Philip Morris
Report of the Surgeon General's Advisory Committee on the Health Consequences of Using Smokeless Tobacco
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- Bailar, J.
- Bauman, K.
- Begun, J.
- Bell, C.S.
- Benowitz, N.
- Biglan, A.
- Blot, W.
- Bond, E.C.
- Boyd, G.
- Breslow, L.
- Burns, D.M.
- Carlos, J.P.
- Christen, A.G.
- Clark, B.
- Clark, S.
- Cline, R.
- Connolly, G.
- Corbin, S.B.
- Cowan, N.
- Darby, C.
- Davis, D.L.
- Davis, M.
- Devita, V.T.
- Edmunds, K.
- Erickson, D.
- Ernster, V.L.
- Ertwine, R.
- Feinleib, M.
- Fisher, C.
- Fraumeni, J.F.
- Glynn, T.J.
- Grabowski, J.
- Greenwald, P.
- Greer, R.O.
- Gritz, E.R.
- Gust, S.
- Harris, C.
- Hayden, B.
- Hecht, S.S.
- Henningfield, J.
- Hoffmann, D.
- Hunter, D.
- Jacob, K.
- Jaffe, J.
- Johnson, M.
- Joseph, L.P.
- Kegeles, S.S.
- Kerringan, M.J.
- Kinnard, M.
- Kleinman, D.
- Knill, V.
- Kozlowski, L.
- Krasnegor, N.A.
- Levy, S.
- Lindewall, D.G.
- Margus, P.
- Massey, M.M.
- Mattson, M.
- Mccormickpickett, N.
- Mcginnis, M.
- Mcmillan, G.C.
- Mcpherson, L.
- Mecklenburg, R.
- Morsette, R.
- Mugge, E.
- Nelson, A.
- Nemethcoslett, R.
- Odont
- Pindborg, J.J.
- Pinney, J.M.
- Plog, S.
- Pollack, E.S.
- Pomerleau, O.
- Riseberg, R.J.
- Robertson, T.L.
- Rothman, K.
- Rouse, B.A.
- Rudner, N.
- Schroeder, K.L.
- Schwalb, E.
- Scottenfeld, D.
- Shapiro, B.
- Shea, J.
- Shopland, D.R.
- Sieber, S.
- Silber, D.
- Silverman, S.
- Slaughter, C.
- Steele, D.
- Stephen, K.W.
- Swansburg, D.S.
- Tannenbaum, S.R.
- Thomas, D.B.
- Wilson, R.W.
- Winn, D.M.
- Wynder, E.L.
- Yaffe, S.J.
- Zitans, M.
- Bauman, K.
- Document File
- 2501258000/2501258259a/19521 - 22080
- Named Organization
- Addiction Research Foundation
- Ahf, American Health Foundation
- Biol of Dependence + Abuse Potential
- Biostatistics Branch
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- Board of Health Promotion +Prevention
- Carcinogenesis Experts
- Cardiac Diseases Branch
- Center for Preventive Services
- Center for Research for Mothers + Childr
- Centers for Disease Control
- Dental Disease Prevention Activity
- Division of Cancer Etiology
- Division of Cancer Prevention + Control
- Division of Clinical Research
- Division of Epidemiology + Statistical A
- Division of Health Promotion + Disease P
- FDA, Food and Drug Administration
- Fred Hutchinson Cancer Research Center
- Harvard
- Hhs, Dept of Health and Human Services
- Human Learning + Behavioral Branch
- in Univ Indianapolis
- Inst for the Study of Smoking Behavior +
- Inst of Medicine
- Intl Agency for Research on Cancer
- Jonsson Comprehensive Cancer Center
- La State Univ Shreveport
- Lab of Human Carcinogenesis
- Ma Dept of Public Health
- Ma Inst of Technology Cambridge
- Nas, Natl Academy of Sciences
- Natl Center for Health Statistics
- Natl Heart Lung + Blood Inst
- Natl Inst for Child Health + Human Devel
- Natl Inst of Child Health + Human Develo
- Natl Inst of Dental Research
- Natl Inst on Drug Abuse
- NCI, Natl Cancer Inst
- Office of Disease Prevention + Health Pr
- Office of Health Planning + Evaluation
- Office of the Inspector General Dallas
- Office of the Inspector General Washingt
- Office of the Surgeon General
