Use in Sports

Fig. 11.1

Tobacco and bubble gum. Shows similarities between kids bubble gum and tobacco products; similar in packaging and in the way the product looks inside the package; note how the gum is shredded like the leafy tobacco product

Tobacco in all forms kills an estimated 440,000 Americans each year. Tobacco has also been associated with cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, bladder, and acute myeloid leukemia. It has also been well documented that smoking substantially increases the risk of heart disease, including stroke, heart attack, vascular disease, and aneurysm. Globally the consequences are horrific. By the year 2020, it is estimated that 8.4 million people will die annually as a result of tobacco-related diseases [3, 4]. This is too important public health issue to ignore, and we need to arm all health professionals with information to combat the tobacco industry.

Tobacco use also has significant oral health sequelae as well. Due to ingredients in spit tobacco, there is a firm link to increased periodontal disease and some potential links to dental caries and oral mucous membrane disease from its use. Smoking is also strongly associated with severity of periodontal disease as well [4].

The team dentist or dental consultant to any sports league or team should know the basics of tobacco carcinogenesis and oral disease associated with tobacco use. Our profession needs to be a source of truth about the dangers of tobacco use in sports. This chapter will give the reader a basic understanding of these important issues. We will explore the history of tobacco in the world and in sports, followed by the physiologic and addictive properties of nicotine and the carcinogenic potential of tobacco.

11.2 Tobacco History and Relation to Sports

We begin this section by looking at a brief history of tobacco and its economic impact. Then we will review the types of tobacco products used and how they are used in the context of sport. Properties of tobacco and the ingredients that affect users will be reviewed next. We then will explore the newest delivery system for tobacco in the e-cigarette. Finally we will review the use of tobacco by young athletes. We will look in detail of the special case of tobacco use in baseball in the next section.

11.2.1 Tobacco History, Types, and Economics

Tobacco is a leafy plant that grows in warm climates. After harvest the leaves are dried and prepared for use in its multiple forms. The dried leaves can be smoked in a pipe or rolled in a cigar or in a cigarette, they can be chewed as in spit tobacco, or they can be sniffed through the nose as snuff. Nicotine is one of the many chemicals that are found in tobacco, and its presence makes tobacco an addictive drug, even though it is not regulated as such.

Tobacco has a long history of use in the Americas that began long before the Europeans came to the New World. The Mayans depicted tobacco use in their art from times before European exploration. Native Americans smoked tobacco in pipes for religious ceremonies and medical purposes. Today tobacco is used with great frequency throughout the world. The same qualities that encouraged Native Americans to use tobacco as a medicine and as a religious aid are the same qualities that encourage its use today. Today we recognize these qualities as physiologic and pharmacologic, and we also recognize the dangers of tobacco use today that were unknown to earlier users of tobacco.

Tobacco was the first cash crop grown in the New World after European settlement in the 1600s. Tobacco helped to finance the American Revolution against England, and George Washington was a tobacco grower [5]. By the 1800s many people were using small amounts of tobacco either smoking or chewing. Invention of cigarette making automation in 1881 allowed mass production of cigarettes, and smoking took off as an American pastime [5]. World War I and World War II solidified tobacco’s grip on the world. Soldiers were given free cigarettes , and they consumed large quantities of a very addictive drug, this before the dangers of tobacco use were known and world tobacco addiction was set in motion [5]. Tobacco use would now be guaranteed for generations to come. Tobacco would be used by athletes since it was a way of life around the world and still the dangers of tobacco use were unknown or hidden. Smoking though was not convenient for athletes engaged in competition, and chewing tobacco became the vehicle of choice to deliver the tobacco drugs to athletes.

The financial health of tobacco companies are good even if the health of their customers is not.

Selling an addictive drug to the masses without regulation or medical intervention is a recipe for wild profit. Tobacco companies in the 1950s and 1960s made large profits, and they wisely diversified their businesses. Tobacco companies show profits in the billions of dollars each year, and they pay incredible amounts of taxes to governments that are strapped for cash. We expect to see tobacco companies to be around for years to come even though the numbers of people smoking continues to go down.

From here on the major focus will be given to the use of spit tobacco since this is the form most often used by athletes.

