Patterns of use and incidence of smokeless tobacco consumption in school-age children

Origins in the USA in the 1980s of the warning that smokeless tobacco is not a safe alternative to cigarettes: a historical, documents-based assessment with implications for comparative warnings on less harmful tobacco/nicotine products

BACKGROUND

Before the 1980s in the USA, smokeless tobacco carried no health warnings, was not judged to cause disease, and was a declining practice. In 1986, the federal government passed legislation requiring rotating warnings on "mouth cancer," "gum disease and tooth loss," and "This product is not a safe alternative to cigarettes." This paper explores the history of the establishment of these warnings with emphasis on the 'not a safe alternative' warning and the bases for claiming that smokeless was 'not safe' (absolute harm) versus 'not safer than cigarettes' (relative harm).

METHODS

Results of searches of Truth Tobacco Industry Document archives and transcripts of legislative hearings were analyzed. Critical assessments were made of the evidence-base.

RESULTS

New evidence of oral cancer causation emerged along with a much-publicized case of a teenager dying of oral cancer. Public health concerns also arose over a widespread, successful marketing campaign implying smokeless was a safe alternative to cigarettes. Industry wanted pre-emptive federal warnings, to prevent a diversity of pending state warnings. To avoid an addiction warning, the industry accepted a compromise 'not a safe alternative' warning, which had not been initially proposed and which the cigarette industry may have sought in order to constrain the smokeless tobacco industry. The evidence presented supported smokeless only as 'not safe' and not 'as harmful as cigarette smoking.'

CONCLUSIONS

The comparative warning was a compromise to prevent an addiction warning and consistent with the preferences of cigarette companies. Prior surveys indicated that the public generally did not view smokeless tobacco as harmless, but they did generally report smokeless as less harmful than cigarettes despite expert interpretations to the contrary. As would not have been appreciated by public health supporters at the outset, subsequent research has shown that the 'not a safe alternative' message is misinterpreted by consumers to indicate that smokeless is 'not safer' than cigarettes-which was not established and has been disconfirmed by subsequent assessments of that question. Though many countries have banned smokeless tobacco (but not cigarettes), where smokeless is legally available accurate information on the nature of harms and differential harms needs to be developed.

Oral spit tobacco: addiction, prevention and treatment

The prevalence of smokeless tobacco is significant and reaches as high as 17% past month use in white males aged 18-25. Smokeless tobacco use is of concern because of the potential for addiction and the associated negative health consequences. This article reviews the basis for addiction to smokeless tobacco, examining the nicotine content in smokeless tobacco products, pharmacokinetics, psychoactive effects, tolerance, and withdrawal. It also explores the negative health consequences which include a number of oral pathologies and increased cardiovascular risk factors. Furthermore, it examines the factors associated with the initiation of smokeless tobacco use, and the current prevention programs that address these factors. Current smokeless tobacco treatment approaches are also discussed as well as predictors for abstinence. Finally, the future directions are discussed in light of the limited amount of research that has been conducted in the smokeless tobacco area, particularly related to prevention and treatment.

Smokeless tobacco, reaction time, and strength in athletes

PURPOSE

This study investigated the effects of smokeless tobacco on reaction time and strength in a group of Division III athletes.

METHODS

Athletes were tested for simple and choice reaction time, maximum voluntary force, and maximum rate of force generation of the knee extensors on a KinCom dynamometer at 250 degrees.s-1. Smokeless tobacco-using athletes (N = 20) were tested while both using and after abstaining from smokeless tobacco. Another group of athletes (N = 20) who did not use smokeless tobacco served as a control group.

RESULTS

Simple and complex reaction times were not affected by smokeless tobacco use or abstention. In the simple reaction time test, maximum voluntary knee extensor force was higher in the smokeless tobacco-using group while abstaining (P < 0.05). Maximum rate of force generation in the simple reaction time test was not statistically different between the conditions. In the choice reaction test, both strength parameters (maximum force and maximum rate of force generation) were higher in the user group while abstaining (P < 0.05) compared with the using condition. The strength parameter measurements in the control group were not statistically different from the tobacco-using group, while either using or abstaining.

CONCLUSIONS

We conclude that smokeless tobacco use has no effect on reaction time but may detrimentally influence maximum voluntary force and maximum rate of force generation.

