling 
events and allowing those ads to be filmed for television  broadcast  (80).  In  1991 the FTC 
announced  it had adopted final amendments  to its regulations  under the  1986 Act. 
Utilitarian  items,  such as golf balls,  cuspidors  and tee-shirts,  are no longer exempt  from 
the health warning  requirement. 
	 A pa~cular point  of contention  is the promotional  prwctice of distnbutingfree 
samples of spit tobacco 
Industry  critics  are concerned  that many under-age  youth can readily  obtain  spit tobacco 
through  distribution  of free spit tobacco  samples.  This activity  is not addressed  in the 
1986 Act.  Industry  codes and standards  regarding  distribution  of samples say, in part:  1) 
mail-in  requests  for spit tobacco products  may be honored  if it can be reasonably 
ascertained  that the intended  recipient  is 18 years of age or older,  and 2) whenever 
samples are distributed,  persons  who appear  to be under 
18 years of age shall be required  to furnish proof  of age
I got free  samples at fairs 
(116).  Critics  say spit tobacco  companies  and their 
and rodeos.  -- User,  age 
representatives  do not adhere  to these codes and 
16, started  at age 9. 
standards.  For example,  on the coupon for mail-in offers 
of free samples,  the requester  must merely ~  that (s)he 
is 18 years of age or older.  In reality,  a spit tobacco  company,  using this procedure, 
cannot verify  age.  A Doctors  Ought to Care (DOC~ member  alleges,  based on extensive 
personal  observation,  that young peoples  age is rarely  verifkd  before they receive  a free 
sample.  Key informants  strongly recommended  banning the distribution  of samples 
through  the mail or in other  situations where age cannot be verified  or banning  free 
samples altogether.  NCI agrees,  saying  the offer of free tobacco products  is reminiscent 
of the drug pusher  who gives the frost free sample to get his customer  hooked.  (68) 
k  State and local tobacco  laws and enforcement  are weak. 
Loopholes  exist in State and local tobacco  control  and access laws.  By 1990 only three 
States met the standards  for  basic coverage  based on the criteria  established  by the 
Office of Smoking and Health  (OSH of CDC),  which in addition  to a minimum  age for 
sale, recommend  penalties  for merchants  selling tobacco to minors  (68).  No State law is 
considered  comprehensive  by OSH standards,  i.e.,  in addition to the above,  there 
12  should be a requirement  for warning  signs at the point of purchase,  provision  to revoke 
merchant  licenses  for violation  and a ban on the distribution  of free tobacco products  (68). 
Only 22 States prohibit  distribution  of tobacco product  samples to minors  (75). 
States and localities  do not enforce  existing tobacco  control  and access laws.  In  1992 the 
OIG surveyed the States about tobacco  control  and access,  and found virtually  none 
enforce  their laws prohibiting  the sale of tobacco to minors  (81).  Eighty-five  percent  of 
key informants  believe  enforcement  of spit tobacco  sales laws is ineffective.  Most favor 
stronger  enforcement  including  stiffer penalties  and license revocations  for selling spit 
tobacco to minors.  Smaller,  community-based  studies show that minors can generally 
purchase  tobacco products  at will, and vendors  rarely  suffer the legal consequences 
(56,57,77,81).  In fact,  in studies across the country,  it has been shown that,  on average, 
75 percent  of retail  stores sell tobacco  to minors as young as age 12 (68).  Fifty-seven 
percent  of our  1992 spit tobacco  users reported  it was easy to purchase  spit tobacco as a 
minor.  Fifty-three  percent  stated they were  never or  hardly ever asked  for proof  of 
age when they purchased  their  spit tobacco. 
  Expetis favor  revisions to spit tobacco  control policies. 
Revisions  to policies  on product  promotion  and legal restrictions  would improve  attempts 
to discourage  spit tobacco  use by young people.  For both areas,  key informants  strongly 
support requiring  warning  labels on billboards  and raising the legal age for purchasing  to 
21.  They also see higher Federal  and State excise taxes on spit tobacco  as beneficial. 
Research  has shown higher prices  will effectively  discourage  purchase  by young people 
(35,74).  In fact,  other than developing  serious health problems  from use,  higher price 
was the only strong reason to quit for many of our  1992 users.  Finally,  key informants 
support further  promotional  restrictions:  banning giveaway  items imprinted  with brand 
logos,  or appearance  of brand  logos in televised  events;  elimination  of advertising 
messages  implying  spit tobacco  is a healthier  choice than cigarettes;  and limiting the 
number  or type of events a spit tobacco company  can sponsor. 
Under-Age  Spit  Tobacco  Use  Is A Community  Problem,  Requiring  Broad 
Interventions. 
k  Spit tobacco  use is o$ien socially  acceptable  within a community. 
Communities  sometimes  do not understand  the social and legal issues of tobacco use until 
their consciousness  is raised.  Several local studies have shown that adherence  to laws 
restricting  tobacco  sales to minors  greatly  improved  after educating  the community  in 
general,  and the tobacco  vendors  in particular,  on the tobacco  access laws (77,81).  A 
community  physician  suggested  local education  requires  demonstrating  how easy it is for 
youth to obtain tobacco,  generating  concern  over the health problems  of tobacco  use, and 
subsequently  developing  local and school policies  on tobacco  control  (83).  All key 
informants  agree parents  need to be better  informed  of the adverse  effects  of spit tobacco 
use.  Community  education  may even have to extend to legislators  or the judiciary  who  write and enforce  laws (77, 84).  For example,  Davis County,  Utah demonstrated  an 
apparent  decrease  of spit tobacco  use among county male athletes,  by using these and 
other methods that alerted  the entire community  to the problem  and the proposed  solution 
(18), 
~  Schools do not control spit tobacco  use. 
Schools,  whose students are predominantly  under  age 18, do not uniformly  ban spit 
tobacco  use.  In 1990,  11 States did not have laws restricting  tobacco use in schools and 
only  16 State departments  of education  had a policy on tobacco  use in schools (75).  The 
1986 OIG report  found that schools frequently  do not prohibit  spit tobacco use or do not 
enforce  the rules.  In the  1992 study,  while users 
said their  school rules did not permit  spit tobacco 
My wrestling  coach wrestles  with 
use on the school property  (83%) or at school-
Copenhagen  in his mouth. 
sponsored events  (67 %), 26 percent  also said 
enforcement  of the school rules ranged  from 
If youre  not spitting on the floor, 
sometimes  to  never.  Of the  1992 users,  76 
teachers  usuaily  dont bother  you.  
percent  have seen a coach or teacher  at their 
school use spit tobacco.  A young user related, 
that on one occasion,  he was sent to the school office for using spit tobacco  in class. 
When  he arrived,  the dean of boys called him in, closed the d~o~ and offered  him a dip of 
snuff.  Two-thirds  of our  1992 users reported  taking a dip or thaw  before  class. 
Experts  favor tobacco-free  schools as a goal.  NCI (68), PHS Healthy  People  2000 (75), 
the World  Health  Organization  (35) and the First International  Conference  on Smokeless 
Tobacco  (47) all strongly  support this policy.  Prohibiting  all spit tobacco use on school 
grounds  or at school-sponsored  events,  and prohibiting  teachers  and coaches  from using in 
a students presence  are policies  the key informants  overwhelmingly  endorsed  as well.  In 
addition,  97 percent  of key informants  believe  school programs  need to provide  cessation 
guides or counseling  for young users who wish to quit. 
~  Spit tobacco  cumculufor  young people  are inadequtie. 
Young users are  still ignorant  about addiction  and other health effects associated  with spit 
tobacco  use.  In  1986, 81 percent  of OIG users
 interviewed  saw spit tobacco  as much 
safer to use than cigarettes.  Youthful users

continue  to believe  this according  to 91

percent  of key informants.  Among our  1992
 Cigarettes  can ruin your kings.  Cant 
get new lufigs.  Spit tobaccm doesnt 
users,  63 percent  saw spit tobacco  as safer

to use than cigarettes  and  15 percent  didnt
 affect  your stamina.  
know.  The  1986 OIG study found many