- Office on Smoking + Health
- Oh State Univ Columbus
- or Research Inst Eugene
- Periodontal + Soft Tissue Diseases Resea
- Prevention Research Branch
- Prospect Associates
- Royal Dental College Copenhagen
- San Diego Medical Center
- Sgc, Surgeon General's (Advisory) Comm
- Ski, Sloan-Kettering Inst
- Smokeless Tobacco Council
- Survey Planning + Development Branch
- Tobacco + Health Research Inst
- Ucla
- Univ of Ca Los Angeles
- Univ of Ca San Diego
- Univ of Ca San Francisco
- Univ of Co Health Sciences Center Denver
- Univ of Ct Health Center Farmington
- Univ of Glasglow Glasglow
- Univ of Ky Lexington
- Univ of Ma Medical School Worcester
- Univ of Mn Minneapolis
- US Public Health Service
- Veterans Administration Medical Center
- Ftr, Fabriques De Tabac Reunies S.A.
- Ahf, American Health Foundation
- Litigation
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- CONF, CONFIDENTIAL
- OVER, OVER SIZE DOCUPARE, PARENT
- Master ID
- 2501258001/8225
Related Documents: - Date Loaded
- 24 May 1999
- UCSF Legacy ID
- vjr02a00
Document Images
Report of the Surgeon General's
Advisory Committee on the
Health Consequences of Using
Smokeless Tobacco
SE 4,~~~
~NP~v
April 1, 1986
Fabriques de Tabac R6unies S,A.
C. Documentation I BibliothEque
2003 NEUCHATEL
Prepublication Copy
CONTENTS
FOREWOR.D . . . . . . . . . . . . . . . . . . . . . . . . . . .
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACXNOWLEDG MENTS . . . . . . . . . . . . . . . . . . . . . . . .
INTRODUCTION, OVERVIEW, AND CONCLUSIONS . . . . . . . . . . . .
CHAPTER 1-PREVALENCE AND TRENDS OF SMOKELESS
TOBACCO USE IN THE UNITED STATES . . . . . . . . .
v
vii
xv
1-1
CHAPTER 2--CARCINOGENESIS ASSOCIATED WITH
SMOKELESS TOBACCO USE . . . . . . . . . . . . . . . 2-1
CHAPTER 3--NONCANCEROUS AND PRECANCEROUS ORAL HEALTH
EFFECTS ASSOCIATED WITH SMOKELESS TOBACCO USE ... 3-1
CHAPTER 4--NICOTINE EJCPOSURE: PHARMACOKINETICS,
ADDICTION, AND OTHER PHYSIOLOGIC EFFECTS . . . . . . 4-1
FOREWORD
This Report on the Health Consequences of Using Smokeless Tobacco completes
the Public Health Service's initial examination of smokeless tobacco's role in
the causation of cancer, noncancerous and precancerous oral diseases or condi-
tions, addiction, and other adverse health effects. Almost 30 years after the
Public Health Service's first statement on the health effects of cigarette
smoking, it is now possible to issue the first comprehensive, indepth review
of the relationship between smokeless tobacco use and health.
Ironically, while cigarette smoking has declined during the past 20
years, the- production and apparent consumption of smokeless tobacco products
have risen significantly. These increases are in marked contrast to the
decline in smokeless tobacco use in the United States during the first half
of this century. Indeed, smokeless tobacco products, particularly chewing
tobacco and snuff, have recently emerged as popular products for the first
time since the turn of the century. National estimates indicate that at
least 12 million Americans used some form of smokeless tobacco during 1985
with use increasing especially among male adolescents and young male adults.
