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July 11, 1990, Vol 264, No. 2 >
ARTICLE | July 11, 1990

Smokeless Tobacco Use and Health Effects Among Baseball Players FREE

Virginia L. Ernster, PhD; Deborah G. Grady, MD, MPH; John C. Greene, DMD, MPH; Margaret Walsh, EdD; Paul Robertson, DDS; Troy E. Daniels, DDS; Neal Benowitz, MD; David Siegel, MD; Barbara Gerbert, PhD; Walter W. Hauck, PhD
[+] Author Affiliations

Reprint requests to Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA 94143-0560 (Dr Ernster, c/o Editor).


JAMA. 1990;264(2):218-224. doi:10.1001/jama.1990.03450020070029
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References

The effects of smokeless tobacco (ST) use were studied in 1109 members of major and minor league professional baseball teams during spring training in 1988. The prevalence of current ST use was 39%. The median age at initiation among users was 18 years, and the median duration of use was 5 years. Among users, 75% cited a snuff brand as their usual ST product. Oral leukoplakia was present in 46% (196/423) of current-week ST users and 1.4% (7/493) of nonusers (odds ratio, 60; 95% confidence interval, 28 to 130). Prevalence of oral leukoplakia among ST users increased with hours used per day and decreased with time lapsed since last use, and was higher in snuff users than in chewing tobacco users. Of the subjects with oral leukoplakia who underwent punch biopsy, 91 had benign hyperkeratosis and one had mild dysplasia. Overall prevalence of dental caries, gingivitis, and plaque did not differ between ST users and nonusers. In analyses confined to facial surfaces of mandibular incisor teeth, where ST is most commonly used, there were significant increases among users in both gingival recession and attachment loss. Users of ST did not differ from nonusers in blood pressure, pulse, total or high-density lipoprotein cholesterol level, or white blood cell count, but among users high-density lipoprotein cholesterol levels were inversely associated with serum cotinine levels. The major health effects of ST use among professional baseball players are oral leukoplakia and localized periodontal disease. The study population was young, physically fit, and characterized by relatively moderate short-term ST use.

(JAMA. 1990;264:218-224)