Dad has been using for 26 years,  and 
youth were unaware  of the potential  health

it hasnt done anything to him. 
risks of spit tobacco  use,  including

addiction.  In  1992 over half of key

informants  still rate elementary,  junior  high and senior high students as unaware  of the 
health risks of spit tobacco  use.  Eighty percent  of our  1992 users could name oral cancer, 
14  but their knowledge  was weak for gum recession  (24 %), throat  cancer  (20 %), addiction 
(13 %) and leukoplakia  (7%).  Even if young users are intellectually  aware of the effects, 
they dont really believe  that spit tobacco  endangers  their  health -- It cant happen to me 
syndrome. 
Experts  see a need to improve  the frequency  and content  of school curricula  addressing 
spit tobacco.  School education  about the health consequences  of tobacco  use was 
mandated  by law in only 20 States in 1989 (68).  Two-thirds  of key informants 
recommend  the annual inclusion  of the health effects of spit tobacco use in school 
curricula  for elementary,  junior  high and senior high schools.  Eighty-two  percent  say spit 
tobacco  education  should start in the third  grade or earlier,  even in kindergarten;  others 
agree  (18 ,68, 85-87).  Thus,  tailoring  curricula  to the students age level is necessary 
(55,86-89).  One analysis  of 28 examples  of spit tobacco  educational  materials  (1976 to 
1986) found the focus was correct  (young white males),  but social and reading  levels 
tended to be aimed at 7th grade or older  (89).  Just providing  information  on the hazards 
of tobacco use,  which many schools do, has been found largely  ineffective  (68).  Simply 
teaching  youth to say no does little to combat peer pressure  to adopt peer group 
opinions and values and to gain group acceptance  (90,91).  So, linking the course content 
to what motivates  young people  to use is another  improvement  (55,68,90,92). 
b  Educaled,  proactive  health professwnals  are impotiant  to community  intervention. 
Health professionals  have a unique opportunity  to discourage  spit tobacco  use.  The dental 
profession  treats  62 percent  of the American  population  within any one year interval, 
including  75 percent  of persons  age 5 to 17 (60).  Given this large amount  of contact,  the 
NCI calls the profession  a resource  to combat tobacco use by completing  better  oral 
examinations,  influencing  patients  avoidance  or discontinuance  of tobacco  use,  and 
promoting  the adoption  of comprehensive  tobacco control  policies  (60).  In addition, 
physicians  are seen as a credible  source of cessation  advice.  At the time of consultation, 
patients  are sensitized  to their health,  thus creating  the  teachable moment.  (68)  Key 
informants  unanimously  favored  strong,  proactive  education,  intervention,  counseling  and 
advocacy  roles for health professionals. 
Many  health professionals,  however,  are not doing as well as they could.  Despite  the fact 
that most physicians  believe  it is their  responsibility  to encourage  their patient  to abstain 
from using tobacco,  many fail to do so routinely  with all patients  (68).  Some are 
ambivalent  about the economic  value of interventions,  and they have a fear of losing 
patients  (93).  Key informants  strongly believed  that health professionals,  particularly 
dentists,  dental hygienists,  school nurses and family physicians,  are not sufficiently  trained 
to prevent  or intervene  in spit tobacco use.  Basic skills needed are the ability to recognize 
spit tobacco use and its adverse  effects,  and the signs and effects  of addiction.  One key 
informant  and his colleagues  wrote,  The Ml  extent of tobaccos  contributions  to oral 
disease often remains  unrecognized  by oral health professionals.  (33)  Counseling 
techniques,  and available  educational  and cessation  materials  are also appropriate  training 
topics,  either  in the professional  schools or as part of continuing  education  afterwards. 
15
 ~  Divorcing  baseball fioin  spit tobacco  use is another  eductional  stralegy. 
In some cases,  sport and spit tobacco  use are so closely intertwined  that it is as much a 
part of some sports as uniforms  and officials  (43).  Major  League Baseball  (MLB) was 
displeased  with the tendency  of the spit tobacco  industry  to presume  and trade  on the link 
between  spit tobacco and baseball  (94).  They were also concerned  with evidence that 
young spit tobacco users were emulating  baseball players.  MLB,  therefore,  began a major 
initiative  to break their link with spit tobacco  use that included  a spit tobacco  white 
paper  for the Commissioners  office,  the creation  of an MLB fund to support player 
health and safety vis-a-vis  spit tobacco  use, and an attempt  to convince two major 
networks  cameramen  not to focus on spit tobacco use.  Other steps under consideration 
are a media campaign  featuring  MLB players  who have quit,  setting a date when spit 
tobacco use would not be allowed  in the ballpark,  and assisting currently  addicted  players 
to quit.  Individual  MLB teams have instituted  additional  policies  of their  own.k 
Breaking  the association  between  spit tobacco  use and sport has also been a goal of other 
professional  and amateur  sport associations.  In 1992 all players  in the Class A minor 
league were prohibited  from using spit tobacco.  Little League,l  Babe Ruth League, 
American  League  (ages 16 to  18) and US Olympic baseball  have all banned tobacco  use. 
Some have also begun educational  campaigns  (95).  The NCAA banned tobacco  use 
during tournament  play,  followed by a Southeastern  Conference  baseball ban for all league 
games  (96). 
16
 CONCLUSIONS 
The responsibility  for addressing  the problem  of spit tobacco  use by young people  rests 
with many groups at the national,  State and local levels.  At the Federal  level  besides the 
Department  of Health  and Human  Services  (primarily  the Public Health  Service),  several 
other Departments  or agencies  are involved  -- the Federal  Trade  Commission,  the 
Department  of Agriculture,  and the Department  of the Treasury.  Below,  we lay out four 
broad areas for action by all responsible  groups.  We strongly encourage  the Department 
of Health  and Human  Services to take the lead in coordinating  efforts to deal with the 
problem  of spit tobacco  use.  We believe these efforts  should have four major goals: 
To convince  the general  public,  including  young people,  that spit tobacco  is a 
dangerous  and addictive  drug,  not a safe alternative  to smoking. 
Based on this awareness,  to encourage  States and communities  to take actions that 
effectively  combat young peoples  spit tobacco use. 
To solicit support from health care providers  and organized  athletics  which have a 
unique and important  role in deterring  spit tobacco  use. 
To provide  leadership  for the re-examination  of legislation  and regulatory  provisions 
governing  spit tobacco  and for assuring  a coordinated  plan for deterring  spit tobacco 
use. 
Promote  Commumly  Awareness  And Action. 
Responsible  groups  should lead a public  information  campaign  to raise community 
awareness  and concern  about the problem  of youth use of spit tobacco.  To support 
community  efforts to curtail use,  these groups  should actively promote  tobacco  control 
policies  for schools in coopemtion  with the Federal  and State Education  departments. 
Suppoti  Improved  Staie And Local  Tobacco Control. 
Responsible  groups  should support State and local laws that strongly restrict  tobacco  sales 
to minors  and the sustained enforcement  of these laws. 
Seek 17ze Suppoti  And Involvement  Of Health  Care Prwiders  And  Organized Athletics. 
Medical  and dental professionals  have a unique  opportunity  to positively  impact  the 
problem  of spit tobacco  use by young people.  Responsible  groups  should make every 
effort to equip,  encourage  and involve these professionals.  These groups  should alSO 
actively  promote  collaborative  efforts to deter  spit tobacco  use by athletes  at all levels. 
17  Re-examine  iVahonalTobacco Control Policy And Coordinate APlan  For Detemng 
Youth Use Of Spit Tobacco. 
Responsible  groups  should re-examine  national tobacco control policy  for areas that need 
strengthening,  e.g.,  legal age of purchase,  higher excise taxes indexed for inflation,  and 
amendments  to the  1986 Act.  These groups  should also develop a coordinated  plan for 
research  and information  dissemination  on spit tobacco  issues among the various  groups 
responsible  for spit tobacco  issues. 
18
 ENDNOTES