The increased use and appeal of this product assume major public health
significance because the evidence reveals that smokeless tobacco can cause
oral cancer, can lead to the development of oral leukoplakias and other oral
conditions, and can cause addiction to nicotine. The strength of the associa-
tion between these conditions and smokeless tobacco use combined with the
upward trend in this behavior incites the same alarm as was true with the
knowledge that spitting spread tuberculosis. That concern led to the original
public rejection of tobacco chewing and dipping as unsanitary and antisocial.
It is critical that our society prevents the use of this health hazard and
avoids the tragic mistake of replacing the ashtray with the spittoon.
This report is the work of numerous experts within the Department of
Health and Human Services and in the non-Federal scientific community. I
express my gratitude for their contributions. '
C. Everett Koop, M.D.
U.S. Surgeon General
11L
PREFACE
This report discusses the health consequences of smokeless tobacco use.
It constitutes a comprehensive review by an Advisory Committee to the Surgeon
General of the available scientific literature to determine whether using
smokeless tobacco increases the risk of cancer and noncancerous oral diseases
and effects, leads to addiction and dependence, and contributes to other .
health consequences.
r AFTER A CAREFUL EXAMINATION OF THE RELEVANT EPIDEMIOLOGIC, ERPERIMENTAL,
AND CLINICAL DATA, THE COMMITTEE CONCLUDES 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 NONCANCEROUS ORAL
CONDITIONS AND CAN LEAD TO NICOTINE ADDICTION AND DEPENDENCE.
The major overall conclusions of this report are the following:
'1. It is estimated that smokeless tobacco was used by at least 12
million people in the United States in 1985 and that half of these
were regular users. The use of smokeless tobacco, particularly moist
snuff, is increasing, especially among male adolescents and young
male adults.
2. The scientific evidence is strong that the use of snuff can cause
cancer in humans. The evidence for causality is strongest for
cancer of the oral cavity, wherein cancer may occur several times
more frequently in snuff dippers compared to nontobacco users. The
excess risk of cancer of the cheek and gum may reach nearly fiftyfold
among long-term snuff users.
3. Some investigations suggest that the use of chewing tobacco may
also increase the risk of oral cancer, but the evidence is not as
strong and the risks have yet to be quantified.
4. Experimental investigations reveal potent carcinogens in smokeless
tobacco. These include nitrosamines, polycyclic aromatic hydrocarbons,
and radiation-emitting polonium: The tobacco-specific nitrosamines
often have been detected at levels 100 or more times higher than
Government-regulated levels of other nitrosamines permitted in foods
eaten by Americans.
5. Smokeless tobacco use can lead to the development of oral leukoplakias
(white patches or plaques of the oral mucosa), particularly at the
site of tobacco placement. Based on evidence from several studies,
a portion of leukoplakias can undergo transformation to dysplasia
and further to cancer.
6. Gingival recession is a commonly reported outcome of smokeless tobacco
use.
2501250004
V
7. A number of studies have shown that nicotine exposure from smoking
cigarettes can cause addiction in humans. In this regard, nicotine
is similar to other addictive drugs such as morphine and cocaine.
Since nicotine levels in the body resulting from smokeless tobacco use
are similar in magnitude to nicotine levels from cigarette smoking,
it is concluded that smokeless tobacco use also can be addictive.
Besides, recent studies have shown that nicotine administered orally
has the potential to produce a physiologic dependence. .
8. Some evidence suggests that nicotine may play a contributory or sup-
portive role in the pathogenesis of coronary artery and peripheral
vascular disease, hypertension, peptic ulcers, and fetal mortality
and morbidity.