REFERENCES

1 +
Boyd GM, Glover ED.  Smokeless tobacco use by youth in the U.S. J Sch Health. 1989;;59:189-194.
2 +
Reducing the Health Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon General, 1989 . Rockville, Md: Office on Smoking and Health; 1989;.
3 +
Marcus AC, Crane LA, Shopland DR, Lynn WR.  Use of smokeless tobacco in the United States: recent estimates from the current population survey . NCI Monogr. 1989;;8:17-24.
4 +
Novotny TE, Pierce JP, Fiore MC, Davis RM.  Smokeless tobacco use in the United States: the adult use of tobacco surveys . NCI Monogr. 1989;;8:25-28.
5 +
Rouse BA.  Epidemiology of smokeless tobacco use: a national study . NCI Monogr. 1989;;8:29-34.
6 +
Ernster VL.  Advertising and promotion of smokeless tobacco products . NCI Monogr. 1989;; 8:87-94.
7 +
Hoffmann D, Hecht SS.  Nicotine-derived N-nitrosamines and tobacco-related cancer: current status and future directions . Cancer Res. 1985;; 45:935-944.
8 +
The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General . Bethesda, Md: National Institutes of Health; (April) 1986;. Publication N086-2874.
9 +
Hoffmann D, Harley NH, Fisenne I, Adams JD, Brunnemann KD.  Carcinogenic agents in snuff . J Natl Cancer Inst. 1986;;76:435-437.
10 +
Gritz ER, Baer-Weiss V, Benowitz N, Vunakis HV, Jarvik ME.  Plasma nicotine and cotinine concentrations in habitual smokeless tobacco users . Clin Pharmacol Ther. 1981;;30:201-209.
11 +
Benowitz NL, Porchet H, Sheiner L, Jacob P.  Nicotine absorption and cardiovascular effects with smokeless tobacco use: comparison with cigarettes and nicotine gum . Clin Pharmacol Ther. 1988;;44: 23-28.
12 +
Evaluation of the Carcinogenic Risk of Chemicals to Humans . Lyon, France: International Agency for Research on Cancer; 1985;;37.
13 +
Connolly GN, Winn DM, Hecht SS, Henningfield JE, Walker B, Hoffmann D.  Thereemergence of smokeless tobacco . N Engl J Med. 1986;;314:1020-1027.
14 +
Winn DM.  Smokeless tobacco and cancer: the epidemiologic evidence . CA. 1988;;38:236-243.
15 +
Schroeder KL, Chen MS.  Smokeless tobacco and blood pressure . N Engl J Med. 1985;;312:919.
16 +
Weintraub JA, Burt BA.  Periodontal effects and dental caries associated with smokeless tobacco . Public Health Rep. 1987;;102:30.
17 +
Jacob P III, Wilson M, Benowitz NL.  Improved gas chromatographic method for the determination of nicotine and cotinine in biologic fluids . J Chromatogr. 1981;;222:61-70.
18 +
Cummings SR, Richard RJ.  Optimum cutoff points for biochemical validation of smoking status . Am J Public Health. 1988;;78:574-575.
19 +
Greer RO Jr, Poulson TC.  Oral tissue alterations associated with the use of smokeless tobacco by teen-agers . Oral Surg. 1983;;56:275-284.
20 +
Axell T, Mornstad H, Studnstrom B.  The relation of the clinical picture to the histopathology of snuff dipper's lesions in a Swedish population . J Oral Pathol. 1976;;5:229-236.
21 +
Ramfjord SP.  Indices for prevalence and incidence of periodontal disease . J Periodontol. 1959;; 30:51-59.
22 +
Silness J, Loe H.  Periodontal disease in pregnancy, II: correlation between oral hygiene and periodontal condition . Acta Ondontol Scand. 1964;;22:121.
23 +
Loe H, Silness J.  Periodontal disease in pregnancy, I: prevalence and severity . Acta Ondontol Scand. 1963;;21:533.
24 +
Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989;.
25 +
Liang KY, Zeger SL.  Longitudinal data analysis using generalized linear models . Biometrika . 1986;;73:13-22.
26 +
Grady D, Greene J, Ernster VL, et al.  Oral mucosal lesions in smokeless tobacco users . J Am Dent Assoc. 1990;;121:117-123.
27 +
Offenbacher S, Weathers DR.  Effects of smokeless tobacco on the periodontal mucosal and caries status of adolescent males . J Oral Pathol. 1985;; 14:169-181.
28 +
Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, Fraumeni JF Jr.  Snuff dipping and oral cancer among women in the southern United States . N Engl J Med. 1981;;304:745-749.
29 +
Connolly GN, Orleans CT, Kogan M.  Use of smokeless tobacco in major-league baseball . N Engl J Med. 1988;;318:1281-1284.
30 +
Boyd G.  Use of smokeless tobacco among children and adolescents in the United States . Prev Med. 1987;;16:402-421.
31 +
Mahboubi E, Sayed GM.  Oral cavity and pharynx . In: Schottenfeld D, Fraumeni JF Jr, eds. Cancer Epidemiology and Prevention . Philadelphia, Pa: WB Saunders Co; 1982;:583-595.
32 +
Hirsch JM, Heyden G, Thilander H.  A clinical, histomorphological and histochemical study on snuff-induced lesions of varying severity . J Oral Pathol. 1982;;11:387-398.
33 +
Poulson TC.  A comparison of the use of smokeless tobacco in rural and urban teenagers . CA . 1984;;34:248-261.
34 +
