Oral spit tobacco: addiction, prevention and treatment

Heterogeneity of Harmful Constituent Profiles in Smokeless Tobacco Products from Five African Countries

Addictive, toxic, and carcinogenic constituents present in smokeless tobacco (SLT) products are responsible for the harmful effects associated with SLT use. There are limited data on levels of such constituents in SLT products used in Africa, a region with high prevalence of SLT use and the associated morbidity and mortality. Manufactured and custom-made SLT products were purchased from five African countries (South Africa, Uganda, Mauritania, Nigeria, and Zambia) using a standard approach for sample collection, labeling, and storage. Moisture content, pH, total and unprotonated (biologically available) nicotine, five tobacco-specific N-nitrosamines (TSNA), 10 polycyclic aromatic hydrocarbons (PAH), five metals and metalloids (As, Cd, Cr, Ni, and Pb), nitrate, and nitrite were analyzed. A total of 54 samples representing 15 varieties of manufactured SLT products and 13 varieties of custom-made SLT products were purchased and analyzed. In all samples, the total nicotine ranged from 1.6 to 20.5 mg/g product and unprotonated nicotine accounted for 5.3-99.6% of the total nicotine content. The sum of all five TSNA ranged from 1.6 to 100 μg/g product, with significant within-country variations observed across both the manufactured and custom-made varieties. Significant variations were also found for PAH, metals and metalloids, nitrates, and nitrites. This is the most comprehensive report on the chemical profiling of products from African countries. This is also the first study illustrating the variability of harmful constituents within the same types and brands of African SLT. Our findings emphasize the need for consumer education and interventions to reduce SLT use in Africa. The data reported here can be useful to regulators in considering measures to prevent the occurrence of high levels of known toxicants and carcinogens in manufactured products.

The Consequence of Aqueous Extract of Tobacco Leaves (Nicotiana tabacum. L) on Feed Intake, Body Mass, and Hematological Indices of Male Wistar Rats fed under Equal Environmental Conditions

OBJECTIVE

While the dangers of consuming tobacco by smoking has been of concern, the hazardous effect of other forms of tobacco consumption (in smokeless form) on health indices are less well explored. In this paper, we explored the effect of different doses of aqueous extract of tobacco leaves on feed intake, body mass, and hematological indices of male Wistar rats under equal environmental conditions.

METHOD

Using an oral route of administration, the rats (n = 24; w = 65-85 g; 2-3 weeks old) were administered at different doses of 100, 200, 400, 0 mg/kg body weight (b.w.) per day to group A, B, C, and D for 42 days, after phytochemical and acute toxicity testing of the tobacco leaves.

RESULTS

Compared to the negative control group (D), packed cell volume, hemoglobin concentration, red blood cells, and lymphocytes reduced dose-dependently in contrast to the white blood cells, neutrophils, mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, and mean corpuscular volume. As body mass and feed intake in relation to the different doses of aqueous extract of tobacco leaves reduced significantly (p < 0.05), the reverse was observed for body mass and feed intake in relation to room temperature.

CONCLUSIONS

By influencing hematological indices, feed intake, and body mass, the extract of tobacco leaves can be hazardous to health. However, to assess safety and to come up with a conscious conclusion, future studies should explore the effect of the extract on organs histopathology, biochemical parameters, and lipid profile of the body.

Smokeless Tobacco Point of Sale Advertising, Placement and Promotion: Associations With Store and Neighborhood Characteristics

Introduction: Objectives of this study were to determine retail and neighborhood characteristics associated with smokeless tobacco (ST) product promotion, price promotion, and storefront advertising among retailers in Oklahoma.

Methods: In this statewide point-of-sale study, we collected data from 1,354 ST retailers. Using store characteristics and census tract information, we estimated summary statistics and adjusted prevalence ratios during 2019–2020.

Results: Of ST retailers audited, 11.0% demonstrated ST youth promotion, 43.0% ST price promotions, and 19.6% ST storefront advertising. The adjusted prevalence ratio (aPR) for convenience stores was higher for all three ST strategies: youth promotion (aPR = 3.4, 95% CI 1.9, 6.2), price promotion (aPR = 3.8, 95% CI 2.9, 5.0), and storefront advertising (aPR=16.4, 95% CI 6.7, 40.3) compared to other store types. Metropolitan tobacco retailers had higher aPRs for youth promotion (aPR = 1.7, 95% CI 1.12 2.6) and storefront advertising (aPR = 1.5, 95% CI 1.2, 1.9).

Conclusions: Findings of this study suggest there are currently ample opportunities for youth and adults at risk for tobacco initiation to be exposed to ST products in the retail environment. Convenience stores, more likely to be found and utilized in rural areas compared to metropolitan areas, are disproportionately more likely to engage in marketing strategies that could lure youth into trying smokeless tobacco.

Betel Quid Addiction: A Review of Its Addiction Mechanisms and Pharmacological Management as an Emerging Modality for Habit Cessation

Areca-nut (AN) and added smokeless-tobacco (SLT) are considered agents that may cause addiction to betel-quid (BQ). However, the primary addictive substance in AN is not clearly understood. Objective: The present review evaluates possible addictive chemicals in AN with their mechanisms of action for progression to BQ dependence, as it is essential to overcome barriers in BQ cessation. It also identifies innovative treatment modalities in BQ cessation including the scope for research on pharmacotherapy using Monoamine-oxidase Inhibitors, Selective Serotonin Re-uptake Inhibitors and Norepinephrine Dopamine Reuptake Inhibitors. Methods: This is a narrative review on addictive properties of BQ and trials undertaken to promote cessation of SLT or AN use. Results: Twenty interventional studies, three by behavioral therapy and seventeen using pharmacotherapy were reviewed. There was heterogeneity in reported follow up times, most studies reporting data at 12 weeks with abstinence rates of 45-55% for SLT cessation and at 8 weeks with abstinence rates around 35% for AN cessation. Conclusion: Even though literature reveals a few cessation programs through behavioral support for BQ addiction, its success has been limited in certain instances mainly due to addictive properties of AN, resulting in withdrawal and relapse. Hence, in line with pharmacotherapy in tobacco smoking cessation, potential pharmacological agents to assist in cessation of SLT and AN require more attention. Several clinical trials for SLT cessation have been carried out with varying levels of success using Nicotine Replacement Therapy and Varenicline while trials on antidepressants for SLT and AN cessation are also emerging.