vi
ACKNOWLEDGMENTS
This report was prepared by the Department of Health and Human Services
under the direction and general editorship of Joseph W. Cullen, Ph.D., Chairman
of the Advisory Committee on the Health Consequences of Using Smokeless To-
bacco and Deputy Director, Division of Cancer Prevention and Control, National
Cancer Institute, Bethesda, Maryland. The following individuals were members
of the Advisory Committee:
Catherine S. Bell, M.S., Acting Chief, Prevention Research Branch, Division
of Clinical Research, National Institute on Drug Abuse, Rockville, Maryland
William Blot, Ph.D., Chief, Biostatistics Branch, Division of Cancer Etiology,
National Cancer Institute, Bethesda, Maryland
James P. Carlos, D.D.S., M.P.H., Associate Director, Epidemiology and Oral
Disease Prevention Program, National Institute of Dental Research, Bethesda,
Maryland
J. David Erickson, D.D.S., M.P.H., Ph.D., Chief, Birth Defects and Genetic
Diseases Branch, Centers for Disease Control, Atlanta, Georgia
Manning Feinleib, M.D., Dr.P.H., Director, National Center for Health Statistics,
Hyattsville, Maryland
Jerome Jaffe, M.D., Director, Addiction Research Center, National Institute on
Drug Abuse, Baltimore, Maryland
Michael McGinnis, M.D., M.A., M.P.P., Deputy Assistant Secretary for Health,
Director, Office of Disease Prevention and Health Promotion, United States
Public Health Service, Washington, D.C.
Robert Mecklenburg, D.D.S., M.P.H., Assistant Surgeon General, Chief Dental
Officer, United States Public Health Service, Rockville, Maryland '
Susan Sieber, Ph.D., Deputy Director, Division of Cancer Etiology, National
Cancer Institute, Bethesda, Maryland
Sumner J. Yaffe, M.D., Director, Center for Research for Mothers and Children,
National Institute of Child Health and Human Development, Bethesda, Maryland
The Advisory Committee was supported by the following technical experts
in the areas listed below:
Carcinogenesis
IV
William Blot, Ph.D., (Coordinator), Chief, Biostatistics Branch, Division of t11
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Gayle Boyd, Ph.D., Research Psychologist, Division of Cancer Prevention and ~
Control, National Cancer Institute, Silver Spring, Maryland ~
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vii
Virginia L. Ernster, Ph.D., Associate Professor of Epidemiology, University
of California, San Francisco, California
Curtis Harris, M.D., Chief, Laboratory of Human Carcinogenesis, Division of
Cancer Etiology, National Cancer Institute, Bethesda, Maryland
Dietrich Hoffmann, Ph.D., Associate Director, Chemistry and Biochemistry,
Naylor Dana Institute for Disease Prevention, American Health Foundation,
Valhalla, New York
Kenneth Rothman, Dr.P.H., Professor of Family and Community Medicine, Univer-
sity of Massachusetts Medical School, Worcester, Massachusetts
David Schottenfeld, M.D., Chief, Division of Epidemiology, Memorial Sloan-
Kettering Cancer Center, New York, New York
Steven R. Tannenbaum, Ph.D., Professor of Toxicology and Food Chemistry,
Department of Applied Biological Sciences, Massachusetts Institute of
Technology, Cambridge, Massachusetts
David B. Thomas, M.D., Dr.P.H., Head, Program in Epidemiology, Fred Hutchinson
Cancer Research Center, Seattle, Washington
Non-Cancer Oral Effects
Arden G. Christen, D.D.S., M.S.D., M.A., Chairman, Department of Preventive
Dentistry, Indiana University Dental School, Indianapolis, Indiana
Stephen B. Corbin, D.D.S., M.P.H., Chief, Dental Disease Prevention Activity,
Center for Preventive Services, Centers for Disease Control, Rockville,
Maryland
Robert 0. Greer, Jr., D.D.S., Sc.D., Professor, Division of Oral Pathology
and Oncology, University of Colorado Health Sciences Center, Denver,.
