Note On Smokeless Tobacco

To the extent that chewing tobacco and dipping snuff can cause nicotine to be delivered to the brain in sufficient doses, they present a similar risk of nicotine dependence in the regular user. These products may prove more difficult to treat than cigarette use, because they are sometimes viewed as less risky alternatives to cigarettes. One study quoted in a Surgeon General's report on smoking reported that 77 percent of youth thought that cigarette smoking was very harmful, but only 40 percent rated smokeless tobacco as very harmful. Once the ''negative publicity'' on smokeless tobacco use reaches a level close to the bad press on smoking, there should be a growing demand for using the smoking therapies as treatments for the use of smokeless tobacco.

In addition to the problems associated with nicotine addiction, smokeless tobacco can cause bleeding gums and sores of the mouth that never heal. It is also associated with cancer. Smokeless tobacco also stains the teeth a dark yellow-brown color, gives the user bad-smelling breath, and can cause dizziness, hiccups, and vomiting in the individual. A further risk associated with smokeless tobacco is that youth who use it are more likely to try smoking than those who do not use it.

(See also: Addictions: Concepts and Definitions; Nicotine Delivery Systems for Smoking Cessation; Tobacco: Treatment Types)

BIBLIOGRAPHY

CINCIRIPINI, P. M., McClURE, J. B. (1998). Smoking Cessation: Recent Developments in Behavioral and Pharmacologic Interventions, Oncology, 12. Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (2000). Monitoring the Future national survey results on drug use, 1975-1999 Volume I: Secondary school students (NIH Publication No. 00-4802). Rockville, MD: National Institute on Drug Abuse. SCHWARTZ, J. L. (1987). Review and evaluation of smoking cessation methods: The United States and Canada, 1978-1985. Washington, DC: Division of Cancer Prevention and Control, National Cancer Institute.

U.S. Department of Health and Human Services. (1990). The health benefits of smoking cessation: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (1989). Reducing the health consequences of smoking: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2000). Reducing tobacco use: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (1988). The health consequences of smoking: Nicotine addiction: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office. U.S. Department of Health, Education and Welfare. (1979). Smoking and health: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office.

Lynn T. Kozlowski Revised by Patricia Ohlenroth

Tobacco, Pharmacotherapy Although tobacco use causes a powerful addiction, people who want to stop using it can be helped, and at far less expense than treatment of tobacco-caused dis-eases—which will kill approximately one in two smokers who do not quit. The effort to find pharmacological agents that would help tobacco users quit is not a new development. In the late 1890s and early 1900s, a number of potent medicines were advertised as being useful for reducing tobacco craving and helping break the habit. Such advertising was possible because at the time there were no regulations requiring a seller to demonstrate that the product was effective. None of the products offered to the public between the early 1900s and the late 1970s were demonstrably better than placebos in helping smokers quit. Effective pharmacological approaches to treating nicotine addiction, including transdermal patches that deliver nicotine through the skin, and resin complexes (gum) that release nicotine when chewed, were among the important medical advances of the 1980s and 1990s. To understand how pharmacotherapy works, it is necessary to understand the role of Nicotine in the addiction to tobacco.

Nicotine is a naturally occurring alkaloid present in the tobacco leaf. It is a small lipid and water-soluble molecule, rapidly absorbed through the skin and mucosal lining of the mouth and nose or by inhalation in the lungs. In the lungs, nicotine is rapidly extracted from tobacco smoke within a few seconds because of the massive area for gas exchange in the alveoli; it is passed into the pulmonary veins, and pumped through the left ventricle of the heart into the arterial circulation within another few seconds. Within 10 seconds, a highly concentrated bullet (bolus) of nicotine-rich blood reaches organs such as the brain as well as the fetus of a pregnant woman. Arterial blood levels may be ten times higher than venous levels within 15 to 20 seconds after smoking. Nicotine arterial boli from smoking a single cigarette may be three to five times more concentrated than the low, steady levels obtained from nicotine gum or patch systems. These spikes probably contribute to the pleasure sought by the cigarette smoker, but, fortunately, they are not necessary to relieve withdrawal symptoms. Nicotine Gum and patches, which provide more steady nicotine levels without arterial spikes, may selectively relieve withdrawal without the highly addictive nicotine spikes produced by cigarettes. Although Smokeless Tobacco users do not obtain the same rapid nicotine increase as smokers, they may, by repeatedly putting new ''pinches'' in their mouths, achieve stable nicotine levels higher than those typical of smokers.

Most cigarettes on the U.S. market contain 8 to 9 milligrams (mg) of nicotine, and the average smoker obtains 1 to 2 mg per cigarette. In general, the type of cigarette or nicotine delivery rating reported by the manufacturer bears almost no relation to the level of nicotine obtained by the typical smoker, because smokers may change their behavior to compensate for differences in cigarette brands. For example, they may take additional puffs on low-nicotine brands.

Cigarette smoking produces rapid and large physiological changes, but, to a lesser extent, smokeless tobacco produces similar effects. Nicotine gum and patch treatments have the advantages of much slower nicotine delivery, and they produce less severe physiological changes. This slower delivery rate may be less pleasurable to the tobacco user, but the user is less likely to have difficulty giving up the gum or the patch after treatment.

Tobacco-caused cancer may be considered a side effect of nicotine dependence in much the same way that Acquired Immunodeficiency Syndrome (AIDS) may occur as a side effect of heroin dependence. In both cases, the exposure to the disease-causing toxins or to HIV occurs repeatedly and often frequently because individuals are dependent on a drug that has reduced (if not nearly eliminated) their ability to abstain from the highly contaminated drug delivery system they know may lead to disease and premature death.

The physiological basis of drug dependence became increasingly well understood in the past few decades and especially with regard to nicotine dependence in the 1970s and 1980s. Awareness of the physiology of nicotine dependence can help researchers understand the problems faced by people attempting to give up tobacco and can provide a more rational basis for the development of treatment programs that may prevent the occurrence of cancer and other diseases or contribute to remission in people who have been treated for cancer.

Tolerance as a result of repeated nicotine exposure is a crucial factor in the development of lung and other cancers. Essentially, smokers self-administer much greater amounts of tobacco-delivered toxins than would be the case if they had not developed tolerance. In turn, with development of nicotine dependence, smokers come to feel normal, comfortable, and most effective when taking the drug and to feel unhappy and ineffective when deprived of the drug. This process makes it more difficult to achieve and sustain even short-term abstinence.

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