[Old and new tobacco products]

Tobacco use is not just about manufactured cigarettes. Rolling tobacco, highly prized in the wake of price increases, is estimated to carry more toxic agents than its counterpart. This study shows that the use of cigar, pipe, cigarillos and narghile also leads to a cohort of pathologies similar to or more than what is known for smoking single cigarettes. Exotic, liquid or heated forms do just as much. The non-smoked tobacco, often fallen into disuse in France is very used in the United States and especially in Scandinavia. Denuded of inhaled products, it is often pointed as a form of reduction of smoking risks. Its use by athletes in all countries as a doping attitude, especially in ski disciplines, required a campaign of prevention within the federations concerned.

Shammah (Smokeless Tobacco) and Public Health

Shammah is a preparation of smokeless tobacco (ST) that is frequently used in the Arabian Peninsula, especially in Saudi Arabia. A mixture of powdered tobacco, lime, ash, black pepper, oils and flavorings, shammah in is placed in the buccal cavity or lower labial vestibule of the mouth. The user (or dipper) spits out insoluble debris. ST is linked to a number of harmful effects such as dental disease, oral cancer, oesophagus cancer, and pancreas cancer. It also causes adverse reproductive effects including stillbirth, premature birth and low birth weight. The importation of ST products is prohibited in Saudi Arabia. Legislative action to combat the use of ST (moist snuff and chewing tobacco) in Saudi Arabia appeared in 1990. The actual percentage use may be higher than reported since shammah is illegal in Saudi Arabia and there may be some unwillingness to admit to its use. Data on ST use in the Arabian Peninsula are sparse. Most studies conducted there focused on the prevalence of shammah use among adolescents rather than among adults. This review paper aimed to understand the pattern of use of shammah and its adverse health effects. It also aimed to provide suitable epidemiological data for public health policy makers.

Tobacco use transitions in the United States: The National Longitudinal Study of Adolescent Health

OBJECTIVES

The purpose of this study is to evaluate and describe transitions in cigarette and smokeless tobacco (ST) use, including dual use, prospectively from adolescence into young adulthood.

METHODS

The current study utilizes four waves of the National Longitudinal Study of Adolescent Health (Add Health) to examine patterns of cigarette and ST use (within 30 days of survey) over time among a cohort in the United States beginning in 7th-12th grade (1995) into young adulthood (2008-2009). Transition probabilities were estimated using Markov modeling.

RESULTS

Among the cohort (N=20,774), 48.7% reported using cigarettes, 12.8% reported using ST, and 7.2% reported dual use (cigarettes and ST in the same wave) in at least one wave. In general, the risk for transitioning between cigarettes and ST was higher for males and those who were older. Dual users exhibited a high probability (81%) of continuing dual use over time.

CONCLUSIONS

Findings suggest that adolescents who use multiple tobacco products are likely to continue such use as they move into young adulthood. When addressing tobacco use among adolescents and young adults, multiple forms of tobacco use should be considered.

Assessing Constituent Levels in Smokeless Tobacco Products: A New Approach to Engaging and Educating the Public

INTRODUCTION

Providing accurate information about the constituents in nicotine-containing products may help tobacco users make informed decisions about product choices. An experimental study examined a novel approach for presenting accurate constituent information about brands and types of smokeless tobacco (SLT) that could be understood by the general public.

METHODS

Participants were recruited through Amazon's Mechanical Turk and presented information online about 2 constituent dimensions of SLT products-nicotine and/or toxicity (for simplicity, "toxicity" in this study refers to carcinogenic constituents) Participants completed measures of knowledge and tobacco health risks at 2 time points: before and after exposure to constituent information.

RESULTS

Participants were found to increase their knowledge that toxicity contributes to disease risk and nicotine contributes to addiction, that SLT products vary in their levels of nicotine and toxicity, and that both SLT and cigarette products have higher toxicity than medicinal nicotine replacement therapies (e.g., nicotine lozenges). Study results showed no differences when presenting toxicity information alone versus presenting it in conjunction with nicotine information, and found no misperceptions or confusions about the relative harmfulness of cigarettes, SLT, or nicotine replacement therapy.

CONCLUSIONS

Providing tobacco constituent information to smokers and nonsmokers will improve their knowledge about the relative toxicity across products and variations within a class of tobacco products without compromising the health risks associated with tobacco use.

Perception and practices of physicians in addressing the smokeless tobacco epidemic: findings from two States in India

BACKGROUND

Smokeless tobacco use in South Asia is believed to be a significant contributor to morbidity and mortality. In India, only a few studies involving health educational intervention by health care providers have demonstrated reduction in smokeless tobacco usage. In the present study we assessed the cessation efforts towards smokeless tobacco by physicians in two high tobacco prevalence states of India. The study also identified opportunities and barriers for integration of tobacco cessation services in routine practices of physicians.

