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Smokeless Tobacco

Scientific Name(s): Nicotiana tabacum L.
Common Name(s): Ariva, Chewing tobacco, Commit, Compressed tobacco lozenges, Copenhagen, Dry snuff, Iq-mik (Alaska), Moist snuff, Revel, Skoal Dry, Smokeless tobacco, Snus (Sweden)., Stonewall

Medically reviewed by Last updated on Jul 13, 2022.

Clinical Overview


The role of smokeless tobacco in smoking cessation is debated. Issues relate to the lack of evidence for efficacy in achieving long-term smoking cessation (greater than 6 months) and the health risks of smokeless tobacco products. Concern has been raised that smokeless tobacco use serves as a gateway to smoking.


Users of smokeless tobacco regulate consumption to meet cravings and withdrawal symptoms.


None well documented.


Avoid use. Smokeless tobacco use during pregnancy is associated with decreased birth weight and increased risk of preterm delivery.


None well documented.

Adverse Reactions

An increased risk of oropharyngeal cancer exists. Data for other cancers are less consistent. An association between the risk of fatal myocardial infarction and fatal stroke in users of smokeless tobacco has been shown. Other oral pathologies, such as inflammation, leukoplakia, and tooth decay have been described with smokeless tobacco use.


The International Agency for Research on Cancer (IARC) recognizes that smokeless tobacco contains at least 30 cancer-causing agents and is carcinogenic to humans.

Scientific Family

  • Solanaceae (nightshade)


Smokeless tobacco products are derived from the same botanical source as smoking tobacco (Nicotiana tabacum). The tobacco plant originated in South America more than 7,000 years ago. Smokeless tobacco products often are flavored with sugar or artificial sweeteners.Hatsukami 2007, USDA 2010


American Indians may have been using tobacco throughout North and South America by the time the first European explorers arrived in the late 1400s and early 1500s. Tobacco use spread to Europe, Africa, China, and Japan over the next few centuries. Snuff use (at the time, finely ground tobacco that primarily was sniffed through the nose) was introduced to North American colonists in Jamestown, VA in 1611. Tobacco chewing by colonists probably began in the early 1700s and was widely accepted by the 1850s. Snuff was the most popular form of smokeless tobacco in Europe and America prior to the 1800s. A current practice in the United States and many other parts of the world is "snuff dipping" in which, the small amount of powdered tobacco is placed in the buccal area between the gum and cheek where it is retained for a period of time. The resultant saliva is then usually spit or swallowed. Snuff is taken as loose portions or from small prepackaged bags of tobacco. In many parts of the world, the tobacco is mixed with other stimulants such as betel or areca nut. Some users chew a portion of smokeless tobacco.Grasso 1998, Hatsukami 2007, National Toxicology Program 2002


Tobacco contains more than 2,500 chemical constituents. Some of these constituents are present naturally while others are added during cultivation, harvesting, and processing. For example, chewing tobacco consists of the tobacco leaf with the stem removed, with added sweeteners, and flavorings (eg, honey, licorice, rum). Snuff consists of the entire tobacco leaf (dried and powdered or finely cut) and additives such as menthol, peppermint oil, camphor, attar of roses, and oil of cloves.

Scientific literature lists at least 30 carcinogenic agents in smokeless tobacco forms. Of these agents, N-nitrosamines are considered the major contributors to carcinogenic activity. Volatile and nonvolatile nitrosamines include tobacco-specific N-nitrosamines (TSNAs), polynuclear aromatic hydrocarbons, and polonium-210 (210Po). The most carcinogenic TSNAs, including 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N-nitrosonornicotine (NNN), are found in concentrations that produced cancer in laboratory animals. Despite newer products claiming processing that reduces tobacco-specific nitrosamine content, smokeless tobacco products still contain carcinogenic nitrosamines in concentrations higher than those permitted in food.

