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Smokeless Tobacco, E-cigarettes, Vaping: What is the Real Deal?

By Cindy Chang, M.D., Brad Coleman, Katherine Dec, M.D. on March 14, 2017 march Print

Smokeless tobacco is any product in which tobacco is held in the mouth so that nicotine can be absorbed. Smokeless tobacco can go by other names, such as chewing, oral and spitting tobacco, or snuff, dip and chew. In general, the two basic types of smokeless tobacco are:

Chewing tobacco: Long strands of loose leaves, plugs ortwists of tobacco.

Snuff: Finely ground tobacco packaged in cans or pouches and sold as dry or moist.

An electronic cigarette, or e-cigarette, is an electronic handheld device that vaporizes a flavored liquid that contains nicotine. “Vaping” refers to inhalation of the vapor, and has increased in popularity because of the myth that it is less addictive and less dangerous than solid tobacco products. In 2015, e-cigarettes were the most commonly used smoking product among middle school and high school students.

Oral tobacco products are not regulated by the Food and Drug Administration (FDA); there is also no regulation over what can be placed in the tobacco product. As of 2016, the FDA has extended regulations to e-cigarettes.


Many health hazards are attributed to the use of tobacco products. Most people are able to associate diseases such as heart disease and lung cancer with cigarette smoking, while the adverse effects of smokeless tobacco and e-cigarettes may seem comparatively benign to them.

It is a myth that smokeless tobacco is “less dangerous” than other products where tobacco is burnt and nicotine absorbed through the lungs. The long-term health effects of e-cigarette use are unknown. E-cigarettes have been touted as a smoking cessation treatment tool. However, when young people use e-cigarettes, there is a link to tobacco smoking later.

Appearance and Medical Issues with smokeless tobacco:

  • 50 times more likely to suffer from oral cancers
  • Leukoplakia (white mouth lesions that are precancerous)
  • Tooth decay (due to high levels of sugar in chew)
  • Stained and discolored teeth
  • Bad breath
  • Gum disease, recession (and eventually tooth loss)
  • Increased heart rate, blood pressure and epinephrine levels (Two times the risk of dying from cardiovascular disease compared to non-users.)
  • Other Cancers: kidney, pancreas, digestive system
  • Death

Smokeless tobacco use is often initiated and established during adolescence. A container of spit tobacco can have as much nicotine as 80 cigarettes, and studies have shown that smokeless tobacco users show symptoms of nicotine dependence at least as frequently as cigarette smokers. Smokeless tobacco use also serves as a gateway drug for cigarette smoking among young adult males, with both past and current users approximately 225 percent more likely to have initiated smoking than non-users. Evidence shows that smoking can then be a first step toward other substance abuse.

There has always been a link between sports and smokeless tobacco. A 1991 study demonstrated that about 50 percent of varsity baseball players and 25 percent of intramural baseball players used one or both forms of smokeless tobacco; the mean age for initiation of all tobacco products was 15 years old.

A large NCAA study published in 2001 showed that for the eight categories of substance use, smokeless tobacco was the thirdmost widely used at 22.5 percent (behind alcohol and marijuana), with wide variations according to sport. In rural areas, prevalence of smokeless tobacco use is about three times that of urban areas, and again is higher among subgroups of male students, such as rodeo athletes (42%), smokers (32%), wrestlers (19%), baseball players and Future Farmers of America members (18%), and football players (16%).

Fortunately, there has been a declining trend in smokeless tobacco use among adolescent males that parallels recent declines in smoking among that same group. In 2007, estimates for smokeless tobacco use indicated approximately 13 percent of male and 2.3 percent of female high school students were users. There has been a substantial decrease in use among 8th -, 10th - and 12th-grade students who perceive that regular smokeless tobacco use is harmful, which parallels their perceptions of cigarette smoking. Education can make a difference.

In order to prevent and reduce tobacco addiction in high school athletes, comprehensive school policies should include enforcement of tobacco-free campus environments, prohibiting tobacco use at all school facilities and events, and encouraging and helping students and staff to quit using tobacco. Unfortunately, the sad truth is that coaches, teachers and other role models are also smokeless tobacco users. The message sent to students is confusing: “It’s OK for us to use, but not for you to use.” For school policies to be most effective, enforcement must come from the topdown.

The Centers for Disease Control and Prevention have developed guidelines for school-based health programs to prevent tobacco use and addiction. These stress the importance of providing prevention education during the years when the risk of becoming addicted to tobacco is greatest, and offer opportunities for positive role modeling.

A coordinated school health program involving teachers, coaches, students, families, administrators and community leaders delivers consistent messages about tobacco use, including smokeless tobacco and e-cigarettes. Alcohol and substance use prevention and treatment programs should also address tobacco use. Well-developed programs can dramatically decrease the likelihood that a young person will be a regular tobacco user as an adult.

Campaign for Tobacco-Free Kids. The path to tobacco addiction starts at very young ages. Campaign for Tobacco-Free Kids, Washington DC. 2015. Available here. Accessed February 3, 2017.

Gingiss PL, Gottlieb NH. A comparison of smokeless tobacco and smoking practices of university varsity and intramural baseball players. Addictive behaviors. 1991 Jan 1;16(5):335-40.

Green GA, Uryasz FD, Petr TA, Bray CD. NCAA study of substance use and abuse habits of college student-athletes. Clinical journal of sport medicine. 2001 Jan 1;11(1):51-6.

Guidelines for School Health Programs to Prevent Tobacco Use: Summary. Accessed February 3, 2017.

Haddock CK, Vander Weg M, et al. Evidence that smokeless tobacco use is a gateway for smoking initiation in young adult males. Preventive medicine. 2001 Mar 31;32(3):262-7.

Nelson DE, Mowery P, Tomar S, et al. Trends in smokeless tobacco use among adults and adolescents in the United States. American Journal of Public Health. 2006 May;96(5):897-905.

Walsh MM, Langer TJ, Kavanagh N, et al. Smokeless tobacco cessation cluster randomized trial with rural high school males: Interventioninteraction with baseline smoking. Nicotine & Tobacco Research. 2010 Jun 1;12(6):543-50.

“FDA’s New Regulations for E-Cigarettes, Cigars, and All Other Tobacco Products”. US Department of Health and Human Services. US Food and Drug Administration. 12 August 2016

Mith L, Brar K, Srinivasan K, et al. E-cigarettes: how ”safe” are they?. Journal of Family Practice. 2016 Jun 1;65(6):380-6.