Wad, quid, chaw, plug - not a safe choice.

In the 1970s tobacco companies began promoting smokeless tobacco as a safe alternative to smoking. Many of the smokeless tobacco products were promoted through advertising by well-known sports personalities and entertainers. Since that time its use has been rapidly increasing, especially among young male high school and college students.

National estimates indicate that more than 22 million persons, age 12 and older, have used some form of smokeless tobacco. Recent surveys in some regions of the United States indicate that between 8 percent and 36 percent of male high school students are regular users. The use of smokeless tobacco among professional baseball players has ranged as high as 42 percent.

The old days. In his voyages to the New World, Christopher Columbus and his crew reported finding Indians using tobacco in various forms. They smoked, chewed, or sniffed finely ground tobacco leaves for both ceremonial and medicinal purposes.

After its discovery in the New World, tobacco was introduced in Europe, where by the late sixteenth century its use had become extremely popular. Often demand would exceed the supply and this would cause the use of snuff to become an expensive pleasure. In addition to recreational use, tobacco was believed to have curative powers and was used in various ointments and pastes to treat a long list of illnesses and conditions, ranging from burns and infections to toothaches.

Not all countries condoned the use of smokeless tobacco. The popular use of snuff was condemned by some doctors, scientists, and clergy. Some physicians stated that it caused such things as deterioration of the brain, destruction of the nostrils, wrinkling of the skin, loss of smell, and cancer. In some countries, users were severely punished. Yet its use often flourished.

In Great Britain, snuff taking became an important part of daily life and was commonly used by both men and women. A small quantity of the finely powdered tobacco was placed on the back of the hand, and was then snuffed up the nostrils. Some also preferred to "dip,"a method of placing a small amount of snuff in the mouth between the gum and cheek.

Many of the Colonists in America preferred to chew tobacco. For the pioneer or the person working outdoors, this seemed a more convenient way to use tobacco. The use of chewing tobacco became known as the "American habit." Cuspidors and spittoons became a necessity in many public buildings. Smokeless tobacco continued its popularity until the end of the nineteenth century, when there was public outcry against such an unsanitary practice. About this time it was also discovered that serious diseases could be spread by spitting on floors or into a cuspidor.

The cigarette-manufacturing machine was invented in the 1880s, which made cigarettes more easily available. In the 1920s cigarette consumption surpassed other forms of tobacco use, and smokeless tobacco was mostly reserved for the "rural" men and women in the southeastern and southwestern United States.

Use today. With its comeback in the seventies smokeless tobacco today is available in a variety of forms; moist or dry snuff, loose-leaf tobacco, and block, or "plug," tobacco. The two most popular forms currently used are moist snuff and chewing tobacco. Snuff is a cured, finely ground tobacco that is marketed in small cans. Often sweeteners or flavorings are added during manufacturing. Moist snuff is placed in the mouth, generally between the lower lip and gum. This "dip" is left in place and not actively chewed.

Chewing tobacco comes in several forms, loose-leaf, plug, and the less popular twist. The loose-leaf type consists of shredded tobacco leaves that are loosely packed. Flavorings, such as wintergreen, mint, cherry, and others, are often added. The small amount placed inside the cheek is referred to as a "wad," "quid," or "chaw." When this is held in the mouth or chewed, it creates an excess amount of saliva causing the user to frequently expectorate. Less commonly used, a "plug" is tobacco that is pressed into a block and is used similarly to loose-leaf tobacco.

Not a safe alternative. Studies have shown that smokeless tobacco contains many harmful agents. Its use may have a profound deleterious effect on both hard and soft oral tissues. Chronic users are at risk for developing tissue changes in the oral cavity that may lead to oral cancer. In addition, smokeless tobacco contains nicotine, which is well documented for its addictive nature.

The oral lesion most often associated with smokeless tobacco is leukoplakia. Oral leukoplakia is a clinical term used for a white patch in the mouth that does not wipe off, and does not appear to be any other specific disease. Although there are many causes of oral leukoplakia, tobacco use, regardless of form, plays a major role in its development. When caused by smokeless tobacco, oral leukoplakia may vary from slight wrinkling of the oral mucosa to a very obvious thickened, corrugated white patch. The area of leukoplakia is usually at the site where the smokeless tobacco is held.

