Its not just a horrifying poster

Dec. 1, 1998
Everyone knows Sean Marsee, the poster boy for smokeless tobacco. His tragic death in 1984 from complications of tongue cancer inspired the graphic portrait that hangs in many dental offices, presenting a familiar face to most hygienists.

The hygiene operatory is still the best place to warn smokeless tobacco users of the proven dangers.

Cathy Hester Seckman, RDH

Everyone knows Sean Marsee, the poster boy for smokeless tobacco. His tragic death in 1984 from complications of tongue cancer inspired the graphic portrait that hangs in many dental offices, presenting a familiar face to most hygienists.

But what can we say to teenagers who see the poster? When they look at that final photo, in which Sean`s eyes show his knowledge of his own death, they typically back away, look away, and try to ignore it.

"That`s not real," a young snuff user said to me once. "That`s just some picture." It seemed impossible to explain to the boy that Sean certainly was real - that he lived, laughed, dipped snuff, and died.

What is smokeless tobacco exactly? Unless you`ve caught your teenager with it lately or you have an unenlightened brother, you might not know. "Spit tobacco" is simply tobacco without the cigarette or cigar paper wrapped around it. With this kind, you don`t light it and inhale the smoke, you chew on it or hold it in your mouth and let the nicotine leach out into your saliva and the soft tissues of your mouth. It takes just a few minutes for a substantial nicotine jolt to reach your bloodstream via absorption through the mucosa. You get as much nicotine from the average 30-minute "chew" as you do from two or three cigarettes. Swallowing too much of that tobacco-laced saliva, though, can cause indigestion, so many chewers spit out the excess regularly. Sounds appetizing, doesn`t it?

It was the tobacco of choice in the United States prior to 1900, when spittoons were common in homes, taverns, and businesses. The spread of tuberculosis after the turn of the century made public spitting socially unacceptable, and commercially produced cigarettes became more common. Smokeless tobacco made a comeback in the 1970s, when the hazards of active and passive smoking became common knowledge. At first, tobacco users saw it as a healthier way to ingest nicotine.

Today, smokeless tobacco comes in two forms, "chew" and "snuff." Chew is leafy, bulky tobacco that can be sold in pouches or in long, dried "plugs." This type is usually held in the cheek and chewed occasionally, the way a cow chews a cud. Snuff is finely ground tobacco that can be sold loose in tins or packed into neat, tissue-paper pouches. Users pinch out a "dip" of snuff or take a paper pouch and tuck it between the cheek and gum.

Besides the addictive nicotine and the smooth-tasting wintergreen, modern smokeless tobacco can contain formaldehyde, polonium, and dozens of known cancer-causing chemicals and radioactive elements.

If you can call it that, the advantage of smokeless tobacco is implied in the name. It`s smokeless, so none of the nicotine or other chemicals directly affect your lungs. This makes it particularly attractive to athletes, who need to keep their lungs healthy. It`s why Sean Marsee started dipping instead of smoking - he was a medal-winning high school track star. Smokeless tobacco is also discreet, so long as you keep your spitting to a minimum. A dentist once bragged to me that he could hold a dip in his mouth for an entire day at work without any of his patients realizing it. Because it`s smokeless, you can dip or chew in theaters, at work, or anywhere smoking is prohibited.

To the uninformed, it might seem like the perfect tobacco product. It does give you a nicotine high, yet it doesn`t do some other things. It doesn`t ruin your lungs, it doesn`t shorten your wind for sports, it doesn`t anger nonsmokers around you, and you can do it without anyone - such as your parents - noticing.

Statistics compiled by the U.S. Department of Health and Human Services (HHS) tell us most smokeless tobacco users are young males. Twelve times as many men as women use it. The average consumer is between 18 and 30, although children as young as eight or 10 admit to being regular snuff users. One million adolescent boys currently use spit tobacco, according to the HHS. One state`s study concluded that nearly 10 percent of the third to sixth graders had tried it, and another state reported nearly half of its high school males had experimented with it.

Smokeless tobacco use is common in isolated groups of women, such as Native Americans and elderly Southern women. But, overall, just 2 percent of young American women report smokeless tobacco use.

Because young males are the most frequent users, tobacco companies target them heavily. Smokeless tobacco is marketed in different strengths, beginning with mild, mint-flavored tobacco with a lower pH and working up to "choice" blends of stronger, full-strength tobacco. A chilling example of targeting is one print ad, done in question-and-answer format and aimed at beginners At the bottom of the ad is a coupon that can be mailed in exchange for a free tin of moist smokeless tobacco in beginners` strength.

And the advertising has been working. Annual sales of smokeless tobacco products exceed $1 billion, according to Oral Health America. In a 1993 monograph, "Smokeless Tobacco or Health," the National Institutes of Health stated that sales have been on the rise. Between 1972 and 1991, the weight of smokeless tobacco products sold in the United States rose from 117.5 million pounds to 125.1 million pounds. This is in sharp contrast to the national decline of cigarette sales, which in 1991 were at their lowest level since the early 1940s.

Smokeless tobacco`s popularity has continued to rise despite growing evidence of its dangers, which every hygienist knows can range all the way from gum recession to death from oral cancer. The United States, according to the HHS, has one of the highest rates of smokeless tobacco use in the world. Use is also high in Sweden and India. But, in most of Europe, it is practically nonexistent. Smokeless tobacco has actually been banned in several countries, including Ireland, Israel, New Zealand, and Taiwan. A focused effort, however, is under way in the United States to reduce those millions of pounds being sold every year, as well as those thousands of deaths from oral cancer.

