Smokeless tobacco is a broad term covering many types of tobacco not intended to be smoked, providing users with a hit of nicotine without the large numbers of chemicals found in combusted tobacco smoke. This term includes chewing tobacco (“dip”), dry snuff, and other new products such as “orbs,” dissolvable strips and sticks. Snus is also technically a form of smokeless tobacco, but is covered in detail on a separate page.
Finding out more about the types of smokeless tobacco, the history of smokeless tobacco and the research into the health effects serves as an introduction to this form of tobacco harm reduction.
History of Smokeless Tobacco
Like the history of most tobacco use, smokeless tobacco use can ultimately be traced back to the Native Americans. Tobacco is a native plant of both North and South America, and was used by the Mayans, Incans and Native American tribes for a variety of medicinal and ceremonial purposes. However, there is very limited evidence available on the specifics, and in many cases images appearing to depict tobacco use can’t be reliably interpreted. What is known is that from the arrival of the first Europeans in 1492, the traditional methods of tobacco use – chewing, smoking and sniffing – were emulated, and tobacco plants were brought back to Europe. It soon became popular across the continent, as with those who settled in the Americas. In the colonial period, tobacco was a key commodity and was central to the economy, even being used as currency in Maryland and Virginia.
The most widespread form of smokeless tobacco is simply chewing tobacco, which was popular in the 19th century and continued into the 20th century until advanced in technology made cigarettes a viable alternative. In the 1800s chewing tobacco was known as the “American habit,” and became closely associated with the rise of baseball. At the time, baseball players were using chewing tobacco just like everybody else was, but when cigarettes became more popular the baseball players weren’t too sure if smoking would affect their playing, so continued to chew. However, some high profile players died from oral and throat cancers, including Babe Ruth, as science was beginning to investigate the potential risks of chewing tobacco.
Although smokeless tobacco fell from favor, there was a resurgence in its use in the 1970s when people begun to understand how dangerous combusted tobacco is. Its use remains popular, with research from 2012 showing that 3.5 percent of people aged 12 and over in the US had used smokeless tobacco in the last month.
Types of Smokeless Tobacco
Chewing Tobacco (“Dip”) – The simplest form of smokeless tobacco is chewing tobacco, in which a wad of loose tobacco is held in the mouth (between the teeth or gums and the cheek) and occasionally chewed, and the nicotine is absorbed into the mouth tissue. After brown-colored saliva builds up, the accumulated liquid is spat out.
Snuff – Snuff is a dry, powdered form of smokeless tobacco, which is usually sniffed up into the nose, but in the form of moist snus is used more like chewing tobacco (except without spitting) and is contained within a pouch.
Dissolvable Tobacco – Orbs, strips and sticks are other forms of smokeless tobacco, and are all fairly recent ideas revolving around finely ground tobacco that dissolves in the mouth of the user and provides nicotine in the process. The differences in name merely represent the different shapes the mixture is available in. There are pharmaceutical equivalents of orbs (nicotine lozenges), but most of these products are produced by tobacco companies.
Potential Health Effects of Smokeless Tobacco
There are many concerns about health risks potentially associated with the use of smokeless tobacco. Much of this concern is related to the presence of tobacco-specific nitrosamines in products such as chewing tobacco, and it’s frequently suggested that there is an increased risk of oral and throat cancers. Other concerns include dental problems, cardiovascular disease and the potential effects when used during pregnancy.
Research into Smokeless Tobacco Health Risks
Oral cancers – The main focus of the research into the safety of smokeless tobacco has been the potential increase in cancer risk, especially oral cancer. There have been many pieces of research conducted on the topic, and covering a wide range of different cancers. In 2009, Peter Lee and Jan Hamling published a review of all of this available evidence into the association between smokeless tobacco use and cancers, accounting for the known risk factors of smoking and drinking alcohol. For oral cancer, the available studies which adjusted for smoking showed an increase in oral cancer risk of 36 percent compared to non-tobacco users. When alcohol consumption was also considered, the increase in risk shrunk to the point of non-significance, and this same result was also obtained when researchers focused on studies on modern products (studies from 1990 onwards). In other words, smokeless tobacco doesn’t notably increase risk compared to non-tobacco users. At most, the increase in oral or facial cancer risk from is very minor. A recent piece of research from New England found a four-fold increase in risk of head and neck squamous cell carcinoma from 10 years or more of smokeless tobacco use (compared to non-tobacco-users), but this finding runs contrary to much of the epidemiological conclusions thus far, and would require further confirmation.
Other cancers – The 2009 systematic review also reported risks for numerous other types of cancer, including esophageal, stomach, nasal, prostate, lung, kidney and all cancers combined, and found no significant increase in risk for anything other than prostate cancer. However, this part of the data comes from just four studies, and is unusual because prostate cancer isn’t usually associated with smoking. Other research focusing on users of dry snuff has found increases in risk (compared to non-tobacco users) of between 4 and 13 times, but there are also concerns about the quality of the evidence on this issue. Orbs, lozenges, strips and sticks are assumed to have the same low risk profile in terms of cancer as snus and other forms of smokeless tobacco. However, variation between different products (dependent on contamination, manufacturing processes and other factors) means that some may carry a greater risk than others. Older US-made smokeless tobaccos appeared to have a greater increase in risk than those from Sweden, for example, but now the risks in either case are very small.
Cardiovascular disease – There have also been numerous pieces of research investigating the potential risk of cardiovascular disease in smokeless tobacco users. An increase in heart rate is a consequence of all nicotine consumption, but this appears to be related to the concentrations of nicotine in the blood. Because smokeless tobacco delivers less nicotine over a longer period than combusted tobacco, the corresponding increase in heart rate is smaller, and the impact on cardiovascular health also appears to decrease accordingly. Research looking at smokeless tobacco users over a course of 20 years found no significant increase in cardiovascular mortality of any kind compared to non-users, after adjusting for confounding variable such as smoking status. Smoking is related to cardiovascular deaths, but smokeless tobacco use is not.
During pregnancy – The risk associated with smoking and pregnancy is also related to nicotine, so it’s generally advised to avoid all forms of nicotine consumption during pregnancy. There has been limited research into the effects of smokeless tobacco on developing fetuses, so the risks are currently unclear. Some research from India found increases in the chance of stillbirth and lower birth weights when pregnant women used smokeless tobacco products, but the lower quality of Indian smokeless tobacco may be responsible. Some research on pregnant snus users in Sweden has found evidence of lower birth weights, but this finding needs to be corroborated, and the picture painted by research to date is generally unclear. For example, a piece of research focusing on snuff use during pregnancy didn’t find a significant decrease in birth weight.
Dental and oral health – The potential effect of smokeless tobacco on dental health has also been investigated. Leukoplakia is one concern, which is white patches on the gums on the inside of the cheeks, and there is a definite relationship with smokeless tobacco use, even been observed to relate to the position the tobacco is held. The condition disappears after smokeless tobacco use is stopped, and although there are related cancer concerns, the overall evidence on the issue indicates that this isn’t a significant risk for smokeless tobacco users. Gingivitis and periodontitis are concerns with chewing tobacco use, but there is no association with gum recession (in the absence of pre-existing gingivitis). Research has shown an association between the decay of root surfaces of the teeth and chewing tobacco use, more so than in non-tobacco users and even smokers, which may be a consequence of the sugars added or the impact on enzymes in the mouth. Nasal snuff users, as may be expected, didn’t show this effect.
Although smokeless tobacco is legal in the vast majority of places around the world, snus has been banned in the EU, although Sweden is exempt from this rule.