A global assessment of knowledge of dental students about nicotine replacement therapy: findings from 43 countries.

OBJECTIVES: Knowledge of nicotine replacement therapy (NRT) is a competency that is expected from receiving training in the treatment for tobacco dependence. This study therefore assessed the knowledge of dental students in 43 countries about NRT. METHODS: The 2005-2011 dental Global Health Professions Student Survey data were analysed for 13,040 third-year dental students from 43 countries. Knowledge about NRT was self-reported and country-specific prevalence estimates were calculated. To assess for correlates of knowledge about NRT amongst dental students, a multivariate logistic regression model was fitted (P < 0.05), with pooled data from all 43 countries. The model assessed for geographical location, gross national income, tobacco cessation training in school, sex, current tobacco use and survey year. RESULTS: Amongst all dental students, the proportion that knew about NRT ranged from 37.0% (Mongolia) to 97.6% (Slovakia). The odds of knowing about NRT were lower amongst dental students in the Eastern Mediterranean region (aOR = 0.52; 95% CI: 0.34-0.79) compared to those in the European region. Dental students in upper-middle-income (aOR = 2.46; 95% CI: 1.57-3.85) and high-income countries (aOR=4.55; 95% CI: 2.28-9.09) both had higher odds of knowing about NRT compared to dental students in low-income countries. Also, current use of any tobacco product and receipt of tobacco cessation training in school were both associated with higher likelihood of knowing about NRT. No significant gender differences in knowledge of NRT were observed. CONCLUSIONS: A large proportion of dental students in several countries knew about NRT. However, disparities in knowledge existed across regions. Enhanced efforts are needed to formally train dental students on tobacco cessation techniques.

Race/ethnicity in biomedical research and clinical practice.

There is ongoing debate as to whether persons of different racial/ethnic groups are biologically significantly different, and, if such differences exist, whether they are relevant in relation to disease susceptibility and to treatment outcomes. There is also debate about the benefits of using race/ethnicity as a factor in clinical decision making, and as a variable in biomedical or public health research, because of the emotional sensitivities attached to race/ethnic categorisation. Such categorisation may also divert attention from underlying issues such as socioeconomic status and lack of access to modern health care. In this short article we will discuss these controversies, and will emphasize the importance of responsible and sensitive use of race/ethnicity as a variable in biomedical research and in clinical practice.

Epidemiological association between osteoporosis and combined smoking and use of snuff among South African women.

OBJECTIVES: This study sought to explore the epidemiological association between the exclusive use and the combined use of snuff and smoking on the prevalence of osteoporosis in a national population sample of South African women who were 40 years and older. MATERIALS AND METHODS: This study involved a nationally representative sample of South African women who were 40 years and older and took part in the 2003/2004 South African Demographic and Health Survey (n = 2050). Data on tobacco use patterns, dietary calcium intake and other relevant factors were obtained through an interviewer-administered questionnaire. As part of the data collection procedure, participants were asked whether a doctor, a nurse or any other health professional had ever told them they had osteoporosis. Those who answered in the affirmative and/or presented medications for osteoporosis were regarded as having osteoporosis. RESULTS: The prevalence of osteoporosis was higher among those who had ever used both snuff and smoked (17.2%) either in the past or currently than among those who had ever used snuff only (5%) or smoked only (5.1%). Even after controlling for potential confounders in a multivariable-adjusted logistic regression, the combined use of snuff and smoking remained positively associated with osteoporosis (odds ratio = 3.60, 95% confidence interval: 1.03-12.61). However, higher dietary calcium intake was negatively associated with osteoporosis. CONCLUSIONS: Based on these findings, it can be concluded that the combined lifetime use of both snuff and cigarettes may increase the odds of developing osteoporosis among women who are 40 years and older.

Paedodontic general anaesthesia and compliance with follow-up visits at a tertiary oral and dental hospital, South Africa.