a.	 While  current,  national data is not available,  data from these select States indicate 
a potentially  serious problem  with spit tobacco use exists in all States. 
b.	 Despite varying  methodologies  among the national  surveys,  sufficient 
commonatities  permit  meaningful  comparisons,...  [Comparisons]  between the  1970 
NHIS and  1985 CPS for the purpose  of examining trends  are appropriate.  (4) 
c.	 In addition,  the  1985 NIDA Household  Survey showed past year  spit tobacco use 
by males age 12 to 17 had risen to only one percent  behind  18 to 24 year olds,  and 
was more than double the rate of all other adult male age groups  (144).  In fact, 
12-17 year old males had the highest past year use of all male age groups  in the 
Western  (25 percent),  North  Central  (22 percent)  and Southern  (24 percent) 
regions  of the nation. 
d.	 NCAA comparative  data from  1985 and 1989 on spit tobacco  use.  Spit tobacco 
use increased  across both genders,  all racial/ethnic  groups,  all sports,  all NCAA 
divisions and in most geographical  regions  of the country. 
Percent use of spit tobaccoin last 12 months by student-athletes  by sport 
Male  1985  1989  Female  1985  1989 
Baseball  45%  57%  Softball  8%  9% 
Basketball  8%  15%  Basketball  2%  4% 
Football  30%  40%  Swimming  3%  3% 
Track  9%  20%  Track  3%  5% 
Tennis  12%  29%  Tennis 
Percent use by student-athlete  by regionand collegedivision 
I I 
East  15%  25%  Division I  19%  27% 
!  ! 
Midwest  19%  33%  Dhision  II  I  23%  !  29% 
South  !  25%  !  23%  Division III  19%  27% 
I 
west  24%  24%  Source:  NCAA  (5),  1989 
I  I  85 (N  =  2,039),  89 (N  =  2,282) 
e.	 N  =  3,159  in 1986 and N  =  2,852  in 1989.  Unfortunately,  spit tobacco  questions 
were omitted  from the Senior Survey in 1990 and 1991. 
19
 f.	 For example,  nicotine  (or another  addictive  drug) causes dose-related  changes in 
mood or feeling,  and users often compulsively  use tobacco  despite the damage it 
does to their health.  Effects  of the drug,  desirable  for the user,  reinforce  him/her 
to use it again.  Over time the user will develop a tolerance  for the drug so that a 
dose produces  less effect.  Physical  dependence  can also occur accompanied  by 
withdrawal  symptoms  such as craving,  difficulty  sleeping or concentrating, 
restlessness  and excessive  hunger,  if the user stops. 
!?.  Ninety-five  percent  of oral cancers  occur in persons  over the age of 40 (40). 
h.  These  effects are sometimes  suggested,  but not proven,  for short-term  use. 
i.	 Curiosity  also encourages  young people to use (49).  In the 1986 and  1992 studies 
users placed  curiosity  among the top reasons for trying  spit tobacco. 
A public  health advocacy  group comprised  of medical professionals. 
j. 
k.	 The Rangers  have stopped supplying  spit tobacco  in the clubhouse  (146), the 
Dodgers  have banned  all players  from carrying  spit tobacco  while in uniform  and 
the Athletics  recently  banned tobacco  advertising  in their program. (95) 
1.  Little  League  banned the use of tobacco  35 years ago. 
20
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28
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United  States,   Preventive Medicine,  16:402-421,  1987. 
124.	 a.  Davis,  S.,  Severson,  R.K.,  Increasing  Incidence  of Cancer  of the Tongue in 
the United  States Among Young Adults  (letter),  Lancet,  2:8564:910-1,  October 
17, 1987. 
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Males  (letter)  New England Journal  of Medicine,  315:10:647,  September  4,  1986. 
c.  Schantz,  S.P.,  R.M.  Byers,  H.  Goepfert,  Tobacco  and Cancer  of the Tongue 
in Young Adults (letter) Journal  of the Amencan Medical  Association, 
259:13:1943-4,  April  1, 1988. 
125.	 Dent,  Clyde W.,  Steven Sussman,  C. Anderson  Johnson,  William  B. Hansen  and 
Brian R. Flay,  Adolescent  Smokeless Tobacco  Incidence:  Relations  with Other 
Drugs  and Psychosocial  Variables,   Preventive  Medicine,  16:422-431,  1987. 
32  126.  DiFranza,  Joseph R.,  MD,  Joe B. Tye,  MBA,  Who Profits  From Tobacco  Sales 
to Children?  Journal  of the American  Medical Association,  263:20:2784-2787, 
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127.  Eakin,  Elizabeth,  Herbert  Severson,  Russell E.  Glasgow,  Developmentand 
Evaluation  of a Smokless Tobacco  Cessation  Program,  Smokeless  Tobacco  Use in 
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Advertising  of Smokeless Tobacco,   FTC News,  Washington  D.C.  20580, 
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130.  Getz,  J. G.,  R.I.  Evans,  M.J.  Sharp,  A. Reifman,  Perception  of Significant 
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presented  at the First International  Conference  on Smokeless Tobacco:  Tobacco 
and Health,  Columbus  OH, April  10-13,  1991. 
131.  Gordon,  Mitchell,  Bucking Bad News:  U.S.  Tobacco,  Top Snuff Maker,  Heads 
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1986. 
132.  Hatsukami,  Dorothy,  Deborah  Anton,  Robert  Keenan,  and Allan Callies, 
Smokeless Tobacco  Abstinence  Effects and Nicotine  Gum Dose,  
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133,  Hoffmann,  D.,  M.V.  Djordjevic,  K.D.  Brunnemann,  New Brands of Oral Snuff,  
Food  Chemistry and  Toxicology,  29:1:65-68,  1991 
134.  Journal  of Dental  E2iucation, Curriculum  Guidelines  for Predoctoral  Preventive 
Dentistry,  55:11:746-750,  1991. 
135.  Keenan,  Robert  M.,  Dorothy  Hatsukami,  and Deborah  J. Anton,  The Effects  of 
Short-Term  Smokeless Deprivation  on Performance,  Psychopha~cology, 
98:126-130,  1989. 
136.  Malvitz,  Dolores  M.,  DrPH,  Moon S. Chen,  Jr.,  PhD,  MPH,  Ellen M.  Capwell, 
MA,  CHES,  Robert  J, Caswell,  PhD,  Kathleen  L.  Schroeder,  DDS,  MSC, Herbert 
H.  Severson,  PhD,  Conference  on Measuring  the Impact  of Public Law 99-252,  
Journal  of Public Health Dentistry,  50:1:64-103,  Winter  1990. 
137.  Mangskau,  Kathleen,  RDH,  Dental Program  Director,  Division  of Maternal  and 
Child Health,  North  Dakota  State Department  of Health  and Consolidated 
Laboratories,  in a letter dated July 24,  1992. 
33  138.  Marcus,  Alfred  C.,  Lori  A. Crane,  Donald R. Shopland,  and William  R. Lynn, 
Use of Smokeless Tobacco  in the United  States:  Recent Estimates  From the 
Current  Population  Survey,   Smokeless  Tobacco  Use in the  United States: 
Nationul  Cancer Institute  Monographs,  8:17-23,  1989. 
139.  McGinnis,  J. Michael,  Tobacco  and Health:  Trends  in Smoking and Smokeless 
Tobacco  Consumption  in the United  States,   Annual  Review  Public Health,  8:441-
67,  1987. 
140.  National  Academy  of Sciences,  Institute  of Medicine,  letter from Executive  Officer 
to Acting Assistant  Secretary  for Health,  Department  of Health  and Human 
Services,  May  15, 1986. 
141.  Novotny,  Thomas  E.,  John P. Pierce,  Michael  C. Fiore,  and Ronald M.  Davis, 
Smokeless Tobacco  Use in the United  States:  The Adult Use of Tobacco 
Surveys,  Smokeless  Tobacco  Use in the  United States: National  Cancer Institute 
Monographs,  8:25-28,  1989. 
142.  Poulson,  Todd C.,  DDS,  James E. Lindenrnuth,  DDS,  Robert  O. Greer,  Jr.,  DDS, 
SCD. A Comparison  of the Use of Smokeless Tobacco  in Rural  and Urban 
Teenagers,  Ca-A Cancer Journal for  the Clinician,  34:248-61,  1984. 
143.  Riley,  Willam  T.,  James Barenie,  and David Myers,  Typology and Correlates  of 
Smokeless Tobacco  Use,  Journal  of Adolescent  Health  Care,  10:357-362,  1989. 
144.  Rouse,  Beatrice  A.,  Epidemiology  of Smokeless Tobacco  Use:  A National 
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145.  Schroeder,  K. L.,  H.A.  Soiler,  M.S.  Chen,  Jr.  et al.,  Screening for Smokeless 
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Journul  of the Amen-can Dental Association,  116:37-42, January  1988. 
146.  Sherrington,  Kevin,  Taking a Dip in Class A Ball Puts Umpires  on Defensive,  
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147.  Stevens,  Victor J.,  PhD,  Herbert  Severson,  PhD,  Edward  Liechtenstein, PhD,  Sally 
Jo Little,  RDH,  MS,  Joseph Leben,  DMD,  Making the Most of a Teachable 
Moment:  Smokeless Tobacco  Intervention  in the Dental  Office Setting,  abstract 
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1992. 
148.  Sullivan,  Louis W.,  MD,  Secretary  of Health  and Human  Services,  remarks  before 
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3,  1990 
34
 149.  Sullivan,  Louis W.,  MD,  Secretary  of Health and Human  Services,  remarks  before 
Healthy  Oklahoma  2000/Southwest  Tobacco  Use Prevention  Conference,  Oklahoma 
City,  OK, November  7,  1991. 
150.  U.S.  Department  of Health  and Human  Services,  Centers  for Disease  Control, 
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Americas:  Executive  Summary,  a 1992 report  of the Surgeon General,  in 
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152.  U.S.  Tobacco  Company,  UST 1990 Annuul  Report. 
153.  U.S.  Tobacco  Company,  UST Coporate  Citizenship Report,  1991. 
154.  Walker,  Chris,  SEC Bans Use of Tobacco  in League Baseball  Games,  l%e 
Montgomery  Adve~ser,  page  5B, January  27,  1992. 
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Baseball  Players,   University  of California,  San Francisco,  CA. 
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1992. 
35  APPENDIX  A

