Prevalence of Spit Tobacco Use Across Studies of Professional Baseball Players

By John C. Greene, DMD, MPH;
Margaret M. Walsh, MS, EdD; and
Mark A. Letendre, ATC

The use of spit tobacco among professional baseball players continues to be alarmingly high in spite of efforts to make players aware of the harmful effects of such use. Approximately 35 percent to 40 percent of professional baseball players still use spit tobacco, and about half of those have associated oral lesions. Efforts of the National Spit Tobacco Education Program are expected to result in a significant reduction in spit tobacco use in the next decade.

Article copyright 1998 Journal of the California Dental Association.
Photographs copyright of the authors.

The 1986 Surgeon General's Report on the Health Consequences of Using Smokeless Tobacco1 called national attention to the health risks of using this form of tobacco (now called "spit" tobacco because the term "smokeless" incorrectly suggests that it is harmless). The report expressed concern about the fact that about 6 million people in the United States used spit tobacco one or more times per week in 1985. The report also pointed out that use was increasing, particularly among male adolescents and young male adults. In the preface to the report, then-U.S. Surgeon General C. Everett Koop expressed alarm about the combination of the increasing use of these products and the strength of the association between their use and such conditions as oral cancer, oral leukoplakias, and other oral problems.

A report from a National Institutes of Health Consensus Development Conference concluded that "observations in humans provide convincing evidence for an increased risk of oral cancer as a result of the use of smokeless tobacco."(2) Case reports and epidemiologic studies in humans have documented this association, and laboratory studies have demonstrated that carcinogenic compounds present in high levels in spit tobacco produce cancer in laboratory animals. One epidemiologic study estimated that the risk of oral and pharyngeal cancer in humans is four times higher in those who use snuff (a form of spit tobacco).(3) Furthermore, this case-control study found that long-term chronic users of snuff have nearly a fiftyfold increased risk of developing cancers of the gingiva and buccal mucosa.

A 1994 report estimated that the number of current users of spit tobacco in the United States had increased to 7 million.(4) The most common form of spit tobacco used today is moist oral snuff or "dip," which is finely ground or shredded tobacco sold in round tin cans. A pinch of the moist snuff is placed and held between the lower or upper lip or cheek and the gingiva. Chewing tobacco is loose, coarse strands of tobacco sold in pouches and placed in wads between the cheek and the gingiva. For convenience, both forms are referred to as spit tobacco to differentiate them from smoked tobacco.

To learn about the health effects of spit tobacco use, special attention has been paid to professional baseball players because of their traditional heavy use of spit tobacco and their high public profile. Because of the findings from these studies, increasing efforts are now being made to reduce spit tobacco use in this high-profile population for its own sake and to help decrease spit tobacco use in the general population that tends to emulate its behavior.

This report presents available published and previously unpublished data from studies of professional baseball players conducted by the authors' group at the University of California San Francisco with similar data published by other authors, to show how the prevalence of spit tobacco use in this population may have changed during the period 1985 to 1997. This is the period for which data are available and are presented here as a group even though they are not directly comparable, due to differences in definitions of current user and study participation rates.

Methods

A Medline search was conducted using the key words "tobacco" and "baseball" to locate published English-language reports of studies of spit tobacco use by baseball players.

The search yielded six publications(5-10) that appeared in the literature subsequent to the surgeon general's report in 1986. These publications were examined to obtain findings related to the prevalence of spit tobacco use and the prevalence of associated oral lesions among the users. These studies were conducted at different times by different investigators and used somewhat different methods. Since this report compares data collected in these studies, a short description of the methods employed in each one follows.

Cummings and colleagues(6) studied one minor-league team during the 1985 regular season. Players were asked whether they were current spit tobacco users and their self-reports were verified by bioassays of their saliva. Oral examinations were conducted on 25 players using a flashlight and tongue blades.

Connolly and colleagues(5) surveyed members of seven major-league baseball teams during spring training in 1987. Anonymous questionnaires were used to gather information about spit tobacco use patterns and were completed by 265 players. Players were asked whether they were current spit tobacco users. Brief oral examinations were performed on some of the players to verify self-reports of "sore mouths" associated with spit tobacco use.