OBJECTIVES: The study aimed to describe the demographic profile of children receiving dental general anaesthesia (DGA) at the Pretoria Oral-and-Dental Hospital, South Africa, the type of treatment received and the level of compliance with the six-month preventive follow-up visit. METHODS: Retrospective review of records of children treated under DGA between January 2009 and December 2010. RESULTS: The study group contained 78-children. Of these, 79.5% were between one and four years of age (mean 3.7-years; SD: 2.01), and 54% were female. The parents of more than half the sample (56.4%) were unemployed. The majority (55.2%) recorded no medical condition prior to undergoing DGA. Of the treatments performed, 63% were extractions (mean = 4.7 teeth/child), 51% involved placement of composite restorations (mean = 3.4 teeth) and 18% were fitting of stainless steel crowns (mean = 2.1 teeth). No preventive treatment was performed under DGA. Only 14 children (18%) returned within 15-months for follow-ups. Seven returnees were re-booked for a second DGA appointment for severely carious teeth; the rest received preventive treatment. Female children (Odds Ratio (OR): 0.28; p = 0.04) and children with no medical-condition (OR: 0.20; p = 0.03) were less likely to return for a follow-up visit. Children with employed parents were more likely (OR: 3.50; p = 0.09) to return for follow-ups. CONCLUSION: This study highlights the importance of preventive treatment prior to and during DGA, especially in a setting where the caries disease burden and unemployment are high.

Trends and ethnic disparities in oral and oro-pharyngeal cancers in South Africa, 1992-2001.

OBJECTIVE: To describe trends in the epidemiology of oral and of oro-pharyngeal (OAP) cancers in South Africa for the atest period available. METHODS: Data were obtained from the South African pathology-based National Cancer Registry. All new cases of OAP cancers diagnosed and confirmed histologically from 1992 to 2001 are included for the ICD-10 sites C00 to C14, excluding those involving the major salivary glands (C07-C08) and the nasopharynx (C11). OAP cancer incidence is reported by demographics (gender, age, race/ethnicity) and the anatomical sites involved. The analysis on anatomical sites was restricted to squamous cell carcinomas. RESULTS: Overall, males had a much higher OAP cancer incidence rate (world age-Standardised incidence rate [ASIR] = 7.01/100 000 per year) than females (ASIR = 1.99). However, among Asian/Indian South Africans, OAP cancer incidence was higher among females (ASIR = 4.60) than among males (ASIR = 3.80). OAP cancer, excluding those involving the lip, was highest among Coloureds (ASIR = 5.72) and lowest among Blacks (ASIR = 3.16). OAP cancer incidence was stable overall, but incidence rates increased significantly among Coloured South Africans over the period under review (p < 0.05). Cancer specifically involving the oro-pharyngeal was most common among Coloureds and showed an increasing trend during the period under review. CONCLUSIONS: Variations in the incidence of OAP cancers by gender, race/ethnicity and anatomic site indicate a need for culturally-targeted reductions in major risk factors, including promoting tobacco cessation and prevention of risky alcohol use. The implications of the role of the human papillomavirus (HPV) in the prevention of squamous cell carcinomas involving the oro-pharyngeal in South Africa require further investigation.

Systemic health status and self-reported periodontal health among South Africans.