Colorado
Lireka P. Joseph, Dr.P.H., Medical Radiation Specialist, Food and Drug Adminis-
tration, Rockville, Maryland
Stephen S. Kegeles, Ph.D., Professor, Department of Behavioral Sciences and
Community Health, University of Connecticut Health Center, Farmington,
Connecticut
Matthew Kinnard, Ph.D., Health Science Administrator, Periodontal and Soft
Tissue Diseases Research Branch, National Institute of Dental Research,
Bethesda, Maryland
Dushanka Kleinman, D.D.S., M.Sc.D., Special Assistant to the Associate Director
for Program Coordination, Epidemiology and Oral Disease Prevention Program,
National Institute of Dental Research, Bethesda, Maryland
Robert Mecklenburg, D.D.S., M.P.H., (Coordinator), Assistant Surgeon General,
Chief Dental Officer, United States Public Health Service, Rockville, Maryland
2501250007
.
f
viii
Kathleen L. Schroeder, D.D.S., M.S., Assistant Professor, Department of Oral
Biology, Ohio State University College of Dentistry, Columbus, Ohio
Addiction and Dependence
Catherine S. Bell, M.S., (Coordinator), Acting Chief, Prevention Research
Branch, Division of Clinical Research, National Institute on Drug Abuse,
Rockville, Maryland
Neal Benowitz, M.D., Associate Professor of Medicine, Chief of Clinical Pharma-
cology and Experimental Therapeutics, University of California, San Francisco,
California
Anthony Biglan, Ph.D., Research Scientist, Oregon Research Institute, Eugene,
Oregon
John Grabowski, Ph.D., Associate Professor, Department of Psychiatry, School
of Medicine, Louisiana State University, Shreveport, Louisiana
Steven Gust', Ph.D., Research Associate, Department of Psychiatry, University
of Minnesota, Minneapolis, Minnesota
Jack Henningfield, Ph.D., Chief, Biology of Dependence and Abuse Potential
Assessment Laboratory, Addiction Research Center, National Institutg on
Drug Abuse, Baltimore, Maryland
Lynn Kozlowski, Ph.D., Senior Scientist, The Smoking Research Program, Addic-
tion Research Foundation, Toronto, Ontario, CANADA
Norman A. Krasnegor, Ph.D., Chief, Human Learning and Behavioral Branch,
Center for Research for Mothers and Children, National Institute for Child
Health and Human Development, Bethesda, Maryland
Ovide Pomerleau, Ph.D., Chief of Psychology Service, Veterans Administration
Medical Center, Newington, Connecticut
The following individuals prepared draft chapters or portions of the
report as indicated:
Chapter I. Prevalence and Trends of Smokeless Tobacco Use in the United States
Gayle Boyd, Ph.D., Research Psychologist, Division of Cancer Prevention and
Control, National Cancer Institute, Silver Spring, Maryland
Rebecca Cline, Ph.D., Senior Associate, Prospect Associates, Rockville, Maryland
Charles Darby, M.A., Technical Support Staff Coordinator for Addiction and
Dependence Experts, Senior Associate, Prospect Associates, Rockville, Maryland
Margaret Mattson, Ph.D., Special Assistant for Science, Office of the Director,
Division of Cancer Prevention and Control, National Cancer Institute,
Bethesda, Maryland
2501258000
ix
Chapter II. Carcino,genesis Associated With Smokeless Tobacco Use
William Blot, Ph.D., Chief, Biostatistics Branch, Division of Cancer Etiology,
National Cancer Institute, Bethesda, Maryland
Virginia L. Ernster, Ph.D., Associate Professor of Epidemiology, University
of California, San Francisco, California
~
Curtis Harris, M.D., Chief, Laboratory of Human Carcinogenesis, Division of
Cancer Etiology, National Cancer Institute, Bethesda, Maryland
Stephen S. Hecht, Ph.D., Chief, Division of Chemical Carcinogenesis, Naylor
Dana Institute for Disease Prevention, American Health Foundation, Valhalla,
New York
Dietrich Hoffmann, Ph.D., Associate Director, Chemistry and Biochemistry,
Naylor Dana Institute for Disease Prevention, American Health Foundation,
Valhalla, New York
Kenneth Rothman, Dr.P.H., Professor of Family and Community Medicine, Univer-
sity of Massachusetts Medical School, Worcester, Massachusetts
