Trends in smokeless tobacco use among adults and adolescents in the United States

Smokeless tobacco use among operating engineers

Workers in blue collar occupations have been shown to have higher rates of smokeless tobacco (ST) use compared to other occupational groups. Guided by the Health Promotion Model, the purpose of this study was to understand various factors that predict ST use in Operating Engineers. A cross-sectional design was used to determine variables related to ST use among Operating Engineers. Engineers (N = 498) were recruited during their 3-day apprentice certification course to participate in the study. Logistic regression was used to assess the associations between personal, psychological and behavioral characteristics associated with ST use. Past month ST use was reported among 13% of operating engineers surveyed. Multivariate analysis showed that younger age and lower rates of past month cigarette use were significantly associated with ST use, while higher rates of problem drinking were marginally associated with ST use. Operating Engineers are at high risk for using ST products with rates in this sample well over the national average. Work site interventions, which have shown promise in other studies, may be useful in decreasing ST use among this population.

Smokeless tobacco use and its relation to panic disorder, major depression, and posttraumatic stress disorder in American Indians

INTRODUCTION

Rates of nicotine use are high in American Indians. Anxiety and depression tend to be associated with cigarette use, but the association of anxiety and depression with smokeless tobacco (ST) is less clear. We asked if panic disorder, major depression, and posttraumatic stress disorder (PTSD) are related to lifetime ST use in 2 American Indian tribes.

METHODS

Logistic regression analyses examined the association between lifetime panic disorder, major depression, and PTSD and the odds of lifetime ST use status after controlling for sociodemographic characteristics, smoking status, and alcohol use disorders in 1,506 Northern Plains and 1,268 Southwest tribal members.

RESULTS

Odds of lifetime ST use was 1.6 times higher in Northern Plains tribal members with a lifetime history of PTSD after controlling for sociodemographic variables and smoking (95% CI: 1.1, 2.3; p = .01). This association remained significant after further adjustment for panic disorder and major depression (odds ratio [OR] = 1.5; 95% CI: 1.0, 2.2; p = .04) but was diminished after accounting for alcohol use (OR = 1.3; 95% CI: 0.9, 1.9; p = .23). In the Southwest, lifetime psychiatric disorders were not associated with lifetime ST use status. Increasing psychiatric comorbidity was significantly linked to increased odds of ST use in both tribes.

CONCLUSIONS

This study is the first to examine psychiatric conditions and lifetime ST use in a large, geographically diverse American Indian community sample. Although approximately 30% of tribal members were lifetime users of ST, the association with lifetime psychiatric disorders was not as strong as those observed with cigarette smoking. Understanding shared mechanisms between all forms of tobacco use with anxiety and depressive disorders remains an important area for investigation.

Smokeless tobacco marketing and sales practices in Appalachian Ohio following federal regulations

INTRODUCTION

Smokeless tobacco (ST) use is increasingly prevalent among poor and vulnerable groups, especially rural males. Access to tobacco products, as well as marketing messages, is associated with tobacco usage. In June 2010, the Tobacco Control Act (TCA) marked the beginning of federal regulation of the sale and marketing of tobacco products--including ST. The goal of this study was to describe marketing practices over time and to provide early assessment of the federal regulation in rural tobacco-licensed retail outlets.

METHODS

Observational data were collected from a sample of retail outlets within three Ohio Appalachian counties. From an estimated 300 retail establishments, a stratified random sample was drawn (n = 86). Trained observers surveyed the sales and marketing of tobacco products. Baseline surveys were conducted between November 2009 and May 2010 before the TCA; follow-up surveys were repeated in August 2010.

RESULTS

Follow-up surveys were completed for 79 tobacco-licensed retail outlets. The majority of retail outlets were gas stations or convenience stores. Compared with baseline, there was a significant reduction in the frequency of exterior and interior advertisements observed after the TCA (p < .01). Despite the lack of change in the proportion of stores advertising ST, the number of ST brands being advertised doubled between baseline and follow-up.

CONCLUSION

Initial compliance with certain elements of the federal restrictions appears to be high in Appalachian Ohio. The significant increase in ST brands advertised suggests that advertising remains a clear presence in retail outlets in Appalachian Ohio.

Health, masculinity and smokeless tobacco use among college-aged men

Existing work on smokeless tobacco (SLT) often focuses on correlates and predictors of use, ignoring the social and cultural context surrounding initiation and continued use of SLT products. The current study takes a qualitative approach using guided focus groups to examine this unexplored context. The findings show that male SLT users gain social rewards from dipping with other men, and usage is initiated and continued in spite of known potential health consequences. For the men participating in this study SLT use was primarily initiated at social or athletic events with the encouragement of other men and continued for relational maintenance and bonding. Additionally, the men reported that the social rewards received from using SLT far outweighed any potential health consequences or negative social repercussions they might also experience. Implications for future research and health interventions targeting SLT use are discussed.

Injury rates and injury risk factors among Federal Bureau of Investigation new agent trainees

BACKGROUND

A one-year prospective examination of injury rates and injury risk factors was conducted in Federal Bureau of Investigation (FBI) new agent training.

METHODS

Injury incidents were obtained from medical records and injury compensation forms. Potential injury risk factors were acquired from a lifestyle questionnaire and existing data at the FBI Academy.

