Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

SPIT TOBACCO AND YOUTH 

I

OEI 06-92-00500 
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. 

percent use during preced~ 30 days 

Grades 9 to 12 

Males Females 

m White Total Wite Total 

1990 23.9% 19.1% 1.5% 1.4% 

1991 23.6% 19.2% 1.4% 1.3% 

Source: YRBS, 1990 (N = 11,631) 

& 1991 (N = 12,272) 

Table 1 

In some States, current use by high school 

males is much higher than the composite 

YRBS rate. Overall male usage rates in 

grades 9 to 12 are as high as 34 percent in 

Tennessee and 33 percent in Montana (3). 

Other States with high overall prevalence 

among high school males are Colorado 

A 1990 and 1991 school-based survey in 22 

select States (Youth Risk Behavior Survey -

YRBS) shows that nearly 20 percent of 

males in grades 9 to 12 were current users 

of spit tobacco (1-3).a Among white males, 

an even higher 1 in 4 currently use spit 

tobacco (see Table 1). Use among white 

male 12th graders in 1990 was 26 percent. 

Rates for Hispanic and Black teens are 

notably lower, as are female use rates. 

Current UseBy Grade 

Grade Alabama Tennessee 

9th 36.6% 35.2% 

Ml 26.7% 37.1% 

1Ith 26.9% 30.7% 

12th 31,1% 33.7% 

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 

that of men age 50 and over. z‘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&cticut’s 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 State’s 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 

Maine’s 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 

Table 3 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 

County’s male 7th graders and 83.3 percent of 8th graders currently used spit tobacco. 

Over 50 percent of McKenzie County’s male 9th, loth, and 1lth graders and Adams 

County’s 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 

Virginia’s 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 Illinois’s 5th graders (11), 3 percent of Oklahoma’s (20) 

and Missouri’s 6th graders (12), and one percent of Maine’s (8) and Connecticut’s 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. cancercausing 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). Pinkerton’s Red 

Man moist snuff has the highest nitrosamine level of any snuff sold in the United States, 

followed by U.S. Tobacco Company’s (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 user’s 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). UST’s 

Copenhagen and Pinkerton’s 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 
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lTPI’ 

�	 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 

I are attributed to use of smoked and spit 

~!nn~~at mlm ram-war ad Aiqj. He had tobacco (40). Those who use spit tobacco ~=- @-... .W..ML -.u _“ 

used about 40 years. ..wJ ~ut pati of his are at risk for gum and cheek lesions that ~ 

mouth out, but it got inlto his throat. ” in particular can lead to cancer (40). 

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	 Dm”ly,sustained use is often the p~ern for young people; many admit to nicoti”ne 

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 onefourth 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 “I’ve quit 4 or 5 times, but only for a 

tobacco found 37 percent of young users week. Then 1 think, using hasn’t 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 
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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 haven’t tried to quit. 

But when we tell them the health consequences, and then they try to quit, they can’t. ” 

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 people’s 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 don’t use a Iot of candy. w time when the 1992 users started their spit 

A user’s 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


shaping youthful behavior (26). That is, many 

“Famous athletes use dip. One


baseball players use spit tobacco, and young people of the things that goes along with


are aware they do. Researchers studied 1109 p~y~g ball is taking a dip. ”


8 
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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 tapeshaped 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 
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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, UST’s profits increased steadily. Further, in 1990 pinkerton 

introduced Red Man moist snuff to compete against UST (26). 

w Spit tobacco companies ach”velymarket products in selective venues. 

Most of the industry’s 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 industry’s 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. He’s 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. 

�	 Amen”canpublic 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 don’t read or don’t heed the warning labels on 

11 
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spit tobacco containers, the labels are too small or the wording isn’t 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 Commission’s (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 distn”butingfree 

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 people’s 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 

“My wrestling coach wrestles with 

Copenhagen in his mouth.” 

“If you’re not spitting on the floor, 

teachers usuaily don’t bother you. ” 

that on one occasion, he was sent to the 

enforce the rules. In the 1992 study, while users 

said their school rules did not permit spit tobacco 

use on the school property (83%) or at schoolsponsored events (67 %), 26 percent also said 

enforcement of the school rules ranged from 

“sometimes” to “never”. Of the 1992 users, 76 

percent have seen a coach or teacher at their 

school use spit tobacco. A young user related, 

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 student’s 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 cum”culufor 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


safer to use than cigarettes. Youthful users


continue to believe this according to 91


percent of key informants. Among our 1992


users, 63 percent saw spit tobacco as safer


to use than cigarettes and 15 percent didn’t


know. The 1986 OIG study found many


youth were unaware of the potential health


risks of spit tobacco use, including


addiction. In 1992 over half of key


interviewed saw spit tobacco as much 

“Cigarettes can ruin your kings. Can’t 

get new lufigs. Spit tobaccm doesn’t 

affect your stamina. ” 

“Dad has been using for 26 years, and 

it hasn’t done anything to him.” 