Carcinoma of buccal mucosa in smokeless tobacco users: a preliminary study of the use of cytology for early detection

A type of smokeless tobacco, known as Maras powder, is widely used in lieu of cigarettes in the south-eastern region of Turkey. In the present study, we evaluated cytological smears obtained from the lesion of lower lip mucosa of 80 smokeless tobacco users. There were severe epithelial abnormalities in seven out of the 80 subjects. Punch biopsies from these cases disclosed dysplasia in three cases, carcinoma in situ in two, and carcinoma in the other two cases. There was mild dysplasia in two punch biopsies of the remaining 73 cases. Oral cancer in tobacco powder users appeared to be related to the length of use, as it was observed only in subjects with 15 or more years of exposure.

Smokeless tobacco consumption in Grant County, New Mexico

A telephone survey was conducted in order to assess the prevalence of smokeless tobacco consumption in Grant County, New Mexico. Systematic random sampling was used, and 1 out of 25 phone numbers were selected from the county telephone directory. One hundred seventy-eight respondents were surveyed. Thirty-three percent of 96 males and 7% of 82 females identified themselves as smokeless tobacco users.

Smokeless tobacco abstinence effects and nicotine gum dose

There were two experiments on abstinence from smokeless tobacco. The purpose of the first experiment was to determine abstinence effects from smokeless tobacco. The purpose of the second experiment was to examine the effects of different doses of nicotine gum on smokeless tobacco abstinence effects. The subjects were male Copenhagen smokeless tobacco users who underwent 3 days of baseline measurement while continuing to use smokeless tobacco ad libitum, and 5 days of the experimental condition. In the first experiment, the subjects were assigned randomly to one of two groups and compared: continuous smokeless tobacco users (n = 10), and deprivation plus no nicotine gum (n = 10). In the second experiment, subjects were assigned randomly and in a double-blind fashion to one of three groups and compared: (1) deprivation plus 0 mg nicotine gum (n = 20); (2) deprivation plus 2 mg nicotine gum (n = 20); and (3) deprivation plus 4 mg nicotine gum (n = 20). The first experiment showed significant increases upon abstinence for the following variables: (1) craving; (2) difficulty concentrating; (3) restlessness; (4) excessive hunger; (5) eating; (6) reaction time; (7) variability of reaction time and (8) total withdrawal scores for both the self-rated and the observer-rated forms. The second experiment showed that nicotine gum failed to significantly reduce smokeless tobacco abstinence effects, although those with high cotinine levels may receive some benefit from nicotine gum.

Cytogenetic surveillance of tobacco-areca nut (mava) chewers, including patients with oral cancers and premalignant conditions

Three cytogenetic endpoints were studied in non-chewing healthy controls and 3 groups of tobacco-areca nut chewers, viz. normal chewers, chewers with oral submucous fibrosis and chewers with oral cancer. Frequencies of sister-chromatid exchanges and chromosome aberrations in peripheral blood lymphocytes and of micronucleated cells in exfoliated buccal mucosa were evaluated. All the parameters showed statistically significant elevations in all 3 groups of chewers compared to the controls. The data indicate possible application of the parameters as sensitive endpoints for monitoring tobacco-areca nut chewers, the group of individuals at higher risk of developing oral cancer, the commonest cancer among Indian males.

Demographic and predictive correlates of smokeless tobacco use in elementary school children

BACKGROUND

To assess the basic demographics and predictive correlates of smokeless tobacco use in school-age children, a stratified random sample of 559 rural and urban first, third, fifth, and seventh graders in western North Carolina was surveyed regarding experimentation with smokeless tobacco.

METHODS

Two versions of a survey were developed: a shorter version administered orally to first graders and a longer version provided to others. Reported percentages across demographic variables were broken down in a 4 x 2 x 2 analysis of variance; correlations were used to assess the relationships among potentially predictive variables.

RESULTS

Results indicated that 36 percent of male rural first graders had tried smokeless tobacco, increasing to 70 percent by the seventh grade. Overall, rural males were more likely to have tried or be regularly using smokeless tobacco than were urban males or females. Other questions correlating with smokeless tobacco use indicated that it is predicted by three general concerns: a) perceived flavor, b) self-concept and presentation to peers, and c) family influence.

DISCUSSION

Educational interventions must begin at the kindergarten or first grade levels. Programs for adolescents must provide for alternative ways of receiving perceived social image benefits of smokeless tobacco use. Familial support must be considered in all programming.