MATERIALS AND METHODS

This mixed method study involved qualitative (phase I) and quantitative research study (phase II). In phase I, 59 in-depth interviews with physicians were conducted. In phase II, a quantitative study conducted among 238 physicians. An inductive approach was followed to analyze qualitative data using ATLAS. Ti software. The Chi-square test was employed to test the association between different variables of interest using SPSS version 17.

RESULTS

The majority of physicians related only respiratory problems and cancer with smokeless tobacco. Other major health effects like cardio-vascular problems, oral diseases, and effects on reproductive and neonatal health were recognized only by a few physicians. The age-group of 10-19 years was identified as most vulnerable to smokeless tobacco use. Less than one-third of physicians reported recording smokeless tobacco history of all patients. Findings indicated that less than half of physicians provided information on harmful health effects of smokeless tobacco with regard to specific diseases.

CONCLUSIONS

The study revealed a low level of knowledge of physicians about harmful effects of tobacco and their suboptimal engagement in tobacco control practices. The study indicates the need of capacity building initiatives to equip physicians with skills in tobacco cessation.

Attentional bias in snus users: an experimental study

The use of nicotine in the form of "snus" is substantial and increasing in some geographic areas, in particular among young people. It has previously been suggested that addictions may operate through a mechanism of attentional bias, in which stimuli representative of the dependent substance increase in salience, thus increasing the addictive behavior. However, this hypothesis has not been tested for the case of snus. The current experiment used a modified Stroop task and a dot-probe task to investigate whether 40 snus users show an attentional bias towards snus-relevant stimuli, compared to 40 non-snus users. There were no significant differences between the two groups on reaction times or accuracy on either Stroop or dot-probe task, thus failing to show an attentional bias towards snus-relevant stimuli for snus users. This could imply that other mechanisms may contribute to maintenance of snus use than for other addictions. However, this is the first experimental study investigating attentional bias in snus users, and more research is warranted.

Public education about the relative harm of tobacco products: an intervention for tobacco control professionals

BACKGROUND

In the USA, new regulations require the collection of information on tobacco constituents by brand and variety and publication of this information in a way not likely to be misconstrued by consumers. Understanding of such information becomes increasingly important as new tobacco products are marketed and modifications are made to reduce the toxicity of some products. This pilot study assessed the current knowledge of tobacco control professionals regarding the relative harmfulness of several tobacco products, and evaluated an online educational intervention aimed at improving understanding of variations in nicotine and tobacco-specific N-nitrosamines (TSNAs).

METHODS

Fifty-two tobacco control professionals participated in an online intervention which presented and discussed the results of constituent analyses of Camel Snus and Marlboro Snus compared to several conventional smokeless tobacco products. Comparisons with cigarettes were also discussed. Pre- and post-intervention questions assessed understanding of the concepts.

RESULTS

Pre-intervention responses demonstrated that 31% did not know that cigarettes are more harmful than smokeless tobacco, 67% did not know that smokeless products higher in nicotine are likely to be more effective substitutes for cigarettes, 52% did not know TSNAs are the major carcinogens in tobacco and 81% did not know new snus products tend to be lower in TSNAs than conventional spit tobacco. After intervention participation, knowledge increased on all points except one where pretest results were 100% correct.

CONCLUSIONS

Public education campaigns are urgently needed for tobacco control professionals and consumers to increase awareness and understanding of the continuum of risk among tobacco products.

Areca use among adolescents in Yap and Pohnpei, the Federated States of Micronesia

Objective

Areca (Betel Nut) is the fourth most commonly used psychoactive drug throughout the world and is legal in U.S. It is carcinogenic. Within a health program in the Federated States of Micronesia we surveyed use among adolescents.

Methods

One hundred 7^th and 8th graders in Yap and Pohnpei were surveyed and clinical oral examinations conducted. The questionnaire included items on Areca: age first used Areca, whether peers or family members used Areca, frequency of use, whether tobacco was used, and source of Areca. Questions also assessed anxiety and depression. Two scales assessed getting along with other kids and adaptation to school.

Results

61.5-71.4% of adolescents had ever used Areca and 54.7-68.6% used it at least once in the last month.

Conclusion

Most adolescents surveyed in Yap and Pohnpei used Areca, which may place these youth at increased risk for cancer and health disparities.

Factors influencing smokeless tobacco use in rural Ohio Appalachia

The burden of smokeless tobacco (ST) use disproportionally impacts males in rural Ohio Appalachia. The purpose of this study was to describe the cultural factors contributing to this disparity and to articulate the way in which culture, through interpersonal factors (i.e. social norms and social networks) and community factors (i.e. marketing and availability), impacts ST initiation and use of ST among boys and men in Ohio Appalachia. Fifteen focus groups and 23 individual qualitative interviews were conducted with adult (n = 63) and adolescent (n = 53) residents in Ohio Appalachian counties to ascertain factors associated with ST use and the impact of ST marketing. Transcriptions were independently coded according to questions and themes. ST use appears to be a rite of passage in the development of masculine identity in Ohio Appalachian culture. Interpersonal factors had the greatest influence on initiation and continued use of ST. Ohio Appalachian boys either emulated current ST users or were actively encouraged to use ST through male family and peer networks. Users perceived their acceptance into the male social network as predicated on ST use. Community factors, including ST advertisement and access to ST, reinforced and normalized underlying cultural values. In addition to policy aimed at reducing tobacco marketing and access, interventions designed to reduce ST use in Ohio Appalachia should incorporate efforts to (1) shift the perception of cultural norms regarding ST use and (2) address male social networks as vehicles in ST initiation.