11.2.2 Properties and Ingredients of Spit Tobacco

Spit tobacco is the preferred form of tobacco used by athletes during competition. It requires no use of hands to deliver the drug to the athletes and requires no flame to burn leaves to create smoke to inhale. Contact of the tobacco product with a mucous membrane is how the chemicals are delivered to the user. Spit tobacco comes in a few forms. There are plugs or blocks of tobacco where a plug is bitten or cut off, leafy tobacco for chew and snuff which is moisturized finely ground tobacco. In the Far East, betel quids with tobacco and areca nut products are popular.

Oral Use Tobacco Products : General

  1. 1.

    Chewing tobacco : leafy rough cut ex. Red Man

  2. 2.

    Dipping tobacco : fine ground moist ex. Copenhagen

  3. 3.

    Snus : similar to dip; Scandinavia

  4. 4.

    Snuff : fine ground tobacco that is inhaled

  5. 5.

    Betel quid with tobacco : betel leaf and tobacco leaf

  6. 6.

    Gutka : betel leaf areca nut and tobacco


There are wide varieties in the ingredients of the betel leaf and areca nut product used mainly in Asia. Generally areca nut products are the most carcinogenic.

The type of tobacco used in a particular product will determine the chemical content of the product. The composition of the tobacco will depend on genetic makeup, growth environmental conditions, and all steps of processing and handling [6]. There have been over 3000 possible chemical components identified that may exist in different tobaccos [7].

Possible Ingredients of Spit Tobacco

Spit tobacco possible ingredients:

  • Polonium 210

  • N-Nitrosamines

  • Formaldehyde

  • Nicotine

  • Cadmium

  • Cyanide

  • Arsenic

  • Benzene

  • Lead

There are at least 28 carcinogens identified in spit tobacco products; most are nonvolatile alkaloid-derived, tobacco-specific N-nitrosamines; and these compounds are normal ingredients of these tobacco products [8]. Another group of carcinogens in spit tobacco are polycyclic aromatic hydrocarbons (PAH). These chemicals originate primarily from polluted air and possibly from the fire curing of some tobaccos. Additionally, formaldehyde another known carcinogen is found in most spit tobacco. Formaldehyde is formed from natural occurring alkyl aldehydes during heating in the tobacco processing steps. Radioactive polonium-210 is also found in most tobacco and comes from the soil where the tobacco grows [6].

Nicotine, a highly addictive drug, is found in all forms of spit tobacco in high concentrations. Nicotine, like most drugs of abuse, stimulates the release of dopamine in the brain. Dopamine is the primary neurotransmitter involved in pleasure and reward [9]. Release of pleasure and reward transmitter dopamine makes this drug very addictive.

Neurochemical and Related Effects of Nicotine


Increase dopamine

Increase pleasure, reward

Increase norepinephrine

Arousal, appetite suppression

Increase acetylcholine

Arousal, cognitive enhancement

Increase glutamate

Learning, memory enhancement

Increase serotonin

Mood modulation, appetite suppression

Increase β-endorphin

Reduction of anxiety and tension

Increase GABA

Reduction of anxiety and tension

Still there is no regulation of this drug from normal regulatory agencies. The FDA controls issues like sales of tobacco to minor children, forces warning labels on packaging, and controls some of the marketing of tobacco products. Not only is this drug very addictive, but it also exhibits many potent cardiovascular effects.

Nicotine Pharmacodynamics

Central nervous system

  • Pleasure

  • Arousal, enhanced vigilance

  • Improved task performance

  • Anxiety relief

Cardiovascular system

  • Increased heart rate

  • Increased cardiac output

  • Increased blood pressure

  • Coronary vasoconstriction

  • Cutaneous vasoconstriction


  • Appetite suppression

  • Increased metabolic rate

  • Skeletal muscle relaxation

These cardiovascular effects are likely the effects that give athletes the false sense of improved athletic performance after tobacco use.

Myth: Spit Tobacco Can Enhance Athletic Performance


  • Increases heart rate

  • Increases blood pressure

  • Causes arrhythmias

  • Causes vasoconstriction which can slow reaction time and cause dizziness

  • Decrease pituitary secretion of vasopressin which can adversely affect memory and learning

There may be very transient increases in performance followed by performance reduction. Addiction, carcinogenesis and vasoactive properties make tobacco a very dangerous product.

