No Smoke, but Plenty of Danger
By now, most of us know that smoking
cigarettes isn't healthy: The smoke you
inhale contains toxic compounds that
increase your risk of lung cancer. But what
about smokeless tobacco? Is that "little
pinch" really going to hurt you?
Yes. Smokeless tobacco "is basically as
harmful as cigarettes," says Andres Pinto,
D.D.S., D.M.D., of the University of
Pennsylvania School of Dental Medicine.
"People think it's not going to your lungs
so it's OK, but if you use it for a long
enough time, you'll increase your odds of
acquiring oral and lung cancer."
In the United States, about 4 percent of men
and less than 1 percent of women use
smokeless tobacco. The rate varies by state.
For example, 18.4 percent of men in West
Virginia use smokeless tobacco, but only 2.6
percent of men in Arizona use it.
Rates of smokeless tobacco use among U.S.
adults are highest in young men, American
Indians, and people who live in the South or
in rural areas.
Overall, about 22 million Americans use
smokeless tobacco, which comes in three
basic forms: chew, snuff and plug. Chew, or
chewing tobacco, consists of shredded
tobacco leaves; snuff is loose ground
tobacco leaves; and a plug is a firm
compressed chunk of ground tobacco leaves.
Sugar, salts or flavorings sometimes are
added to improve the taste.
Just like cigarettes, smokeless tobacco
contains chemicals. But unlike cigarettes,
smokeless tobacco is in direct contact with
the tissues in your mouth. This may make
smokeless tobacco even more addictive than
cigarettes, because nicotine — the addictive
substance in tobacco — enters your
bloodstream faster. Holding smokeless
tobacco in your mouth for 30 minutes exposes
you to the same amount of nicotine as
smoking four cigarettes.
Using smokeless tobacco heavily or for a
long time dramatically increases your risk
of developing oral cancer. "The most common
site [for oral cancer] is the tongue,
followed by the cheek on the side that you
put the tobacco," Dr. Pinto says.
As little as one year of use can cause a
white patch to develop in your mouth. These
patches should be biopsied, because they may
contain cancer cells. Don't wait for
symptoms before you visit your doctor: Until
it spreads, oral cancer causes no symptoms.
Using smokeless tobacco can cause other
▪ Smokeless tobacco is a breeding ground for
bacteria, collects food
and other debris, and sits in your mouth for hours at a time.
▪ Using smokeless tobacco has been
associated with receding gums
and periodontal disease, although these conditions also depend
on how well you take care of your teeth.
▪ The area where the tobacco sits can become
unusually dry, which
increases your risk of tooth decay.
▪ Using smokeless tobacco can reduce your
senses of taste and
smell, and can contribute to bad breath and discolored teeth.
▪ You are more likely to get a coating of
bacteria and debris on your
tongue if you use smokeless tobacco. An advanced stage of this
called black hairy tongue. Your risk of these conditions
decreases if you
practice good oral-hygiene habits.
When you see the warning on cigarette
packages — "Quitting smoking now greatly
reduces serious risks to your health" — what
comes to mind? Lung cancer, probably.
Emphysema, maybe. But, did you know that
smoking is a huge factor in gum disease,
which can lead to serious oral problems,
including the loss of your teeth?
"Smoking is a major risk factor for
developing periodontal (gum) disease," says
Jonathan Korostoff, D.M.D., Ph.D., an
assistant professor in the department of
periodontics at the University of
Pennsylvania School of Dental Medicine. "In
fact, when you look at the scientific
literature on gum disease, smoking
supersedes any other risk factor that has
been identified to date."
Not only does smoking increase the chance
that you will develop gum disease, it makes
treatment much more difficult and less
likely to be successful. Smoking also
lessens your mouth's ability to heal, so
much so that many dentists refuse to
consider implants in patients who smoke.