Chemical analysis of Alaskan Iq'mik smokeless tobacco

INTRODUCTION

Iq'mik, a form of smokeless tobacco (ST), is traditionally used by Cup'ik and Yup'ik Eskimo people of western Alaska. Iq'mik is sometimes incorrectly considered to be a healthier alternative to smoking because its ingredients are perceived as "natural." Our chemical characterization of iq'mik shows that iq'mik is not a safe alternative to smoking or other ST use.

METHODS

We measured nicotine and pH levels of tobacco and ash used to prepare iq'mik. We also characterized levels of toxins which are known to be present in ST including tobacco-specific nitrosamines (TSNAs) and polycyclic aromatic hydrocarbons (PAHs) using chromatographic separations coupled with isotope dilution mass spectrometry.

RESULTS

Nicotine content in the iq'mik tobacco was very high, ranging from 35 to 43 mg/g, with a mean of 39 mg/g. The pH of the iq'mik tobacco-ash mixture was 11, an extremely high level compared with most ST products. High levels of PAHs were seen in the fire-cured tobacco samples with a benzo[a]pyrene level of 87 ng/g. Average TSNA levels in the tobacco were 34, 2,700, and 340 ng/g for 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), N'-nitrosonornicotine (NNN), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), respectively.

CONCLUSIONS

Iq'mik contains high levels of the more easily absorbed unionized nicotine as well as known carcinogenic TSNAs and PAHs. The perception that iq'mik is less hazardous than other tobacco products due to the use of "natural" ingredients is not warranted. This chemical characterization of iq'mik gives a better understanding of the risk of possible adverse health effects of its use.

Increased pouch sizes and resulting changes in the amounts of nicotine and tobacco-specific N-nitrosamines in single pouches of Camel Snus and Marlboro Snus

INTRODUCTION

Initial analyses of the novel smokeless tobacco products Camel Snus and Marlboro Snus demonstrated that these products contain relatively low amounts of nicotine and the carcinogenic tobacco-specific nitrosamines N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), as compared with traditional smokeless products. It is unknown whether the modifications in packaging, flavors, and pouch sizes that occurred for both Camel Snus and Marlboro Snus since their first introduction to the market were accompanied by any changes in nicotine or nitrosamine levels.

METHODS

We examined the available data on nicotine and NNN and NNK levels in 60 samples of Camel Snus and 87 samples of Marlboro Snus that were analyzed in our laboratory between 2006 and 2010.

RESULTS

Due to the increase in pouch size, the amounts of total nicotine, unprotonated nicotine, and the sum of NNN and NNK present in the large Camel Snus pouches released in 2010 are 1.9-fold, 2.4-fold, and 3.3-fold higher, respectively, than in the original smaller pouches that entered the market in 2006. Total and unprotonated nicotine content in the current version of Marlboro Snus pouches are 2.1-fold and 1.9-fold higher, respectively, and the sum of NNN and NNK is 1.5-fold lower than in the original version.

CONCLUSIONS

We observed an increase in nicotine content in single portions of Camel Snus and Marlboro Snus, and an increase in tobacco-specific N-nitrosamine content in single portions of Camel Snus, due to the increases in pouch size that occurred between 2006 and 2010. This finding stresses the importance of tobacco product regulation and ingredient disclosures.

Tobacco use among southwestern Alaska Native people

INTRODUCTION

We examined the characteristics, attitudes, beliefs, and exposure to tobacco products in a cohort of rural dwelling Alaska Native (AN) people.

METHODS

We conducted a study of 400 of AN adult tobacco users and nonusers living in Southwestern Alaska. Questionnaires covered variables such as demographics, tobacco-use history, current tobacco use and dependence scales, general health status, attitudes and beliefs about tobacco, and quitting history.

RESULTS

The study population smoked 7.8 cigarettes per day compared with 16.8 on average for the U.S. population: a significant proportion of the population engaged in dual use of cigarettes and smokeless tobacco products. Over one third (40.9%), first tried tobacco at age 11 or younger. The mean measures of tobacco addiction (e.g., Fagerstrom Test for Nicotine Dependence, Severson Scale of Smokeless Tobacco Dependence) scores were lower compared with other U.S. populations.

CONCLUSIONS

Very high tobacco-use prevalence, dual product use, and early tobacco use are observed in Southwestern AN people. Unexpectedly these did not appear to be correlated with heavier individual tobacco use or higher levels of addiction in this population.

Monitoring tobacco-specific N-nitrosamines and nicotine in novel Marlboro and Camel smokeless tobacco products: findings from Round 1 of the New Product Watch

INTRODUCTION

Information on chemical composition of the new oral "spitless" smokeless tobacco products is scarce, and it is not clear whether there is some variability as a function of purchase place or time due to either unintended or intended manufacturing variations or other conditions.

METHODS

We analyzed tobacco-specific N-nitrosamines (TSNA) and nicotine in Marlboro Snus, Camel Snus, and dissolvable Camel products Orbs, Sticks, and Strips that were purchased in various regions of the country during the summer of 2010.

RESULTS

A total of 117 samples were received from different states representing six regions of the country. Levels of unprotonated nicotine in Marlboro Snus and Camel Snus varied significantly by regions, with the differences between the highest and the lowest average regional levels being relatively small in Marlboro Snus (∼1.3-fold) and large in Camel Snus (∼3-fold). Some regional variations in TSNA levels were also observed. Overall, Camel Snus had significantly higher TSNA levels than Marlboro Snus, and Camel Strips had the lowest TSNA levels among all novel products analyzed here. The amount of unprotonated nicotine in the dissolvable Camel products was comparable to the levels found in Marlboro Snus.