David Schottenfeld, M.D., Chief, Division of Epidemiology, Memorial Sloan-
Kettering Cancer Center, New York, New York
Steven R. Tannenbaum, Ph.D., Professor of Toxicology and Food Chemistry,
Department of Applied Biological Sciences, Massachusetts Institute of
Technology, Cambridge, Massachusetts
David B. Thomas, M.D., Dr.P.H., Head, Program in Epidemiology, Fred Hutchinson
Cancer Research Center, Seattle, Washington
National Center for Health Statistics, Hyattsville, Maryland
Deborah M. Winn, Ph.D., Epidemiologist, Survey Planning and Development Branch,
Chapter III. Noncancerous and Precancerous Oral Health Effects Associated With
Smokeless Tobacco Use
Stephen B. Corbin, D.D.S., M.P.H., Chief, Dental Disease Prevention Activity,
Center for Preventive Services, Centers for Disease Control, Rockville,
Maryland
Lireka P. Joseph, Dr.P.H., Medical Radiation Specialist, Food and Drug Admin-
istration, Rockville, Maryland
Dushanka IKleinman, D.D.S., M.Sc.D., Special Assistant to the Associate Director
for Program Coordination, Epidemiology and Oral Disease Prevention Program,
National Institute of Dental Research, Bethesda, Maryland
Chapter IV. Nicotine Exposure: Pharmacokinetics, Addiction, and Other
Physiologic Effects
Neal Benowitz, M.D., Associate Professor of Medicine, Chief of Clinical Pharma-
cology and Experimental Therapeutics, University of California, San Francisco,
California 2501250009
.
.
x
Anthony Biglan, Ph.D., Research Scientist, Oregon Research Institute, Eugene,
Oregon
Jack Henningfield, Ph.D., Chief, Biology of Dependence and Abuse Potential
Assessment Laboratory, Addiction Research Center, National Institute on
Drug Abuse, Baltimore, Maryland
Margaret Mattson, Ph.D., Special Assistant for Science, Office of the Director,
Division of Cancer Prevention and Control, National Cancer Institute, Bethesda,
Maryland
The Advisory Committee and authors acknowledge with gratitude the follow-
ing distinguished scientists, physicians, and others who lent their support
in the development of this report by contributing critical reviews of the
manuscript or assisting in other ways:
John Bailar, M.D., Ph.D., Lecturer, Department of Biostatistics, Harvard
School of Public Health, Boston, Massachusetts '
Enriqueta C. Bond, Ph.D.., Director, Division of Health Promotion and Disease
Prevention, Institute of Medicine, Washington, D.C.
Lester Breslow, M.D., M.P.H., Professor Emeritus, School of Public Health,
University of California, Los Angeles, California
David M. Burns, M.D., Associate Professor of Medicine, Division of Pulmonary
and Critical Care Medicine, University of California, San Diego Medical
Center, San Diego, California
Greg Connolly, D.M.D., M.P.H., Director, Division of Dental Health, Massachusetts
Department of Public Health, Boston, Massachusetts
D. Layten Davis, Ph.D., Director, University of Kentucky, Tobacco and Health
Research Institute, Lexington, Kentucky
Miriam Davis, Ph.D., Program Analyst, Office of Health Planning and Evaluation,
Office of the Assistant Secretary for Health, Washington, D.C.
Vincent T. DeVita, Jr., M.D., Director, National Cancer Institute, Bethesda,
Maryland
Joseph F. Fraumeni, Jr., M.D., Associate Director for Epidemiology and Bio-
statistics, Division of Cancer Etiology, National Cancer Institute, Bethesda,.
Maryland
Thomas J. Glynn, Ph.D., Program Director for Smoking Research, Division of
Cancer Prevention and Control, National Cancer Institute, Bethesda, Maryland
Peter Greenwald, M.D., Dr.P.H., Director, Division of Cancer Prevention and I"~J
Control, National Cancer Institute, Bethesda, Maryland ~
a
~
Ellen R. Gritz, Ph.D., Director, Division of Cancer Control, UCLA Jonsson ~
Comprehensive Cancer Center, Los Angeles, California ~
a
Dianne G. Lindewall, Ph.D., Program Analyst, Office of Health Planning and a
Evaluation, Office of the Assistant Secretary for Health, Washington, D.C.
xi