PROFILES  OF  1992  SPIT  TOBACCO  USERS 
These are brief profdes  of some young users we interviewed  for the study. 
1.  Jack  from Arkansas,  17 years old, white. 
Jack has used spit tobacco  regularly  since the sixth grade.  His father  was a 
professional  bass fisherman  who had received  free spit tobacco  samples.  His 
father died of oral cancer  after using for 40 years.  Jack has health problems  from 
using -- receding,  sore gums,  peeling  skin inside his cheek,  sores on his tongue 
and frequent  sore throats.  In fact,  he admits he is addicted,  but he hasnt tried to 
quit.  His special interest  is high school rodeo;  using spit tobacco  is a thing all 
real cowboys  should do.   He says his school coaches borrow  spit tobacco  from 
him  all the time.  
2.  Carlos  from Texas,  16 years old, Hispanic. 
Carlos  has been a regular  user since the ninth grade.  Baseball  is his sport -- he 
plays on his school team,  and he watches  it on television.  He started  using spit 
tobacco  because  the older baseball players  used;  it was just  something  everyone 
else did.  Now hes hooked and says he cant play ball without it due to cravings. 
Carlos  has tried to quit three times with no success.  He thinks  spit tobacco 
probably  isnt good for him, but he and his parents  think its better than smoking 
or taking  drugs. 
3.  Cal,  7, Lee,  10,  and  Scooter,  11 are three brothers  from Florida 
All three  boys started using spit tobacco  very young -- Cal has used chewing 
tobacco  regularly  since Kindergarten,  Lee  since he was 3 years old and Skooter 
since seeond grade.  Cal and Lee  say they now use all day long and sometimes  go 
to sleep with spit tobacco  in their  mouths.  Their  father,  who buys spit tobacco  for 
them,  has used chewing tobacco  for over 25 years and says he has no bad health 
effects.  The boys do agree,  though,  that regular  use can cause mouth or throat 
cancer.  The town they live in has a drug problem.  Dad feels that  spit tobacco  is a 
better  alternative  to hard drugs  ..and  candy. 
A  -1  4.  Susan  from  Oregon,  16 years old, Native American. 
Susan started regular  spit tobacco use when she was  12.  Her friends gave it to 
her;  she really enjoyed the taste and buzz it gave her.  After that,  she still didnt 
buy her own because  an older  sister or her boyfriend  got it for her.  Susan enjoys 
doing  Indian dances  and sews Copenhagen  can lids on her dress for decoration. 
Before using spit tobacco,  she used alcohol,  marijuana  and LSD.  After  she started 
using spit tobacco,  she began  smoking cigarettes.  These days,  Susan just  smokes. 
It took her five quit attempts  before  she succeeded  with the help of a residential 
drug treatment  program  that she entered  due to her alcohol and other drug use. 
5.  Randy  from Pennsylvania,  17 years old, white. 
Randy is a college  freshman  who has been a regular  spit tobacco  user since grade 
eleven;  he started when he was fourteen.  He plays golf and tennis,  although  he is 
also a football and baseball  fan.  His friends  encouraged  him to use, but no one in 
his family has the habit.  Randy dips moist snuff about five times a day,  going 
through  about three  cans a week.  He believes that spit tobacco  is safer than 
cigarettes  and that gum and mouth problems  are very rare among users.  Besides, 
he likes the taste.  In high school,  his health teacher,  who dips snuff,  showed them 
a five-minute  tape about the dangers  of spit tobacco  use.  Randy thought  it was just 
a scare attempt. 
A  -2  Males  Currently+ Use  Spit Tobacco  At High Rates  In Twenty  States! 
(Source:  YRBS 1991,Grades  9-12) 
  33%  or  more 
El%2!0-24%  2532% 
#......~.......j.. .....  19% or less  (over  1 in 5 males)  (over  1 in 4  males)  (over  1 in 3 males) 
+  Prececkg  30  days 
Weicjled  data  **  Qrveys  did not  Wlude  students  from  the  largest  city. 
 
