U.S. Public Health Service and Deputy Assistant Secretary for Health
U.S. Department of Health and Human Services
Presented at the Panel on Smokeless Tobacco at the Annual Meeting of the
American Public Health Association
Las Vegas, Nevada
September 29, 1986
In spite of the tremendous effort that the United States government has made since 1964 against smoking (in spite of its apparently
schizophrenic attitude toward price supports for tobacco, efforts to promote American brands of cigarettes abroad, "smokeless
tobacco" or "spit tobacco" has never in the history of tobacco received any attention from the Public Health Service
or from the government in reference to health issues.
When I realized this was the situation, I tried to encourage the Public Health Service to do an annual report on smokeless
tobacco just the way they did on cigarettes, but was told there were no such funds. The nice thing about Washington is that
there are also some funds held on contingency basis and I appealed to the Director of the Preventive section of the National
Cancer Institute Dr. Peter Greenwald, who empowered and funded Dr. Joe Cullen to work with me on a Surgeon General's Report
on Smokeless Tobacco. That was the first and last of its kind.
Dr. Bill Foege, former Director of the Centers for Disease Control, was the Chairman of the Program Committee of the American
Public Health Association in 1986 and invited me to join a panel at their annual meeting in Las Vegas. I wanted to make it
clear that the health effects of smokeless tobacco were serious, measurable, and preventable. Sadly, the production and use
of smokeless tobacco products has been climbing right at the time the trend line for cigarette smoking was steadily downward.
Statistics indicate that in 1985 an estimated 12 million people, age 12 and over - males for the most part - used some form
of smokeless tobacco and about half of that number or 6 million used smokeless tobacco on a daily basis. In part of the south
and the southwest, chewing tobacco was a right of passage into adolescence along with a shotgun and a half-ton truck. Sadly
enough most youngsters are introduced to smokeless tobacco by an older brother, a father, an uncle, or a grandfather.
Smokeless tobacco is essentially the same leaf that is used in cigarettes, cigars, or pipe tobacco, but instead of being burned
it is chewed, squeezed, or sniffed. It is chewing tobacco that is sold either as a pouch full of loose shredded leaf or as
a compressed plug of tobacco, both forms are moved about the oral cavity and chewed. Snuff is finely ground tobacco that is
either sold dry or moist. The dry, granular form is either sniffed - a rare habit in this country - or is brushed into one's
gums, or "painted" on. It is a common practice among some southern rural women, but rarely seen elsewhere. It started
in the cotton factories where cotton dust would "explode" in the presence of an open flame, such as a match. Therefore,
factory workers were forbidden to smoke or strike a match and to get their "fix" they splintered the ends of twigs,
spit on them, dipped them in powered snuff and painted their gums. This accounts for a 50-fold increase in cancer of the gums
among such women as compared to those who do not use painted snuff. The moistened form of snuff is the most widely promoted
and advertised. A pinch of it is taken from the tin and pressed back into the mouth between the cheek and the lower gum. Continual
moderate squeezing releases the nicotine, which passes through the buccal membranes, into the bloodstream and right to the
heart and brain.
For those not adept at handling a cud, smokeless comes wrapped like tea in a bag appropriately called "bandits" -
for indeed they do rob the user of control of his own behavior and later of his health and life.
The committee pulled together by Joe Cullen mentioned above, reported back to me on the "consequences" of using smokeless
tobacco. Their conclusion was that "the oral use of smokeless tobacco represents a significant health risk. It is not
a safe substitute for smoking cigarettes. It can cause cancer and a number of non-cancerous oral conditions and can lead to
nicotine addiction and dependence."
They refined their comments by stating that there is a strong association between the use of smokeless tobacco and cancer
of the oral cavity, the cheek, and the pharynx, claiming that such cases accounted for about 3 out of every 100 cancer related
I went into the contents of smokeless tobacco and what we thought the cancer causing culprits were and what kinds of cancer
Smokeless tobacco is also responsible for oral leukoplakias in both teenage and adult users. Leukoplakia is a pre-cancerous
lesion. There are also adverse effects on gingival and periodontal tissue and teeth including the development of plaque or
permanent staining. There is some evidence that smokeless tobacco may contribute in some way to development of coronary artery
and peripheral vascular disease, hypertension, peptic ulcers, and fetal morbidity and mortality. Nicotine found in tobacco,
whether smoked or chewed, is an addictive drug, like morphine or cocaine.
I called attention to the fact Congress enacted and the President signed PL 99-252, "The Comprehensive Smokeless Tobacco
Health Education Act of 1986." Developed by the Senate Committee on Labor and Human Resources it received strong bipartisan
support from Committee Chairman Orrin G. Hatch and Ranking Minority Member Edward M. Kennedy.
Since the passage of the Bill, the center of interest has shifted to the Federal Trade Commission, which is charged with producing
guidelines for compliance. So far, at the time of this lecture, the FTC's proposal published in the Federal Register leave
much to be desired. There is a question in my mind - and those of the supporting Senators and Representatives as to the degree
of care with which the FTC staff is following the letter, the spirit, and the legislative history of this particular law.
In summary, all reports point conclusively in only one direction and that is the use of smokeless tobacco presents a serious
health risk to the American population and it is a matter, which requires the vigilance of all public health workers and the
concern of the public at large.