OBJECTIVES: This study sought to determine the association between systemic health and self-reported poor periodontal health in South Africa. METHODS: This secondary data analysis focused on dentate adults aged >15 years (n=6,319) who participated in the South African Demographic and Health Survey (SADHS) during 2003/2004.Information obtained included socio-demographic data, and data on health risk behaviours (tobacco and alcohol use) and chronic diseases. The main outcome measure is self-reported poor periodontal health (defined as having had pain or problems with the gums in the 6 months prior to the survey date). Data analysis included t-test, chi-square and multiple logistic regression analysis. RESULTS: Of the respondents, 4.6% (95% CI = 3.9-5.5) self-reported having had a 'gum problem' or poor periodontal health. Those who reported poor periodontal health were significantly older than those who did not report poor periodontal health (36.2 yrs vs. 38.8 yrs; p = 0.02). In a multi-variable adjusted model, those categorized as problem drinkers (2.53; 95% CI = 1.68 - 3.82) as compared to non-drinkers, those who had suffered a stroke (4.13; 95% CI = 1.53- 11.11), or who suffered from arthritis (1.70; 95% CI = 1.00-2.90) all demonstrated significantly higher odds of reporting poor periodontal health. When compared to white South Africans, black South Africans had the highest odds of reporting poor periodontal health (3.91; 95% CI =1.38 -11.05). CONCLUSION: There is a significant association between chronic systemic conditions such as having had a stroke or suffering from arthritis and poor periodontal health in South Africa.

Principal motives for toothbrushing in a population of South African adolescents: implications for oral health promotion.

BACKGROUND: Little is known of the motives for tooth-brushing among adolescents in resource-poor settings. AIM: To investigate the principal motive for tooth-brushing among a rural population of South African adolescents. METHODS: The participants were high school students between the ages of 12 and 19 years who provided baseline data during 2005 as part of a tobacco use prevention trial (n = 2119). Information was obtained using a self-administered survey questionnaire, including demographic data, data on the employment status of the parents, oral health practices and risk behaviors. The main outcome measure was the principal reason for brushing. Data was analyzed using chi-square statistics and multiple logistic regression analysis. RESULTS: Of the study participants, only 27.2% had ever visited a dentist. For 28.9%, both parents are unemployed. The principal motive for brushing among most adolescents (84.9%), including those who reported frequent sugar intake, was related to cosmetic rather than preventive dental health reasons. Motives for brushing were not associated with brushing frequency. However, the socially disadvantaged, current smokers, and those who reported a past suicide attempt were significantly less likely to brush for cosmetic reasons. CONCLUSIONS: Motives for tooth-brushing among adolescents may reflect their psychosocial state rather than knowledge of the preventive effect of brushing.

Clinical correlates of oral malodour in a population of patients attending a preventive clinic in Pretoria, South Africa.

AIM: This study investigates the occurrence of oral malodour in an adult dental clinic population in Pretoria, South Africa, and the clinical parameters associated with the condition. METHODS: Data collected from new patients (n=896), examined by oral hygiene students under supervision of instructors, between January - October 2004, were retrospectively analysed. Subjects self-reported their medical history and smoking status. Caries experience, plaque index, pocket depths, bleeding on probing (BOP), tongue coating status, and oral hygiene practises were recorded. Malodour was diagnosed using the halimeter (> or = 120ppb) and an organoleptic measurement (0-5 point scale) of > or = 3. Data analysis included chi-square, t-tests and logistical regression. RESULTS: 15.1% presented with organoleptically-determined malodour and 20.9% presented with malodour detected by the use of the halimeter. Irrespective of the diagnostic tool used, tongue coating, increased plaque levels and BOP were associated with an increased likelihood for oral malodour, while regular flossing reduced the likelihood of presenting with the condition. Periodontitis was associated with oral malodour when applying organoleptic ratings, but not with the halimeter. CONCLUSIONS: Oral malodour prevalence corresponds with values reported in developed countries. Interdental flossing was the most effective self-care practise associated with a reduced likelihood of presenting with malodour. Halimeter performance should be further investigated in relation to varying degrees of severity of periodontal disease.

Prevalence and socio-economic disparities in fissure sealant placement among adolescents in the Limpopo Province, South Africa.

