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Smokeless tobacco is used by approximately 5 million U.S. adults. Most users are teenage (20 percent of male high school students) and young adult males, who are often emulating a professional sports figure or a family member. There are two types of smokeless tobacco -chewing tobacco and snuff. Chewing tobacco comes in three forms: loose leaf, plug, or twist. Chewing tobacco contains tobacco leaves treated with molasses and other flavorings. The user places a "quid" of tobacco in the mouth between the teeth and gums and then sucks or chews the quid to release the nicotine. Once the quid becomes ineffective, the user spits it out and inserts another. Dipping is another method of using chewing tobacco. The dipper takes a small amount of tobacco and places it between the lower lip and teeth to stimulate the flow of saliva and release the nicotine. Dipping rapidly releases the nicotine into the bloodstream. sundrugstore.com

Snuff can come in either a dry or moist powdered form 'or sachets (tea bag-like pouches) of tobacco. The most common placement of snuff is inside the cheek. In European countries, inhaling dry snuff is more common than in the United States.

Smokeless tobacco is just as addictive as cigarettes because of its nicotine content. There is nicotine in all tobacco products, but smokeless tobacco contains more nicotine than do cigarettes. Holding an average-sized dip or chew in the mouth for 30 minutes delivers as much nicotine as smoking four cigarettes. A two-can-a-week snuff dipper gets as much nicotine as a one-and-a-half-pack-a-day smoker.

One of the major risks of chewing tobacco is leukoplakia, a condition characterized by leathery white patches inside the mouth produced by contact with irritants in tobacco juice. Smokeless tobacco contains 10 times the amount of cancer-producing substances found in cigarettes and 100 times more than the Food and Drug Administration allows in foods and other substances used by the public. Between 3 and 17 percent of diagnosed leukoplakia cases develop into oral cancer. It is estimated that 75 percent of the 30,000 oral cancer cases in 1999 resulted from either smokeless tobacco or cigarettes. Users of smokeless tobacco are 50 times more likely to develop oral cancers than are nonusers. Warning signs of oral cancers include lumps in the jaw or neck area; color changes or lumps inside the lips; white, smooth, or scaly patches in the mouth or on the neck, lips, or tongue; a red spot or sore on the lips or gums or inside the mouth that does not heal in two weeks; repeated bleeding in the mouth; and difficulty or abnormality in speaking or swallowing.

The lag time between first use and contracting cancer is shorter for smokeless tobacco users than for smokers because absorption through the gums is the most efficient route of nicotine administration. A growing body of evidence suggests that long-term use of smokeless tobacco also increases the risk of cancer of the larynx, esophagus, nasal cavity, pancreas, kidney, and bladder. Moreover, many smokeless tobacco users eventually "graduate" to cigarettes.

Chewers and dippers do not face the specific hazards associated with heat and smoke, but they do run other tobacco-related risks. The stimulant effects of nicotine may create the same circulatory and respiratory problems for chewers as for smokers. Chronic smokeless tobacco use also results in delayed wound healing, peptic ulcer disease, and reproductive disturbances.

Like smoked tobacco, smokeless tobacco also impairs the senses of taste and smell, causing the user to add salt and sugar to food, which may contribute to high blood pressure and obesity. Some smokeless tobacco products contain high levels of sodium (salt), which also contributes to high blood pressure. In addition, dental problems are common among users of smokeless tobacco. Contact with tobacco juice causes receding gums, tooth decay, bad breath, and discolored teeth. Damage to both the teeth and jawbone can contribute to early loss of teeth. Users of all tobacco products may not be able to use the vitamins and other nutrients in food effectively. In some cases, vitamin supplements may be recommended by a physician.

Smokeless tobacco users have the same problems that smokers do when trying to quit. Withdrawal symptoms are almost universal; relapse is common. Some or many of the following symptoms often accompany nicotine withdrawal: headache, gastrointestinal discomfort, sleeping problems, irritability, anxiety, aggressiveness, craving for tobacco, and a reduction in heart rate, blood pressure, and hormone secretions.

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