The role of race and ethnic status on the psychosocial correlates of smokeless tobacco use in adolescent males

From a stratified, random sampling of non-urban high schools in the Southeast, survey data were obtained from 5374 adolescent males. Over half reported trying smokeless tobacco, and approximately one third of these reported a regular, substantial level of use. The average age at initial use was 12.2 yr. and was negatively correlated with the level of use. Factor analysis of the psychosocial items resulted in four factors: substance use/deviant style, modeling, perceived negative consequences, and health behavior. Discriminant analysis of initial use indicated that substance use and modeling influences were the strongest predictors of trying smokeless tobacco. Regression analysis of level of smokeless tobacco use indicated that substance use, modeling, and perceived negative consequences were equivalent in their contribution. Separate analyses were performed for American Indian, Black, and White males. Although predictors of initial use were similar, level of smokeless tobacco use was most associated with the use of other substances in Blacks and with modeling influences in Whites.

Patterns and causes of gender differences in smoking

In the early twentieth century in the United States and other Western countries, women were much less likely than men to smoke cigarettes, due in part to widespread social disapproval of women's smoking. During the mid-twentieth century, growing social acceptance of women's smoking contributed to increased smoking adoption by women. Increased social acceptance of women's smoking was part of a general liberalization of norms concerning women's behavior, reflecting increasing equality between the sexes. These historical trends were due in part to increases in women's employment. However, in the contemporary period employment appears to have little or no effect on women's smoking. Sex role norms and general expectations concerning gender-appropriate behavior have had a variety of effects on gender differences in smoking. First, general characteristics of traditional sex roles, including men's greater social power and generally greater restrictions on women's behavior, contributed to widespread social pressures against women's smoking. Second, traditional sex role norms and expectations have fostered gender differences in personal characteristics and experiences which influence smoking adoption. For example, rebelliousness has been more expected and accepted for males, and greater rebelliousness among adolescent males has contributed to greater smoking adoption by males. Finally, certain aspects of sex roles have contributed to gender differences in appraisal of the costs and benefits of smoking. For example, physical attractiveness is emphasized more for females and the contemporary beauty ideal is very slender, so females are more likely to view weight control as a benefit of smoking. Several other hypotheses concerning the causes of gender differences in smoking are not supported by the available evidence. For example, it appears that women's generally greater concern with health has not contributed significantly to gender differences in the prevalence of smoking. Similarly, it appears that sex differences in physiological responses to smoking have made only minor contributions to gender differences in smoking adoption or cessation.

Smokeless tobacco use in adolescent females: prevalence and psychosocial factors among racial/ethnic groups

From a stratified, random sampling of Southeastern, nonurban high schools, survey data on smokeless tobacco use and potential psychosocial risk factors were obtained from 5683 adolescent females. Of the 15.3% who reported trying smokeless tobacco, most (75%) reported only experimental use. Factor analysis of the psychosocial items resulted in four factors: perceived negative consequences, substance use, modeling, and active lifestyle. Discriminant analysis on use indicated that modeling influences and use of other substances were the strongest predictors of initial smokeless tobacco use. Level of use, however, was most strongly associated with lower perceived negative consequences for use and the use of other substances. Separate analyses on American Indian, Black, and White subgroups suggested that factors associated with initial use were similar but that substantial differences exist between subgroups on risk factors for level of smokeless tobacco use.

Patterns of cigarette and smokeless tobacco use among children and adolescents

Although cigarette and smokeless tobacco use are recognized as major problems among school-age youth, few nationwide or statewide data exist on the prevalence and patterns of use. To determine the patterns of tobacco use among children and adolescents in Missouri, self-report information was obtained from a representative sample of 5,431 students in grades 5, 8, and 12. Both cigarette smoking and smokeless tobacco use were more common among males than females for each grade level except the 12th, where 30% of females and 28% of males had smoked during the previous week. Smoking prevalence was considerably lower among blacks than whites. Smokeless tobacco use was rare among both blacks and females. Smokeless tobacco use was more common than cigarette smoking in rural areas, where 17% of 8th-grade males and 31% of 12th-grade males had used smokeless tobacco during the previous week. The mean age at first use of cigarettes was slightly lower in the rural than the urban area, whereas the mean age of initial smokeless tobacco use was more than a year earlier in the rural area. Data regarding the perceived difficulty of quitting smoking and quit rates suggested that adolescent females have more difficulty quitting smoking than males. Male smokeless tobacco users appeared to be more addicted than male cigarette smokers. Smokeless tobacco brand preference indicated that users may switch to progressively stronger types of smokeless tobacco as they get older and a nicotine tolerance is developed. The current study emphasizes the urgent need for carefully targeted tobacco prevention and cessation efforts among school-age youth.