CONCLUSIONS

Our study demonstrates some regional variations in the levels of nicotine and TSNA in Marlboro and Camel novel smokeless tobacco products. Continued monitoring of this category of products is needed as the existing products are being test marketed and modified, and new products are being introduced. This information is particularly important given its relevance to Food and Drug Administration regulation of tobacco products.

Comparing an immediate cessation versus reduction approach to smokeless tobacco cessation

INTRODUCTION

Relatively few studies have investigated pharmacological or behavioral treatment of smokeless tobacco (ST) users who do not have immediate quit plans. In this study, we compared a reduction treatment approach with an immediate cessation approach in a population of ST users who reported no immediate plans to quit.

METHODS

Subjects randomly assigned to the immediate cessation condition set a quit date soon after enrollment and were offered 2 weeks of nicotine patch therapy to help in their cessation efforts. Subjects assigned to the ST reduction group were provided with their choice of either 4 mg nicotine lozenge or ST brand switching to help them reduce their ST use or levels of nicotine exposure, respectively. Quit date was 6 weeks after the onset of treatment. Follow-up was at 12 weeks and 26 weeks postenrollment and 26 weeks postquit.

RESULTS

Both 7-day point prevalence abstinence and prolonged abstinence rates following the quit date were significantly higher in the immediate cessation group versus the reduction group at 12 and 26 weeks (all p values ≤ .04) and for prolonged abstinence at 6 months postquit (p = .002). Significant reductions in ST use among nonquitters were observed for both groups (p < .0001) with no differences between groups.

CONCLUSION

Our study demonstrated that immediate cessation with an established quit date resulted in greater cessation success than a gradual reduction approach among ST users who do not have an immediate quit plan but are motivated to quit.

Smokeless tobacco use in the United States military: a systematic review

INTRODUCTION

Smokeless tobacco (ST) use represents an important target for intervention in the U.S. military population because it impairs "military readiness" and harms the health of the military. This paper aims to provide a systematic review of ST studies conducted in the U.S. military population in order to assess the content of existing ST research in this population, provide estimates of prevalence and clinically relevant use patterns, and discuss how these findings might be used to guide future ST research among this population.

METHODS

We reviewed articles published through December 2010 using PubMed and PsycINFO databases, Google Scholar, and any relevant articles' reference lists. Inclusion criteria included focus on a U.S. military sample, English language, measured tobacco use, and ST prevalence was reported or could be calculated. To the extent possible, each article was coded for demographics, socioeconomic status, prevalence, amount, frequency, and length of use, and quit intentions/attempts.

RESULTS

Thirty-nine articles met criteria for inclusion. Less than half focused primarily on ST use among military personnel. The remaining studies measured ST use in the context of other behaviors. Findings related to clinically relevant behaviors included a need for more cohort and intervention studies, a better understanding of ST use in combination with cigarettes (i.e., concurrent use), and identifying risk factors for ST initiation and use.

DISCUSSION

ST use is prevalent among military personnel, as is concurrent use of cigarettes and ST. We provide a number of recommendations to guide future research in this important, yet understudied, area.

Smoke extracts and nicotine, but not tobacco extracts, potentiate firing and burst activity of ventral tegmental area dopaminergic neurons in mice

Nicotine prominently mediates the behavioral effects of tobacco consumption, either through smoking or when taking tobacco by snuff or chew. However, many studies question the exclusive role of nicotine in these effects. The use of preparations containing all the components of tobacco, such as tobacco and smoke extracts, may be more suitable than nicotine alone to investigate the behavioral effects of smoking and tobacco intake. In the present study, the electrophysiological effects of tobacco and smoke on ventral tegmental area dopaminergic (DA) neurons were examined in vivo in anesthetized wild-type (WT), β2-nicotinic acetylcholine receptor (nAChR) knockout (β2-/-), α4-/-, and α6-/- mice and compared with those of nicotine alone. In WT mice, smoke and nicotine had similar potentiating effects on DA cell activity, but the action of tobacco on neuronal firing was weak and often inhibitory. In particular, nicotine triggered strong bursting activity, whereas no bursting activity was observed after tobacco extract (ToE) administration. In β2-/- mice, nicotine or extract elicited no modification of the firing patterns of DA cells, indicating that extract acts predominantly through nAChRs. The differences between DA cell activation profiles induced by tobacco and nicotine alone observed in WT persisted in α6-/- mice but not in α4-/- mice. These results would suggest that tobacco has lower addiction-generating properties compared with either nicotine alone or smoke. The weak activation and prominent inhibition obtained with ToEs suggest that tobacco contains compounds that counteract some of the activating effects of nicotine and promote inhibition on DA cell acting through α4β2*-nAChRs. The nature of these compounds remains to be elucidated. It nevertheless confirms that nicotine is the main substance involved in the tobacco addiction-related activation of mesolimbic DA neurons.

Impact of differing definitions of dual tobacco use: implications for studying dual use and a call for operational definitions

INTRODUCTION

Concomitant use of two forms of tobacco is an increasing public health concern, yet there is little consensus regarding a consistent definition of so-called "dual use." We defined dual use as cigarette and smokeless tobacco (ST) consumption with either product used daily or nondaily.

METHODS

We analyzed a cohort of 36,013 Air Force recruits. We categorized dual tobacco use across 2 dimensions, type of tobacco products (cigarettes, ST, or others), and the frequency of use (daily vs. nondaily). We determined how varying the definition impacted the prevalence estimates and evaluated the prevalence estimate based on our recommended definition of dual use. Multivariate logistic regression analysis was used to evaluate the risk profile of dual users of ST and cigarettes versus mono users of ST and mono users of cigarettes.

