Smokeless Tobacco Products

Why it Matters

  • While less lethal than smoking tobacco, smokeless tobacco (SLT) contains nicotine, which is addictive. Its use still poses health risks.1
  • SLT causes cancers of the oral cavity, esophagus, and pancreas.2
  • Although cigarette use declined significantly, the prevalence of SLT use showed no statistical change from 2005 (2.7%) to 2010 (3.0%).3
  • There is no proof that any SLT products help people who smoke to quit smoking.4
  • People who use SLT exclusively have higher observed levels of exposure to nicotine and carcinogenic tobacco-specific nitrosamines, as measured by cotinine and NNAL biomarker concentrations, than people who smoke exclusively cigarettes.5
  • Nicotine and carbon monoxide in smokeless tobacco products may be responsible for severe adverse pregnancy outcomes, such as preterm birth.6
  • The nicotine absorbed per dip is equivalent to 3-4 cigarettes.7
  • According to the American Academy of Family Physicians (AAFP), groups more likely to use SLT include men, athletes, and people who live in rural areas.
  • In 2016 3.4% of adults aged 18 years and older used smokeless tobacco.8
  • Among high school students, use of smokeless tobacco in 2019 was 3.8%.9
  • By industry, the prevalence of SLT use in 2010 was highest among people working in mining industries (18.8%). By occupation it was highest for people working in construction and extraction (10.8%).10
  • From 2011 to 2019, current use of smokeless tobacco went down among middle and high school students:11
    • Nearly two of every 100 middle school students (1.8%) reported in 2019 that they had used smokeless tobacco in the past 30 days—a decrease from 2.2% in 2011.
    • Nearly five of every 100 high school students (4.8%) reported in 2019 that they had used smokeless tobacco in the past 30 days—a decrease from 7.9% in 2011.

What We Know About What Works

  • The Fagerström Test for Nicotine Dependence (FTND) has demonstrated good reliability as a measure of dependence among people who use SLT.12
  • Randomized control trials on behavioral interventions alone for SLT indicate a statistically and clinically significant benefit.13
  • Regular telephone support/quitlines also demonstrate a positive benefit.14
  • Among 12 studies in the U.S. assessing nicotine replacement therapy (NRT), neither nicotine gum nor patch increased abstinence; however, five studies of NRT lozenges showed significant abstinence.15
  • Studies indicate an SLT abstinence impact with varenicline but not with bupropion.16
  • A Cochrane Review of only U.S. studies found similar results.17
  • In a study assessing effective anti-SLT messaging among young males in rural areas, researchers found that “dipping” is perceived as safe. Members of the target audience are receptive to straightforward facts delivered by authentic messengers about the potential harmful consequences of SLT use, specifically those that leverage the progression of short-term consequences (e.g. white patches) to long-term health effects.18

What’s Relevant in Pennsylvania

  • Act 84 of 2016 imposed tax on other tobacco products in Pennsylvania, including smokeless tobacco. The rate for smokeless tobacco is 55 cents per ounce, with a minimum tax per package of 66 cents.
  • In 2017, four percent of adults in Pennsylvania used smokeless tobacco.19

What Other States Are Doing

  • Spit Tobacco Intervention is designed to promote cessation and reduce initiation of spit tobacco use among male high school athletes in California. In two test sites results varied with one demonstrating no impact on initiation but a positive impact on cessation and the other site showing opposite results.
  • Spit It Out–West Virginia was a campaign to increase access to smokeless tobacco prevention and cessation services. Although the program ended in 2017, resources are available that describes the program and its impact.

References and Resources

  1. American Cancer Society: Health Risks of Smokeless Tobacco.
  2. Mazurek J., Syamlal G., King B., Castellan R. Smokeless Tobacco Use Among Working Adults – United States 2005 and 2010. Morbidity and Mortality Weekly Report. June 6, 2014.
  3. Ibid
  4. American Cancer Society: Health Risks of Smokeless Tobacco.
  5. Rostron B., Chang C., van Bemmel D., Xia Y., Blount B. Nicotine and Toxicant Exposure among U.S. Smokeless Tobacco Users: Results from 1999 to 2012 National Health and Nutrition Examination Survey Data. Cancer Epidemiology, Biomarkers & Prevention. November 2015.
  6. U.S. Department of Health and Human Services.The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control
    and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
  7. Jewel T. How Much Nicotine is in a Cigarette and Other Tobacco Products? Healthline, November 2019.
  8. Center for Behavioral Health Statistics and Quality. 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, 2017, Rockville, MD
  9. Creamer M., Everett Jones S., Gentzke A., Jamal A., King B. Tobacco Product Use Among Hight School Students – Youth Risk Behavior Survey, United States 2019. MMWR Suppl 2020;69(Suppl-1):56-61. DOI:
  10. Mazurek J., Syamlal G., King B., Castellan R. Smokeless Tobacco Use Among Working Adults – United States 2005 and 2010. Morbidity and Mortality Weekly Report. June 6, 2014.
  11. Wang TW, Gentzke AS, Creamer MR et al. Tobacco Product Use and Associated Factors Among Middle and High School Students—United States, 2019. Morbidity and Mortality Weekly Report, 2019;68(12)
  12. Mushtaq N., Beebe L. Psychometric Properties of Fagerström Test for Nicotine Dependence for Smokeless Tobacco Users. Nicotine & Tobacco Research, Volume 19, Issue 9, September 2017.
  13. Nethan S., Sinha D., Chandan K., Mehrotra R. Smokeless Tobacco Cessation Interventions: A Systematic Review. Indian J Med Res 148, October 2018. DOI:10.4103/ijmr.IJMR_1983_17.
  14. Ibid.
  15. Ibid.
  16. Ibid.
  17. Ebbert JO, Elrashidi MY, Stead LF. Interventions for smokeless tobacco use cessation (Review). Cochrane Database of Systematic Reviews 2015, Issuee 10.Art.No.:CD004306. DOI:10.1002/14651858.CD0043006.pub5.
  18. Walker MW, Evans SA, Wimpy C, Berger AT, Smith AA. Developing Smokeless Tobacco Prevention Messaging for At-Risk Youth: Early Lessons from “The Real Cost” Smokeless Campaign. Health Equity. 2018;2(1):167-173. Published 2018 Aug 1. doi:10.1089/heq.2018.0029
  19. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, State Tobacco Activities Tracking and Evaluation
    System, 2017.

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