Psychosocial factors in the use of smokeless tobacco and their implications for P.L. 99-252

This article briefly reviews the prevalence of smokeless tobacco use by males in the United States, the relationship of smokeless tobacco use to cigarette use, and patterns of use that include dosage, topography, products, and function of use. The primary focus of the article is to describe the concurrent and predictive factors associated with onset, use, and cessation of smokeless tobacco. The implications of P.L. 99-252, the Comprehensive Smokeless Tobacco Act of 1986, are discussed in the context of what is known about the psychosocial variables associated with the use of smokeless tobacco.

Evaluating the impact of P.L. 99-252 on decreasing smokeless tobacco use

Literally, Public Law 99-252 (otherwise known as the Comprehensive Smokeless Tobacco Health Education Act of 1986) includes provisions that are informational in nature. Implicitly, however, this law is considered part of the federal effort in disease prevention and health promotion. This paper reviews the societal and legislative context of that act and presents a plan to evaluate the impact of this law on decreasing smokeless tobacco use. The uniqueness of this plan is its incorporation of nine disciplinary perspectives in the derivation of indicators to measure process, impact, and outcome measures for decreasing smokeless tobacco use. A basic prevention strategy is suggested by this interdisciplinary approach. In addition, specific lessons could be applied from the history of successes in public health to decreasing smokeless tobacco use.

Typology and correlates of smokeless tobacco use

The incidence, use patterns, and correlates of smokeless tobacco have become increasingly important as usage rates rise and harmful health effects become established. The present study assessed the incidence of smokeless tobacco use in a Southeastern U.S. sample and selected correlates of use. From the responses of 3725 high school students, 19.9% reported trying smokeless tobacco products (35.5% for males, 5.8% for females). Most agreed that tobacco use has harmful health consequences. Those disagreeing with these health beliefs were more likely to use smokeless tobacco. Cigarette smoking was strongly associated with initial use. Of those reporting any use of smokeless tobacco, most used it for less than an hour per day, but 18% reported 3 or more hours of use per day. Forty-four percent reported a first use of smokeless tobacco before 13 years of age. Early initial use was associated with greater frequency and duration of use. Early initial users also reported greater influence from family and advertisements. Encouragement from friends, however, appeared to be the major factor regardless of age at initial use. Of particular concern is that 8.4% of those having any experience with smokeless tobacco felt they were addicted to the substance. Finally, 27.9% reported swallowing the substance or spittle, suggesting the need for further research on the potential health implications of this behavior.

Georgia pharmacists' attitudes toward cigarettes and smokeless tobacco

To determine the degree to which pharmacists might cooperate with other health-care providers in reducing tobacco use, the authors surveyed 500 Georgia pharmacists on their knowledge, attitudes, and sales practices regarding cigarettes and smokeless tobacco (ST). Analysis of the 152 questionnaires (30.3%) returned showed that respondents' knowledge of the effects of tobacco use, especially cigarettes, was high. Overall, pharmacists believe that pharmacies should not sell cigarettes and ST; sales to minors and radio and television advertising of tobacco should be prohibited; and ST is not a safe alternative to cigarettes. More employee pharmacists than managers sold cigarettes when they did not believe they should, citing the reason that higher management makes the decision. Managers who didn't believe they should sell tobacco products said they did so because they felt the public should be free to choose. These findings may reflect a tendency of pharmacists to accept employment without control over conditions, and suggest that encouraging pharmacists to use their influence to discourage tobacco use might be acceptable to practitioners.

Smokeless tobacco use among American college students

This study sought to delineate patterns of smokeless tobacco use among college students in the United States. A national sample (N = 5,894) of approximately equal numbers of men and women from 72 colleges and universities participated in the study. Eight percent of the college students in the Northeast used smokeless tobacco, whereas 15% in the South Central United States were using it. Seventeen percent of the American Indian, 14% of Mexican-American, 12% of white, and 4% of black students reported they had dipped or chewed. Smokeless tobacco users were more likely to have family and friends who also used smokeless tobacco. Almost two thirds (63%) of current users plan to continue to dip or chew. More than half (57%) the users consumed less than two cans or pouches per week. Smokeless tobacco is a serious problem in American colleges and universities. Unless prevention and cessation efforts target this group, the problem will continue to increase and ultimately could result in an oral cancer epidemic.