RESULTS

Varying definitions of dual use vary prevalence estimates 50-fold (0.5%-25.3%). Including only ST and cigarettes narrows the prevalence estimate to less than 4-fold (2.0%-9.7%). Dual users are more likely to be young Caucasian males, with lower education, and from families with relatively higher incomes. Compared with mono users, dual users of cigarettes and ST have a distinct pattern of risk profiles.

CONCLUSIONS

Depending on the definition of dual use, markedly different prevalence and risk profiles are observed. Dual users of ST and cigarettes are a unique group of tobacco users. We propose a common definition of dual use to advance our understanding of this unique group.

Areca nut dependence among chewers in a South Indian community who do not also use tobacco

AIMS

Previously reported research suggests a dependence syndrome for areca nut use, though well-designed studies are virtually non-existent. The goal of this study was to examine evidence of areca dependence in a sample of areca-only (i.e. no tobacco) chewers using modified measurement scales.

DESIGN

A purposive sample of chewers, identified via local informants and advertisements, was surveyed from January to March of 2005.

SETTING

Six villages in Dakshina Kannada District, Karnataka State, India.

PARTICIPANTS

Fifty-nine daily areca chewers who do not also currently use any form of tobacco.

MEASUREMENTS

Questionnaires included modified versions of the Fagerström Tolerance Questionnaire, Cigarette Dependence Scale (CDS-5) and the Smokeless Tobacco Dependence Scale (STDS). Additional questions assessed demographic characteristics and patterns of use.

FINDINGS

Approximately half of respondents reported 1-3 chews/day (mean = 1.9; SD = 0.98). The average number of chewing episodes/day was 4.4 (SD = 3.4) and the average number of nuts/day was 1.2 (SD = 1.1). Users' typical chew lasts up to 20 minutes and includes spitting out the juices and rinsing the mouth with water. Overall, the levels of reported dependence symptoms were quite low, but approximately 44% of chewers endorsed at least one of the following items: continued use despite illness or mouth wounds, difficulty refraining from chewing in forbidden places, or craving during periods of abstinence. Approximately 15.4% of chewers reported at least one intentional quit attempt and a subset had summary scores indicative of dependence (13.6% had scores >16 on the CDS-5 and 5.3% had scores >11 on the STDS). Dependence scores were positively correlated with frequency of chews/day.

CONCLUSIONS

The symptoms of dependence observed in a subset of areca-only chewers warrant further investigation. Next steps should include well-controlled laboratory evaluation of dependence features.

Outcome expectations and use of smokeless tobacco (snus): a cross-sectional study among young Norwegian snus users

In this study, measures of outcome expectancies related to use of snus (wet snuff) were used to predict reported frequency of snus use. Data stem from a nation-wide survey in Norway among 16- to 20-year-olds. Only users of snus were included in the statistical analyses (n = 589). The main outcome measure, frequency of snus use, was measured as a categorical variable - occasional, weekly and daily use. Four dimensions of outcome expectancies (mood regulation, smoking control, weight control and negative health outcomes) were measured and confirmed in a confirmatory factor analysis. Informants tended to believe that snus use is harmful to health, but still they supported the idea of snus as a way to control own cigarette smoking. In a SEM model, two of the four dimensions of outcome expectancies turned out to be particularly significant predictors of frequency of snus use - mood regulation and smoking control. No significant interactions with gender were found. Males scored higher than females on "mood regulation", and "smoking control", while females scored higher than males on "negative health outcomes". If more smokers were convinced that snus use is a less harmful alternative, more of them might start using snus, not only because there is some association between health outcome expectancies and snus use, but also because snus use by many is perceived as a remedy to stop smoking and as a way to gain some of the mood regulation benefits which are usually associated with smoking.

Smokeless tobacco cessation cluster randomized trial with rural high school males: intervention interaction with baseline smoking

INTRODUCTION

Adolescent males in rural areas use smokeless tobacco (ST). We assessed the efficacy of a school-based nurse-directed ST intervention among rural high school males.

METHODS

Study high schools were randomly selected from a public high school list of California rural counties. Consenting high schools were stratified by school size and randomly assigned within strata to intervention or no-intervention groups. After gaining parental consent, male students completed baseline and 1-year follow-up questionnaires. The intervention included peer-led educational sessions and an oral exam by the school nurse who also provided brief tobacco cessation counseling. We used binary generalized estimating equation (GEE) models accounting for clustering within schools to test no difference between groups after adjusting for year in high school using both completers only and multiple imputation for those lost to follow-up. Subgroup analyses assessed Baseline Factor x Group interaction in GEE models.

RESULTS

Twenty-one rural counties (72%), 41 randomly selected high schools (56%), and 4,731 male students (50%) participated with 65% retention. Nonsmoking ST users in the intervention group were significantly more likely to stop using ST at follow-up than those in the no-intervention group; there was no intervention effect among baseline ST users who also smoked. A higher percentage of baseline nonsmoking ST users reported smoking at follow-up than baseline non-ST-using smokers who reported using ST.

DISCUSSION

A school-based nurse-directed ST cessation program was efficacious among rural nonsmoking ST-using high school males. The potential program reach holds significant public health value. Baseline ST use facilitated smoking at follow-up.