Wisniewski and Bartolucci(7) provided questionnaires about spit tobacco use to the head athletic trainers of all major league teams prior to spring training in 1987. These, in turn, were distributed to the players, who completed them during the 1987 preseason/season. Players were asked if they were currently using spit tobacco. These confidential questionnaires were collected by the head athletic trainers from 25 of the 26 major-league teams then in existence and returned directly to the principal investigator for analysis. Oral examinations were not conducted.

Figure 1. Looking for tobacco-associated oral lesions.

Ernster and colleagues(8) studied players attending spring training camps of seven major-league clubs and their associated minor-league teams during spring training in 1988. The Ernster report presents data on the first of a three-year study of these teams. Questionnaires asking for information about spit tobacco use were completed by 1,109 players. Players were asked if they had ever used spit tobacco and whether they had used it in the past month, week, or day. Current-month users were those who had used more than once in the past month. Oral examinations, using a full complement of portable equipment, were conducted by trained examiners as a portion of the players' regular medical examination (Figure 1).

Figure 2. Tobacco-associated oral leukoplakia.

In this study and in all of those conducted by the UCSF group, oral leukoplakia was defined clinically as any white opaque, leathery-appearing, slightly raised, and irregularly corrugated changes in the oral mucosa that were not characteristic of another white lesion such as lichen planus or spongy nevus.(11) For convenience, oral mucosal changes characteristic of oral leukoplakia are referred to as "oral lesions" (Figure 2).

Greene and colleagues(9) reported on data from the second and third years (1989 and 1990) of the study that was conducted by the same team, using the same study methods as in the Ernster report. The data reported in this portion of the study are from 894 players attending major- and minor-league training camps in 1989 and 1990 who were not included in the first-year report. The majority of the 894 players were from the minor-league camps since each major-league camp had approximately 60 players and the associated minor-league camp had about 125 players. Players were considered to be current users if they reported using spit tobacco in the prior week.

The 1992 study reported by Greene and colleagues10 was conducted during the regular baseball season and included 128 of the 262 rostered players from 10 major-league teams who consented to participate. Players who reported using spit tobacco during the prior week were considered current users. Oral examinations were conducted using portable equipment.
In addition to the published data cited above, data that were previously collected by the authors' group at UCSF but have not been published before are presented in this report to help identify trends that might be occurring in spit tobacco use or in the prevalence of associated oral lesions. These include data for 1987, 1995, 1996, and 1997.

The first study of this group was a pilot study conducted by Greene and colleagues in 1987 and involved 61 players attending one major-league team's spring training camp. Oral examinations, using portable dental equipment, were conducted by specially trained and calibrated dentists as a part of the regular medical examination. Standardized questionnaires were used to elicit tobacco use histories. Players were classified as current spit tobacco users if they reported use in the prior week.

Greene performed oral examinations on players attending one major league team's training camp in the springs of 1995 and 1996 using the same methods and definitions as those described in the publication by Ernster and colleagues.(8) Specially trained dentists, using portable dental chairs and lights, conducted the examinations as a part of the regular medical examinations. Players were classified as current users if they reported using spit tobacco in the prior month, based on information obtained by questionnaire.

In 1997, Greene and Walsh conducted a study of 99 players attending two major-league teams' spring training camps and on 205 players attending their associated minor-league training camps. Spit tobacco use information was obtained by questionnaire. Again, specially trained dentists using portable dental equipment conducted oral examinations as a part of the regular medical examinations. Players were classified as current users if they reported using spit tobacco in the prior month.

Results

Table 1 presents previously reported and unreported data for major-league players. The observed prevalence of spit tobacco use among players attending major-league spring training camps during the 10-year period from 1987 to 1997 ranges from a high of 46 percent in 1987 to a low of 35 percent in 1997. The prevalence of associated oral lesions in the same group varies from a low of 27 percent to a high of 54 percent. Table 1 also presents for each study the percent of the population studied that returned questionnaires or received oral examinations.

Table 2 presents similar spit tobacco use data for players attending minor-league spring training camps for 1985, 1988, 1989 and 1990, 1995 and 1997. Recorded spit tobacco use ranges from a high of 68 percent to a low of 29 percent, and associated oral lesion prevalence ranges from 18 percent to 59 percent of those who use spit tobacco.

Discussion

The high prevalence of spit tobacco use among young males reported in the surgeon general's report in 1986 stimulated widespread interest in this subject. As a result, several groups began to study spit tobacco use among professional baseball players, where use traditionally has been high. Published data from these studies are consistent with the public perception that many baseball players use spit tobacco.