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 
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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 don’t really believe that spit tobacco endangers their health “It can’t 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 tobacco’s 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 educti”onal 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 Commissioner’s 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 people’s 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 iVah”onalTobacco Control Policy And Coordinate APlan For Detem”ng 

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% I 27% 

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. 

j. A public health advocacy group comprised of medical professionals. 

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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24 

——+. ___ 
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31 
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35 
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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 hasn’t 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 he’s hooked and says he can’t play ball without it due to cravings. 

Carlos has tried to quit three times with no success. He thinks spit tobacco 

probably isn’t good for him, but he and his parents think it’s 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 didn’t 

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) 

20-24% 25–32% 33% or more 

#~j � . 19% or less El%! (over 1 in 5 males) (over 1 in 4 males) (over 1 in 3 males) 

� Weicjled data ** Qrveys did not ‘Wlude students from the largest city. + Prececkg 30 days 

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, 

Rural community, NW Arkan.ws Mean age = 15.9 

31.8% 2.3% 

rural population 

[9a	 University of Kenmcky 7-12th grades 

1 Metro. & 1 non-Metro. county 

1,067 Phase 1: Saliva sample collected Use in Past 

(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 

w Public Schools 

17% 5-6th 3% 5-6th 

29% 7-9th 1% 7-9th 

39% 10- 12th 1% lo-12th 

Br ownaon, et al, (1990) 5,8, 12th grades 

78 hfkoUri Schools 

5,431 Representative sample, mra] Use in Previous 7 Days 

counties were oversampld Urban: ~ 

5rll— 1% 

8th 

5% 

13% 17% 

12tb 15% 31% 

$1 Jone s &Pyper(1986) 7-12th grades 2,181 Stratified random sample 

Dan e County, Wisconsin 

Male Only: 

> Ilwk; Daily Use: 

7th 9% 3% 

8rir 12% 6% 

9rb 12% 3% 

Ioth 16% 8% 

llth 14% 11% 

12dl 22% 15% 

Kegel es, et. al. (1989) 7-12th grades 7,457 

59 co nnecticut towns& 106 schools 

Daily Use: Daily Use: 

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 

12 

02 

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 SMSA’S, 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 

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% 

Weighted data 

2.0% 

South Carolina Weighted data 

You&i Rlak Behavior Survey (1991) 9-12th grades School based survey (YRBS) 29% 

South Dakots 

10.0% 

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 

3 

Bib 

3 

3 

3 

68 

Investigators/hcation 

Youth Risk Behavior Survey (1991) 

Pemsylvania 

Youth Risk Behavior Survey (1991) 

W]aconsin 

Youth Risk Behavior Survey (1991) 

Wyoming 

Youth Risk Behavior Suxvey (1991-92) 

Age/Grade 

9-12th grades 

9-12th grades 

9-12th grades 

9-12th grades 

Sample N Miacellaneoua Study Information 

School based survey (YRBS) 

Unweighed data excludes students 

from the largeat city. 

School based survey (YRBS) 

Unweighed data 

School based survey (YRBS) 

Unweighed data 

School based survey (YRBS) 

