Cancer Causes & Control

, Volume 16, Issue 4, pp 347–358 | Cite as

Two large prospective studies of mortality among men who use snuff or chewing tobacco (United States)

  • S. Jane. Henley
  • Michael J. Thun
  • Cari Connell
  • Eugenia E. Calle


Background: Few prospective studies have examined the health risks associated with use of snuff and chewing tobacco.

Methods: We studied the association between the use of spit tobacco (snuff or chewing tobacco) and mortality among men enrolled in Cancer Prevention Study I (CPS-I) in 1959 or Cancer Prevention Study II (CPS-II) in 1982. Analyses were based on men who reported exclusive use of snuff or chewing tobacco (7745 in CPS-I, 3327 in CPS-II) or no previous use of any tobacco product (69,662 in CPS-I, 111,482 in CPS-II) at baseline. Twelve-year follow-up of CPS-I, and 18-year follow-up of CPS-II identified 11,871 and 19,588 deaths, respectively. Cox proportional hazards models were used to control for age and other covariates.

Results: Men who currently used snuff or chewing tobacco at baseline had higher death rates from all causes than men who did not in both CPS-I (hazard ratio [HR]=1.17, 95% CI=1.11–1.23) and CPS-II (HR=1.18, 95% CI=1.08–1.29). In CPS-I, current use of spit tobacco was statistically significantly associated with death from coronary heart disease (CHD), stroke, and diseases of the respiratory, digestive, and genitourinary systems, but not with death from cancer. In CPS-II, use of these products was significantly associated with death from CHD, stroke, all cancers combined, lung cancer, and cirrhosis. The associations with cardiovascular and other non-malignant endpoints were attenuated, but not eliminated, by controlling for measured covariates. Former use of spit tobacco was not associated with any endpoint in CPS-II. No clear dose response was observed with either the frequency or duration of usage for any endpoint.

Conclusions: These two prospective studies provide limited evidence that current use of chewing tobacco or snuff may increase mortality from heart disease and stroke.