RESULTS

A total of 426 men and 105 women participated in the project. Thirty-five percent of men and 42% of women experienced one or more injuries during training. The injury incidence rate was 2.5 and 3.2 injuries/1,000 person-days for men and women, respectively (risk ratio (women/men) = 1.3, 95% confidence interval = 0.9-1.7). The activities most commonly associated with injuries (% of total) were defensive tactics training (58%), physical fitness training (20%), physical fitness testing (5%), and firearms training (3%). Among the men, higher injury risk was associated with older age, slower 300-meter sprint time, slower 1.5-mile run time, lower total points on the physical fitness test (PFT), lower self-rated physical activity, lower frequency of aerobic exercise, a prior upper or lower limb injury, and prior foot or knee pain that limited activity. Among the women higher injury risk was associated with slower 300-meter sprint time, slower 1.5-mile run time, lower total points on the PFT, and prior back pain that limited activity.

CONCLUSION

The results of this investigation supported those of a previous retrospective investigation emphasizing that lower fitness and self-reported pain limiting activity were associated with higher injury risk among FBI new agents.

Assessment of smokeless tobacco use in the history and physical examination by primary healthcare providers

PURPOSE

Following a simple descriptive research design, we examined how and to what extent primary healthcare providers in rural southern regions of the United States ask patients about the use of smokeless tobacco as indicated in the document used for the patient history.

DATA SOURCES

Copies of blank history and physical forms used in offices of primary care providers in Alabama, Georgia, South Carolina, and Tennessee were examined to identify items related specifically to tobacco use.

CONCLUSIONS

Twenty-nine providers returned history and physical forms, which revealed 24% showed no item related to tobacco use. Others included questions related to smoking, but only 7% mentioned any sort of smokeless tobacco use.

IMPLICATIONS FOR PRACTICE

Although a few studies have suggested the use of smokeless tobacco to be less harmful than smoking, all forms of smokeless tobacco are recognized carcinogens and dangerous for health. It is not sufficient to simply ask patients about smoking behaviors. Primary care providers, especially nurse practitioners, have the unique opportunity to assess use of smokeless tobacco and to offer treatment and counsel to help patients to stop the behavior.

Trends in smokeless tobacco use in the us workforce: 1987-2005

The primary aim was to examine whether increasing workplace smoking restrictions have led to an increase in smokeless tobacco use among US workers. Smokeless tobacco exposure increases the risk of oral cavity, esophageal, and pancreatic cancers, and stroke. The prevalence of smokeless tobacco use decreased from 1987-2000, except among men 25-44. While smokeless tobacco use has declined in the general population, it may be that the prevalence of smokeless tobacco use has increased among workers due to workplace smoking restrictions, which have been shown to have increased over the years. Using the most current nationally representative National Health Interview Survey (NHIS) data, we examined whether increasing workplace smoking restrictions have led to an increase in smokeless tobacco use among US workers (n = 125,838). There were no significant changes in smokeless tobacco use prevalence from 1987-2005 (pooled prevalence = 3.53%); rates also were lower in smoke free workplaces. Worker groups with high rates of smokeless tobacco use included farm workers (10.51%) and blue collar workers (7.26%). Results indicate that smokeless tobacco prevention strategies targeting particular worker groups are warranted.

Do state expenditures on tobacco control programs decrease use of tobacco products among college students?

The objective of this paper is to investigate the effects of state tobacco control program expenditures on individual-level tobacco use behaviors among young adults. Data come from the 1997, 1999 and 2001 waves of the Harvard School of Public Health College Alcohol Study (CAS). Our findings indicate that a higher level of state spending on tobacco control programs in the prior year is associated with a statistically significant increase in the probability that current daily smokers report at least one attempt to quit smoking in the past year. We also find evidence that higher state expenditures on tobacco control programs in the prior year are associated with reductions in the prevalence of daily smoking and 30-day cigar use among college students. We do not find any statistically significant association between state tobacco control program expenditures and the number of attempts to quit smoking among those with at least one attempt, or on the prevalence of smokeless tobacco use in the past month.

Tobacco use and exposure in rural areas: Findings from the Behavioral Risk Factor Surveillance System

Evidence suggests that those residing in rural areas may be disproportionately affected by the health burden of tobacco use. The present study examined tobacco use, self-reported exposure to tobacco smoke, and policies regarding public smoking according to area of residence using data from the 2006 and 2008 Behavioral Risk Factor Surveillance System. Results indicated that, relative to those from suburban and urban locations, adults residing in rural areas were significantly more likely to smoke cigarettes (22.2% versus 17.3% (suburban) and 18.1% (urban), p<.001) and to use smokeless tobacco (p<.001). Rural residents were also more likely than those living in suburban and urban areas to report that someone had smoked in their presence during the past seven days both at home (p<.001) and at work (p<.001). Finally, rural participants reported policies that afforded less protection from tobacco smoke both at home and in the workplace. These findings suggest that those living in rural areas are at increased risk for tobacco-related illness due to both their own tobacco use and exposure to others' cigarette smoke.

Testing the universality of the effects of the communities that care prevention system for preventing adolescent drug use and delinquency

Universal community-oriented interventions are an important component in the prevention of youth health and behavior problems. Testing the universality of the effects of an intervention that was designed to be universal is important because it provides information about how the program operates and for whom and under what conditions it is most effective. The present study examined whether the previously established significant effects of the universal, community-based Communities That Care (CTC) prevention program on the prevalence of substance use and the variety of delinquent behaviors held equally for boys and girls and in risk-related subgroups defined by early substance use, early delinquency, and high levels of community-targeted risk at baseline. Interaction analyses of data from a panel of 4,407 students followed from Grade 5 to Grade 8 in the first randomized trial of CTC in 12 matched community pairs suggests that CTC reduced students' substance use and delinquency equally across risk-related subgroups and gender, with two exceptions: The effect of CTC on reducing substance use in 8th grade was stronger for boys than girls and the impact of CTC on reducing 8th-grade delinquency was stronger for students who were nondelinquent at baseline.