1 
Includes Washngtm.  DC. 
B-1
  APPENDIX  C 
SUMMARY  OF  NATIONAL  AND  REGIONAL  PREVALENCE  STUDx13S 
c-1   Regional  Studies - Suit Tobacco 
Bib  Investigatorslhxation  Age/Grade  Sample  N  Miaeellaneous  Study Information  Current  Use 
(Laat 30 days)  of 
Spit Tobacco 
1 Used  Regularly 
Males  Females 
13  Schlife  (1987)  K-12th  gradea  4,965  Native  American  Study  33.7%  1  27.5%  1 
8 rural  regions  in Alaska 
Schh-ske (1986)  Mean  Age  =  13.8  254  Native  American  Study  20.2%  1  27.4%  1 
3 reservations&  1 urban  area,  WA 
Schinke  (1987)  Mean  Age  =  12.3  144  Native  American  Study  42.6%  ~  34.0%   
Washington,  Alaaka 
Wolfe  and Carlos  (1987)  9-10th grades  226  Native  American  Study  55.9%  1 
Navajo  Boarding  School,  NM 
Jewett  (1988)  K-6th grades  1,010  Native  Amercian  Study  39.2%  1  35.1%  1 
Rosebud  Reservation,  SD  7-12th grades  571 
Hall  and Dexter  (1989)  6,9,11th  grades  257  Native  American  Study  34.0%  ~  24.0%   
3 tribes,  15 schools,  WA 
Jewett  (1988)  7-12th grades  1056  Native  American  Study  36.2%  1  32.4%  1 
4 reservations&  urban  non-Indians, 
South Dakota  and Montana 
Batliner  (1988)  4-8th grades  623  Native  American  Study  47.0%  1  45.0%  1 
South Dakota  & Montana 
Foster  (1988)  7-12th grades  114  Native  American  Study  38.0%  1  37.0%   
Boarding  School,  SD 
13  Foster  (1988)  K-12th  grades  195  Non-Native  Americans  18.4%    8.7%  1 
South Dakota  (Comparative  group to Native  Americans) 
Hall & Dexter  (1988)  6,8,11 thgrades  853  Non-Native  Americans  20,0%  1  4.0%  1 
Washington  (Comparative  group to Native  Americans) 
Jewett  (1988)  7-12th grades  23,693  Non-Native  Americans  7.8%  1  0.0%  1 
Metropolitan  Minneapolis  (Comparative  group to Native  Americans) 
Jewett  (1988)  7-12th grades  12,590  Non-Native  Americans  6.8%  1  0.0%  1 
Greater  Minneapolis  (Comparative  group to Native  Americans) 
c-2  .  Bib  Investigator/hation  AgelGrade  Sample  N  Miscellaneous  Study  Information  Current  Use 
(Last 30 days)  of 
Spit Tobacco 
1 Used  Regtdarly 
MaIes  Females 
13  Bather  (1988)  4-8th grades  527  Non-Native  Americans  14.6%  1  1.6% 1 
South Dakota,  Montana & Nebraska  (Comparative  group to Native Americans) 
52	 Marty,  et al. (1986)  10-12th grades  179  Predominantly  Caucaaian, blue collar,  31.8%  2.3% 
Rural  community,  NW  Arkan.ws  Mean  age  =  15.9  rural  population 
[9a	 University  of Kenmcky  7-12th grades  1,067  Phase  1: Saliva  sample  collected  Use in Past 
1 Metro.  & 1 non-Metro.  county  (471 sent for biochemical  testing) 
m 
Phase  2:85  metro  8tb grsders  were  42%  of those 
exposed  to 3-sessiOns  of  in households 
education  intervention.  in volved  in tobacco 
:9b	 w est Virginia  University  5-1 2th grades  4,230  Stratified  random  sample  17%  5-6th  3%  5-6th 
w  Public  Schools 
29%  7-9th  1%  7-9th 
39%  10-12th  1%  lo-12th 
12  Br ownaon,  et al,  (1990)  5,8, 12th grades  5,431  Representative  sample,  mra]  Use in Previous  7 Days 
78 hfkoUri  Schools  counties  were  oversampld  Urban:  ~ 
5rll  1%  5% 
8th  13%  17% 
12tb  15%  31% 
$1  Jone s &Pyper(1986)  7-12th grades  2,181  Stratified  random  sample  Male  Only: 
Dan e County,  Wisconsin  >  Ilwk;  Daily  Use: 
7th  9%  3% 
8rir  12%  6% 
9rb  12%  3% 
Ioth  16%  8% 
llth  14%  11% 
12dl  22%  15% 
02  Kegel es, et. al. (1989)  7-12th grades  7,457  Daily  Use:  Daily  Use: 
59 co nnecticut  towns&  106 schools  mh  2 .0%  7th  .4% 
8tb  5 .3%  8th  .4% 
9th  7 .1%  9tb  .5% 
10th 5 .5%  IOth  .0% 
Ilth  7 .1%  Ilth  .3% 
12th 8 .0%  12th  .2% 
c-3   Blb  Invedgatoralbeation  Age/Grade  Sample  N  Miscellaneous  Study  Information  Current  Use 
(Last 30 days)  of 
Spit Tobacco 
1 Used  Regularly 
Males  Females 
18  Leopardi,  et. al. (1989)  7-12th grades  8,902  Survey  I  - 16-item prevalence  survey  Weekly  Use:  Weeklv  Use: 
Davis  County,  Utah  Survey  II -473  males  in sports  classes  12.1 %  Total  1.1%  Total 
AI1 11 Junior  highs&  7 Senior  highs  had survey & oral exam.  10.2%  JH  1.1%  JH 