The stimulant effects of nicotine give athletes some sense of improved performance, some are mental and some are physical. The pharmacology of nicotine leads some researchers to pose the question of whether the use of nicotine constitutes legal doping in sport. Nicotine has been found in some studies to enhance information processing and attentional processes in human subjects [10]. Multiple studies have been done to test the hypothesis of improved physical performance from use of spit tobacco. These studies have shown no statistically significant increase in strength, power, or athletic skills while using tobacco products [1, 11].

11.2.3 E-Cigarettes

Electronic cigarettes are one of the newest tobacco products being used by people today. E-cigarettes work by using a battery to heat and atomize a nicotine-filled liquid into a vapor for the user to inhale or “vape.” E-cigarettes are diverse in that they are sold in many different forms, from small disposable cigarette-style types to larger reusable devices. Within this new market, submarkets have also developed for modifying reusable devices. These include larger reservoirs for the liquid, different batteries and atomizers, and coils to heat dry substances, such as marijuana.

E-cigarettes gained popularity as nicotine delivery alternatives to smoking. E-cigarettes are marketed as aids for cigarette cessation and as tolerable in more social settings where cigarette use is not permitted. Cigarettes have developed a social stigma, whereas the same stigma does not yet apply to their electronic counterparts. One survey of young adults, average age 30 who reported using e-cigarettes, was aimed at assessing perceptions on e-cigarette usage. This study found that users perceived e-cigarettes to be an aid to decrease or stop smoking and that they are more socially acceptable than smoking a cigarette. Other so-called benefits include the abundance of flavors and the perception that they are healthier than cigarettes. When prompted as to the side effects of use, most common responses were coughing, throat irritation, and lightheadedness. This survey also found that many users were not only unsure of the long-term health risks but they also unsure of the ingredients in the liquid itself [12].

The liquid used for e-cigarettes is available in over 7700 flavors and contains “propylene or polyethylene glycol, glycerin, additives and nicotine” [13]. Once heated, the composition of the aerosol/vapor has been found to include “nicotine, ultrafine particles, tobacco specific nitrosamines (TSNAs) and other toxic compounds such as acetaldehyde, acrolein, and toluene, although at significantly lower levels than in cigarettes” [13]. These ultrafine particles, in higher concentrations, have been associated with cardiovascular and respiratory disease. No direct relationship between e-cigarette use and oral health consequences has been reported, but given that the liquid does contain high levels of nicotine, the possibility still exists.

E-cigarettes do pose a dental trauma risk as we have begun to see. According to the US Fire Administration, between 2009 and 2014, there were 25 reported incidents involving explosions and fires as a result of e-cigarette use [14]. Some of the most common injuries reported after an e-cigarette explosion include “intraoral burns, luxation injuries, and chipped and fractured teeth” [14]. These may seem insignificant, but serious accidents have occurred. These include formation of an antra-oral communication, spinal fracture, and respiratory tract burns. Eighty percent of these adverse outcomes transpired during use [14]. Furthermore, if an explosion does occur while in use, it is important to evaluate the patient for trauma to the head and neck region, possible concussion, and maintenance of a patent airway [15].