Tobacco use, heavy use, and dependence among adolescents and young adults in the United States

Tobacco involvement among US youth was investigated in a national survey conducted in 2005-2007 of 2,274 respondents aged 14-21, including those not in school. Logistic regressions predicted tobacco involvement. Males had higher rates of tobacco use than females, but males and females had equal rates of heavy use and dependence. Tobacco involvement increased with age. Whites were more tobacco involved than minorities. Tobacco involvement declined with increasing socioeconomic status. Reduced tobacco use was associated with being married and with being a student. Smokeless tobacco use was associated with being male, older, white, and lower socioeconomic status. The implications of these results are discussed.

Smokeless tobacco use and periodontal health in a rural male population

BACKGROUND

Despite the reported effects of smokeless tobacco (ST) on the periodontium and high prevalence of ST use in rural populations and in men, studies on this specific topic are limited. The purpose of this cross-sectional investigation is to evaluate the periodontal health status of male ST users from a rural population.

METHODS

Adult male residents of two rural Appalachian Ohio counties and daily ST users, with a unilateral mandibular oral ST keratosis lesion, were recruited. Subjects completed a questionnaire and received oral examination. Teeth present, ST keratosis lesion, plaque and gingival index, probing depth (PD), recession depth (RD), and attachment level were recorded. Statistical analysis compared ST-site mandibular teeth (teeth adjacent to the subject's unilateral ST keratosis lesion) to NST-site teeth (contralateral corresponding teeth).

RESULTS

This study includes 73 ST users. Recession prevalence is much greater in ST-site quadrants (36%) compared to NST-site quadrants (18%; P <0.001). Twice as many teeth had recession on ST-site (approximately 20%) than NST-site (approximately 10%; P = 0.0001). Average buccal RD on ST-site teeth did not differ from that on the NST-site teeth (P = 0.0875). Although average buccal attachment loss is greater on ST-site teeth (P = 0.016), the mean difference is <0.5 mm. When stratified by years of ST use, subjects using ST for 10 to 18 years exhibit the most differences between ST and NST sites, whereas subjects using ST for <10 years show no differences.

CONCLUSION

The results indicate that greater gingival recession prevalence and extent are associated with ST placement site in rural male ST users.

Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA

BACKGROUND

Snus (a form of smokeless tobacco) is less dangerous than cigarettes. Some health professionals argue that snus should be promoted as a component of a harm reduction strategy, while others oppose this approach. Major US tobacco companies (RJ Reynolds and Philip Morris) are marketing snus products as cigarette brand line extensions. The population effects of smokeless tobacco promotion will depend on the combined effects of changes in individual risk with population changes in tobacco use patterns.

OBJECTIVE

To quantitatively evaluate the health impact of smokeless tobacco promotion as part of a harm reduction strategy in the US.

METHODS

A Monte Carlo simulation of a decision tree model of tobacco initiation and use was used to estimate the health effects associated with five different patterns of increased smokeless tobacco use.

RESULTS

With cigarette smoking having a health effect of 100, the base case scenario (based on current US prevalence rates) yields a total health effect of 24.2 (5% to 95% interval 21.7 to 26.5) and the aggressive smokeless promotion (less cigarette use and increased smokeless, health-concerned smokers switching to snus, smokers in smokefree environments switching to snus) was associated with a health effect of 30.4 (5% to 95% interval 25.9 to 35.2). The anticipated health effects for additional scenarios with lower rates of smokeless uptake also overlapped with the base case.

CONCLUSIONS

Promoting smokeless tobacco as a safer alternative to cigarettes is unlikely to result in substantial health benefits at a population level.

Prevalence and correlates of tobacco use among middle and high school students in western Alaska

OBJECTIVES

Tobacco use is the leading cause of preventable death in the United States and contributes to increased incidence, morbidity and mortality from cancer, heart disease, stroke, complications of pregnancy and respiratory illness. Tobacco use rates are highest among American Indians and Alaska Natives. This study examined the prevalence and correlates of tobacco use among youth residing in rural western Alaska.

STUDY DESIGN

Data were analysed from the 2003 Youth Risk Behavior Survey (YRBS) administered to a regional sample of adolescents attending school in western Alaska.

METHODS

Data were analysed from 260 middle school (52% female, 87% Alaska Native) and 258 high school (48% female, 93% Alaska Native) students.

RESULTS

Among middle school students, 39% reported current use of ST, 24% reported cigarette smoking and 50% reported current use of any tobacco product. On multivariate analysis, independent correlates of current use of any tobacco were Alaska Native ethnicity (p=0.002) and ever use of marijuana (p<0.001). Among high school students, 38% reported current ST use, 43% reported cigarette smoking and 60% reported current use of any tobacco product. Independent correlates of current use of any tobacco were increasing age (p=0.007), ever use of marijuana (p<0.001), current use of marijuana (p=0.005) and reporting a suicide attempt within the past 12 months (p=0.003). No significant gender differences on tobacco use emerged for middle or high school students.

CONCLUSIONS

This study documents the high tobacco use rates among youth residing in western Alaska, with over half of the adolescents reporting tobacco use. Developing interventions to promote tobacco use prevention and cessation is an essential step towards reducing tobacco-related health disparities in this rural population. Expanded efforts are needed to address tobacco use among youth residing in this region of Alaska.