15.0%  SH  1.0%  SH 
14  North  Dakota  State Department  of  7-12th grades  36,693  7-12th  20.4% 
Health  and Consolidated  Laboratories  Sioux county 
(1991),  212 ND School  Districts  62.9% 
20  State Department  of Education  (89-90)  6,8,10,12th  grades  1989-90 Drug  & Alcohol  Use Among  Dailv  Use: 
Oklahoma  Oklahoma  Students.  6th  3% 
8th  6% 
10th  8% 
12th  11% 
103  Bauman,  et. al. (1989)  12-14 yrS  21,203  Probability  samples  of households.  &  m  &  W 
10 SMSAS,  Southeaatem  U.S.  o-4  .2%  o-4  .1% 
5-9  .3%  5-9  .0% 
10-14  3.5%  10-14  .1% 
15-19  11.4%  15-19  .2% 
20-24  10.6%  20-24  .5% 
104  Peterson,  Marek,  & Mann  (1989)  10th grade  1,631  14 rural and suburban  school  districts.  10th Graders  10th Graders 
Schools  in Washington  state.  Last Month  Last Month 
25.3%  2.8% 
Last Week  Last  Week 
17.7%  1.4% 
8  Tri-Agency  Tobacco  Free  Project  5,7,9,12th  grade  26,911  Maine  Youth Tobacco  Use Survey  Last Week 
(1991),  Maine  5th  1.4% 
7th  2.7% 
9th  6.6% 
12th  10.2% 
9  Tri-Agency  Tobacco  Free  Project  5,7,9  & 12th grade  22,147  Maine  Youth Tobacco  Use Survey  Last Week 
(1989),  Maine  5th  1.5% 
7th  4.0 % 
9th  6.0% 
12rh  8.7% 
c-4   I  Bib  Investigators/Location  Age/Grade  sample  N  Miscellaneous  Study Information  Current  Use 
(Last 30 days)  of 
Spit Tobacco 
1 Used Regularly 
Males  Females 
10  Tri-Agency  Tobacco  Free  Project  5,7,9  & 12th grade  28,(KW  Maine  Youth Tobacco  Use Survey  Last  Week 
(1987),  Maine  5th  1.8% 
7th  3.5% 
9th  7.8% 
12th  8.3% 
49  Simon,  Stotts  & Pollard  (1992)  5th - 12th grade  4,230  Stratified  random  sample  by student  Almost  Daily  Use 
West  Vkginia  achievement  & socialeconomic  status.  6th  6.3% 
Includes  no racial  and ethnic  categories.  7th  9.6% 
8th  11.0% 
9th  22.6% 
loth  19.5% 
Ilrh  21.9% 
12th 20.8% 
11  Illinois  Department  of Public  Health  5,7,9,  & llth  grades  7,118  Random  sampling  of 65 schools  =  Non-Metro. 
(1987),  Illinois  9-19 years  in Illinois.  5th  3.7%  4.8% 
(excluding  Chicago)  7th  7.2%  11.8% 
9th  14.6%  26.7% 
llth  16.4%  28.4% 
85  Center  for Health  Statistics  & Bureau  of  18-24 years  2,400  Randomly  selected  adult households.  7% 
Community  Health  & Prevention, 
(1988),  Wkconsin 
85a  Murray,  D.,  (1986)  9th grade  3,500  +  Randomly  selected  9th graders  Last Week  Previous  Day 
Wlaconsin  Public  Schools  in public  schools.  5.0%  3.0% 
105  University  of Minnesota  7-12th gradea  14,000  Adolescent  Health  Survey  of  !21?i!Y  !X!Y 
50 different  Native  American  tribes  Native  American  adolescents.  7th  10.7%  7th  6.4% 
8th  11.5%  8th  7.1% 
9th  14.9%  9th  10.4% 
IOth  16.0%  10th  8.9% 
llth  18.8%  llth  7.9% 
12th 20.3%  12th  6.4% 
106  Pomrehn,  et. al.  10,11 & 12th grades  1245  Adolescent  Tobacco  Use Prevention  Study  10th  12.5% 
Three  communities  in Eastern  Iowa	 llth  15.9% 
12th  13.6% 
c-5   Bib  Investigators/Location  AgelGrade  Sample  N  Miscellaneous  Stndy Information  Current  Use 
(Last 30 days)  of 
Spit Tobacco 
1 Used  Regularly 
Males  Females 
107  Edumson,  et. al.  (1987)  College  Freshman- 289  Random  sample  of undergraduate  male  EIU?MS 
E.@ Carolina  University  Senior  students  at East  Carolina  University.  17-18 yrs  18.3% 
Looked  at personality  characteristics.  19-20 yrs  14.8% 
Chewing 
17-18 yrs  12.2% 
19-20 yrs  10.2% 
7  Connecticut  Department  of Henlth  4th-12th  grades  6981  Connecticut  Health  Check  4tb  1.0% 
Services,  (89-90)  (7-12th  5th  1.0% 
grades)  7th  4.0% 
8th  1.0% 
9th  3.0% 
lotb  7.0% 
Ilth  7.0% 
12th 10.0% 
108  Youth Rlak Behavior  Survey (1991)  9-12th grades  2450  School  based survey  (YRBS)  Total  26.1%  ~  2.4% 
Nebraska  Weighted  data  =5  19.6%  s  15  2.7% 
16,17  26.6%  16,17  2.5% 
>  18  36.1%  >  18  1.6% 
White  27.8% 
Black  3.0% 
Hispanic  18.5 % 
Other  24.2% 
109  Youth Risk  Behavior  Survey  (1991)  9-12th grades  2455  School  baaed survey  (YRBS)  ~  30.7%  T~  2.0% 
Alabama  Weighted  data  s  15  31.3% 
16,17  31.0% 
z  18  28.6% 
White  39.2%