Smokeless tobacco use by youth in the U.S

Oral snuff and chewing tobacco, commonly referred to as smokeless tobacco, are being used by many adolescent and young adult males, and no indication exists that use by this group is declining. Users are at risk for oral cancer, noncancerous oral pathology such as leukoplakias, and addiction. Information about patterns of smokeless tobacco use and motivations of users may help planners develop and implement interventions. Variables include the importance of peer and family influences, social image, knowledge of harmful effects, regional differences, use of other substances, and addiction. Due to the addictive nature of smokeless tobacco, older youth may need cessation programs. Health educators are encouraged to include smokeless tobacco in their tobacco use prevention programs and to develop and implement comprehensive tobacco interventions appropriate for their youth population.

Age of initiation and switching patterns between smokeless tobacco and cigarettes among college students in the United States

A stratified, random, multi-stage, cluster sample of physical activity classes among 72 colleges and universities throughout the United States yielded 5,894 usable responses (males = 2,888); (females = 3,006). Twenty-three per cent of the students who began smoking before the age of 10 were current smokers, while 61 per cent of those who began using smokeless tobacco before the age of 10 were current smokeless tobacco users. College students were more likely to switch from smokeless tobacco to cigarettes than from smoking cigarettes to smokeless tobacco.

An interpretative review of smokeless tobacco research in the United States: Part II

This is the second part of a two-part series reviewing the published literature of smokeless tobacco in the United States. The article explores smokeless tobacco as a pharmacologically addicting substance, educational interventions designed to prevent use or help users quit, and outlines areas of future research.

Prevention of tobacco use among adolescents in public schools in San Diego County, U.S.A

Project S.H.O.U.T. (which stands for "Students Helping Others Understand Tobacco") is a tobacco-use prevention project funded by the United States National Cancer Institute for preventing the use of cigarettes and smokeless tobacco (snuff and chewing tobacco) in public schools in San Diego County, California. Based on principles of behavior modification, Project S.H.O.U.T. teaches students how to anticipate and overcome negative peer pressure to use tobacco and reinforces them for having done so. Preliminary results indicate that the prevalence of tobacco use among students receiving peer pressure resistance skills training was somewhat but not statistically significantly lower than the control group after one year of intervention. In addition, students in a third lottery condition, who were reinforced for simply not using tobacco, showed lower prevalence rates compared to controls. Additional support for the efficacy of the intervention program was provided by the refusal skills assessment test, which indicated that students exposed to the intervention were able to refuse tobacco offers more effectively than the control students. Our results indicate that tobacco use prevention experts should do more than provide decision-making and behavioral skills for resisting tobacco use, but should also reinforce the non-use of tobacco.

Patterns and prevalence of smokeless tobacco use by high school seniors in New York

Patterns and prevalence of smokeless tobacco use by high school seniors in New York state were identified in this study. A questionnaire was administered to a sample of 10% of each senior class in 96 randomly selected public and nonpublic secondary schools in New York; 1,830 students participated. Data analysis included descriptive statistics, t-tests, and chi-square tests. Comparisons were made by gender, hometown status, concurrent use of smokeless tobacco and cigarettes, and smokeless tobacco use versus cigarette smoking. Results revealed a significant difference existed between males and females and between urban and rural smokeless tobacco use (p = .05). Use of chewing tobacco related significantly to use of cigarettes (p = .05). A significant difference existed between prevalence of cigarette smoking and smokeless tobacco use (p = .05). Smokeless tobacco use by high school seniors in New York is predominantly a habit of rural males. Use of chewing tobacco is related to cigarette smoking, and smokeless tobacco was less prevalent than cigarette smoking in the sample (p = .05). Further research on the relationship between smokeless tobacco and cigarette smoking should be conducted. Use of chemical assays or the bogus pipeline to validate self-reported data is recommended. Identified high-risk groups such as rural males should receive particular attention in future research efforts.

Smokeless tobacco on campus

Self-reports on smokeless tobacco consumption were obtained from 438 students attending a small Midwestern liberal arts college. While use among 249 female students was negligible, 9% of 189 male respondents reported routine use of smokeless tobacco products.

An interpretative review of smokeless tobacco research in the United States: Part I

The first part of a two-part series reviewing the published literature of smokeless tobacco in the United States and concomitant health effects associated with its use. This article delineates the current status of its prevalence, behavioral psychosocial factors associated with use, and review of the negative health effects associated with regular use.