The use of focus groups to compare tobacco attitudes and behaviors between youth in urban and rural settings

This exploratory study uses focus groups to examine the attitudes and behaviors of male adolescent tobacco users from urban and rural settings. Five focus groups, three urban and two rural, were conducted (n = 28). Results indicate that this is an interesting topic that generated interactions and discussion among participants. Themes that have emerged from the data include the sociability of tobacco initiation and access; tobacco preferences linked to image; social norms against secondhand smoke exposure, especially around children; ambivalence toward daily use as a habit versus an addiction; and avoidance of discussing cessation. The data from this study can help health departments distinguish and target prevention and intervention programs for youth in urban and rural settings.

Analysis of 23 polycyclic aromatic hydrocarbons in smokeless tobacco by gas chromatography-mass spectrometry

Smokeless tobacco contains 28 known carcinogens and causes precancerous oral lesions and oral and pancreatic cancer. A recent study conducted by our research team identified eight different polycyclic aromatic hydrocarbons (PAHs) in U.S. moist snuff, encouraging further investigations of this group of toxicants and carcinogens in smokeless tobacco products. In this study, we developed a gas chromatography-mass spectrometry method that allows simultaneous analysis of 23 various PAHs in smokeless tobacco after a simple two-step extraction and purification procedure. The method produced coefficients of variation under 10% for most PAHs. The limits of quantitation for different PAHs varied between 0.3 and 11 ng/g tobacco, starting with a 300 mg sample. The recovery of the stable isotope-labeled internal standards averaged 87%. The method was applied to analysis of 23 moist snuff samples that included various flavors of the most popular U.S. moist snuff brands, as well as 17 samples representing the currently marketed brands of spit-free tobacco pouches, a relatively new type of smokeless tobacco. The sum of all detected PAHs in conventional moist snuff averaged 11.6 (+/-3.7) microg/g dry weight; 20% of this amount was comprised of carcinogenic PAHs. The levels of PAHs in new spit-free tobacco products were much lower than those in moist snuff; the sum of all detected PAHs averaged 1.3 (+/-0.28) microg/g dry weight. Our findings render PAHs one of the most prevalent groups of carcinogens in smokeless tobacco. Urgent measures are required from the U.S. tobacco industry to modify manufacturing processes so that the levels of these toxicants and carcinogens in U.S. moist snuff are greatly reduced.

Branding the rodeo: a case study of tobacco sports sponsorship

Rodeo is one of the few sports still sponsored by the tobacco industry, particularly the US Smokeless Tobacco Company. Rodeo is popular in rural communities, where smokeless tobacco use is more prevalent. We used previously secret tobacco industry documents to examine the history and internal motivations for tobacco company rodeo sponsorship. Rodeos allow tobacco companies to reach rural audiences and young people, enhance brand image, conduct market research, and generate positive press. Relationships with athletes and fans were used to fight proposed restrictions on tobacco sports sponsorship. Rodeo sponsorship was intended to enhance tobacco sales, not the sport. Rural communities should question the tradition of tobacco sponsorship of rodeo sports and reject these predatory marketing practices.

Surveillance methods for identifying, characterizing, and monitoring tobacco products: potential reduced exposure products as an example

Tobacco products are widely sold and marketed, yet integrated data systems for identifying, tracking, and characterizing products are lacking. Tobacco manufacturers recently have developed potential reduced exposure products (PREP) with implied or explicit health claims. Currently, a systematic approach for identifying, defining, and evaluating PREPs sold at the local, state, or national levels in the United States has not been developed. Identifying, characterizing, and monitoring new tobacco products could be greatly enhanced with a responsive surveillance system. This article critically reviews available surveillance data sources for identifying and tracking tobacco products, including PREPs, evaluating strengths and weaknesses of potential data sources in light of their reliability and validity. With the absence of regulations mandating disclosure of product-specific information, it is likely that public health officials will need to rely on a variety of imperfect data sources to help identify, characterize, and monitor tobacco products, including PREPs.

Test marketing of new smokeless tobacco products in four U.S. cities

INTRODUCTION

This exploratory study was designed to assess the availability, price, and point-of-purchase marketing strategies for new smokeless tobacco products in 4 test market areas.

METHODS

A random sample of 50 gas stations, convenience and food stores, and tobacco shops was selected in each of 4 test market areas. Pairs of observers visited each store, recorded product information, and engaged vendors in conversation about product demand.

RESULTS

Snus was available in 64% of the stores, but availability and price differed by brand. Point-of-purchase marketing also varied by brand on a variety of dimensions and all brands appeared to be marketed primarily to smokers. Camel Snus was described by store attendants as having the highest demand and was also the most expensive of the observed products. In light of the number of test market cities and intensity of promotion at retail locations, Camel Snus was the most intensively marketed product.

DISCUSSION

The results appear to reflect differences in marketing strategy by American snus manufacturers. These strategies may help to predict future marketing of snus and other tobacco products and may provide a baseline for later assessments of product acceptance.

Are smokers receptive to using smokeless tobacco as a substitute?

OBJECTIVES

Few studies have addressed the feasibility of promoting smokeless tobacco as an alternative for smokers. This study was intended to assess the characteristics and degree to which smokers from California are receptive to using the substitute for harm reduction.

METHODS

Daily cigarette smokers (n=2995) were selected from the 2005 California Tobacco Survey. Using ordinal logistic regression, four sets of variables (demographics, tobacco use, motivations and intentions to quit smoking) were examined as predictors of the outcome, willingness to use a form of smokeless tobacco perceived to be less harmful than cigarettes.