Black  6.8%

Hispanic
 ----
Other  16.9%

C-6   Bib  Inveetigatore/LOcation  Age/Grade  Sample  N  Miscellaneous  Study  Information  Current  Use 
(Last 30 days)  of 
Spit Tobacco 
1 Used  Regularly 
Meles  Females 
110  Youth  Risk  Behavior  Survey  (1990)  9-12th  grades  1889  School  based  survey  (YRBS)  <  15  20.2%  5  15  1.7% 
Temessee  Unweighed  data  16,17  24.3%  16,17  1.4% 
2  18  27.5%  2  18  .9% 
White  28.6%

Black  2.8%

Hkpanic
 ----
Other
 ----
111  Youth Rkk  Behavior  Survey  (1991)  9-12th grades  2457  School  based  survey  (YRBS)  ~  34.4%  _Total  1.2% 
Temessee  Unweighed  data  s  15  30.6%  s  15  .7% 
16,17  35.8%  16,17  1.5% 
>  18  36.6%  >  18  1.6% 
White  35.8% 
Black  22.1% 
Other  29.0% 
112  Youth  Risk  Behavior  Survey  (1991)  9-12th grades  2192  School  based  survey  (YRBS)  ~  29.0%  T- 1.8% 
Pennsylvania  Unweighed  data  <  15  28.0%  5  15  1.0% 
16,17  29.0%  16,17  2.3% 
>  18  30.8%  ?  18  1.6% 
White  30.4%  White  1.7% 
Black  17.3%  Black  ---
Hispanic  5.9%  Hispanic  ---
Other  30.0%  Other  3.1% 
113  Youth  Risk  Behavior  Survey  (1990)  9-12th grades  School  based  survey  (YRBS)  9th, White  23 .0% 
North  Carolina  12th, White  18.0% 
9th, Black  7.0% 
12th, Black  2.0  % 
114  Youth  Risk  Behavior  Survey  (1990)  9-12th grades  School  based  survey  (YRBS)  19%    3.0% 
Mississippi 
3  Youth  Rtsk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  22%  2.0% 
Georgia  Weighted  data 
c-7   Blb  Investigators/LOeation  Age/Grade  Sample  N  MiasAlaneoua  Study  Information  CurrmM Use 
(Last 30 days)  of 
Spit Tobacco 
1 Used  Regularly 
Males  Females 
3  Youth Risk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  24%  3.0% 
Idaho  Weighted  data 
3  Youth  R]sk  Behavior  Survey  (1991)  9-12th grades  School  baaed survey  (YRBS)  27%  4.0% 
New Mexico  Weighted  data 
3  Youth R]sk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  19%  2.0% 
New  York  Weighted  data excludes  students 
from the largest  city. 
3  Youth Risk Behavior  Survey (1991)  9-12th grades  School based  survey  (YRBS)  20%  2.0% 
South Carolina  Weighted  data 
3  You&i Rlak Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  29%  10.0% 
South Dakots  Weighted  data 
3  Youth  Rkk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  12%  2.0% 
Utah  Weighted  data 
3  Youth Risk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  32%  6.0% 
Colorado  Unweighed  dats 
3  Youth Risk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  5.0%  2.0% 
Washington  D.C.  Unweigbted  data 
3  Youth R]sk Behavior  Survey  (1991)  9-12th grades  School based  survey  (YRBS)  14%  2.0% 
Hawaii  Unweighed  data 
3  Youth  R]sk  Behavior  Survey  (1991)  9-12th grades  School based  survey  (YRBS)  33%  7.0% 
Montana  Unweighed  data 
3  Youth R]sk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  22%  4.0% 
New Hampshke  Unweighed  data 
3  Youth Risk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  14%  2.0% 
New Jersey  Unweighed  data excludes  students 
from the largest  city. 
3  Youth  Risk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  28%  5.0% 
Oregon  Unweighed  data 
C-8   Bib  Investigators/hcation  Age/Grade  Sample  N  Miacellaneoua  Study  Information  Current  Use 
30
(Last  days)  of 
Spit Tobacco 
1 Used  Regularly 
Males  Females 
3  Youth  Risk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  29%  2.0% 
Pemsylvania  Unweighed  data excludes  students 
from the largeat  city. 
3  Youth  Risk  Behavior  Survey  (1991)  9-12th grades  School based  survey  (YRBS)  19%  3.0% 
W]aconsin  Unweighed  data  I 
I

3  Youth  Risk  Behavior  Survey  (1991)  9-12th grades  School  based  survey  (YRBS)  31%  5.0%
Wyoming  Unweighed  data 
68  Youth  Risk  Behavior  Suxvey (1991-92)  9-12th grades  School  based  survey  (YRBS)  White  NA  WMte  NA 
9-12th  29%  39%  I  9-12th  4%  13% 
9th  24%  38%  9th  3%  11% 
Ioth  31%  34%  lotb  5%  13% 
llth  30%  47%  llth  4%  16% 
12th  32%  35%  12th  4%  14% 
c-9   -N-a--t-in--n-a--l  S--t-m--lies   - Snit Tnhmvn
-r.  - -------
Bib  Inveatigatorsll.ocation  AgelGrade  Sample  N  Miscellaneous  Study  Information  Current  Use 
(Last 30 days)  of 
Spit Tobacco 
 Used  Regularly 
Males  Femalea 
97  U.S.  Department  of Health  and Human  9-12th grades  11,631  National  School  Based  Youth  Rkk  ~  19.1%  Total  1.4% 
Services  (1991)  Behavior  Survey  (YRBS)  White  23.9%  ~e  1.5% 
High  School  students  in U.S.  1990 Data  Black  3.1%  Black  .8% 
Hispanic  10.9%  Hispanic  1.0% 
Seniors  21.1% 
Sr./Whhe  26.0% 
1  U.S.  Department  of Health  and Human  9-12th gradea  12,272  National  School  Based  Youth Risk  ~  19.2%  T~  1.3% 
Services  (1992)  Behavior  Survey  (YRBS)  White  23.6%  White  1.4% 
High School  students  in U.S.  1991 Data  Black  3,6%  Black  .7% 
Hispanic  10.7%  Hispanic  .6% 
98  Glover,  Laflin,  & Edwards  (1989)  Mean  age=20.8  yrs  5,894  Stratified,  random,  multi-cluster  12% of all college  age 
College  students  across  eight regions  1/3 were  freshman  sample  of physical  activity  classes 
among  72 colleges  and universities 
throughout  the U.S. 
1986 Data 
99  National  Institute  on Drug  Abuse  Ages  12-17 & 18-25  NIDA  Household  Survey  on drug abuse  Ages  12-17  6.6%  Ages  12-17  ----
(1988)  1988 Data  Ages  18-25  12.3%  Ages  18-25  ----
100	 National  Institute  on Drug  Abuse  Ages  12-17 & 18-25  NIDA  Household  Survey  on drug abuse  Ages  12-17  7.4%  Ages  12-17  ----
(1990)  1990 Data  Ages  18-25  12.1 %  Ages  18-25  ----
101  National  Institute  on Dmg  Abuse  Ages  12-17 & 18-25  NIDA  Household  Survey  on drug abuse  Ages  12-17  5.3 %  Ages  12-17  ,5% 
(1991)  1991 Data  Ages  18-25  11 .6%  Ages  18-25  .4% 
6  National  InstiNte  on Drug  Abuse  12th grade  3159  NIDA  Senior  Survey  Seniors  22.2%  Seniors  1.6% 
(1986)  1986 Data  Sr./White  25.7% 
6  National  Instimte  on Drug  Abuse  12tb grade  3357  NIDA  Senior  Survey  Seniors  22.8%  Seniors  .6% 
(1987)  1987 Data  Sr.lWhite  25.4% 
6  National  Institute  on Drug  Abuse  12th grade  3378  NIDA  Senior  Survey  Seniors  19.9%  Seniors  1.7% 
(1988)  1988 Data  Sr. /White  21 .9% 
6  National  Institute  on Drug  Abuse  12th grade  2852  NIDA  Senior  Survey  Seniors  16%  Seniors  1.2% 
(1989)  1989 Data  Sr./White  19% 
c-lo   APPENDIX  D