mortality tobacco 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Substance Abuse and Mental Health Services Administration (2004) Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies, NSDUH Series H-25, DHHS Publication No. SMA 04–3964.Google Scholar
  2. 2.
    U.S. Department of Health and Human Services (1986) The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services,National Institutes of Health, National Cancer Institute.Google Scholar
  3. 3.
    Tomar, SL 2003Trends and patterns of tobacco use in the United StatesAm J Med Sci326248254PubMedGoogle Scholar
  4. 4.
    Bell, RA, Spangler, JG, Quandt, SA 2000Smokeless tobacco use among adults in the SoutheastSouth Med J93456462PubMedGoogle Scholar
  5. 5.
    U.S. Department of Health and Human Services (2002) 10′th Report on Carcinogens: U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program.Google Scholar
  6. 6.
    Critchley, JA, Unal, B 2003Health effects associated with smokeless tobacco: a systematic reviewThorax58435443PubMedGoogle Scholar
  7. 7.
    Huhtasaari, F, Asplund, K, Lundberg, V, Stegmayr, B, Wester, PO 1992Tobacco and myocardial infarction: is snuff less dangerous than cigarettes?BMJ Med J30512521256Google Scholar
  8. 8.
    Bolinder, G, Alfredsson, L, Englund, A, Faire, U 1994Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workersAm J Public Health84399404PubMedGoogle Scholar
  9. 9.
    Huhtasaari, F, Lundberg, V, Eliasson, M, Janlert, U, Asplund, K 1999Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged menJ Am Coll Cardiol3417841790PubMedGoogle Scholar
  10. 10.
    Asplund, K, Nasic, S, Janlert, U, Stegmayr, B 2003Smokeless tobacco as a possible risk factor for stroke in men: a nested case-control studyStroke3417541759PubMedGoogle Scholar
  11. 11.
    Wallenfeldt, K, Hulthe, J, Bokemark, L, Wikstrand, J, Fagerberg, B 2001Carotid and femoral atherosclerosis, cardiovascular risk factors and C-reactive protein in relation to smokeless tobacco use or smoking in 58-year-old menJ Int Med250492501Google Scholar
  12. 12.
    Ahlbom, A, Olsson, UA, Pershagen, G 1997Halsorisker med snus (Health risks by snuff). Position paperSwedish National Board of Health and WelfareStockholmGoogle Scholar
  13. 13.
    Accortt, NA, Waterbor, JW, Beall, C, Howard, G 2002Chronic disease mortality in a cohort of smokeless tobacco usersAm J Epidemiol156730737PubMedGoogle Scholar
  14. 14.
    Thun M, Day-Lally C, Meyers D, et al. (1992) Trends in tobacco smoking and mortality from cigarette use in Cancer Prevention Studies I (1959 through 1965) and II (1982 through 1988). In: Shopland D, Burns D, Garfinkel L, Samet J, eds. National Cancer Institute. Changes in Cigarette-related Disease Risks and Their Implication for Prevention and Control. Smoking and Tobacco Control Monograph No. 8. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Pub No. 97-4213, pp. 305–382.Google Scholar
  15. 15.
    Hammond, E 1966Smoking in relation to the death rates of one million men and womenHaenszel, W eds. Epidemiologic Approaches to the Study of Cancer and Other Chronic Diseases. Natl Cancer Inst Monogr 19.US Department of health, Education, and WelfareRockville, MD127204Google Scholar
  16. 16.
    Garfinkel, L 1985Selection, follow-up and analysis in the American Cancer Society prospective studiesMonogr Natl Cancer Inst674952Google Scholar
  17. 17.
    Stellman, SD, Garfinkel, L 1986Smoking habits and tar levels in a new American Cancer Society prospective study of 1.2 million men and womenJ Natl Cancer Inst7610571063PubMedGoogle Scholar
  18. 18.
    Thun, M, Calle, E, Rodriguez, C, Wingo, P 2000Epidemiological research at the American Cancer SocietyCancer Epidemiol Biomark Prev9861868Google Scholar
  19. 19.
    Calle, E, Terrell, D 1993Utility of the National Death Index for ascertainment of mortality among Cancer Prevention Study II particpantsAm J Epidemiol137235241PubMedGoogle Scholar
  20. 20.
    World Health Organization. International Classification of Diseases (1957) Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. 7th rev. Vol. 1. Geneva: World Health Organization.Google Scholar
  21. 21.
    World Health Organization (1977). International Classification of Diseases, Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. 9th rev. Vol. 1. Geneva: World Health Organization.Google Scholar
  22. 22.
    IARC2004Tobacco Smoke and Involuntary SmokingInternational Agency for Research on CancerLyonVol. 83.Google Scholar
  23. 23.
    U.S. Department of Health and Human Services (2004) The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.Google Scholar
  24. 24.
    Cox, D 1972Regression models and life tablesJ R Stat Soc34187220Google Scholar
  25. 25.
    Breslow, N, Day, N 1980Statistical Methods in Cancer Research. The Analysis of Case-Control StudiesInternational Agency for Research on CancerLyon, FranceVol. 1.Google Scholar
  26. 26.
    Stockwell, H, Lyman, G 1986Impact of smoking and smokeless tobacco on the risk of cancer of the head and neckHead Neck Surg9104110PubMedGoogle Scholar
  27. 27.
    Winn, DM, Blot, WJ, Shy, CM, Pickle, LW, Toledo, A, Fraumeni, JF,Jr 1981Snuff dipping and oral cancer among women in the southern United StatesNew Engl J Med304745749PubMedGoogle Scholar
  28. 28.
    Sankaranarayanan, R, Duffy, S, Day, N, Nair, M, Padmakumary, G 1989A case-control investigation of cancer of the oral tongue and the floor of the mouth in southern indiaInt J Cancer60617621Google Scholar
  29. 29.
    Sankaranarayanan, R, Duffy, S, Padmakumary, G, Day, N, Padmanabhan, T 1969Tobacco chewing, alcohol and nasal snuff in cancer of the gingiva in Kerala, IndiaBrit J Cancer60638643Google Scholar
  30. 30.
    Sankaranarayanan, R, Duffy, SW, Day, NE, Nair, MK, Padmakumary, G 1989A case-control investigation of cancer of the oral tongue and the floor of the mouth in southern IndiaInt. J. Cancer44617621PubMedGoogle Scholar
  31. 31.
    Sankaranarayanan, R, Duffy, S, Padmakumary, G, Day, N, Nair, M 1990Risk factors for cancer of the buccal and labial mucosa in Kerala, southern IndiaJ Epidemiol Commun Health44286292Google Scholar
  32. 32.
    Dikshit, RK, Buch, JG, Mansuri, SM 1987Effect of tobacco consumption on semen quality of a population of hypofertile malesFertil Steril48334336PubMedGoogle Scholar
  33. 33.
    Rao, DN, Ganesh, B, Rao, RS, Desai, PB 1994Risk assessment of tobacco, alcohol and diet in oral cancer–a case-control studyInt J Cancer58469473PubMedGoogle Scholar
  34. 34.
    Gupta, PC, Mehta, FS, Irani, RR 1980Comparison of mortality rates among bidi smokers and tobacco chewersIndian J Cancer17149151PubMedGoogle Scholar
  35. 35.
    Gupta, PC, Mehta, FS, Daftary, DK,  et al. 1980Incidence rates of oral cancer and natural history of oral precancerous lesions in a 10-year follow-up study of Indian villagersCommun Dent Oral Epidemiol8283333Google Scholar
  36. 36.
    Idris, AM, Ahmed, HM, Malik, MO 1995Toombak dipping and cancer of the oral cavity in the Sudan: a case-control studyInt J Cancer63477480PubMedGoogle Scholar
  37. 37.
    Lewin, F, Norell, SE, Johansson, H,  et al. 1998Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in SwedenCancer8213671375PubMedGoogle Scholar
  38. 38.
    Schildt, EB, Eriksson, M, Hardell, L, Magnuson, A 1998Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control studyInt J Cancer77341346PubMedGoogle Scholar
  39. 39.
    IARC1985Tobacco Habits Other than Smoking; Betel-Quid and Areca Nut Chewing; and Some Related NitrosaminesInternational Agency for Reseach on CancerLyonVol. 37.Google Scholar
  40. 40.
    National Cancer Institute2004SEER Cancer Statistics Review, 1975–2001US Department of Health and Human Services, Public Health ServiceBethesda, MDGoogle Scholar
  41. 41.
    Rodu, B, Cole, P 2002Smokeless tobacco use and cancer of the upper respiratory tractOral Surg Oral Med Oral Pathol Oral Radiol Endod93511515PubMedGoogle Scholar
  42. 42.
    Foulds, J, Ramstrom, L, Burke, M, Fagerstrom, K 2003Effect of smokeless tobacco (snus) on smoking and public health in SwedenTob Control12349359PubMedGoogle Scholar
  43. 43.
    U.S. Smokeless Tobacco Company Request for Advisory Opinion (2002) reqadvisoryop.pdf (accessed September 13, 2002).Google Scholar

Copyright information

© Springer 2005

Authors and Affiliations

  • S. Jane. Henley
    • 1
  • Michael J. Thun
    • 1
  • Cari Connell
    • 1
  • Eugenia E. Calle
    • 1
  1. 1.Epidemiology and Surveillance ResearchAmerican Cancer SocietyAtlantaUSA

Personalised recommendations