OBJECTIVES: This study investigated socio-economic factors associated with the placement of fissure sealants in a population of South African adolescents. METHOD: The study participants were high school students aged 12 to layers who provided baseline data during 2005 in a tobacco-use prevention trial, and consented to oral examination (n=1103). Information was obtained using a self-administered survey questionnaire, including demographic data, data on oral health behaviour, the employment status of parents/guardians, and the family structure of the household and on health insurance enrolment. The main outcome measure was the presence of a fissure sealant on any tooth, recorded using the WHO oral examination protocol. Data were analysed using chi-square statistics and multiple logistic regression analysis (p<0.05). RESULTS: Overall, only 3.5% (n=37) of the study participants had a fissure sealant, and only 31.3% (n=345) had ever made a dental visit. Those who had attended seeking mostly preventive care were significantly more likely to have a fissure sealant than those who had visited mostly when they were in pain (14.2% vs. 2.9%; p<0.001). In the multi-variable adjusted analysis, those reporting to have parents who are both employed (OR = 2.76; 2.26 - 3.38), and reporting regular preventive dental visits (OR = 3.55; 2.28 -5.58) were positively associated with receiving fissure sealant, while those who self-identified as black (OR = 0.04; 0.01 - 0.13), were significantly less likely to present with a fissure sealant as compared with other ethnicity/race groups. CONCLUSIONS: Higher socio-economic status and regular access to preventive care were significantly associated with the placement of fissure sealants in the studied population.

Nicotine dependence, socioeconomic status, lifestyle behaviours and lifetime quit attempts among adult smokers in South Africa.

BACKGROUND: Smoking cessation is a complex process influenced by factors such as smokers' nicotine dependence levels, socioeconomic status (SES) and other lifestyle behaviours. Little is known about these relationships in South Africa (SA). OBJECTIVES: To explore the relationship between nicotine dependence, SES, lifestyle behaviours and lifetime quit attempts among adult smokers in SA. METHODS: This study used data from 2 651 participants aged ≥16 years in the 2011 South African Social Attitudes Survey. Information on SES (measured by asset ownership), binge drinking, physical activity, fruit and vegetable intake, intention to quit smoking and lifetime quit attempts was extracted. Nicotine dependence was measured using the Heaviness of Smoking Index (HSI). All data were weighted to account for the complex survey design and to yield nationally representative estimates. Data analysis included binary logistic regression with high nicotine dependence (HND) defined as HSI ≥4 and lifetime quit attempts as separate outcomes. RESULTS: The prevalence of smoking was 20.1% (31.6% for males and 9.5% for females), and was highest in the mixed-ancestry group (37.0%). Overall, 14.5% of smokers had HND, with a higher proportion in the high-SES group. The odds of HND increased with every 10  years of smoking history (odds ratio (OR) 2.05; 95% confidence interval (CI) 1.40 - 3.00) but decreased among participants who reported frequent physical activity (OR 0.4; 95% CI 0.18 - 0.86) and those who planned to quit (OR 0.37; 95% CI 0.19 - 0.75). Quit attempts were more likely among participants who reported frequent fruit and vegetable intake (OR 1.8; 95% CI 1.07 - 2.98) and less likely among those reporting binge drinking (OR 0.31; 95% CI 0.16 - 0.59) or assessed as having HND (OR 0.32; 95% CI 0.17 - 0.58). CONCLUSIONS: Most adult smokers in SA have low nicotine dependence. However, the association of HND with high SES in this study suggests that although cessation treatment based on an integrated lifestyle behavioural intervention package may suffice for most smokers, a more intense cessation treatment package is needed for smokers of higher SES.

Developing smokeless tobacco products for smokers: an examination of tobacco industry documents.

