Smokeless tobacco (also called spit tobacco) has long been associated with baseball. In 1988, Connolly et al. (3) found a current use rate of 34% among 282 major league baseball players surveyed. Subsequent work by others has shown use rates varying from 24.8 to 46% (3,5,7,16-18). The use rate in the general population was 3.4% in the 2000 National Household Survey on Drug Abuse (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, http://www.samhsa.gov/oas/NHSDA/2kNHSDA/chapter4.htm). Baseball players are a high-risk group and as such are excellent subjects for an investigation of the health effects of tobacco.
The harmful effects of smokeless tobacco are well known. A report from the Surgeon General in 1986 affirmed the clear association between smokeless tobacco use and oral cancer. The report also linked smokeless tobacco use to oral leukoplakia, gingival recession, and nicotine dependence and suggested that it may play a contributory role in the development of coronary artery disease, peripheral vascular disease, hypertension, peptic ulcers, and fetal mortality and morbidity (14).
The first study of the health effects of smokeless tobacco in baseball players was by Ernster et al. (4). They examined over 1000 players and found a high prevalence of oral leukoplakia, with 46% of smokeless tobacco users having these lesions on examination. We conducted a similar study in a professional baseball organization in 1990 and found oral leukoplakia in 28.4% of all current users compared with 6.0% in nonusers (18). We now report on our findings in this same organization over the following decade.
Each year, the Pittsburgh Pirates baseball club conducts its spring training camp in Bradenton, FL. Players and coaches are present from the organization's rookie league club, two single A teams, one double A team, one triple A team, and the major league baseball team. Typically, between 200 and 250 men attend spring training. The smokeless tobacco study was incorporated as part of the preparticipation evaluation of all personnel. The institutional review board of the principal investigator's home institution reviewed the protocol and approved the study design. Permission for the study was obtained from the management, who were aware of the study and its purpose. Participation by the players and coaches was on a voluntary basis.
Before their physical examination, participants were asked to complete a questionnaire about their use of tobacco. A detailed oral cavity examination was then performed using a bright, handheld light and a tongue depressor. All examinations during the 10-yr study were performed by only two examiners (K.S. and J.G.C.) and were entered onto a standardized oral cavity examination form. The examiners were blinded to the questionnaire results. If a leukoplakia lesion was detected, it was classified into one of three grades. The classification system shown below was modified from the previous classification systems used by Greer and Poulson (8) and Axell et al. (1,2) and was used in our pilot study in 1990 (18).
- Grade I: superficial lesion with color similar to surrounding mucosa with slight wrinkling and no obvious thickening.
- Grade II: superficial whitish or reddish lesion with moderate wrinkling and no obvious thickening.
- Grade III: red or white lesion with intervening furrows of normal mucosal color, obvious thickening, and wrinkling.
Summary statistics are given for all the outcome variables. Categorical variables, such as the presence of leukoplakia, were analyzed by their frequencies. Comparison was made between categorical variables in year 1 versus year 10 of the study using a chi-square test of proportions.
We performed 2266 mouth examinations on participants who had completed the questionnaire. The sample size each year ranged from 190 to 259. The study group is considered a representative sample because over 90% of men in training camp participated in the study each year. Demographics of the population can be found in Table 1.
There is considerable turnover in a professional baseball organization due to trades, retirement, and release of contracts. We estimate that in our population, 20-25% of the participants each year are new. As a result, approximately every 5 yr the organizational roster is almost completely different.
The use of smokeless tobacco products showed a clear decrease during the 10 yr of the study. In 1991, 41.1% of participants described themselves as current users of smokeless tobacco; by 2000, this figure was down to 25.6% (P = 0.029) (Fig. 1). Many of the participants use tobacco only during the baseball season, quitting tobacco entirely during the off-season. In general, about one third of tobacco users in the study fall into this group. There was a decline in both seasonal use and year round use during the 10-yr course of the study.
There are two general types of smokeless tobacco available: moist snuff and loose leaf tobacco. There was some slight variation from year to year, but generally 63% of smokeless tobacco users used moist snuff exclusively, 20% used loose leaf tobacco exclusively, and 17% used both types of tobacco.
Cigarette smoking in this population is very low. Only 2% of the population described themselves as regular smokers. Due to the small number of smokers, no clear association was found between the use of smokeless tobacco and cigarette smoking.
Leukoplakia was found in about one third of tobacco users over the course of the study (range, 27.9-43.6%). Those that never used tobacco had a prevalence of 4.0%, and those that previously used but quit had an intermediate prevalence of 9.5% (P < 0.001).