The prevalence of smokeless tobacco use among adolescent male athletes

In assessing the prevalence and perceptions of use of smokeless tobacco among adolescent male athletes, several findings have public health implications. Almost a third of the sample had tried smokeless tobacco and 8% were current users. Racial differences between blacks and whites were remarkable. Differences in income strata and urban/rural settings were not significant. Peer influence was the major factor that initiated smokeless tobacco use. Abnormal mucosal findings were much more prevalent in those who had dipped smokeless tobacco than in those who had not. Most significant was a prevalence of oral leukoplakia in 5.2% of those who had ever dipped, which was 50 times that of nondippers. Using smokeless tobacco for more than 2 years or using more than three tins per week seemed to be of possible predictive value regarding the incidence of oral leukoplakia. Fifteen percent of current users had observable leukoplakia. Components necessary for effective intervention/prevention programs were elucidated with an emphasis on an increased role by dentists and other health professionals.

Prevalence of smokeless tobacco use in Pitt County, North Carolina

The purpose of this study was to estimate the prevalence of smokeless tobacco use in the largest tobacco-producing county in the United States. A 1-in-100 systematic random telephone sample was taken from the county telephone directory. A total of 280 complete questionnaires were obtained. Results indicate that .40 +/- .042 [p +/- SE(p)] males and .09 +/- .024 of females use smokeless tobacco. The point prevalence for the total population was estimated to be .15.

Smokeless tobacco use. A dangerous nicotine habit

Much attention has been focused on cigarette smoking and its health implications. Numerous campaigns have been launched to help people stop smoking or prevent them from starting. While smoking has been receiving this attention, use of smokeless tobacco has been increasing at an alarming rate. Smokeless tobacco exposes the user to all the nicotine effects of cigarette smoking. Oropharyngeal cancer and erosive effects on the oral structures are known hazards, but the long-term total-body effects have yet to be determined. Physicians need to identify patients who use smokeless tobacco so that intervention strategies can be employed. Preventive techniques, especially those aimed at children, may be the most effective means of controlling this health threat.

Prevalence and patterns of smokeless tobacco use in a southeastern university

The purpose of this study was to determine prevalence and patterns of use for tobacco products, especially, the use of smokeless tobacco among students at a university in the Southeastern United States. Six-hundred and thirty-two students, representing both sexes, participated in the survey, which elicited information regarding current and former use of tobacco products. Smokeless tobacco use was considerably more prevalent among male students than among female students; the reverse was true for cigarette smoking. Overall, the prevalence of tobacco use in this study indicates a need to begin health education programs regarding the adverse health effects of smokeless tobacco use with males and to revise smoking education programs to place more emphasis on female usage.

Implications of Smokeless Tobacco Use Among Athletes

In brief: This literature review delineates the current status of smokeless tobacco. It discusses the prevalence and terminology as well as periodontal effects, buccal mucosal and soft-tissue alterations, leukoplakia, cancer, carcinogenic components, hemodynamic alterations, and potential addiction. It is clear that physicians and dentists should discourage their patients from using smokeless tobacco. Young people particularly may be influenced by popular sports figures and celebrities who convey the erroneous impression that smokeless tobacco is harmless.

Smokeless tobacco use among adolescents: demographic differences, other substance use, and psychological correlates

Survey data on smokeless tobacco and other substance use were obtained from 2,926 seventh, ninth, and eleventh graders in Ventura County, California public schools. Patterns of smokeless tobacco use were examined relative to other drug use, particularly cigarette smoking. Few females used smokeless tobacco regularly, as compared to 4.7 percent of the males. The data supported the view that the recent increases in smokeless tobacco use were related to male tobacco users' belief that smokeless tobacco was less harmful to physical health than cigarette smoking. A Guttman scalogram analysis showed that tobacco use, either cigarette smoking or smokeless tobacco use, occurred after marijuana use rather than before. Perceived parental attitudes toward marijuana use predicted both cigarette smoking and use of smokeless tobacco, whereas perceived parental attitudes toward alcohol use was only related to use of cigarettes. Quality of life measures were inversely related to both cigarette smoking and smokeless tobacco use, but mood state measures predicted only cigarette smoking. Implications of the results for a historical hydraulic model of aggregate drug use are discussed with recommendations for improved approaches to the prevention of drug abuse.