OBJECTIVE: To investigate whether development of smokeless tobacco products (SLT) is intended to target current smokers. METHODS: This study analysed internal tobacco industry documents to describe research related to the smokeless tobacco market. Relevant documents included those detailing the development and targeting of SLT products with a particular emphasis on moist snuff. RESULTS: Cigarette and SLT manufacturers recognised that shifting demographics of SLT users, as well as indoor smoking restrictions, health concerns and reduced social acceptability of smoking could impact the growth of the SLT market. Manufacturers developed new SLT products to target cigarette smokers promoting dual cigarette and SLT use. CONCLUSIONS: Heavy marketing of new SLT products may encourage dual use and result in unknown public health effects. SLT products have been designed to augment cigarette use and offset regulatory strategies such as clean indoor air laws. In the United States, the SLT strategy may provide cigarette companies with a diversified range of products under the prospect of federal regulation. These products may pose significant challenges to efforts by federal agencies to reduce harm caused by tobacco use.

Association of snuff use with chronic bronchitis among South African women: implications for tobacco harm reduction.

OBJECTIVE: Nasal use of snuff is the predominant form of tobacco use among black South African women. This study examines the association between snuff use and chronic bronchitis (CB) among black South African women. DESIGN: The study investigated a nationally representative sample of 4464 black South African women > or = 25 years old who participated in the 1998 South African Demographic and Health Survey. Data on participants' tobacco use patterns, medical history and other relevant factors were obtained through an interviewer-administered questionnaire. Peak expiratory flow rates (PEFR) were also measured. Data analysis included chi(2) statistics, Student t tests and multiple logistic regression analysis. OUTCOME MEASURE: CB, defined as reporting a productive cough for > or = 3 months/year for at least 2 successive years. RESULTS: The prevalence of current snuff use was 16.1% (n = 719). Compared to non-users of snuff, snuff users were not only more likely to present with a history of tuberculosis (TB) (23.3% vs 15.9%; p = 0.06), but they were also more likely to present with CB (5.3% vs 2.8%; p<0.01) and a lower PEFR (275 litres/min vs 293 litres/min; p<0.01). Significant determinants of CB included snuff use > 8 times/day (odds ratio (OR) 2.86, 95% CI 1.17 to 7.02), a history of TB (OR 7.23, 95% CI 4.02 to 13.03), current smoking (OR 2.84, 95% CI 1.60 to 5.04) and exposure to smoky cooking fuels (OR 1.98, 95% CI 1.32 to 2.96). CONCLUSIONS: These data suggest that snuff use, in the form predominantly used in South Africa, increases the risk of CB. This challenges the idea that snuff may be a much less harmful alternative to smoking in South Africa.

Early-phase dental students' motivations and expectations concerning the study and profession of dentistry.

This study investigated the career choice and aspirations of early phase dental students in the four dental schools in South Africa, namely the University of the Western Cape (UWC), University of the Witwatersrand (Wits), University of Limpopo (Medunsa) and University of Pretoria (UP). Willing participants completed a self-administered questionnaire (n=184). Motivations for entering a dentistry programme were similar across race and university, with wanting a secure job most often stated as an important factor. For a third of respondents, dentistry was not a first choice. Amongst the White students, it was a first choice for 82% compared with 59% amongst Black Africans. Expected income five-years after graduation also differed significantly across race and university, with White and UP students expecting to earn considerably higher than the others. About 36% of students were concerned about the levels of personal debt related to studying, with the White and Asian students less concerned. Those who expected lower levels of income from the profession were more concerned about personal debts. Most students planned to enter general dental practice (GDP) after community service, almost all White and Wits students expressed this intention, compared with only 35% of Black Africans and 39% of Medunsa students. Orthodontics and Maxillofacial & Oral Surgery were the most popular specialities of choice. The professional attribute "Has a friendly manner and good relationship with patients" was ranked high most often. In conclusion, career advice may not need to be tailored differently for the different racial groups. There is however a need for further investigations on how to address the concerns of financial security which may be realised by the practice of dentistry, and in particular the racial disparities observed in expectations of the profession. This study further highlights the need for government financial assistance for students from under-represented groups.

Empirical support for a fissure sealant placement timeframe protocol for black South Africans.