The major chemical groups in tobacco include aliphatic and aromatic hydrocarbons, aldehydes, ketones, alcohols, phenols, ethers, alkaloids (including nicotine, nornicotine, anabasine, anatabine, and myosmine), carboxylic acids, esters, anhydrides, lactones, carbohydrates, amines, amides, imides, nitrites, N- and O-heterocyclic compounds, chlorinated organic compounds, and at least 35 metal compounds. Nicotine content varies with commercial brand, but has been measured for some products and ranges from 1.22% for chewing tobacco to 2.58% for moist snuff. Dry snuff contains approximately 1.82% dry weight.Boffetta 2008, Brunnemann 2002, Djordjevic 2009, Hatsukami 2007, Kotlyar 2007, Melikian 2009, National Toxicology Program 2002, Nilsson 1999

Uses and Pharmacology


In a randomized, controlled, crossover study, the effect of nicotine abstinence and satiety on ergogenic outcomes was investigated in 16 male athletes who regularly used at least one smokeless tobacco (snus) sachet once a day. The mean snus usage was high among participants (8.1 sachets/day). After a 12-hour overnight nicotine abstinence period, mean time to exhaustion was 13.1% longer (24.1 minutes) than during the nicotine satiety period (20.9 minutes), which was statistically significantly different (P=0.0131). No significant differences were found for perception of effort, cerebral oxygenation, or muscular oxygenation between the abstinence and satiety periods. Muscular oxyhemoglobin concentrations, as well as cerebral deoxyhemoglobin concentrations, were significantly lower during the nicotine satiety period during the warm-up phase and all 4 quartiles of time to exhaustion (P-values ranged from P<0.001 to <0.05). Additionally, several physiological variables were significantly higher (ie, VO2, VCO2, ejection time, stroke volume) or lower (ie, heart rate, lactate) at baseline during the abstinence period compared to the satiety period but with no differences observed in these parameters during exercise.(Zondonai 2019)

Data from 10 healthy male nicotine-naïve athletes enrolled in a double-blind, placebo-controlled, crossover trial revealed that the use of snus before aerobic exercise significantly increased cortical inhibition (lower excitability) compared to placebo (P=0.006). No significant changes in muscle strength were observed. Adverse events related to snus included mild throat discomfort, moderate nausea, and dizziness.(Zandonai 2020)

Smoking cessation

The role of smokeless tobacco in smoking cessation is debated.(NIH 2006, Timberlake 2009, Tomar 2009) Issues relate to the lack of evidence for efficacy in achieving long-term smoking cessation (greater than 6 months),(Fagerstrom 2012, Tilashalski 2005, T⊘nnesen 2008) health risks of the smokeless tobacco products,(Lee 2009) and the concern that smokeless tobacco use could serve as a gateway to smoking.(Melikian 2009, NIH 2006, Stellman 2009, Timberlake 2009)

As with smoking tobacco, the pharmacologic effect of smokeless tobacco is related in part to its nicotine content. Blood nicotine levels are achieved rapidly with smokeless tobacco use (within 5 minutes) and can reach 40 ng/mL, comparable with peak levels found in heavy cigarette smokers (who average approximately 35 ng/mL).(Kotlyar 2007, Russell 1980)

Use of smokeless tobacco products is anticipated to increase due to antismoking action, and a perception that such products are safer than smoking prevails. A proposal to give the Food and Drug Administration authority over tobacco products has been considered in the US Senate.(Timberlake 2009, Tomar 2009)


Users of smokeless tobacco regulate consumption to meet cravings and withdrawal symptoms.Boffetta 2008, Melikian 2009

Pregnancy / Lactation

Avoid use. Data from the United States are lacking; however, data from Sweden and India describe an increase in the risk of decreased birth weight, and preterm and stillbirth delivery in pregnant users of smokeless tobacco products.(England 2003, Gupta 2004, Rogers 2009, Rogers 2008) A newborn demonstrated nicotine withdrawal syndrome within hours of birth in a mother who used large amounts of oral (sublabial) moist tobacco (snus) during pregnancy (10 to 20 times/day).(Frøisland 2017)


Theoretically, drug interactions with smokeless tobacco may be similar to smoked tobacco.

One case report documents the potential interaction between tobacco (which contains high levels of vitamin K) and warfarin.Kuykendall 2004, Asplund 2003 Candied smokeless tobacco products contain significant glucose (50 to 150 mg/g) and may contribute to hyperglycemia in susceptible people.Pyles 1981 Tobacco products may affect blood pressure because of its high sodium content.Kuykendall 2004, Asplund 2003