The prevalence of spit tobacco use among players attending major-league spring training camps was high in 1987, when three different assessments were made. The highest of these, 46 percent, was reported by Wisniewski and Bartolucci.(7) This study involved 528 players on 25 of the 26 teams that existed at that time. This use rate was based on an average of only about 21 respondents per team during the "preseason/season." Since as many as 60 players may attend each team's spring training camp, the 528 responses probably represent only about 35 percent of the players in attendance (Table 1). Thus, the reported 46 percent use rate should be viewed as an estimate with some unknown margin of error.

The study by Connolly and colleagues, 5 also in 1987, reported a spit tobacco use rate of 34 percent based on questionnaire responses from players attending seven major-league spring training camps. The response rate for this study was higher, since the average number of respondents reported per team was 36 as compared to 21 in the Wisniewski study. Also, using 60 as the anticipated attendance figure for each camp, this would be a 63 percent response. Therefore the 34 percent use rate reported in this study may be more representative of the actual situation at that time.

The 36 percent spit tobacco use rate in the third 1987 study by Greene and colleagues, included 61 of 62 players (98 percent) attending only one major-league team's training camp out of 26 in existence at that time. While that use rate certainly represents that one team, the question is, how representative was it of all attendees at major league training camps that year. Also, the Greene study considered current users to be only those who reported using spit tobacco in the prior week whereas the Wisniewski and Connolly studies considered current users to be those who said they were "current users" on the confidential questionnaires. Each of these studies has an unknown margin of error, since it is not known how well they represent all of the players attending major league training camps that year. It seems reasonable to assume, however, that the prevalence of spit tobacco use in 1987 was between 34 and 40 percent.

The kind of qualifications discussed above apply to each of the reported data sets when generalizing from them to all of professional baseball or when comparing one study with another. However, taken together, they are informative and indicate that the prevalence of spit tobacco use among professional baseball players was and still is alarmingly high. In assessing the representativeness of the data in these studies, unless the actual numbers are known, it is assumed for this report that 60 players attended each major-league team's spring training camp. For the study that was conducted during the regular season,10 a roster size of 26 players per team was assumed.

The studies conducted in 1988, 1989, and 1990 by Ernster(8) and Greene(9) and colleagues provide the most comprehensive information on the largest number of professional baseball players available today (Table 1). These studies obtained information on the prevalence of spit tobacco use and associated oral lesions on players attending the spring training camps of seven major league clubs. Study staff assisted players in filling out their questionnaires, and oral examinations were conducted by specially trained dentists as a part of the regular medical examination. This way all players were expected to participate in the oral examinations, and most did. Thus, the data regarding the prevalence of spit tobacco use should be very close to reality for those seven teams and probably for the other 19 teams then in existence. The data for 1988 presented in Table 1 are for 72 percent of the players attending the seven major-league training camps in that year.

The data for 1989 and 1990 represent 85 percent of the players from the same major-league camps and their associated minor-league camps as in the Ernster study, who were not examined previously. The information is presented for both years and both camps because it was not possible to separate the data by year and into major- and minor-leaguers retrospectively as was possible for 1988. The major-league spit tobacco use rate of 44 percent for 1988 should be particularly dependable. However, the 1989, and 1990 rate of 40 percent is so diluted by the large component of minor-league data that it is probably lower than the actual spit tobacco use rate among major-league players at that time. Furthermore, current users in this report were those who used spit tobacco in the past week and, thus, does not include those who used it in the past month but not in the past week.

The spit tobacco use rate of 35 percent found in 1992 (Table 1) probably is considerably lower than what actually existed at that time. Only 128 of 262 (49 percent) rostered players on the 10 teams presented themselves for examination. It is unknown how many users did not choose to participate. The fact that this study was conducted during the regular season on game days when the players were quite busy preparing for competition probably decreased participation in this project. Only players who indicated on their questionnaire that they had used spit tobacco in the previous week were considered to be current users. Because this pilot study of spit tobacco cessation methods took place during the regular season and had such a low participation rate, it is not comparable to the others included in this publication. Thus, the 35 percent spit tobacco use rate should only be considered as the minimum for that year.