RESULTS

A majority of smokers (75.6%) expressed no interest in the tobacco substitute. Contrary to expectation, few of the measures for demographics, tobacco use and motivations to quit smoking were significantly correlated with the outcome. Irrespective of prior use of nicotine replacement therapy, smokers were more receptive if they had previously attempted to quit, or were currently attempting to reduce their consumption of cigarettes.

CONCLUSIONS

Smokeless tobacco is an unacceptable alternative for most California smokers. But, the expected correlates, notably gender, accounted for minimal variability in SLT receptiveness, an observation that challenges concerns about the product's limited appeal to any one group.

Demographic profiles of smokeless tobacco users in the U.S

BACKGROUND

Users of smokeless tobacco (chew or snuff) in the U.S. are viewed demographically as being homogeneous. Prior studies have demonstrated such homogeneity in national survey data but have not utilized latent-variable methods. The objective of this study was to determine whether a single group or underlying subgroups best characterize users of smokeless tobacco.

METHODS

Men aged >17 years who had used smokeless tobacco in the past month (n=4583) were selected from the 2003, 2004, and 2005 National Surveys on Drug Use and Health. A latent-class analysis, conducted in 2008, was based on individual response patterns from six demographic variables and three items pertaining to the use of smokeless tobacco.

RESULTS

Four latent classes were identified: older chew users (17.2%); younger poly-tobacco users (28.7%); skilled laborers with a high school diploma (27.5%); and educated professionals (26.6%). External validation of these classes indicated that older chew users and younger poly-tobacco users were more likely than the educated professionals to be former and current smokers, respectively.

CONCLUSIONS

While users of smokeless tobacco in the U.S. are predominantly white men, they are more heterogeneous with respect to education, occupation, and residency than commonly is perceived.

Receptivity to Taboka and Camel Snus in a U.S. test market

INTRODUCTION

The two largest U.S. cigarette manufacturers introduced Swedish-style low-nitrosamine smokeless tobacco (snus) to several U.S. test markets in summer 2006. Since then, snus brands and test markets have proliferated.

METHODS

This article assesses consumer response by analyzing data from the 2006 and 2007 Indiana Adult Tobacco Survey (IATS), a statewide telephone survey of 3,544 adults. During those years, the IATS included questions on awareness and trial of Camel Snus and Taboka. Analyses examined rates and predictors of awareness and trial statewide, and within the central Indiana test market.

RESULTS

Nineteen percent of Indiana adults were aware of either Taboka or Camel Snus in 2006 and 2007. Estimates are larger (29%) for central Indiana and larger still (70%) for central Indiana smokers. Trial of snus, however, was very low (1.5% statewide), except among male smokers in central Indiana, 20% of whom are estimated to have tried it. Multivariate analyses showed that trial was more likely among men than women (odds ratio [OR] 13.85), residents of central Indiana than those farther from Indianapolis (OR 2.96), recipients than nonrecipients of tobacco promotions (OR 6.08), and those believing that smokeless tobacco is less harmful than cigarettes compared with those who believe it is equally or more harmful (OR 3.86).

DISCUSSION

Results from this study suggest substantial initial interest in the new products among male smokers in this test market, especially those who receive promotional mailings from tobacco companies, which often include coupons for free or discounted products.

Smokeless tobacco use among men in the United States, 2000 and 2005

BACKGROUND

Compared with smoking, there is much less information about smokeless tobacco (ST) use in the United States. The purpose of this study is to characterize and compare ST use among American men in 2000 and 2005.

METHODS

We used US National Health Interview Surveys from 2000 and 2005 to estimate the prevalence of ST use, describe the demographic and socioeconomic profile of ST users and evaluate ST use according to product type and with respect to smoking.

RESULTS

The prevalence of ST use among American men was 4.4% in 2000 and 4.3% in 2005. Almost all ST users were white, about half were 25-44 years old and 80% lived in the South or Midwest, commonly in small metropolitan and rural areas. Educational and income levels of ST users were lower than those of never users of tobacco. One-third of ST users also smoked; cigarette consumption was lower among dual users than among exclusive smokers. In 2005, 1.3 million current ST users were former smokers but 3.2 million smokers were former ST users. ST users were evenly distributed between snuff (43%) and chewing tobacco (44%) in 2000 and 13% used both products. By 2005 snuff use was clearly dominant.

CONCLUSIONS

The prevalence of ST use among men is low but stable; dual use of cigarettes and ST is common, and snuff has become the dominant ST product.

Quitting cigarettes completely or switching to smokeless tobacco: do US data replicate the Swedish results?

BACKGROUND

Swedish male smokers are more likely than female smokers to switch to smokeless tobacco (snus) and males' smoking cessation rate is higher than that of females. These results have fuelled international debate over promoting smokeless tobacco for harm reduction. This study examines whether similar results emerge in the United States, one of few other western countries where smokeless tobacco has long been widely available.

METHODS

US DATA SOURCE: national sample in Tobacco Use Supplement to Current Population Survey, 2002, with 1-year follow-up in 2003. Analyses included adult self-respondents in this longitudinal sample (n = 15,056). Population-weighted rates of quitting smoking and switching to smokeless tobacco were computed for the 1-year period.

