Are adults snoozing while kids are "snusing?"

I recently wrote a blog about hookah smoking—prompted by my sixteen-year-old son—about the practice among teenagers. When he read it online, his blasé response was that it was "so yesterday's news." The preferred method of tobacco in school these days, he said, is smokeless tobacco. In addition to chewing tobacco which comes in the form of loose leaf, plug or twist, the current rage is a less conspicuous product called "Snus", a non-chew, no-spit oral tobacco that's stuffed between the lip and gum.

One of the more popular brands, Camel Snus, manufactured by tobacco giant RJ Reynolds, is sold in tea-bag like pouches about the size of a lozenge. Teachers can't easily detect the pouches, so kids can fly under the radar when they use it in school. Even so, the habit has become so prevalent that there have been recent announcements on the loudspeaker at my son's high school reminding students that smokeless tobacco is a code of conduct violation. When I asked my son how common it was, he guessed that about 10 percent of the boys in his class were using it.

Although teens have been known to exaggerate, his estimate is actually under the national average. A Morbidity and Mortality Weekly Report released in June 2006, revealed that the prevalence of smokeless tobacco use is closer to 14 percent among high school-aged boys and a little over 2 percent among girls. The rate varied widely across states with 4.4% usage among male students in Maryland and 26.5% in West Virginia. Overall, the percentage was highest among white male students (17.6%) and rose each year from 9^th to 12^th grade among male students.

According to the CDC, smokeless tobacco carries four dangerous health effects:

• It contains 28 cancer-causing agents (carcinogens).
• It's a well- known cause of cancer, increasing the risk of cancer of the mouth.
• Oral health problems strongly associated with smokeless tobacco use are leukoplakia (a lesion of the soft tissue that consists of a white patch or plaque that cannot be scraped off) and recession of the gums.
• Smokeless tobacco use can lead to nicotine addiction and dependence and adolescents who use smokeless tobacco are more likely to become cigarette smokers.

It's quite possible that kids are unaware of these warnings. But last week, a 24-year old patient told me that he wished he had known more about the risks when he was using chewing tobacco in high school. When he tried to quit after six years, he found it impossible. He said that coaches and teachers had turned a blind eye to the habit, and that no one warned him that it could be harmful.

Several tobacco companies have banked on the lack of attention paid to smokeless tobacco—the five largest smokeless tobacco manufacturers spent a new record of $250.79 million on smokeless tobacco advertising and promotion during 2005 alone. Despite the 1998 Smokeless Tobacco Master Settlement Agreement—a legal settlement between the states and the tobacco companies prohibiting tobacco companies from taking "any action, directly or indirectly, to target Youth... in the advertising, promotion or marketing of tobacco products."—smokeless tobacco companies have continued to advertise in magazines with high youth readership. According to a new report published in the March 2008 issue of the American Journal of Public Health, magazines with high youth readership accounted for roughly 47 percent of all smokeless tobacco expenditures.

Tobacco-free kids, a non-profit organization dedicated to reducing tobacco use, advises that smokeless tobacco companies in the United States have a long history of creating new products that appeal to kids and marketing them aggressively. The U.S. Smokeless Tobacco Company markets candy-flavored spit tobacco including berry blend, mint, wintergreen, apple blend, vanilla blend and cherry. Indeed, it has been alleged that manufacturers have developed flavored products with lower nicotine concentrations to get users early so that they become dependent and seek out products with a higher nicotine concentration.

This so-called "graduation strategy" worked with my patient. By the time he had graduated from college, he had graduated to cigarettes.

Read our free facts about smoking and our complete Treatment Ratings and Natural Medicine Ratings (subscribers only) on how to quit .

—Orly Avitzur, M.D., medical adviser to Consumers Union