Periodontal disease is a bacterial infection
that destroys soft tissue and bone that
anchors your teeth to your jawbones. It
occurs when bacterial plaque forms on the
teeth. In early stages of the disease, you
may notice that your gums bleed when you
brush or floss. As the infection worsens,
your gums begin to break down and pull away
from your teeth, forming pockets. Later, the
pockets between your teeth and gums deepen
as more of the supporting structures are
destroyed. Ultimately, your teeth may become
loose, painful and may even fall out.
Studies have shown that smokers have more
calculus (tartar), more severe bone loss and
more deep pockets between their teeth and
gums compared to nonsmokers, according to an
analysis by the American Academy of
Periodontology. Among specific findings,
smokers were 2.6 to 6 times more likely to
have gum destruction than nonsmokers, and
severe bone loss was 4.7 times greater among
current or former heavy smokers as compared
to people who never smoked.
Researchers still are studying just what
smoke does to oral tissues, but it appears
to interfere with basic functions that fight
disease and promote healing.
"It appears that certain compounds in the
smoke affect the normal function of the
cells in gum tissue, making smokers more
susceptible to an infection like periodontal
disease," Dr. Korostoff says. "Smoking also
seems to impair blood flow to the gums which
may affect periodontal wound healing."
One reason smokers are more likely to lose
their teeth if they get periodontal disease
is that smoking can slow the healing process
after periodontal treatment or any kind of
oral surgery. One study found that smokers
were twice as likely as nonsmokers to lose
teeth in the five years after completing
periodontal therapy. Additionally, the
American Academy of Periodontology reports
that in most studies of non-surgical
periodontal treatment, smokers showed less
improvement than nonsmokers. Smokers also
responded less favorably than nonsmokers to
It is not just cigarette smokers who are at
risk. All tobacco products, including pipe
tobacco, smokeless tobacco and cigars, can
affect the health of your gums. One study,
reported in the January 1999 issue of the
Journal of the American Dental Association,
showed cigar smokers lose teeth and bone at
rates equal to cigarette smokers. In
addition, experts say pipe smokers
experience similar rates of tooth loss as
cigarette smokers and smokeless tobacco can
cause the gums to recede, increasing the
chance of losing the bone and fibers that
hold teeth in place.
The only good news about smoking and the
health of your teeth and gums is that the
Surgeon General's warning holds true —
quitting now does greatly reduce serious
risks to your health. In a recent study, 11
years after quitting, former smokers'
likelihood of having periodontal disease was
not significantly different from people who
Even reducing the amount you smoke seems to
help. One study found that people who smoked
more than a pack and a half per day were six
times more likely to have periodontal
disease than nonsmokers, while those who
smoked less than a half pack per day had
only three times the risk.
"When I see patients who smoke, whether they
are light or heavy smokers, I tell them I
think they should stop. I see the
destruction it can do," stresses Dr.
Korostoff. "While the past effects of
smoking on the gums can not be reversed,
cessation is beneficial to periodontal
health and is a major preventable risk
factor to periodontal disease."
Tobacco use may pose the greatest threat to
your health as a risk factor for oral
cancer. The American Cancer Society reports
About 90 percent of people with mouth cancer
and some types of throat cancer have used
tobacco. The risk of developing these
cancers increases with how much is smoked or
chewed and the length of the habit.
Smokers are six times more likely than
nonsmokers to develop these cancers.
About 37 percent of patients who continue to
smoke after cancer treatment will develop
second cancers of the mouth, throat or
larynx, compared to only six percent of
those who stop smoking.
Tobacco smoke from cigarettes, cigars or
pipes can cause cancers anywhere in the
mouth or the part of the throat just behind
the mouth, as well as cancers of the larynx,
lungs, esophagus, kidneys, bladder and
several other organs. Pipe smoking also can
cause cancer in the area of the lips that
contact the pipestem.
Smokeless tobacco is associated with cancers
of the cheek, gums and inner surface of the
lips. Smokeless tobacco increases the risk
of these cancers by nearly 50 times.
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