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Wednesday, December 4, 2013
Chewing Tobacco/Smokeless Tobacco
I have Diabetic II patient, who wants to quit chewing tobacco. He chews 2-3 cans per/day. Brand: Skoal Regular Long Cut. He is interested in knowing the sugar content of the amount he chews. He is not motivated to quit related to cancer. He may be motivated to quit related to diabetes.
You raise a question I had never thought of and it turns out to be very interesting and I had to go do some reading. The question is about the sugar content of smokeless tobacco and whether it could have an effect on diabetes control. In 1980, two studies were reported in the Journal of the American Dental Association by dental researchers led by Drs Robert Going and Stephen Hsu. They were interested in the sugar content of tobacco in relation to how it might raise the risk of dental cavities. They found that on average 34% of the weight of pouch tobacco is some kind of simple sugar. For plug tobacco, it was 24% and for snuff 2%. The found that most of that sugar was either glucose, the form we focus on in the blood in diabetes, or sucrose which is converted in people to glucose. Incidentally, the sugar content of the tobacco as it is sold was dramatically higher than the sugar content of the tobacco leaves – meaning that much of the sugar was added. In 1981, a man with diabetes in poor control was described in a letter to the New England Journal of Medicine from the Marshall University School of Medicine and the Huntington West Virginia Veterans Hospital. Despite his being in the hospital and following all the diet instructions he was given, he couldn’t get his blood sugars under control until someone thought about his chewing tobacco. It was labeled “candified” and tasted very sweet. The man was not willing to stop chewing. However, he stopped swallowing the tobacco juice from chewing and that alone was enough to drop his blood sugars from the 300 to 400 mg/dl range down to 160 to 200! The doctors didn’t get to find out how much more it would have dropped if he had stopped chewing entirely. I was not able to get a sugar content for the specific tobacco you mentioned. The range of sugar contents for the pouch tobaccos tested was between 24 and 65% and for the plug tobaccos 13 to 50%. If your patient is chewing 3 cans per day and each has 1.2 ounces, that is about 100 grams of tobacco per day, and provides on average ~34 gm of sugar, with the range between 13 and 65 grams of sugars per day depending on the brand. Even without having the specific content for his brand, that is pretty eye-opening. I don’t know whether the addition of sugar to smokeless tobacco has changed since 1980. So, to answer your question, it is possible that cutting back on some forms of smokeless tobacco, particularly pouch and plug tobacco, could have a substantial effect on blood sugar control in people with diabetes. The best way to answer the question in an individual is to see what happens to the blood sugar if chewing is discontinued for one or several days. Whatever the result, however, that should not detract from the really important message: the cancer risk is the overwhelming reason to stop using smokeless or chewing tobacco.
Robert M Cohen, MD
Professor of Clinical Medicine
College of Medicine
University of Cincinnati