CHEW

06.20.14

Smokeless Tobacco: A Forgotten Teen Risk

11 percent of high school boys admit to using smokeless tobacco—a number that is far too high. It’s time we remember that smoking isn’t the only cancer-causer.

As a general rule, I try to avoid preaching at my patients. People come to me for medical care and advice, not doctrine, and aside from a non-negotiable exception or two, I make an effort to be flexible in my approach to making recommendations. Even for health concerns that resonate with me personally, I don’t think it’s good to moralize or scold.

However, when it comes to tobacco use, it’s hard to keep from wagging my finger. The jury may still be out on saturated fat, and we’re taking a second look at the health benefits of germs, but if there’s one thing that’s unambiguously terrible for you, it’s tobacco. I ask every single patient starting at middle school age about substance use, and those who are honest enough to admit to smoking get a strong recommendation to quit ASAP. (I still try to be nice about it, though.)

Yet it’s important not to focus exclusively on cigarette use among young patients. The recent death of Hall-of-Fame baseball player Tony Gwynn has served as a reminder that smokeless tobacco products can be deadly, too. Chewing tobacco and snuff increase the risk of numerous cancers, including those of the mouth, throat, esophagus, stomach and pancreas. Though some hold out smokeless tobacco as a safer alternative to cigarette smoking, even conservative estimates show that using it increases one’s risk of oral cancer three to ten times over non-users. Cancers of the head and neck are often diagnosed late, and because of this they have a relatively high mortality rate; a little more than half of the people diagnosed with oral cancer will be alive five years later.

Though teens that use tobacco products are still most likely to be smoking cigarettes (though, happily, at record-low rates compared to previous generations), about 6 percent of American high school students reported using smokeless tobacco according to the 2012 National Youth Tobacco Survey. Those numbers skew heavily toward the males, with just over 11 percent of male high school students reporting use. That number is far too high.

When talking to teenagers about the risks of tobacco use, it’s easy to focus on cigarettes and forget about smokeless varieties.

The incidence of oropharyngeal cancer (involving the middle area of the throat) has risen significantly in the developed world over the past few decades, including the United States. Much of this increase is due to human papillomavirus (HPV), the virus that is also strongly linked to cervical cancer. (It’s for this reason that I earnestly recommend vaccination against HPV to all my patients in the appropriate age range, both male and female.) But even a study funded by the smokeless tobacco industry found that use of their products was a significant risk factor in developing these cancers.

Gwynn’s death has turned attention once again to the prevalence of smokeless tobacco use among Major League Baseball players. What effect (if any) an outright ban might have on youth use rates is unclear. What is clear is that far too many teenagers are still using a product known to increase their risk of deadly cancers.

I know that warnings from me won’t magically transform the behavior of all who hear them. Plenty of my patients ignore my advice, as many sheepishly admit when I see them for check-ups and follow-up visits over the years. But they’re certainly not going to heed recommendations that they never hear in the first place. When talking to teenagers about the risks of tobacco use, it’s easy to focus on cigarettes and forget about smokeless varieties. Gwynn’s death should remind parents and medical providers alike to be more thorough, and that no form of tobacco is safe.