Wolfe MD, Carlos JP.  Oral health effects of smokeless tobacco use in Navajo Indian adolescents . Community Dent Oral Epidemiol. 1987;;15: 230-235.
35 +
Weintraub JA, Burt BA.  Periodontal effects and dental caries associated with smokeless tobacco use . Public Health Rep. 1987;;102:30-35.
36 +
Benowitz NL, Jacob P III, Yu L.  Daily use of smokeless tobacco: systemic effects . Ann Intern Med. 1989;;111:112-116.
37 +
Hampson NB.  Smokeless is not saltless . N Engl J Med. 1985;;312:919-920. Letters.
38 +
Benowitz NL.  Pharmacologic aspects of cigarette smoking and nicotine addiction . N Engl J Med. 1988;;319:1318-1330.
39 +
Squires WG Jr, Brandon TA, Zinkgraf S, et al.  Hemodynamic effects of oral smokeless tobacco in dogs and young adults . Prev Med. 1984;;13:195-206.
40 +
Wells DG, Rustick JM.  Hypertension from smokeless tobacco . Anesthesiology . 1986;;65:339. Letters.
41 +
McPhaul M, Punzi HA, Sandy A, Borganelli M, Rude R, Kaplan NM.  Snuff-induced hypertension in pheochromocytoma . JAMA . 1984;;252:2860-2962.
42 +
Green MS, Jucha E, Luz Y.  Blood pressure in smokers and nonsmokers: epidemiologic findings . Am Heart J. 1986;;111:932-940.
43 +
Brischetto CS, Connor WE, Connor SL, Matarazzo JD.  Plasma lipid and lipoprotein profiles of cigarette smokers from randomly selected families: enhancement of hyperlipidemia and depression of high density lipoprotein . Am J Cardiol. 1983;;52:675-680.
44 +
Dwyer JH, Rieger-Ndakorerwa GE, Semmer NU, Fuchs R, Lippert P.  Low-level cigarette smoking and longitudinal change in serum cholesterol among adolescents . JAMA . 1988;;259:2857-2862.
45 +
Tucker LA.  Use of smokeless tobacco, cigarette smoking, and hypercholesterolemia . Am J Public Health. 1989;;79:1048-1050.
46 +
Grimm RH, Neaton JD, Ludwig W.  Prognostic importance of the white blood cell count for coronary, cancer, and all-cause mortality . JAMA . 1985;;254:1932-1937.
47 +
Knoke JD, Hunninghoke DB, Heiss G.  Physiological markers of smoking and their relation to coronary heart disease . Arteriosclerosis . 1987;; 7:477-482.
48 +
 Baseball and smokeless tobacco: an ongoing tradition . U S Tobacco Rev. 1985;;1:4.
49 +
Jones RB.  Use of smokeless tobacco in the 1986 World Series . N Engl J Med. 1987;;316:952. Letters.
50 +
Sussman S, Barovich M.  Smokeless tobacco: less seen at 1988 World Series . Am J Public Health. 1989;;79:521-522.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Boyd GM, Glover ED.  Smokeless tobacco use by youth in the U.S. J Sch Health. 1989;;59:189-194.
2 +
Reducing the Health Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon General, 1989 . Rockville, Md: Office on Smoking and Health; 1989;.
3 +
Marcus AC, Crane LA, Shopland DR, Lynn WR.  Use of smokeless tobacco in the United States: recent estimates from the current population survey . NCI Monogr. 1989;;8:17-24.
4 +
Novotny TE, Pierce JP, Fiore MC, Davis RM.  Smokeless tobacco use in the United States: the adult use of tobacco surveys . NCI Monogr. 1989;;8:25-28.
5 +
Rouse BA.  Epidemiology of smokeless tobacco use: a national study . NCI Monogr. 1989;;8:29-34.
6 +
Ernster VL.  Advertising and promotion of smokeless tobacco products . NCI Monogr. 1989;; 8:87-94.
7 +
Hoffmann D, Hecht SS.  Nicotine-derived N-nitrosamines and tobacco-related cancer: current status and future directions . Cancer Res. 1985;; 45:935-944.
8 +
The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General . Bethesda, Md: National Institutes of Health; (April) 1986;. Publication N086-2874.
9 +
Hoffmann D, Harley NH, Fisenne I, Adams JD, Brunnemann KD.  Carcinogenic agents in snuff . J Natl Cancer Inst. 1986;;76:435-437.
10 +
Gritz ER, Baer-Weiss V, Benowitz N, Vunakis HV, Jarvik ME.  Plasma nicotine and cotinine concentrations in habitual smokeless tobacco users . Clin Pharmacol Ther. 1981;;30:201-209.
11 +
Benowitz NL, Porchet H, Sheiner L, Jacob P.  Nicotine absorption and cardiovascular effects with smokeless tobacco use: comparison with cigarettes and nicotine gum . Clin Pharmacol Ther. 1988;;44: 23-28.
12 +
Evaluation of the Carcinogenic Risk of Chemicals to Humans . Lyon, France: International Agency for Research on Cancer; 1985;;37.
13 +
Connolly GN, Winn DM, Hecht SS, Henningfield JE, Walker B, Hoffmann D.  Thereemergence of smokeless tobacco . N Engl J Med. 1986;;314:1020-1027.
14 +
Winn DM.  Smokeless tobacco and cancer: the epidemiologic evidence . CA. 1988;;38:236-243.
15 +
Schroeder KL, Chen MS.  Smokeless tobacco and blood pressure . N Engl J Med. 1985;;312:919.
16 +
Weintraub JA, Burt BA.  Periodontal effects and dental caries associated with smokeless tobacco . Public Health Rep. 1987;;102:30.
17 +
Jacob P III, Wilson M, Benowitz NL.  Improved gas chromatographic method for the determination of nicotine and cotinine in biologic fluids . J Chromatogr. 1981;;222:61-70.