The 1996 spit tobacco use rate of 41 percent (Table 1) is based on staff-administered questionnaires and oral examinations as a part of the regular medical examinations, as was done in the Ernster studies. However, because the study involved 90 percent of the players attending only one major-league club's spring training camp, there is no way to determine how representative it was of the other camps.

The 35 percent spit tobacco use rate recorded for 1997 (Table 1) represents the lowest and most recent spit tobacco use information for major-league players. The 1997 data were obtained from 83 percent of the players attending two major-league spring training camps as a part of the regular medical examinations, as was done in the Ernster(8) and Greene(9) studies. There still is the question of how representative this spit tobacco use rate was of all major-league training camps, but the number of study subjects is respectable and the lower use rate is consistent with the authors' observations.

Thus, it appears that the use of spit tobacco among major-league baseball players probably was around 34 percent to 40 percent in 1987 and may have increased slightly to 40 percent to 44 percent in the 1988-90 period and then declined to about 35 percent by 1997, about the same level that existed at the beginning of the decade. It is remarkable that there apparently has been so little change during this decade, particularly since so much attention has been drawn to this issue during the past few years.

Data regarding the use of spit tobacco among players attending minor-league spring training camps are more scarce than for the majors. The study by Cummings and colleagues(6) in 1985 (Table 2) involved only 25 players (93 percent) on only one minor-league team during the regular season and found an unusually high spit tobacco use rate of 68 percent. Since this rate is so high and involves so few players, it does not appear to be comparable with the other observations in this report.

Table 2 also presents minor-league player spit tobacco use data for 1988 (42 percent), 1989 and 1990 (40 percent), 1995 (30 percent), and 1997 (29 percent). If these figures are indicative of what has been happening among all minor league players, it is very encouraging. As can be seen in Table 2, each of the studies involved a large percentage of the groups being studied. The 1988 data came from 804 (92 percent) of the players on 35 minor-league teams associated with seven major-league clubs. Each of the minor-league teams has about 25 players attending spring training. The 1989 and 1990 data are from 85 percent of the players attending both major- and minor-league camps that were not examined in 1988. The 1995 data are from 69 (100 percent) of the minor-league players and a few "walk-on" players attending one "major-league" training camp in the year of the major-league players' strike. The data collected in 1997 are from 205 (82 percent) of the players on 10 minor-league teams associated with two major-league clubs who attended minor-league spring training. The decrease in spit tobacco use from 42 percent in 1988 to 29 percent in 1997 among minor-league players probably reflects the ban on spit tobacco use during minor-league games that went into effect in 1993. But the fact that the use rate is still nearly 30 percent indicates how difficult it is to effectively implement a ban of an addictive substance, especially when it is done without providing concurrent help with cessation.

The prevalence of tobacco-related oral lesions in professional baseball players continues to be very high among current users, regardless of their major- or minor-league status. The prevalence of spit tobacco-related oral lesions in professional baseball players reported in the studies during the past 12 years has ranged from 18 percent to 59 percent (Tables 1 and 2). No definition of what was considered a tobacco-associated lesion was given in the study reporting the 18 percent prevalence, and it was based on a very small number. Nevertheless, dividing the number of current spit tobacco users examined in this entire group of studies by the number of players found to have tobacco-related oral lesions yields an oral lesion prevalence of 49 percent of the spit tobacco users.

It would be very helpful if, in the future, a standard definition of current user of spit tobacco could be adopted so data from local and national studies would be more directly comparable. For example, it would be desirable to adopt either current-week user or current-month user, together with a standard definition of which one is chosen.

Data from these studies do not tell the entire story of what has been happening with regard to the spit tobacco issue. When the authors first began to look into this problem in 1986, major-league locker rooms were well-stocked with free samples of dip and chewing tobacco provided by the tobacco companies. These have been replaced by non-nicotine substitutes, and warnings about the dangers of using spit tobacco are posted in prominent places. Players used to say when learning of the harmful effects of spit tobacco, "Why didn't someone tell me this before I got hooked on this stuff ?" That was often followed by a request for help in quitting. No longer heard are claims of ignorance of tobacco being harmful, and more players are asking for help in kicking the addiction.