In one well-documented study of professional baseball players, 46 percent had leukoplakia where the "quid" had been placed. The oral leukoplakia occurred more often among users of moist snuff than users of chewing tobacco. Some studies have shown that as many as 37 percent of smokeless tobacco users may have an area of leukoplakia. Areas of leukoplakia tend to regress or disappear after cessation of smokeless tobacco use, but in some of the more severe cases the lesion may not regress. Development of leukoplakia appears to be related to the frequency and the length of tobacco use. Moreover, oral leukoplakla carries a definite risk in developing oral cancer.

It has been estimated that 3 percent to 6 percent of cases of leukoplakia may undergo malignant transformation (i.e., develop into cancer). Although the probability of a lesion caused by smokeless tobacco becoming premalignant or malignant is unknown, it does appear that a definite association exists. There are many well-documented cases in which malignancies have formed in areas where smokeless tobacco had been placed over a long period of time. What is not known is how many years of smokeless tobacco exposure are necessary for this malignant transformation to take place.

Snuff and chewing tobacco contain substantial quantities of nicotine, a powerfully addictive drug. When these tobacco products are used in the mouth or nose, nicotine is rapidly absorbed through the oral mucosa membrane into the bloodstream. The effects of nicotine are felt throughout the day. Since smokeless tobacco is often used by adolescents, nicotine dependence may lead to the use of cigarettes.

Smokeless tobacco can also cause gum recession and loss of supporting bone around the teeth where tobacco is placed. This is especially a problem in long-term users. Some studies examining smokeless tobacco use in schoolchildren have shown a direct effect between its use and gingivitis.

Smokeless tobacco products may contain various gritty substances such as sand. This can cause the biting surfaces of the teeth to be worn down, a process referred to as attrition. Also, the necks of the teeth where the quid has been placed can become abraded, eroded, or damaged. In a study of professional baseball players, dental abrasion was seen more often in users than in nonusers.

Smokeless tobacco may cause staining of teeth, including white fillings and dentures. In some cases the stain may penetrate the root surface of the tooth as well. The degree of staining may be related to the amount of tobacco used and the amount of dental plaque present. Staining may be severe enough to require cosmetic dental treatment, or replacement of existing stained restorations.

Another common condition caused by smokeless tobacco usage is halitosis, or bad breath. The components of tobacco can produce odors that are inhaled into the lungs, and then exhaled.

The use of smokeless tobacco is known to cause many harmful effects to the tissues inside the mouth. Again, it can lead to the development of oral leukoplakia, which carries a definite risk of developing into oral cancer. The increasing popularity of smokeless tobacco, especially among teenage boys, poses a serious health risk, and every effort should be made to stop its usage. The American Academy of Otolaryngology--Head and Neck Surgery has a new leaflet on smokeless tobacco written for teenagers. It explains why smokeless tobacco is addictive and discusses the adverse side effects. You can order a free copy of "Smokeless Tobacco--Just as Dangerous" by sending a self-addressed, stamped business-sized envelope to Chew, c/o American Academy of Otolaryngology--Head and Neck Surgery, 1 Prince Street, Alexandria, Virginia 22314.

Lane C. Thomsen, D.D.S., is chairman and associate professor of the Department of Oral Diagnosis, Radiology, and Pathology, at the School of Dentistry, Loma Linda University, Loma Linda, California.

12 Steps for Smokers.

1. We admitted we were powerless over nicotin-- that we are not able to control our tobacco use.

2. Came to believe that a Power greater than ourselves could restore us to freedom.

3. Made a decision to turn our wills and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we hod harmed and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these stups, we tried to carry this message to others, and to practice these principles in all our affairs.

Adapte# from the Twelve Steps for Alcoholics, for use in the Breathe-Free Plan to Stop Smoking.