Adverse Reactions

Less data are available regarding the adverse reactions of smokeless tobacco than the adverse effects of smoked tobacco, and generalization from available studies is limited because of the confounding effects of concurrent smoking and geographical diversity. The risks of adverse reactions, however, are greater for smokers than for users of smokeless tobacco, which are in turn greater than for nonusers of tobacco. A relationship exists between the duration of exposure to smokeless tobacco and the risk of adverse reactions. As users increase their consumption of smokeless tobacco to increase effect, exposure to nicotine and carcinogens increases as well.(Boffetta 2008, Boffetta 2009, Critchley 2003, Hecht 2008)

Tobacco dependence

An estimated prevalence for smokeless tobacco use in Americans 18 years of age or older is 20%, and in 2005 an estimated 7.7 million Americans 12 years of age and older were reported to be current (past month) users.(Ebbert 2007, Severson 2009) A case of nicotine withdrawal syndrome has also been reported in a newborn of a mother who used large amounts of smokeless tobacco (snus) during pregnancy.(Frøisland 2017)

Concerns exist regarding the intrinsic health risks of smokeless tobacco use, as well as its role as a gateway to smoking tobacco.(Ebbert 2007)

Strategies for smokeless tobacco cessation include behavioral and pharmacologic therapy, with evidence to suggest behavioral interventions may be successful(Boyle 2008, Danaher 2008, Ebbert 2007, Severson 2008) whereas neither nicotine replacement nor bupropion have been shown to increase long-term abstinence.(Dale 2007, Ebbert 2007, Ebbert 2007)

Risk of cancer

Data from studies conducted in the United States and Scandinavia have shown an increased risk of oropharyngeal cancer from the use of oral tobacco, as well as nasal tobacco products.(Freedman 2016) The data for other cancers, such as esophageal, larynx, lung, and pancreatic cancer, are less consistent.(Accortt 2002, Boffetta 2008, Critchley 2003, Hatsukami 2004, Lee 2009, Niaz 2017) The clinical appearance of oral lesions in users of smokeless tobacco is reported to be different from those of smokers, with differing morphologies described.(Boffetta 2008, Warnakulasuriya 2007)

Risk of cardiovascular events

A meta-analysis of 11 studies conducted in the United States and in Sweden found a small but definitive increase (narrow confidence intervals) in the risk of fatal myocardial infarction and fatal stroke in users of smokeless tobacco versus nonusers. The data for nonfatal cardiovascular disease was limited by heterogeneity.(Boffetta 2009) Previous reviews have been unable to find an association.(Asplund 2003, Critchley 2004, Hatsukami 2004, Huhtasaari 1999) Reviews of the delivery of nicotine via electronic cigarettes and consequent cardiovascular risk, have been published, suggesting a low risk exists.(Benowitz 2016)

Other risks

Oral pathologies, such as gum recession and inflammation, leukoplakia, tooth erosion and decay, and periodontal alveolar bone loss have been associated with smokeless tobacco use.(Critchley 2003, Taybos 2003)


The IARC recognizes that smokeless tobacco contains at least 30 cancer-causing agents and is carcinogenic to humans.Boffetta 2008, Melikian 2009



This information relates to an herbal, vitamin, mineral or other dietary supplement. This product has not been reviewed by the FDA to determine whether it is safe or effective and is not subject to the quality standards and safety information collection standards that are applicable to most prescription drugs. This information should not be used to decide whether or not to take this product. This information does not endorse this product as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this product. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this product. This information is not specific medical advice and does not replace information you receive from your health care provider. You should talk with your health care provider for complete information about the risks and benefits of using this product.

This product may adversely interact with certain health and medical conditions, other prescription and over-the-counter drugs, foods, or other dietary supplements. This product may be unsafe when used before surgery or other medical procedures. It is important to fully inform your doctor about the herbal, vitamins, mineral or any other supplements you are taking before any kind of surgery or medical procedure. With the exception of certain products that are generally recognized as safe in normal quantities, including use of folic acid and prenatal vitamins during pregnancy, this product has not been sufficiently studied to determine whether it is safe to use during pregnancy or nursing or by persons younger than 2 years of age.