Since the mid-1980s, when the carcinogenicity of smokeless tobacco was fully established, the American Cancer Society and other health agencies have concentrated on educating the public about the dangers of its use. Surgeon General Antonia Novello said in 1993, "We have made great progress over the past 40 years in making the United States a smoke-free society. Our task will not be complete, however, until we make the nation free of tobacco use in all forms. To do otherwise would invite unnecessary suffering, disease, and death."

The federal government`s agenda for improving the health of all Americans, Healthy People 2000, calls on dental health professionals to join the fight. The National Spit Tobacco Education Program (NSTEP), says its goal for the year 2000 is to have 75 percent of dentists helping their patients to stop smoking or chewing tobacco.

Dental professionals can make a difference. We`re on the front line of defense when it comes to smokeless tobacco, perfectly placed to see the first health problems caused by its use. You probably can`t count the number of times you`ve seen leukoplakia in a teenage boy`s mouth. Some hygienists march right out to tell the parent; others try to educate the child in a nonthreatening way. When we see the same leukoplakia in an adult, we might be more aggressive and try to scare the guy with statistics.

"Hell, that stuff`ll kill you faster`n cigarettes," I heard a dentist tell a patient once. "You don`t get mouth cancer as easily as you get lung cancer, but once you have it, you`re just about dead meat." The doctor shook his head dolefully.

The dentist was pretty accurate. According to Oral Health America, oral cancer accounts for only 3 percent of all cancers in the United States, but the five-year survival rate is a discouraging 54 percent. The risk of developing oral cancer for long-term users of smokeless tobacco is 50 times greater than for nonusers.

The patient was disturbed by the statistics and said he`d been thinking about stopping. How, he asked us, would he go about it? Is a nicotine patch good for quitting snuff? What strategies work? How successful are people who try? We floundered, not really knowing what to tell him.

We could have used some help from a recent publication, "How to Help Your Patients Stop Using Tobacco." Published by the National Cancer Institute in August 1998, the manual is available free through the American Cancer Society at (800) 4-CANCER. Information on ordering can also be found at The manual offers a simple, four-step program for helping patients quit smokeless tobacco (see page 27). The program is described as the "four A`s."

These intervention strategies were designed to take advantage of the one- to two-minute intervals common in the routine dental appointment. Short, simple presentations have been shown to be very effective in inspiring users to quit. The American Cancer Society, the National Cancer Institute, and the National Institutes for Health invite all dental professionals to include tobacco use intervention services into their practices.

We have a responsibility to help Healthy People 2000 reach its goal. We have a responsibility to help our patients live longer, healthier lives. And we have a responsibility to ourselves to provide the best dental care we know how to give. The next time a patient presents with those telltale white, rubbery patches of mucosa, take the first step: Ask.

Cathy Hester Seckman is based in Calcutta, Ohio.


- "Sean Marsee`s Smokeless Death" - Reader`s Digest, October 1985

- "Tobacco Trends" - Oral Health America`s National Spit Tobacco Education Program Fact Sheet

- "Spit Tobacco, Know the Score" - National Institute of Dental Research and National Cancer Institute, National Institutes of Health Fact Sheet, June 1997

- "Smokeless Tobacco or Health" - National Institutes of Health National Cancer Institute Monograph, May 1993

- "Smokeless Tobacco and Cancer" - American Cancer Society Fact Sheet, March 1998

- "How to Help Your Patients Stop Using Tobacco" - National Cancer Institute workbook, August 1998.

The "Four A`s"

1) Ask. Find out about the patient`s tobacco use. Ask how much they use and how much money they spend. Try to determine their patterns of use. Do they dip at work, while playing sports, when they`re nervous, or when they`re hungry? The patient might be surprised by some of his answers. Find out if the patient has ever tried to quit before. Most tobacco users relapse three or four times before they finally succeed. Knowing that might give your patient confidence to try again.

2) Advise. As his dental health professional, tell the patient that you strongly advise him to stop. Point out the area of leukoplakia, the gum recession, and the stain. Let the patient take a good, hard look at it. Studies have shown a tobacco user is more motivated to stop when the problem is seen as personal. Abstract health statistics are less effective than a mirror. Even if a first effort isn`t successful, reinforcing your concern during recall appointments can eventually make an impression.

3) Assist. This is where some of us fall short, because we don`t know what to say. The NCI program offers several tips we can pass along. Setting a quit date is an important first step. The patient must decide that on a particular day he will get up in the morning and no longer be a tobacco user. Ninety percent of users who successfully stop do it "cold turkey." Quitting with a partner or enlisting the aid of family and friends can be helpful. Your office can provide handouts that list tips for quitting and provide health information. Free brochures are available from the American Cancer Society`s Publications Ordering Service at (800) 4-CANCER.

For long-term users who might need extra help with quitting, the NCI suggests extra appointment time. Interest and sincerity, says the manual, are two of the most effective intervention tools. Ask patients to identify particular strengths and strategies they think might help them quit. Ask what support they can gather from friends and family. If the patient hasn`t been able to quit cold turkey, nicotine gum might be indicated. Studies are underway that test the effectiveness of nicotine gum in the treatment of smokeless tobacco users, and the NCI suggests it would be appropriate and helpful. The HHS has stated that transdermal nicotine patches may be more promising for smokeless tobacco users.

4) Arrange follow-up. Studies indicate that success rates are twice as high when the patient knows you`re interested enough to keep in touch. Call the patient just before his planned quit date as a reminder, then call again a week or two later to see how it`s going.