A New Tobacco Threat?
At the time, Skoal and other smokeless tobacco (ST) products, including chewing tobacco and snuff, were near their peak popularity among teens and young adults, including use by approximately one in five high school seniors.
Two decades later, things are remarkably different. By 2003, ST use among 12th-grade boys had dropped to less than 13 percent, and use among girls remained very low. While the reasons for the decrease are unclear, researchers suggest that increases in excise taxes and extensive antitobacco efforts, though primarily aimed at cigarettes, likely played a role.
Some recent developments, however, have tobacco control researchers and advocates worried that these important gains could be erased. In addition to periodontal problems and cardiovascular disease, ST has been most closely associated with increased risks of oral and pancreatic cancer, so any increase in its use is concerning. That concern is compounded by the results of a new study demonstrating that ST use is strongly associated with smoking initiation.
Although a spit-free ST product called snus has been popular in some Scandinavian countries for several decades, similar products have only recently been introduced in the United States.
Because users don't need to spit, these small, tea bag-like pouches are easier to use and far more discreet than traditional "moist snuff" like Copenhagen or loose-leaf products like Red Man. They typically come in small, decorative tins, and several brands are available in flavors like mint and cinnamon.
U.S. Smokeless Tobacco (UST), Inc., which manufacturers Skoal, launched its first spit-free ST product, Revel, in 2004. Instead of "Just a pinch," marketing materials for Revel proclaim "No smoke, no spit, no boundaries." UST began test marketing its first Skoal-branded spit-free product, Skoal Dry, last year in Louisville, KY, and Austin, TX.
The ease of use and gum-like flavors are reminiscent of earlier history, says Dr. Mark Parascandola, from NCI's Tobacco Control Research Branch.
ST use began to surge among teens and young adults in the 1970s, he explains, when tobacco companies introduced "products with lower nicotine content and attractive flavorings, which made them more accessible to new users." Users would eventually graduate to products with higher nicotine content.
"With these new products," he continues, "there is reason to be concerned we could see a similar phenomenon."
That very scenario is happening in Norway, where, over the past decade, daily use of snus has tripled among teens and young adults. According to Dr. Karl E. Lund, research director at the Norwegian Institute for Alcohol and Drug Research, the company that controls 95 percent of the European snus market, Swedish Match, makes what he calls "starter kits."
"This is snus sold in glamorous metal boxes…where the snus is seasoned with different kinds of fruit flavors," he explains. "[They are] easy to use for snus novices."
Last October, Swedish Match North America announced a partnership with one of the largest U.S. cigarette companies, Lorillard Tobacco Company, to develop new smokeless products for the U.S. market.
Lorillard, however, is playing catch-up to Philip Morris and R.J. Reynolds (RJR), the two biggest U.S. cigarette manufacturers, both of which launched spit-free products last year.
RJR's product, Camel Snus, is being test marketed in Austin and Portland, OR, but can also be ordered by phone or via the Internet. Philip Morris' product, Taboka, is being test marketed in Indianapolis.
"That's a very big concern for the public health community," says Dr. Herbert H. Severson, a tobacco control researcher at the Oregon Research Institute in Eugene. "Most of us [in tobacco control] believe the companies can be successful in increasing the market for oral tobacco."
Count Dr. Michael Siegel, a tobacco control researcher at Boston University, among the believers. In order to be successful, he argues, "they have to have young people use it."
Both Philip Morris and RJR explicitly state in marketing materials and media reports that these new products are for adult smokers searching for a smoking alternative, particularly in smoke-free workplaces or restaurants.
In the case of Taboka, says Dr. Scott Tomar, an ST researcher from the University of Florida, its low nicotine content and Philip Morris' marketing approach suggest it is being positioned, at least for now, as a "situational substitute" for smokers.
Camel Snus, on the other hand, seems to be targeted toward younger users, Dr. Tomar adds. It's being promoted in bars and music magazines geared toward younger audiences, and the marketing materials suggest using it at rock concerts and clubs.
With these new products, the potential for a surge in use among teens and young adults, Dr. Tomar says, is considerable.
"The history of [ST] products in the U.S. and in Sweden and Norway is that it's almost entirely adolescent and young adult males who initiate use," he says.
A big question is what happens after that, because several studies have suggested that ST use among teens can be a smoking gateway.
A 2003 study led by Dr. Tomar, for instance, found that teens using ST at study entry were three times more likely to be smokers 4 years later than those who had not used ST. But a research team from Penn State disputed the findings, arguing that the study failed to account for other smoking initiation risk factors, such as whether parents or close friends smoke or engage in deviant behavior.
However, a new study of nearly 2,300 seventh- and ninth-graders led by Dr. Severson scheduled to be published later this month - which controlled for known smoking initiation risk factors - found that ST use at baseline was independently associated with a more than 2.5-fold increased risk of smoking 2 years later.
That's why any tobacco use needs to be discouraged with young people, Dr. Severson says.
Among teens and parents, he adds, "we have evidence that indicates they believe smokeless tobacco is a safer alternative. What I'm trying to tell people is whether it's safer or not, it can lead to nicotine dependence."
By Carmen Phillips