Subjective attractiveness and perceived trendiness in smoking and snus use: a study among young Norwegians

In Norway, there has been a decline in smoking among adults and young people, but there has also been an increase in the use of snus, particularly among young males. Among females, snus use is less common. This study examines to what extent subjective attractiveness (SA) (the individual's personal opinion regarding how attractive a person who smokes/uses snus is) and perceived trendiness (PT) (the individual's impressions of how popular smoking/use of snus is) may contribute to explaining current trends in smoking and snus use among young people in Norway. Data were collected from a national representative sample of 2400 young people (age 16-20) by telephone interviews. Among males, regular smokers were also likely to be regular snus users and vice versa. SA and PT were significant predictors of their respective behaviours (smoking and snus use) and in some cases of the other behaviour. Smoking and snus use were perceived as unattractive, while snus use was perceived to be trendier than smoking. Males, more than females, perceived snus use to be attractive and trendy. This pattern is partly consistent with current changes in tobacco use in the Norwegian population.

Potential reduced exposure products (PREPs) for smokeless tobacco users: clinical evaluation methodology

Several potential reduced exposure products (PREPs) for smokeless tobacco (SLT) users are marketed in the United States, though their effects are largely unknown. These products include some that are low in tobacco-specific nitrosamines (TSNs), like Stonewall, a pressed tobacco tablet, and General snus, a moist snuff product produced in Sweden. Methodology assessing the toxicant exposure and effects of cigarette-like PREPs for smokers has been developed, and might be modified for use in evaluating PREPs for SLT users. This report describes two studies examining the toxicant exposure and effects of two PREPs for SLT users. Study 1 (n = 13) consisted of four 4.5-hr laboratory sessions where SLT products (own brand, Stonewall, General snus, and tobacco-free placebo) were used for four 30-min episodes and nicotine exposure and tobacco/nicotine abstinence symptoms were measured. Study 2 (n = 19) consisted of four 5-day ad libitum use periods when participants used own brand, Stonewall, General snus, or no SLT and urinary levels of metabolites of nicotine (cotinine) and the TSN 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNAL) and abstinence symptoms were measured. Compared with own brand, Stonewall was associated with lower levels of cotinine and NNAL, while General snus was associated with similar levels of cotinine and lower levels of NNAL. Abstinence symptoms generally did not differ across tobacco conditions. These results show that clinical laboratory methods can be used to evaluate the toxicant exposure and abstinence symptom suppression associated with PREPs for SLT users.

Evidence for endogenous formation of N'-nitrosonornicotine in some long-term nicotine patch users

INTRODUCTION

Nitrosation of nicotine or its metabolites in the human body could lead to formation of the 2 carcinogenic tobacco-specific nitrosamines-N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK).

METHODS

We investigated the possibility of endogenous formation of NNN in people who had stopped smoking and used the 21-mg nicotine patch for 6 months. We quantified urinary biomarkers of exposure to NNN-the sum of NNN and its pyridine-N-glucuronide, referred to as total NNN. Also measured were NNK metabolites-the sum of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its N- and O-glucuronides, referred to as total NNAL.

RESULTS

The average decline of urinary total NNN was less drastic than that of total NNAL: 22% of baseline total NNN and 7.3% of baseline total NNAL were detected in urine 24 weeks after smoking cessation and patch use (p = .02). The average ratio of total NNN to total NNAL in the same urine samples increased from 0.14 in baseline urine to 0.38 after 24 weeks of nicotine patch use.

DISCUSSION

Overall, these results demonstrate that endogenous formation of NNN may occur in nicotine patch users. However, the levels of urinary total NNN during patch use were generally extremely low. Moreover, in 10 of 20 subjects analyzed here, the rate of decline in total NNN was similar to that in total NNAL, indicating that endogenous formation of NNN is virtually nonexistent in these subjects. Supplementation with ascorbic acid could be a simple approach to block possible NNN formation in nicotine patch users.

New and traditional smokeless tobacco: comparison of toxicant and carcinogen levels

Declining cigarette use and spreading bans on smoking in public places in the United States are encouraging the U.S. cigarette industry to turn to another tobacco category, smokeless tobacco products. Currently, a number of new brands are being test marketed, including Taboka, Marlboro Snus, Camel Snus, and Skoal Dry. We report here levels of tobacco-specific nitrosamines (TSNAs), alkaloids, anions, polycyclic aromatic hydrocarbons (PAH), and volatile aldehydes in these products, and compare them to the most popular traditional moist snuff brands. Total TSNAs averaged 1.97 microg/g dry weight tobacco in Taboka, Marlboro Snus, and Camel Snus, 4.54 microg/g tobacco in Skoal Dry, and 7.42 microg/g tobacco in traditional brands. The amounts of unprotonated nicotine averaged 0.961 mg/g tobacco in Taboka, Marlboro Snus, and Skoal Dry, 7.22 mg/g tobacco in Camel Snus, and 7.57 mg/g tobacco in traditional brands. Levels of minor tobacco alkaloids were relatively high in Taboka, Marlboro Snus, and Skoal Dry, as compared to other products analyzed here. Levels of nitrite and nitrate in new U.S. smokeless tobacco products and the Swedish snus General were lower than those in the other products. Remarkably high levels of chloride and some PAH were observed in the traditional moist snuff. Crotonaldehyde levels were about five times higher in Taboka and Marlboro Snus than in traditional products. The large variation in the levels of some toxicants and carcinogens analyzed here indicates that more effort is required from the U.S. tobacco industry to further reduce their amounts in new and traditional smokeless tobacco products.