OBJECTIVES: It is recommended that fissure sealants should be placed within four years after eruption. Due to considerable variations in the eruption times of molar teeth, this recommendation is of limited value from a public health perspective. This study, therefore, sought to provide empirical support for a public health fissure sealant placement timeframe protocol. METHODS: The first and second molar eruption patterns of black South African children aged five to seven and 11 to 16 years were analysed in relation to caries experience using the 1999/2002 National Children's Oral Health Survey. RESULTS: By seven years of age, 90% of first molars had erupted with a caries experience of 3%. By 14 years of age the erupted first molars caries experience was 20%. The 13- and 14-year-olds presented with 86% and 98% erupted second molars with a caries experience of 11% and 20%, respectively. CONCLUSIONS: The study findings suggest that during school-based fissure sealant programmes involving black South African children, first molars should be targeted at age seven (Grade 1), or as soon as possible thereafter. However, caries protection may still be achieved until thirteen years of age (Grade 7). Furthermore, second molars should be sealed between the age of 11 and 13 years (grades 5-7).

Socio-economic inequities in dental caries experience of 12-year-old South Africans: policy implications for prevention.

OBJECTIVES: To examine the socioeconomic inequities in dental caries experience of 12-year-olds, in order to inform policy actions for caries prevention in South Africa. METHODS: Secondary analysis of the 1999-2002 national survey data of 12-year-olds (N=5411), available from 37 regions in 7 of the 9 provinces, was carried out. Logistic regression was used to determine risks for caries experience among 12-year-olds in each province, using parental occupation and racial group as independent variables. Regression curve-estimation was used to examine the spatial relationship between mean DMFT and caries prevalence. RESULTS: The mean DMFT (+/-SD) for the study population was 1.19 (+/-2.13), significant caries index was 3.35 and caries prevalence was 40.1%. The highest mean DMFT was among the Coloured population (2.14+/-2.50). Compared to children in the highest occupational class, the risk for children of the unemployed to experience caries was lower in the North West province (Odds ratio [OR]=0.47; p<0.01), but significantly higher in the coastal provinces-- KwaZulu-Natal and Northern Cape, with OR of 1.32 and 1.52 respectively. The regression curve derived demonstrated that a unit increase in caries experience in low-level caries populations would generate more cases than similar increase in high-level caries populations. CONCLUSIONS: DMFT alone provided an incomplete picture of the impact of caries in South Africa, thus the need to monitor inequities as part of policy impact. The distribution of caries suggests that 'high-risk' approach to prevention in the presence of existing social gaps may inadvertently reinforce inequities in caries-burden and supports the concurrent implementation of population-approach, such as water fluoridation.

Risk Perception and Correlates of Tobacco Use among Young People Outside of Formal School Settings in Lagos State, Nigeria.

BACKGROUND: Tobacco use among youth is a major public health problem. Youth outside of formal school settings are often understudied but may be at increased risk. MATERIALS AND METHODS: A descriptive cross- sectional study was carried out among 326 young people aged 15-24 years in four randomly selected motor parks in Lagos state. Interviewer-administered questionnaires were used to collect data. RESULTS: The mean age of the respondents was 21.0±2.3yrs. Many 252 (77.3%) dropped out before the end of the third year of secondary schooling. The majority were aware that active (78.2%), and passive smoking (77.3%) are harmful to health. Nearly two-thirds of the respondents disagreed with an outright ban of cigarettes (63.2%) and restriction of cigarette sales to persons below 18 years (67.9%) while 254 (66.8%) supported a ban on tobacco smoking in enclosed public places. One hundred and fifty (46.0%) respondents had experimented with smoking of which 106 (32.5%) had progressed to become current smokers. Half of the current smokers, 54 (50.9%), felt the need for a cigarette first thing in the morning. A multivariate analysis for smoking initiation, showed that for every increasing year of age, respondents were 1.08 times more likely to have initiated cigarette smoking; males and respondents who lived alone or with peers were 2.34 times and 1.77 times more likely to have initiated smoking respectively; those who consume alcohol and marijuana were 7.27 and 1.89 times respectively more likely to have initiated smoking while those who consumed alcohol were 6.17 times more likely to be current smokers.