11.2.4 Prevalence of Tobacco Use by Athletes: High School, College, and Professional

Overall use of tobacco products continues to decrease over time according to the CDC. Combustible tobacco product use is declining in high school students overall, and high school athletes are less likely to be smokers than nonathletes to maintain physical fitness and optimize athletic performance. Athletes in high school who use tobacco generally use spit tobacco as it can be used discreetly during practice and games unlike combustible tobacco products which are discouraged by sports organizations. Some trends emerge as we examine spit tobacco use by high school age individuals. Spit tobacco use among high school males is about 14% of total. These users frequently use spit tobacco while playing or watching sports and the greater their involvement in sports, the greater their likelihood of spit tobacco use [16]. Peer pressure is a large part of this spit tobacco use in high school. Among a group of 995 adolescent football players, it was found that 30% of these athletes had tried spit tobacco and that of the players that had tried spit tobacco 60% cited friends’ use as the major reason that they tried tobacco [16]. College years see increases in all types of tobacco use, and students experiment with substances previously not legally available to them [17]. The use of tobacco products by college athletes also is increasing. Much of this spit tobacco use in college is sport specific with baseball having the highest prevalence. Spit tobacco use in baseball is well documented (see ► Sect. 11.3). Spit tobacco use prevalence among college baseball athletes has been seen in the 45–55% range [18, 19]. Of the baseball athletes who use spit tobacco in college, nearly half of these players began their tobacco use during high school years [19]. From the data reviewed, it is found that playing sports in all levels increases the prevalence of spit tobacco use. As health-care professionals, we have a duty to offer cessation programs to assist athletes to break the habit of tobacco use. Interventions with cessation programs are effective and can double the likelihood that an athlete will stop using spit tobacco [20].

11.3 History: Baseball and Tobacco

Baseball, more than any other sport, has been associated with spit tobacco use. This is a short narrative of how tobacco made its way into the culture of baseball. As discovered earlier in the chapter, tobacco has a long and strong economic and use history in the USA from the 1600s on. Baseball rules were being formalized in the mid-nineteenth century, long before the carcinogenic properties of tobacco were discovered. By the late nineteenth century, the average American was consuming more than 3 pounds of tobacco annually [5]; tobacco had been firmly inserted into the culture of baseball. Spit tobacco was the choice of baseball players for obvious reasons; they could use tobacco on the field without using hands to hold a cigarette. Additionally, the baseball fields were not as well-groomed as they are today, and baseball games were very dirty and dusty. Spit tobacco helped the players with increased saliva flow, and an added benefit was that tobacco-laced saliva helped them lube their gloves to keep the leather more supple, and this aided in fielding. The early twentieth century found baseball the most popular sport in the USA, and every professional baseball team had a tobacco sponsor [21]. Bull Durham is one of the oldest brands of spit tobacco in the USA and was a frequent advertiser on outfield fences in many baseball parks in the Southern USA. It is thought that the term “bullpen,” the place where relief pitchers warm up, was coined because of all the Bull Durham signs on outfield fences. The famous “spitball” used by many pitchers was aided by use of tobacco-induced saliva.

It is easy to see how spit tobacco made its way into the culture of baseball from the very beginning. It wasn’t until the Surgeon General’s report in 1964 that linked cigarette smoking with cancer did we know officially that tobacco contained carcinogenic chemicals [22]. It naturally followed that spit tobacco also contained many of the same chemicals and also could be carcinogenic as well [8, 23]. By the mid- to late twentieth century, tobacco was a dangerous part of baseball culture. Perhaps the most famous baseball player of all time Babe Ruth died of head and neck cancer. He was diagnosed in the mid-1940s with nasopharyngeal cancer. Nasopharyngeal cancer today is known to have two major causative agents: alcohol and tobacco. Babe Ruth was known to have been a zealous user of both of these products.

Over the years it has become well-known that tobacco is one of the most significant threats to human health that we know. There have been a number of attempts made to limit the use of spit tobacco in baseball. In 1993 minor league players, coaches, and staff were prohibited from spit tobacco use during games. The thinking behind this was that if minor league player’s tobacco use declined the major league players, tobacco use would naturally decline, since most major league players spend time in the minor leagues. A new MLB labor deal in 2011 prevents the use of spit tobacco in professional baseball during pre- and post-game interviews. This agreement does not ban the use of tobacco during games as long as the tobacco can or pouch is out of sight. Finally in 2016, a new collective bargaining agreement prohibits all new major league baseball players from using spit tobacco.

Baseball Rules Aimed at Spit Tobacco Use

  • 1993: Minor league players, coaches, and staff prohibited from spit tobacco use during games.

  • 2011: MLB labor deal prevents use of spit tobacco during pre- and post-game interviews and requires that spit tobacco cans or pouches are out of sight during games.

  • 2016: Collective bargaining agreement prohibits all new major league baseball players from using spit tobacco.

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Aug 25, 2019 | Posted by in General Dentistry | Comments Off on Use in Sports
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