18 +
Cummings SR, Richard RJ.  Optimum cutoff points for biochemical validation of smoking status . Am J Public Health. 1988;;78:574-575.
19 +
Greer RO Jr, Poulson TC.  Oral tissue alterations associated with the use of smokeless tobacco by teen-agers . Oral Surg. 1983;;56:275-284.
20 +
Axell T, Mornstad H, Studnstrom B.  The relation of the clinical picture to the histopathology of snuff dipper's lesions in a Swedish population . J Oral Pathol. 1976;;5:229-236.
21 +
Ramfjord SP.  Indices for prevalence and incidence of periodontal disease . J Periodontol. 1959;; 30:51-59.
22 +
Silness J, Loe H.  Periodontal disease in pregnancy, II: correlation between oral hygiene and periodontal condition . Acta Ondontol Scand. 1964;;22:121.
23 +
Loe H, Silness J.  Periodontal disease in pregnancy, I: prevalence and severity . Acta Ondontol Scand. 1963;;21:533.
24 +
Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989;.
25 +
Liang KY, Zeger SL.  Longitudinal data analysis using generalized linear models . Biometrika . 1986;;73:13-22.
26 +
Grady D, Greene J, Ernster VL, et al.  Oral mucosal lesions in smokeless tobacco users . J Am Dent Assoc. 1990;;121:117-123.
27 +
Offenbacher S, Weathers DR.  Effects of smokeless tobacco on the periodontal mucosal and caries status of adolescent males . J Oral Pathol. 1985;; 14:169-181.
28 +
Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, Fraumeni JF Jr.  Snuff dipping and oral cancer among women in the southern United States . N Engl J Med. 1981;;304:745-749.
29 +
Connolly GN, Orleans CT, Kogan M.  Use of smokeless tobacco in major-league baseball . N Engl J Med. 1988;;318:1281-1284.
30 +
Boyd G.  Use of smokeless tobacco among children and adolescents in the United States . Prev Med. 1987;;16:402-421.
31 +
Mahboubi E, Sayed GM.  Oral cavity and pharynx . In: Schottenfeld D, Fraumeni JF Jr, eds. Cancer Epidemiology and Prevention . Philadelphia, Pa: WB Saunders Co; 1982;:583-595.
32 +
Hirsch JM, Heyden G, Thilander H.  A clinical, histomorphological and histochemical study on snuff-induced lesions of varying severity . J Oral Pathol. 1982;;11:387-398.
33 +
Poulson TC.  A comparison of the use of smokeless tobacco in rural and urban teenagers . CA . 1984;;34:248-261.
34 +
Wolfe MD, Carlos JP.  Oral health effects of smokeless tobacco use in Navajo Indian adolescents . Community Dent Oral Epidemiol. 1987;;15: 230-235.
35 +
Weintraub JA, Burt BA.  Periodontal effects and dental caries associated with smokeless tobacco use . Public Health Rep. 1987;;102:30-35.
36 +
Benowitz NL, Jacob P III, Yu L.  Daily use of smokeless tobacco: systemic effects . Ann Intern Med. 1989;;111:112-116.
37 +
Hampson NB.  Smokeless is not saltless . N Engl J Med. 1985;;312:919-920. Letters.
38 +
Benowitz NL.  Pharmacologic aspects of cigarette smoking and nicotine addiction . N Engl J Med. 1988;;319:1318-1330.
39 +
Squires WG Jr, Brandon TA, Zinkgraf S, et al.  Hemodynamic effects of oral smokeless tobacco in dogs and young adults . Prev Med. 1984;;13:195-206.
40 +
Wells DG, Rustick JM.  Hypertension from smokeless tobacco . Anesthesiology . 1986;;65:339. Letters.
41 +
McPhaul M, Punzi HA, Sandy A, Borganelli M, Rude R, Kaplan NM.  Snuff-induced hypertension in pheochromocytoma . JAMA . 1984;;252:2860-2962.
42 +
Green MS, Jucha E, Luz Y.  Blood pressure in smokers and nonsmokers: epidemiologic findings . Am Heart J. 1986;;111:932-940.
43 +
Brischetto CS, Connor WE, Connor SL, Matarazzo JD.  Plasma lipid and lipoprotein profiles of cigarette smokers from randomly selected families: enhancement of hyperlipidemia and depression of high density lipoprotein . Am J Cardiol. 1983;;52:675-680.
44 +
Dwyer JH, Rieger-Ndakorerwa GE, Semmer NU, Fuchs R, Lippert P.  Low-level cigarette smoking and longitudinal change in serum cholesterol among adolescents . JAMA . 1988;;259:2857-2862.
45 +
Tucker LA.  Use of smokeless tobacco, cigarette smoking, and hypercholesterolemia . Am J Public Health. 1989;;79:1048-1050.
46 +
Grimm RH, Neaton JD, Ludwig W.  Prognostic importance of the white blood cell count for coronary, cancer, and all-cause mortality . JAMA . 1985;;254:1932-1937.
47 +
Knoke JD, Hunninghoke DB, Heiss G.  Physiological markers of smoking and their relation to coronary heart disease . Arteriosclerosis . 1987;; 7:477-482.
48 +
 Baseball and smokeless tobacco: an ongoing tradition . U S Tobacco Rev. 1985;;1:4.
49 +
Jones RB.  Use of smokeless tobacco in the 1986 World Series . N Engl J Med. 1987;;316:952. Letters.
50 +
Sussman S, Barovich M.  Smokeless tobacco: less seen at 1988 World Series . Am J Public Health. 1989;;79:521-522.

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