Current Use 

(Last 30days) of 

Spit Tobacco 

1 Used Regularly 

Males Females 

29% 2.0% 

19% 3.0% 

I 

31% 5.0% I


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 

---------- -------

----

----

----

----

Natinnal Stmlies -----— - Snit -r. - Tnhmvn

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


Executive Director


Stop Teenage Addiction


to Tobacco


121 Lyman Street, Suite 210


Springfield, MA 01103


Alan Blum, MD


Associate Professor


Department of Family Medicine


Baylor CoUege of Medicine


5510 Greenbriar


Houston, TX 77oO5


Moon Chen, Jr., PhD


Professor, Department of


Preventive Medicine


Ohio State College of Medicine


B110 Starling Loving HsJI


320 West Tenth


Columbus, OH 43210


Arden G. Christen, DDS, MSD


Chairman


Department of Preventive


& Community Dentistry


School of Dentistry


Indiana University


1121 West Michigan Street


[ndiampolis, IN 46202


Gregoxy Connolly, DMD, MPH


Director of Dental HeaJth


Massachusetts Department


of Public Health


150 Tremont Street


Boston, MA 02111


Stephen B. Corbin, DDS, MPH


National Institute for


Dental Research


National Institutes of Health


Building 31


Bethesda, MD 20892


Linda Crossett, RDH, BS


Dental Health Program Specialist


Division of Oral Health


Centers for Disease Control


1600 Clifton Road NE


Mailstop F-1 O


Atlanta, GA 30333


Donald R. Dexter, Jr., DDS


Executive Director of IUamath


Tribal Health


3949 south sixth


IUamath Falls, OR 97603


Joseph DiFranza, MD 

Associate Professor of Family 

& Community Medicine 

University of Massachusetts 

Medical Center


47 Ashui State Road


Fitchburg, MA 01420


Thomas M. DiLorenzo, PhD


Chairman


Department of Psychology


University of Missouri


210 McAlester HalJ


Columbia, MO 65211


Richard 1. Evans, PhD


and Associates


Department of Psychology


University of Houston


Houston, TX 77204-5341


Elbert D. Glover, PhD


Director


Tobacco Research Center


MBR Cancer Center


West Virginia University


Health Science Center


1 Medical Drive


Morgantown, WV 26506


Thomas Glynn, PhD 

Chief, Cancer Prevention 

& Control 

Extramural Research Branch 

National Cancer Institute 

Executive Plaza North, Rm 330 

9000 RockviUe Pike 

Bethesda, MD 20892 

Jerome Goldstein, MD 

Executive Vice President 

American Academy of 

Otolaryngology - Head and 

Neck Surgery 

One Prince Street 

Alexandria, VA 22314 

John Greene, DMD, MPH 

Dean of Dental School 

University of California 

at San Francisco 

513 Parnassus Avenue 

San Francisco, CA 94143-0430 

Robert Greer, DDS, SCD 

Chairman of Oral Pathology 

and Oncology 

University of Colorado 

Dental School


BOX C 285


4200 East Ninth Avenue


Denver, CO 80262


Richard Hastreiter, DDS, MPH


Director, Dental Health Program


Minnesota Department of HealtJI


717 Delaware Stxeet, SE


Minneapolis, MN 55440-9441


Dorothy Hatsukami, PhD


Associate Professor of Psychiatry


Universi~ of Minnesota


Box 392 Mayo


Minneapolis, MN 55455


D-1 
Jack E. Henningfield, PhD


Chief


CJinical Pharmacology Research


Addiction Research Center


National Institute of Drug Abuse


P. O. BOX 5180


Baltimore, MD 21224


Dietrich Hoffman, PhD 

Associate Professor of 

American Health Foundation 

Valhalla, NY 10595 

Thomas Houston, MD


Director, Preventive Medicine


& Public Health Department


American Medical Association


515 North State Street


Chicago, IL 60610


Rhys Jones, DDS, MS


Director of Dental Health Center


St. Luke’s Hospital


855 “A” Avenue NE


Cedar Rapids, IA 52402


Mary Beth Kinney, RDH, MPH


Dental Education Specialist


Indian Health Service


3750 Chemawa Road NE


Salem, OR 97305


Monina Klevens, DDS, MPH


Epidemiology Intelligence


Services Officer


Office of Smoking and Health


Centers for Disease Control


Mail Stop K50


1600 Clifton Road NE


Atlanta, GA 30333


Christopher A. McGrew, MD


Assistant Professor, Orthopedics


and Family Practice


Department of Orthopedics


University of New Mexico


Medical Center


2211 Lomas NE


Albuquerque, NM 87131


Robert Mecklenburg, DDS, MPH


Consultant


National Cancer [nstitmte


12304 Rivers-Edge Drive


Potomac, MD 20854


Sherry Mills, MD, MPH


Chief of the Investigator


Initiated Research Section


National Cancer Institute


9000 Rockville Pike


Executive Plaza North, Rm 320


Bethesda, MD 20892


Michael L. Morgan, DDS, MPH


Chief, Dental Health Services


Oklahoma State Department


of Health


1000 NE Tenth Street


Oklahoma City, OK 73117-1299


Carole Tracy Orleans, PhD


Director


Tobacco Control Research


Fox Chase Cancer Center


510 Township Line Road


Cheltenham, PA 19012


Barbara Park, RDH, MPH


Coordinator for Fluoridation


& Preventive Health Activities


American DentaJ Association


211 East Chicago Avenue


Chicago, IL 60611


Can&ce Schlife, RDH, MPH


Director


Indian Health Service Dental


Disease Prevention Program


Public Health Service


300 San Matea Boulevard NE,


Suite 600


Albuquerque, NM 87108


Herbert H. Severson, PhD


Research Scientist


Oregon Research Institute


1899 Willamette Street


Eugene, OR 97401


Nancy Johnson WiUiams, Ed.D


Associate Professor and Clinical


Coordinator


Department of Dental Hygiene


University of Tennessee


822 Beale Street, Room 321 E


Memphis, TN 38163


Deborah M. Winn, PhD


Chief


Analytical Studies & Decision


Systems Branch 

Epidemiology & Oral Disease 

Prevention Program 

National Institute 

of Dental Research 

5333 Westbard Avenue, Rm 537 

Bethesda, MD 20892 

D-2