WHO framework convention on tobacco control and its relevance to the dental professions in South Africa.

One in nine deaths in South Africa is related to tobacco use. Recognition of the need for global partnership to curb the tobacco epidemic has led to the WHO member states' adoption of the first global public health treaty--the framework convention for tobacco control (FCTC). Relevant to the dental profession, within the FCTC's guiding principle of the need to protect all persons from the initiation, maintenance or increase of tobacco use are articles 12 and 14. These challenge parties to take action to train health workers and to secure treatment for tobacco dependence. Preventing initiation of tobacco use by youths is as fundamental to the prevention of periodontal disease and oro-pharyngeal cancer as providing fluoride and dental sealants for the prevention of dental caries. Tobacco control, whether in private practice or in public service, must be viewed within the context of an ethical obligation for primary prevention. There are science-based clinical guidelines for implementing tobacco prevention and tobacco cessation. Dentists who implement an effective cessation programme in their practices can expect to achieve quit rates of 10-15% each year. However, this primary prevention effort can be no better than the knowledge, skills and values of the practitioners providing the service. The FCTC may change the environment that dentistry is practised in globally. The relevant stakeholders in the dental profession should therefore assume stewardship by providing support for the training of dental professionals in tobacco counselling and advocate for the adequate reimbursement of practitioners providing such services.

Oculocutaneous Albinism and Squamous Cell Carcinoma of the Skin of the Head and Neck in Sub-Saharan Africa.

Oculocutaneous albinism which is characterised by impaired melanin biosynthesis is the most common inherited pigmentary disorder of the skin and it is common among Blacks in sub-Saharan Africa. All albinos are at great risk of developing squamous cell carcinoma of sun-exposed skin, and Black albinos in sub-Saharan Africa are at about a 1000-fold higher risk of developing squamous cell carcinoma of the skin than the general population. In Black albinos, skin carcinoma tends to run an aggressive course and is likely to recur after treatment, very probably because the aetiology and predisposing factors have not changed. Prevention or reduction of occurrence of squamous cell carcinoma of the skin in Black albinos might be achieved through educating the population to increase awareness of the harmful effects of exposure to sunlight and at the same time making available effective screening programs for early detection of premalignant and malignant skin lesions in schools and communities and for early treatment.

Nicotine delivery capabilities of smokeless tobacco products and implications for control of tobacco dependence in South Africa.

OBJECTIVES: Smokeless tobacco (SLT) use is popular among black South African women and children. The study sought to determine the nicotine delivery capability of popular industrialised and traditional SLT brands in South Africa, and to provide information for policy action by regulatory authorities. DESIGN: Laboratory chemical analysis of four industrialised and one traditional SLT products commercially available, using previously published analytical methods. Potential for dependence was inferred from nicotine delivery capabilities determined by the percentage free base nicotine. MEASUREMENTS: Moisture, pH, total nicotine, and percentage free base nicotine. RESULTS: Total nicotine content was between 6-16 mg/g. The pH varied between 7-10 and this correlated with percentage free base nicotine, which ranged between 10-99%. The nicotine delivery capability of the traditional product was lower than that of the industrialised products except for the recently introduced portion bag snus, which had comparable total nicotine but the lowest pH and percentage free base nicotine. The most popular SLT brands showed the highest percentage free base nicotine ever reported for any industrialised SLT or cigarette brands. Small cans contained higher nicotine than the large cans of the same brand tested. Findings from the study support a potential for limited "product graduation" by users. CONCLUSIONS: South African SLT users are mostly exposed to potentially very highly addictive levels of nicotine that may favour tobacco dependence and its consequent health risks. The increasing use of SLT by women of childbearing age support the need for intensified policy action to control its use.