In a comparison of seasonal users versus year-round users, the leukoplakia prevalence was higher among the year-round users. Leukoplakia was found in 21.9% of seasonal users and in 46.8% of year-round users (P < 0.001). Higher-grade lesions were also found more commonly among the year-round users. The prevalence of leukoplakia in the organization (including both users and nonusers) declined concomitantly with the decline in prevalence of smokeless tobacco use. In the first year of the study, when the use rate was 41.1%, the prevalence of leukoplakia among all participants was 22.6%. In the 10th year, when the use rate was 25.6%, the leukoplakia prevalence among all participants was 9.4% (P < 0.001) (Fig. 2).
Over the course of the study, a significantly increased number of participants expressed their desire to quit. In 1991, 29.5% of users wanted to quit; in 2000, the percent of users wanting to quit was up to 52.4 (P = 0.009).
This study is the first to report annual data on smokeless tobacco use and its harmful effects on a single professional baseball organization at all levels over an extended period of time. Others have reported tobacco use primarily at the major league level and often in more than one organization (3-5,7,16). We believe that this study is an accurate reflection of the trends in smokeless tobacco use and its effects on oral health in professional baseball for the decade ending in 2000.
The predominant form of tobacco used was moist snuff, with 63% of users exclusively favoring this form. This is consistent with earlier studies that show baseball players prefer moist snuff (4). One third of current users limited smokeless tobacco use to the baseball season only. In examining self-quantification of smokeless tobacco use, the year-round users significantly cut back on the amount of tobacco used in the off-season. There is clearly something about the culture of baseball that promotes the use of tobacco.
An important finding of the current study is the declining use of smokeless tobacco products by baseball professionals. At the start of the study in 1991, 41.1% of men in the organization were using smokeless tobacco. Ten years later, the use rate was down to 25.6%, a remarkable decline that will perhaps continue. Several factors may be responsible for this decline.
An important factor is the active role taken by Major League Baseball in discouraging tobacco use. On June 15, 1993, Major League Baseball instituted a ban on the use of all tobacco products by players, managers, coaches, and umpires in the minor leagues. Their hope was to "eliminate any perceived linkage between Baseball and tobacco products of any kind" (Press release, Major League Baseball, Office of the Commissioner, New York, NY).
Major League Baseball complemented their tobacco ban in the minor leagues with an education and cessation program targeted for all personnel. The initial cessation program, entitled "Beat the Smokeless Habit, Game Plan for Success," was made available to all professional ballplayers (15). This was followed by the National Spit Tobacco Education Program (9). The athletic trainers in professional baseball were educated on the program and served as facilitators for the athletes.
To help the study population with tobacco cessation, we provided an educational session each year to all minor leaguers during spring training on the harmful effects of smokeless tobacco. In addition, at the time of the mouth examination, if a leukoplakia lesion was detected, immediate information was provided on these lesions and their potential progression to oral cancer, and tobacco cessation was strongly encouraged. Support for cessation was offered to all players during spring training by the principal investigators of the project. A cessation program using nicotine gum was piloted but had limited results (18).
This study confirms the strong association between smokeless tobacco and oral leukoplakia. In general, one third of smokeless tobacco users had leukoplakia lesions. This is similar to the study by Ernster et al. (4) who found leukoplakia in 46% of 423 current users in 1988.
The leukoplakia prevalence in former users (9.5%) was intermediate in the never/rarely used (4.0%) and the current users (38.4%). Previous investigations have shown regression of leukoplakia after cessation (10,12). Our study confirms this trend, but shows that not all regress completely.
As the use of tobacco declined over the 10-yr course of the study, so did the prevalence of leukoplakia. The overall prevalence of leukoplakia fell from 22.6% in 1991 to 9.3% in 2000. These data suggest that the oral health of baseball players can be improved by decreasing the habitual use of smokeless tobacco.
By the end of the study period, over half of the smokeless tobacco users expressed an interest in quitting. Education was a likely factor in promoting a desire to quit. Once the user decides to quit, support by a healthcare provider, such as a physician, dentist, dental hygienist, and an athletic trainer, is needed. Success rates on smokeless tobacco cessation programs vary, ranging from 8 to 32% (6,11,13,19), with the best reported success rates seen when follow-up and support were provided by a dental hygienist (11).
The current study is limited to a single professional baseball organization and confirms the findings of Severson et al. (17), who found a declining prevalence of tobacco use among several organizations. One would have to consider this study an annual "snapshot" of the organization. It cannot be considered a true longitudinal follow-up of a fixed population, but rather a follow-up of a changing population, with an estimated turnover rate of 20-25% per year. However, it should accurately reflect the trend in other professional baseball organizations, which all have significant turnover rates from year to year.