RESULTS

Among US men, few current smokers switched to smokeless tobacco (0.3% in 12 months). Few former smokers turned to smokeless tobacco (1.7%). Switching between cigarettes and smokeless tobacco, infrequent among current tobacco users (<4%), was more often from smokeless to smoking. Men quit smokeless tobacco at three times the rate of quitting cigarettes (38.8% vs 11.6%, p<0.001). Overall, US men have no advantage over women in quitting smoking (11.7% vs 12.4%, p = 0.65), even though men are far likelier to use smokeless tobacco.

CONCLUSION

The Swedish results are not replicated in the United States. Both male and female US smokers appear to have higher quit rates for smoking than have their Swedish counterparts, despite greater use of smokeless tobacco in Sweden. Promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programmes may not result in any positive population effect on smoking cessation.

Patterns of cigarette and smokeless tobacco use before, during, and after pregnancy among Alaska native and white women in Alaska, 2000-2003

OBJECTIVE

To examine patterns of cigarette and smokeless tobacco use before, during, and after pregnancy among Alaska Native (AN) and white women living in Alaska.

METHODS

We used data from the 2000-2003 population-based Pregnancy Risk Assessment Monitoring System to describe patterns of self-reported prenatal tobacco use among AN and white women. We used multiple variable logistic regression analysis to identify maternal factors associated with quitting and relapse. The final sample included 5,458 women.

RESULTS

During 2000-2003, the prevalence of any tobacco use before pregnancy was twofold higher among AN women than among white women (60.0 vs. 27.5%), and the prevalence of any tobacco use during pregnancy and after pregnancy were each nearly threefold higher. Of the 25.8% (SE 0.9) of white women who smoked before pregnancy, 49.0% (SE 2.1) reported that they quit during pregnancy and of those, 41.1% (SE 2.9) relapsed postpartum. Of the 38.5% (SE 0.9) of AN women who smoked before pregnancy, 35.7% (SE 1.4) quit, and of those 57.0% (SE 2.4) relapsed. Of the 14.2% of AN women who chewed tobacco before pregnancy, 15.7% (SE 1.7) quit, and of those, 52.9% (SE 5.9) relapsed.

CONCLUSION

During 2000-2003, the prevalence of tobacco use was two to three times higher among AN women than among white women before, during, and after pregnancy. In addition, AN women had lower quit rates and higher relapse rates than white women. Comprehensive, culturally appropriate tobacco control approaches targeting AN women are needed to increase cessation during pregnancy and to decrease relapse.

Smokeless tobacco use and religiousness

Although smoking shows a strong negative association with religiousness, no studies have appeared of use of smokeless tobacco (ST) and religiousness. To assess an association of use of ST and religiousness, data from 9,374 men aged 17 years and over with complete data on self-reported frequency of attendance at religious services and use of smokeless tobacco were analyzed. Among men aged 17–29 years, 4.9% of frequent attenders (>=24 times/y) and 9.4% of others (<24 times/y) were current users of ST (p=0.002). After adjusting for multiple confounders by logistic regression, infrequent attenders were twice as likely as frequent attenders to be ST users: odds ratio 2.09, 95% confidence limits 1.12–3.92, p=0.02. This negative association suggests a protective effect of early-life religiousness on ST use, which might be taken into account in planning ST prevention efforts.

Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking?

Four arguments have been used to support smokeless tobacco (ST) for harm reduction: (1) Switching from cigarettes to ST would reduce health risks; (2) ST is effective for smoking cessation; (3) ST is an effective nicotine maintenance product; and (4) ST is not a "gateway" for cigarette smoking. There is little evidence to support the first three arguments and most evidence suggests that ST is a gateway for cigarette smoking. There are ethical challenges to promoting ST use. Based on the precautionary principle, the burden of proof is on proponents to provide evidence to support their position; such evidence is lacking.

Systematic review of the relation between smokeless tobacco and cancer of the pancreas in Europe and North America

Background

Recent reviews claiming smokeless tobacco increases pancreatic cancer risk appear not to have considered all available epidemiological evidence; nor were meta-analyses included. We present a systematic review of studies from North America and Europe, since data are lacking from other continents. Risk is also difficult to quantify elsewhere due to the various products, compositions and usage practices involved.

Methods

Epidemiological studies were identified that related pancreatic cancer to use of snuff, chewing tobacco or unspecified smokeless tobacco. Study details and effect estimates (relative risks or odds ratios) were extracted, and combined by meta-analyses.

Results

Nine North American and two Scandinavian studies were identified. Reporting was limited in four studies, so only seven were included in meta-analyses, some providing results for never smokers, some for the overall population of smokers and non-smokers, and some for both.

Giving preference to study-specific estimates for the overall population, if available, and for never smokers otherwise, the random-effects estimate for ever smokeless tobacco use was 1.03 (95% confidence interval 0.71–1.49) based on heterogeneous estimates from seven studies. The estimate varied little by continent, study type, or type of smokeless tobacco.

Giving preference to estimates for never smokers, if available, and overall population estimates otherwise, the estimate was 1.14 (0.67–1.93), again based on heterogeneous estimates. Estimates varied (p = 0.014) between cohort studies (1.75, 1.20–2.54) and case-control studies (0.84, 0.36–1.97). The value for cohort studies derived mainly from one study, which reported an increase for never smokers (2.0, 1.2–3.3), but not overall (0.9, 0.7–1.2). This study also contributed to increases seen for snuff use and for European studies, significant only in fixed-effect analyses.

The studies have various weaknesses, including few exposed cases, reliance in cohort studies on exposure recorded at baseline, poor control groups in some case-control studies, and lack of a dose-response. Publication bias, with some negative studies not being presented, is also possible.