KEY  INFORMANTS  INTERVIEWED

James  A.  Bergman,  JD
 Linda Crossett,  RDH,  BS
 Thomas Glynn,  PhD 
Executive  Director
 Dental Health Program Specialist
 Chief,  Cancer Prevention 
Stop Teenage  Addiction
 Division  of Oral Health
 & Control 
to Tobacco
 Centers for Disease  Control
 Extramural Research Branch 
121 Lyman Street,  Suite 210
 1600 Clifton Road NE
 National Cancer Institute 
Springfield,  MA  01103
 Mailstop  F-1 O
 Executive  Plaza North,  Rm 330 
Atlanta, GA  30333
 9000  RockviUe Pike 
Bethesda,  MD  20892 
Alan Blum,  MD
 Donald  R. Dexter,  Jr., DDS

Associate  Professor
 Executive  Director of IUamath

Department of Family  Medicine
 Tribal Health
 Jerome Goldstein,  MD 
Baylor CoUege of Medicine
 3949  south  sixth
 Executive  Vice President 
5510  Greenbriar
 IUamath Falls,  OR  97603
 American  Academy  of 
Houston,  TX 77oO5
 Otolaryngology  - Head and 
Neck Surgery 
Joseph DiFranza,  MD  One Prince Street 
Moon Chen,  Jr., PhD
 Associate  Professor of Family  Alexandria,  VA  22314 
Professor,  Department  of
 &  Community  Medicine 
Preventive  Medicine
 University  of Massachusetts 
Ohio State College  of Medicine
 Medical  Center
 John Greene,  DMD,  MPH 
B110 Starling Loving  HsJI
 47 Ashui State Road
 Dean of Dental School 
320 West Tenth
 Fitchburg,  MA  01420
 University  of California 
Columbus,  OH  43210
 at San Francisco 
513 Parnassus Avenue 
Thomas  M.  DiLorenzo,  PhD
 San Francisco,  CA  94143-0430 
Arden G. Christen,  DDS,  MSD
 Chairman

Chairman
 Department of Psychology

Department of Preventive
 University  of Missouri
 Robert Greer,  DDS,  SCD 
& Community  Dentistry
 210 McAlester  HalJ
 Chairman of Oral Pathology 
School  of Dentistry
 Columbia,  MO  65211
 and Oncology 
Indiana University
 University  of Colorado 
1121 West Michigan  Street
 Dental School

[ndiampolis,  IN  46202
 Richard 1. Evans,  PhD
 BOX  C 285

and Associates
 4200  East Ninth Avenue

Department of Psychology
 Denver,  CO  80262

Gregoxy Connolly,  DMD,  MPH
 University  of Houston

Director of Dental HeaJth
 Houston,  TX  77204-5341

Massachusetts  Department
 Richard Hastreiter,  DDS,  MPH

of Public  Health
 Director,  Dental Health Program

150 Tremont Street
 Elbert D. Glover,  PhD
 Minnesota  Department  of HealtJI

Boston,  MA  02111
 Director
 717 Delaware  Stxeet, SE

Tobacco  Research Center
 Minneapolis,  MN  55440-9441

MBR Cancer Center

Stephen  B. Corbin,  DDS,  MPH
 West Virginia  University

National Institute for
 Health Science  Center
 Dorothy  Hatsukami,  PhD

Dental Research
 1 Medical  Drive
 Associate  Professor  of Psychiatry

National  Institutes of Health
 Morgantown,  WV  26506
 Universi~  of Minnesota

Building  31
 Box 392 Mayo

Bethesda,  MD  20892
 Minneapolis,  MN  55455

D-1  Jack E. Henningfield,  PhD
 Robert Mecklenburg,  DDS,  MPH
 Nancy Johnson WiUiams,  Ed.D

Chief
 Consultant
 Associate  Professor and Clinical

CJinical Pharmacology  Research
 National Cancer [nstitmte
 Coordinator

Addiction  Research Center
 12304 Rivers-Edge  Drive
 Department of Dental Hygiene

National Institute of Drug Abuse
 Potomac,  MD  20854
 University  of Tennessee

P. O. BOX  5180
 822 Beale Street,  Room 321 E

Baltimore,  MD  21224
 Memphis,  TN  38163

Sherry Mills,  MD,  MPH

Chief of the Investigator

Dietrich  Hoffman,  PhD  Initiated Research Section
 Deborah M. Winn,  PhD

Associate  Professor  of  National Cancer Institute
 Chief

American  Health Foundation  9000  Rockville  Pike
 Analytical  Studies & Decision

Valhalla,  NY  10595  Executive  Plaza North,  Rm 320
 Systems  Branch 
Bethesda,  MD  20892
 Epidemiology  & Oral Disease 
Prevention  Program 
Thomas  Houston,  MD
 National Institute 
Director,  Preventive  Medicine
 Michael  L. Morgan,  DDS,  MPH
 of Dental Research 
& Public Health Department
 Chief,  Dental Health Services
 5333 Westbard Avenue,  Rm 537 
American  Medical  Association
 Oklahoma State Department
 Bethesda,  MD  20892 
515 North State Street
 of Health

Chicago,  IL  60610
 1000 NE Tenth Street

Oklahoma City,  OK  73117-1299

Rhys Jones,  DDS,  MS

Director of Dental Health Center

St.  Lukes Hospital
 Carole Tracy Orleans,  PhD

855  A Avenue  NE
 Director

Cedar Rapids,  IA  52402
 Tobacco  Control Research

Fox Chase Cancer Center

510 Township  Line Road

Mary Beth Kinney,  RDH,  MPH
 Cheltenham,  PA  19012

Dental Education  Specialist

Indian Health Service

3750  Chemawa  Road NE
 Barbara Park, RDH,  MPH

Salem,  OR  97305
 Coordinator for Fluoridation

& Preventive  Health Activities

American  DentaJ Association

Monina Klevens,  DDS,  MPH
 211 East Chicago  Avenue

Epidemiology  Intelligence
 Chicago,  IL  60611

Services  Officer

Office  of Smoking  and Health

Centers for Disease  Control
 Can&ce  Schlife,  RDH,  MPH

Mail Stop K50
 Director

1600 Clifton  Road NE
 Indian Health Service  Dental

Atlanta,  GA  30333
 Disease  Prevention  Program

Public  Health Service

300 San Matea Boulevard  NE,

Christopher  A. McGrew,  MD
 Suite 600

Assistant  Professor,  Orthopedics
 Albuquerque,  NM  87108

and Family  Practice

Department of Orthopedics

University  of New  Mexico
 Herbert H. Severson,  PhD

Medical  Center
 Research Scientist

2211  Lomas NE
 Oregon Research Institute

Albuquerque,  NM  87131
 1899 Willamette  Street

Eugene,  OR  97401

D-2