A weakness of the study is the fact that long-term follow-up data on individuals in the study are not available. In an effort to keep the study strictly anonymous, the authors were not able to track the progression or regression of the leukoplakia lesions found in individual participants. Such data might have been very useful in determining how long it takes to progress from one grade to the next with continued use. Further, it is unknown whether any lesions progressed to oral cancer. Attempting to verify the interobserver reliability of the mouth examinations could further have strengthened the study. Limited availability of the players made that difficult to accomplish.
The major finding of the study is the declining use of smokeless tobacco products by the professional baseball players in this organization and the associated decline in the prevalence of oral leukoplakia. Although causality is difficult to prove, with no available long-term data on individuals, the association between declining smokeless tobacco use and declining oral leukoplakia prevalence is very strong. The authors postulate that the decline in tobacco use is a result of two important factors: the ban of smokeless tobacco use in the minor leagues and the extensive education program undertaken by Major League Baseball and the sports medicine staff of the Pittsburgh Pirates baseball club. The authors are very hopeful that this trend will continue.
The authors thank the management of the Pittsburgh Pirates for their support of this project. They thank the athletic training staff for their assistance in implementing the study, particularly Kent Biggerstaff, Dave Tumbas, Mike Sandoval, Sandy Krum, Bill Henry, and Mark Rogow. The authors acknowledge Dr. John E. Hewett for assistance in the statistical analysis.
1. Axell, T., H. Mornstad, and B. Sundstrom. The relation of the clinical picture to the histopathology of snuff dipper's lesions in a Swedish population. J. Oral. Pathol.
2. Axell, T., and V. Henricsson. Leukoedema-an epidemiologic study with special reference to the influence of tobacco habits. Comm. Dent. Oral Epidemiol.
3. Connolly, G. N., C. T. Orleans, and M. Kogan. Use of smokeless tobacco in major league baseball. N. Engl. J. Med.
4. Ernster, V. L., D. G. Grady, J. C. Greene, et al. Smokeless tobacco use and health effects among baseball players. J. Am. Dent. Assoc.
5. Ernster, V. L., D. G. Grady, and J. C. Greene. Use of smokeless tobacco in major league baseball. N. Engl. J. Med.
6. Gansky, S. A., Ellison, C. Kavanaugh, J. F. Hilton, and M. M. Walsh. Oral screening and brief spit tobacco cessation counseling: a review and findings. J. Dent. Educ.
7. Greene, J. C., M. M. Walsh, and M. A. Letendre. Prevalence of spit tobacco use across studies of professional baseball players. Calif. Dent. Assoc. J.
8. Greer, R. O., and T. C. Poulson. Oral tissue alterations associated with the use of smokeless tobacco by teen-agers. Oral Surg.
9. Jensen, J., and D. Hatsukami. Tough Enough to Quit Using Snuff, a Self-help Manual for Quitting Spit Tobacco
, Chicago: National Spit Tobacco Education Program, 1997.
10. Larsson, A., T. Axell, and G. Andersson. Reversibility of snuff dipper's lesion in Swedish moist snuff users: a clinical and histologic follow-up study. J. Oral Pathol. Med.
11. Little, S. J., V. J. Stevens, H. H. Severson, and E. Lichtenstein. An effective smokeless tobacco intervention for dental hygiene patients. J. Dent. Hyg.
12. Martin, G. C., J. P. Brown, C. W. Eifler, and G. D. Houston. Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J. Am. Dent. Assoc.
13. Masouredis, C. M., J. F. Hilton, D. Grady, et al. A spit tobacco cessation intervention for college athletes: three-month results. Adv. Dent. Res.
14. National Institutes of Health. The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General
. Bethesda, MD: National Institutes of Health, NIH publication no. 86-2874, 1986.
15. Orleans, C. T., G. N. Connolly, and S. Workman. Beat the Smokeless Habit, Game Plan for Success
. Bethesda, MD: U.S. Department of Health and Human Services. NIH Publication no. 92-3270, 16 pp, 1991.
16. Robertson, P. B., M. M. Walsh, and J. C. Greene. Oral effects of smokeless tobacco use by professional baseball players. Adv. Dent. Res.
17. Severson, H. H., K. Klein, E. Lichtensein, N. Kaufman, and C. T. Orleans. Smokeless tobacco use among professional baseball players: survey results, 1998 to 2003. Tob. Control.
18. Sinusas, K., J. G. Coroso, M. D. Sopher, and B. F. Crabtree. Smokeless tobacco use and oral pathology
in a professional baseball organization. J. Fam. Pract.
19. Sinusas, K., and J. G. Coroso. Smokeless tobacco cessation: report of a preliminary trial using nicotine chewing gum. J. Fam. Pract.