Oral Cancer on Rise

by Food and Drug Administration (FDA)

The seventh most common cancer — oral cancer — may be on the rise because of the increased use of snuff and chewing tobacco, or "smokeless tobacco," among teenage boys.

Oral cancer occurs on the lip, tongue, or floor of the mouth. Smoking and drinking also increase the risk of oral cancer, but smokeless tobacco is of special concern because of its appeal to teenage boys.

Smokeless tobacco comes in two basic forms: finely ground tobacco or snuff, and loose leaf tobacco sold in pouches or plugs. An estimated 16 million Americans use smokeless tobacco, 3 million of whom are under 21. Sixteen percent of all males between the ages of 12 and 17 used smokeless tobacco in 1985, according to the American Academy of Otolaryngology — Head and Neck Surgery. The habit has filtered down to even younger ages in some localities: A University of North Carolina study showed that one-third of the first-grade boys in rural North Carolina had tried smokeless tobacco. And according to another study, 21 percent of 112 Arkansas kindergartners had indulged.

Chewing tobacco, a habit commonly associated with elderly gentlemen and southern farmers, caught on among teenagers in the mid-1970s when U.S. Tobacco Company (the major manufacturer of smokeless tobacco) began an aggressive ad campaign especially targeted towards young men. Endorsements by such sports heroes as Catfish Hunter (a former New York Yankee pitcher), Earl Campbell (former running back for the Houston Oilers), and Walt Garrison (former running back, Dallas Cowboys) promoted smokeless tobacco and changed its image. In a growing number of youthful circles, smokeless tobacco became a socially acceptable symbol of virility, machismo and coolness.

In a further bid to attract teenagers, U.S. Tobacco Co. offered free samples of smokeless tobacco and concocted low-nicotine and fruit-flavored brands. (One "adult" brand, for instance, has seven times the amount of nicotine as the "junior brands," and most young boys who might first experiment with the adult brand would end up nauseous.)

By 1985, tobacco's opponents began striking back. In that year, Massachusetts became the first state to require warning labels on smokeless tobacco. Other states considered similar action. Federal legislation requiring uniform labeling was passed in l986. Dentist Greg Connolly, D.M.D., a leading opponent of smokeless tobacco and director of the Office for Nonsmoking and Health in Massachusetts, pressured U.S. Tobacco to stop using current sports heroes to endorse smokeless tobacco products.

Though proponents claim that smokeless tobacco is a safe alternative to smoking, the 1986 Report of the Advisory Committee to the Surgeon General doesn't see it that way. Smokeless tobacco is causally related to oral cancer, says the report. In fact, the report says that the increased risk of cancer of the cheek and gums may reach nearly fiftyfold among long-term snuff users.

Nitrosamines, the chief cancer-causing compounds in smokeless tobacco, are contained in the tobacco. A dip of snuff, for instance, delivers 10 times more nitrosamines than a cigarette.

Despite this risk, the habit is attractive for many users. Jared Taylor of Menlo Park, Calif., a fourth-generation chewer who quit after 15 years because of his concern over the link between chewing tobacco and cancer, nevertheless admits he misses his habit. "We were always a very religious family and thought smoking was a sin — it had to be a sin to burn up anything that tasted that good," says Taylor wryly.

Precancerous signs, such as leukoplakia (a white plaque on the gums, cheek or roof of the mouth) may appear after only one year of use. Once oral cancer strikes, it can spread rapidly — and "the first stop is the neck," says Jerome Goldstein, M.D., executive vice president of the American Academy of Otolaryngology.

"Head and neck surgery can mutilate and affect function," says Connolly. "If the cancer is not caught early enough, a person can lose his teeth, salivary glands, portions of his jaw, or sections of the neck or cheek." The tongue may also have to be cut out — and the person is rendered speechless or speaks in a garbled manner, according to Connolly.

Although sports heroes no longer endorse smokeless tobacco products, baseball players remain major users. A recent survey of 282 major league baseball players published in the )INew England Journal of Medicine )Rshowed that over half were past or current users of smokeless tobacco. In a baseball tradition going back to Babe Ruth, who was a heavy snuff dipper, the bulge in the back pocket — a tin of snuff or chewing tobacco — is a familiar sight on the baseball field. (Ruth, who also smoked, died of throat cancer.)

The American Academy of Otolaryngology has launched a campaign to warn the public — and especially teenage boys — about the dangers of smokeless tobacco. The academy has also formed an organization called "Athletes Through With Chew," whose spokesmen are all-star pitcher Nolan Ryan of the Texas Rangers and Bobby Brown, M.D., president of the American Baseball League.

The teenage set is at risk. William Frederick McGuirt, M.D., a head and neck surgeon at the Bowman Gray School of Medicine in Winston-Salem, N.C., says he is seeing more and younger smokeless tobacco users with either pre-malignant signs of cancer or dental problems such as receding gums.

Most scientists predict that though it will take 20 or 30 years for the rate of oral cancer to increase due to current smokeless tobacco use, such an increase is inevitable.

As Connolly says, "oral cancer is a time bomb ticking away in the mouths of adolescents."

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