Given the apparent knowledge among professional baseball players today about the harmful effects of spit tobacco use and the anti-tobacco policies of Major League Baseball, why hasn't there been a greater reduction in spit tobacco use? It must be remembered that an attempt is being made to change the social norms of an essentially closed society where spit tobacco use has been commonplace and condoned for many years. That is not a simple task. It took nearly 20 years following the first surgeon general's report on the harmful effects of smoking before a significant change in the smoking habits of the people in this country began to show up. It is important, too, to realize that most of the attention for the first half of this decade was devoted to documenting the nature and extent of the spit tobacco problem in professional baseball and identifying the best approach to helping players overcome their addiction. Serious attention has been placed on decreasing spit tobacco use among professional baseball players only in the past few years.

Several very important developments have occurred in the past three or four years that should help to accelerate what may be a decreasing use of spit tobacco by both major- and minor-league players. Among them is the ban on the use of spit tobacco in the minor leagues that was instituted in 1993. This may account in large measure for the encouraging trend that appears to be developing in this population. Perhaps the most significant development is the formation of the National Spit Tobacco Education Program (NSTEP) headed by Joe Garagiola. Garagiola is a former major-league baseball player and a Hall of Fame television broadcaster who has been speaking out on this issue for more than 15 years. The NSTEP program, which began operating in 1994, is funded by grants from the Robert Wood Johnson Foundation and is operated by Oral Health America, American's Fund for Dental Health. Under Garagiola's leadership, NSTEP has carried the spit tobacco message to every major-league club and to millions of baseball fans. Garagiola's NSTEP team is currently working with the baseball commissioner's office to establish a network of trained professionals to provide an effective spit tobacco cessation program for all of professional baseball. That program will need support from the dental profession in detecting oral lesions caused by spit tobacco use and in motivating and helping users overcome their addiction. Studies have now shown that dentists and hygienists working together can be very effective in the cessation process.(12-15)

During the 1997 spring training oral examinations, the UCSF study team was encouraged by the observation that more players seemed proud to say either that they had never used spit tobacco or that they had quit. Spit tobacco users were more reluctant to admit that they were regular users and more anxious to obtain help to quit. The authors' believed they were witnessing a real change in attitudes towards spit tobacco use in this population of professional baseball athletes. With NSTEP now in high gear and with the active involvement and encouragement of Major League Baseball, the Major League Players Association, the Professional Baseball Athletic Trainers Society, and team employee assistance program personnel, there is good reason to anticipate a major reduction in the use of spit tobacco among professional baseball players during the next decade. If this happens among these high-profile athletes, one can also expect a reduction in spit tobacco use among young males throughout the country instead of the continued growth that is occurring today.

Acknowledgments

Special thanks and compliments to the San Francisco Giants Baseball Organization; their top management beginning with Al Rosen and those who have followed; their athletic trainers; and Dr. Charles Pascal, their team dentist, for their leadership and concern for the health of their players, particularly in relation to the spit tobacco issue. Without their help and active involvement, these studies spanning more than a decade would not have been possible. The authors also want to thank all of the professional clubs, especially their athletic trainers, that make up the Cactus League and their associated minor-league teams that have made these studies by the UCSF group possible. They are the San Francisco Giants, the Oakland Athletics, the Anaheim Angels, the Seattle Mariners, the Milwaukee Brewers, the Cleveland Indians, the Chicago Cubs, and the San Diego Padres.

Authors

John C. Greene, DMD, MPH, is a professor and dean emeritus with the University of California at San Francisco School of Dentistry.
Margaret M. Walsh, MS, EdD, is a professor of public health and hygiene at UCSF School of Dentistry.
Mark A. Letendre, ATC, is the head athletic trainer with the San Francisco Giants Baseball Team.

References

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10. Greene JC, Walsh MM and Masouredis C, Report of a pilot study: A program to help major-league baseball players quit using spit tobacco. J Am Dent Assoc 125:559-68, 1994.
11. Pindborg JJ and Renstrup G, Studies in oral leukoplakia, II. Effect of snuff on oral epithelium. Acta Derm Venereol 43:271-6, 1963.
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13. Masouredis CM, Hilton JF et al, A spit tobacco cessation intervention for college athletes: Three-month results. Adv Dent Res 11(3), Sept 1997.
14. Stevens VJ, Severson HH et al, Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office. Am J Public Health 85:231-5, 1995.
15. Walsh MM, Hilton JS et al, Spit tobacco cessation among college athletes: one-year results. Am J Public Health 1998 (in press).

To request a printed copy of this article, please contact, John C. Greene, DMD, MPH, 103 Peacock Drive, San Rafael, CA 94901.