Conclusion

At most, the data suggest a possible effect of smokeless tobacco on pancreatic cancer risk. More evidence is needed. If any risk exists, it is highly likely to be less than that from smoking.

Resolution of oral lesions after tobacco cessation

BACKGROUND

Dentists and other health care professionals are familiar with the impact of tobacco on oral and general health. However, oral health care professionals do not often provide tobacco-cessation counseling to their patients, thus reflecting a significant disconnect between research and clinical practice. This report demonstrates the benefits of tobacco cessation in resolving oral lesions and improving overall periodontal and oral health.

METHODS

A 51-year-old white male presented to the University at Buffalo, School of Dental Medicine clinic requesting an oral and periodontal examination as part of a presurgical protocol prior to cardiac surgery. A review of the patient's history from a health questionnaire revealed that he was using smokeless tobacco every day. An oral examination revealed several white lesions (5 x 10 mm) on the maxillary right and left labial mucosa. The patient was provided with tobacco-cessation counseling as well as oral hygiene instructions and professional dental prophylaxis.

RESULTS

An oral examination 2 weeks after tobacco cessation revealed complete resolution of the oral lesions and overall improvement of periodontal and oral health.

CONCLUSION

Although the findings presented in this article are based only on a single case report, the improvement in the patient's oral health after cessation of tobacco use was dramatic and reinforces the belief that tobacco-cessation counseling should be a routine component of the standard of care for tobacco-using patients.

Prenatal cigarette smoking and smokeless tobacco use among Alaska native and white women in Alaska, 1996-2003

OBJECTIVE

To examine trends in prenatal cigarette smoking and smokeless tobacco use among Alaska Native (AN) and white women in Alaska.

METHODS

Using 1996-2003 data from the population-based Pregnancy Risk Assessment Monitoring System, we determined trends in self-reported prenatal tobacco use among AN and white women and used chi-square tests and multiple variable logistic regression analysis to identify maternal factors associated with prenatal tobacco use.

RESULTS

Over the study period, prevalence of any tobacco use during pregnancy declined by 27% among AN women (from 55.8 to 40.9%) (P < 0.0001) and by 17% among white women (from 18.8 to 15.6%) (P < 0.0001). In 2003, among AN women the prevalence of self-reported smokeless tobacco use was 16.9%, cigarette smoking was 25.7%, and any tobacco use was 40.9%; corresponding values for white women were 0.4, 15.0, and 15.6%, respectively. Western Alaska had the highest prevalence of tobacco use.

CONCLUSION

The prevalence of tobacco use decreased between 1996 and 2003, but remained higher among AN women than white women, especially for smokeless tobacco. Support for cessation interventions targeting pregnant women should be made a public health priority in Alaska.

Factors associated with smokeless tobacco cessation in an Appalachian population

Identifying factors associated with successful tobacco quit attempts may help in the development and targeting of effective cessation strategies. This paper aims to describe factors associated with smokeless tobacco (ST) cessation and compares the results to findings in the smoking cessation literature. Prospective data on 116 men aged 19 to 70 and participating in a ST cessation program were used to examine correlates of successful ST cessation at 1-year post-intervention. Controlling for age, level of education (p=0.002) and daily coffee consumption (p=0.005) had significant independent associations with successful cessation. No ST use variables were significant predictors of cessation success. In a multivariable logistic regression model three factors were significantly associated with cessation: education (p=0.010), coffee consumption (p=0.019), and age (p=0.029). Factors associated with successful ST cessation in this sample are consistent with predictors of smoking cessation reported in the literature. Based on its widespread use and the strength of its association with successful quitting, the role of caffeine consumption in ST cessation merits further study.

Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey

BACKGROUND

Although smokeless tobacco (ST) use has played a major role in the low smoking prevalence among Swedish men, there is little information at the population level about ST as a smoking cessation aid in the U.S.

METHODS

We used the 2000 National Health Interview Survey to derive population estimates for the number of smokers who had tried twelve methods in their most recent quit attempt, and for the numbers and proportions who were former or current smokers at the time of the survey.

RESULTS

An estimated 359,000 men switched to smokeless tobacco in their most recent quit attempt. This method had the highest proportion of successes among those attempting it (73%), representing 261,000 successful quitters (switchers). In comparison, the nicotine patch was used by an estimated 2.9 million men in their most recent quit attempt, and almost one million (35%) were former smokers at the time of the survey. Of the 964,000 men using nicotine gum, about 323,000 (34%) became former smokers. Of the 98,000 men who used the nicotine inhaler, 27,000 quit successfully (28%). None of the estimated 14,000 men who tried the nicotine nasal spray became former smokers. Forty-two percent of switchers also reported quitting smoking all at once, which was higher than among former smokers who used medications (8-19%). Although 40% of switchers quit smoking less than 5 years before the survey, 21% quit over 20 years earlier. Forty-six percent of switchers were current ST users at the time of the survey.

CONCLUSION

Switching to ST compares very favorably with pharmaceutical nicotine as a quit-smoking aid among American men, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. The results of this study show that tobacco harm reduction is a viable cessation option for American smokers.

Depression symptoms and substance abuse in adolescents with asthma

BACKGROUND

Depression and risk behaviors occur often in adolescents in the United States, but their frequency in youth with asthma is not well documented.

OBJECTIVE

To establish rates of and associations between depression and substance use in youth with asthma.