Frequently asked questions

Accortt NA, Waterbor JW, Beall C, Howard G. Chronic disease mortality in a cohort of smokeless tobacco users. Am J Epidemiol. 2002;156(8):730-737.12370161
Asplund K. Smokeless tobacco and cardiovascular disease. Prog Cardiovasc Dis. 2003;45(5):383-394.12704595
Asplund K, Nasic S, Janlert U, Stegmayr B. Smokeless tobacco as a possible risk factor for stroke in men: a nested case-control study. Stroke. 2003;34(7):1754-1759.12775887
Benowitz NL, Burbank AD. Cardiovascular toxicity of nicotine: Implications for electronic cigarette use. Trends Cardiovasc Med. 2016;26(6):515-523.27079891
Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncol. 2008;9(7):667-675.18598931
Boffetta P, Straif K. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis. BMJ. 2009;339:b3060.19690343
Boyle RG, Enstad C, Asche SE, et al. A randomized controlled trial of Telephone Counseling with smokeless tobacco users: the ChewFree Minnesota study. Nicotine Tob Res. 2008;10(9):1433-1440.19023834
Brunnemann KD, Qi J, Hoffmann D. Chemical profile of two types of oral snuff tobacco. Food Chem Toxicol. 2002;40(11):1699-1703.12176096
Critchley JA, Unal B. Health effects associated with smokeless tobacco: a systematic review. Thorax. 2003;58(5):435-443.12728167
Critchley JA, Unal B. Is smokeless tobacco a risk factor for coronary heart disease? A systematic review of epidemiological studies. Eur J Cardiovasc Prev Rehabil. 2004;11(2):101-112.15187813
Dale LC, Ebbert JO, Glover ED, et al. Bupropion SR for the treatment of smokeless tobacco use. Drug Alcohol Depend. 2007;90(1):56-63.17353101
Danaher BG, Smolkowski K, Seeley JR, Severson HH. Mediators of a successful web-based smokeless tobacco cessation program. Addiction. 2008;103(10):1706-1712.18715238
Djordjevic MV, Doran KA. Nicotine content and delivery across tobacco products. Handb Exp Pharmacol. 2009;(192):61-82.19184646
Ebbert JO, Dale LC, Severson H, et al. Nicotine lozenges for the treatment of smokeless tobacco use. Nicotine Tob Res. 2007;9(2):233-240.17365754
Ebbert JO, Montori V, Vickers KS, Erwin PC, Dale LC, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev. 2007;(4):CD004306.17943813
England LJ, Levine RJ, Mills JL, Klebanoff MA, Yu KF, Cnattingius S. Adverse pregnancy outcomes in snuff users. Am J Obstet Gynecol. 2003;189(4):939-943.14586330
Fagerstrom K, Rutqvist LE, Hughes JR. Snus as a smoking cessation aid: a randomized placebo-controlled trial. Nicotine Tob Res. 2012;14(3):306-312.21994343
Freedman ND. Invited Commentary: Smokeless Tobacco-An Important Contributor to Cancer, but More Work Is Needed. Am J Epidemiol. 2016 Oct 15. [Epub ahead of print].27744385
Frøisland DH. Nicotine withdrawal syndrome in a newborn baby after maternal use of oral applied moist tobacco (snus), should result in greater awareness to the use of snus among pregnant women. Acta Paediatr. 2017;106(9):1531. doi:10.1111/apa.1391328508412
Grasso P, Mann AH. Smokeless tobacco and oral cancer: an assessment of evidence derived from laboratory animals. Food Chem Toxicol. 1998;36(11):1015-1029.9771564
Gupta PC, Subramoney S. Smokeless tobacco use, birth weight, and gestational age: population based, prospective cohort study of 1217 women in Mumbai, India. [published correction appears in BMJ. 2010;340:c2191]. BMJ. 2004;328(7455):1538.15198947
Hatsukami DK, Ebbert JO, Feuer RM, Stepanov I, Hecht SS. Changing smokeless tobacco products new tobacco-delivery systems. Am J Prev Med. 2007;33(suppl 6):S368-S378.18021912
Hatsukami DK, Lemmonds C, Tomar SL. Smokeless tobacco use: harm reduction or induction approach? Prev Med. 2004;38(3):309-317.14766113
Hecht SS, Carmella SG, Edmonds A, et al. Exposure to nicotine and a tobacco-specific carcinogen increase with duration of use of smokeless tobacco. Tob Control. 2008;17(2):128-131.18375734
Huhtasaari F, Lundberg V, Eliasson M, Janlert U, Asplund K. Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged men. J Am Coll Cardiol. 1999;34(6):1784-1790.10577570