METHODS

The Centers for Disease Control and Prevention conducted the 2005 Youth Risk Behavior Survey with 13,917 students in grades 9 to 12 from 159 high schools in 40 states, producing a nationally representative distribution of students by grade, sex, and race/ethnicity. The Youth Risk Behavior Survey documents self-reported suicide intent and health risk behaviors, including use of tobacco, marijuana, alcohol, and cocaine.

RESULTS

In 720 adolescents reporting current asthma (5.2% of the total sample), depression symptoms, cigarette smoking, and cocaine use occurred more frequently than in youth without asthma. Substance use increased with depression; of youth with asthma reporting suicidal ideation, 40% had smoked cigarettes, 67% had smoked marijuana, 37% had engaged in binge drinking, and 12% had used cocaine in the past 30 days. Overall odds ratios for substance abuse in the group with asthma were not altered when controlling for age, sex, and race, although odds ratios for specific risk behaviors in those with asthma varied slightly within age, sex, and race groups.

CONCLUSIONS

National rates of depression and associated risk behaviors in youth with asthma have not been previously reported, indicate a need to screen adolescents with asthma for depression, and suggest that risk behaviors in this population may signal heightened need for intervention.

Trends in head and neck cancer incidence in relation to smoking prevalence: an emerging epidemic of human papillomavirus-associated cancers?

The trends in head and neck cancer incidence and smoking prevalence are reviewed, discussing where such trends parallel but also how and why they may not. In the U.S., public health efforts at tobacco control and education have successfully reduced the prevalence of cigarette smoking, resulting in a lower incidence of head and neck cancer. Vigilance at preventing tobacco use and encouraging cessation should continue, and expanded efforts should target particular ethnic and socioeconomic groups. However, an unfortunate stagnation has been observed in oropharyngeal cancer incidence and likely reflects a rising attribution of this disease to oncogenic human papillomavirus, in particular type 16 (HPV-16). For the foreseeable future, this trend in oropharyngeal cancer incidence may continue, but with time the effects of vaccination of the adolescent and young adult female population should result in a lower viral prevalence and hopefully a reduced incidence of oropharyngeal cancer. To hasten the reduction of HPV-16 prevalence in the population, widespread vaccination of adolescent and young adult males should also be considered.

Prospective investigation of the cigarette smoking-head and neck cancer association by sex

BACKGROUND

Men are approximately 3 times more likely to develop squamous cancers of the head and neck (oral cavity, pharynx, and larynx) than women. Very few prospective studies have examined the association between cigarette smoking and cancers of the head and neck in women, even though the rates of smoking in women are increasing rapidly worldwide.

METHODS

The association between cigarette smoking and head and neck cancer was investigated in 476,211 participants, aged 50-71 years, of the National Institutes of Health/American Association of Retired Persons (NIH-AARP) diet and health study by using age-standardized incidence rates and hazard ratios from Cox models adjusted for other risk factors for these cancers.

RESULTS

Over the course of follow-up (1995 through 2000), 584 men and 175 women were diagnosed with head and neck cancer. Nonsmoking (24.4), former smoking (36.9), and current smoking (147.3) men had higher rates of incident head and neck cancer per 100,000 person-years of follow-up than women did in each equivalent category of cigarette use (non: 4.8; former: 17.2; current: 75.7). The hazard ratios associated with smoking were significantly larger in women (12.96; 95% confidence interval [CI], 7.81-21.52) than in men (5.45, 95% CI, 4.22-7.05; P for interaction: <.001) for head and neck cancer overall and also for the 3 subsites (oral cavity, oro-hypopharynx, and larynx) examined in stratified analyses. Ever-smoking accounted for 45% of head and neck cancers in men and 75% in women, assuming causality.

CONCLUSIONS

Cigarette smoking is a strong risk factor for head and neck cancer in both men and women. Incidence rates of head and neck cancer were higher in male smokers than female smokers, but smoking may explain a higher proportion of head and neck cancer in women than in men.

An Epidemic that Deserves More Attention: Epidemiology, Prevention, and Treatment of Smokeless Tobacco

Smokeless tobacco (ST) use is common, especially in southern and rural areas. It is expected to become more popular with the recent move to sell more ST in areas where indoor smoking is banned. ST use usually starts in adolescence, which places this group at high risk. Nicotine dependence occurs almost exclusively in people who start using ST in their adolescent years, so it is crucial to prevent the introduction of ST to this age group. The debate over whether ST is a gateway to smoking or a bridge to quitting has not been fully answered. ST should not replace smoking where indoor smoking is banned. ST is less harmful than smoking, but nicotine replacement therapy (NRT) is much safer than ST. NRT and bupropion are helpful in the treatment of ST dependence by decreasing withdrawal symptoms and preventing weight gain after cessation.

A measure of nicotine dependence for smokeless tobacco users

The objective of the present study was to examine the properties of a modification of the Fagerström Test of Nicotine Dependence in a large sample of smokeless tobacco (ST) users. The subjects for this study included 256 males who were recruited for a tobacco cessation intervention that involved a visit with a dentist and advice to quit smoking during the exam. At baseline, the modified dependence scale was administered to the participants and a saliva sample was collected to measure cotinine. The correlation between the total score and salivary cotinine was moderate among the ST only users (r=0.34), whereas it was lower (r=0.19) among the ST+cigarette users. Among ST only users, the coefficient alpha was 0.40; however it was considerably higher among the ST+cigarettes group (alpha=0.61). In both cases, the coefficient alpha was lower than the recommended value of 0.70. Future research should focus on refining questionnaires that more precisely measure nicotine dependence in smokeless tobacco users.