Kotlyar M, Mendoza-Baumgart MI, Li ZZ, et al. Nicotine pharmacokinetics and subjective effects of three potential reduced exposure products, moist snuff and nicotine lozenge. Tob Control. 2007;16(2):138-142.17400953
Kuykendall JR, Houle MD, Rhodes RS. Possible warfarin failure due to interaction with smokeless tobacco. Ann Pharmacother. 2004;38(4):595-597.14766993
Lee PN, Hamling J. Systematic review of the relation between smokeless tobacco and cancer in Europe and North America. BMC Med. 2009;7:36.19638245
Melikian AA, Hoffmann D. Smokeless tobacco: a gateway to smoking or a way away from smoking. Biomarkers. 2009;14(suppl 1):85-89.19604066
National Toxicology Program. Smokeless tobacco. Rep Carcinog. 2002;10:236-238.15340990
Niaz K, Maqbool F, Khan F, Bahadar H, Ismail Hassan F, Abdollahi M. Smokeless tobacco (paan and gutkha) consumption, prevalence, and contribution to oral cancer. Epidemiol Health. 2017;39:e2017009.28292008
Nicotiana tabacum L. USDA, NRCS. 2007. The PLANTS Database (, February, 2010). National Plant Data Center, Baton Rouge, LA 70874-4490 USA.
NIH State-of-the-Science Panel. National Institutes of Health State-of-the-Science conference statement: tobacco use: prevention, cessation, and control. Ann Intern Med. 2006;145(11):839-844.16954353
Nilsson R. A qualitative and quantitative risk assessment of snuff dipping. [published correction appears in Regul Toxicol Pharmacol. 1999;29(1):97]. Regul Toxicol Pharmacol. 1998;28(1):1-16.9784428
Pyles ST, Van Voris LP, Lotspeich FJ, McCarty SA. Sugar in chewing tobacco. N Engl J Med. 1981;304(6):365.7442789
Rogers JM. Tobacco and pregnancy: overview of exposures and effects. Birth Defects Res C Embryo Today. 2008;84(1):1-15.18383133
Rogers JM. Tobacco and pregnancy. Reprod Toxicol. 2009;28(2):152-160.19450949
Russell MA, Jarvis MJ, Feyerabend C. A new age for snuff? Lancet. 1980;1(8166):474-475.6102195
Severson HH, Gordon JS, Danaher BG, Akers L. evaluation of a Web-based cessation program for smokeless tobacco users. Nicotine Tob Res. 2008;10(2):381-391.18236303
Severson HH, Peterson AL, Andrews JA, et al. Smokeless tobacco cessation in military personnel: a randomized controlled trial. Nicotine Tob Res. 2009;11(6):730-738.19395686
Stellman SD, Djordjevic MV. Monitoring the tobacco use epidemic II: The agent: Current and emerging tobacco products. Prev Med. 2009;48(suppl 1):S11-S15.18848577
Taybos G. Oral changes associated with tobacco use. Am J Med Sci. 2003;326(4):179-182.14557730
Tilashalski K, Rodu B, Cole P. Seven year follow-up of smoking cessation with smokeless tobacco. J Psychoactive Drugs. 2005;37(1):105-108.15916256
Timberlake DS, Zell JA. Review of epidemiologic data on the debate over smokeless tobacco's role in harm reduction. BMC Med. 2009;7:61.19840371
Tomar SL, Fox BJ, Severson HH. Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking? Int J Environ Res Public Health. 2009;6(1):10-24.19440266
T⊘nnesen P, Mikkelsen K, Bremann L. Smoking cessation with smokeless tobacco and group therapy: an open, randomized, controlled trial. Nicotine Tob Res. 2008;10(8):1365-1372.18686184
Warnakulasuriya KA, Ralhan R. Clinical, pathological, cellular and molecular lesions caused by oral smokeless tobacco—a review. J Oral Pathol Med. 2007;36(2):63-77.17238967
Zandonai T, Pizzolato F, Tam E, Bruseghini P, Chiamulera C, Cesari P. The effects of nicotine on cortical excitability after exercise: A double-blind randomized, placebo-controlled, crossover study. J Clin Psychopharmacol. 2020;40(5):495-498. doi:10.1097/JCP.000000000000124632701900
Zandonai T, Tam E, Bruseghini P, Capelli C, Baraldo M, Chiamulera C. Exercise performance increase in smokeless tobacco-user athletes after overnight nicotine abstinence. Scand J Med Sci Sports. 2019;29(3):430-439. doi:10.1111/sms.1333330387193

Further information

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