Smokeless tobacco reduction: preliminary study of tobacco-free snuff versus no snuff

This preliminary study examined the effects of tobacco-free snuff (intervention, n = 52) compared with no snuff (control, n = 54) for reducing tobacco use among smokeless tobacco (ST) users not interested in quitting. Both groups received behavioral instructions, and intervention subjects received tobacco-free snuff for 8 weeks. Participants were required to reduce their intake by 50% during the first 4 weeks and by 75% during the subsequent 4 weeks. Follow-up occurred at 12 weeks. Significant reductions were observed from baseline to week 8 (end of treatment) for both treatment groups in the amount of ST use (tins/week and dips/day, p<.001); mean urinary cotinine (p<.001); and mean urinary total NNAL, a carcinogen biomarker (p<.001). At week 8 the intervention resulted in a lower mean total NNAL (p = .048). Compared with the control condition, the intervention resulted in a higher percentage of subjects achieving at least a 50% reduction in cotinine (p = .046) and total NNAL (p = .002) at the end of treatment, more quit attempts (p = .030), and a longer mean duration of abstinence (p = .013) through follow-up. An ST reduction intervention incorporating tobacco-free snuff could potentially reduce risk for ST-related disease beyond that achieved with no snuff by increasing the number of patients who achieve significant reductions in carcinogen exposure and, more important, by facilitating tobacco abstinence by increasing quit attempts and abstinence duration.

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.

Exposure to nicotine and a tobacco-specific carcinogen increase with duration of use of smokeless tobacco

BACKGROUND

Smokeless tobacco is an efficient delivery vehicle for nicotine and can contain significant amounts of carcinogens. However, few studies have examined factors that might moderate levels of nicotine or carcinogen exposure.

AIMS

To determine the effect of duration of smokeless tobacco use on the uptake of nicotine and a tobacco-specific carcinogen, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK).

METHODS

Questionnaires on use of smokeless tobacco were administered, and urine samples from 212 smokeless tobacco users were analysed for biomarkers of uptake of nicotine and NNK. The biomarkers were cotinine and total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL). Male smokeless tobacco users were recruited for studies designed to investigate methods of reducing smokeless tobacco use. The questionnaire and biomarker data were obtained at baseline, prior to reduction.

RESULTS

Levels of cotinine (p<0.001) and total NNAL (p<0.001) were significantly correlated with duration (in years) of use of smokeless tobacco products. Median cotinine and total NNAL were 2.4 and 2.1 times higher, respectively, in the > or = 21 years of use than in the 0-5 years of use category.

CONCLUSIONS

Smokeless tobacco users adjust their intensity of use with experience in order to increase their nicotine dose, resulting in a corresponding increase in exposure to NNK, a powerful carcinogen. These results indicate the importance of educating smokeless tobacco users about the effects of prolonged use of these products.

Prevalence of alternative forms of tobacco use in a population of young adult military recruits

Recent evidence suggests that the popularity of certain alternative forms of tobacco may be increasing in adolescents. Little is known, however, about the use of these products among young adults. This study examined the use of alternative tobacco products including bidis, cigars, kreteks (clove cigarettes), pipes, and smokeless tobacco in a large sample of young adult military recruits (N=31107). Overall, 18.5% of participants were using some form of alternative tobacco product prior to entry into Basic Military Training. Results revealed a relatively high prevalence of cigar (12.3%) and smokeless tobacco use (6.7%). Use of other products was less common, including 1.1% for pipes, 2.0% for bidis, and 3.0% for kreteks. With the exception of kreteks, which did not differ by gender, the prevalence of use of alternative tobacco products was greater for males than for females (p<.001). Patterns of use also differed according to other demographic characteristics including race, ethnicity, age, and income. Implications for surveillance and tobacco control efforts are discussed.

Smokeless tobacco use and salivary cotinine concentration

The objective of the current study was to examine demographic, tobacco-related, and psychosocial factors associated with cotinine concentration in a group of 256 male smokeless tobacco (ST) users living in the Ohio Appalachian region. Participants completed a survey that included questions on: 1) current and past tobacco use behaviors; 2) demographics; 3) tobacco dependence; 4) decisional balance; 5) health behaviors; and 6) perceived stress and depressive symptoms. Saliva samples were obtained for measurement of cotinine. The variables related to salivary cotinine concentration in the multiple regression model were age, marital status, occupation, quit attempts, years of ST use, and tobacco dependence score (adjusted R(2)=0.24). Among the 199 snuff only users, cotinine concentration was positively related to age, being divorced/widowed/separated, no quit attempts in the previous year, dependence score, and brand of snuff (adjusted R(2)=0.29). This is one of the largest studies to examine influences beyond topography on cotinine concentration in a group of rural ST users. These findings suggest that smokeless tobacco users and smokers share some similarities with respect to tobacco dependence.

Effect of smokeless tobacco product marketing and use on population harm from tobacco use policy perspective for tobacco-risk reduction

This article presents policy perspectives on the marketing of smokeless tobacco products to reduce population harm from tobacco use. Despite consensus that smokeless tobacco products as sold in the United States are less dangerous than cigarettes, there is no consensus on how to proceed. Diverse factions have different policy concerns. While the tobacco industry is exempted from U.S. Food and Drug Administration (FDA) oversight, the pharmaceutical industry whose nicotine replacement therapy (NRT) medicines compete with smokeless tobacco as noncombustible nicotine-delivery systems are regulated by the FDA. Some public health experts support smokeless tobacco use to reduce population harm from tobacco; other public health experts oppose promoting smokeless tobacco for harm reduction. Adult consumers can freely purchase currently-marketed smokeless tobacco products and even more-deadly cigarettes. Concerns with and advantages of smokeless tobacco products are discussed. In that noncombustible medicinal nicotine-delivery systems have been proven to be effective smoking-cessation aids, smokeless tobacco, as another source of psychoactive doses of nicotine, could be used similarly, in a dose-response fashion as a smoking-cessation aid (consistent with FDA principles for evaluating generic versions of drugs). Price measures should be used on tobacco products to make costs to consumers proportional to product health risks (which would make smokeless tobacco much cheaper than cigarettes), and smokeless tobacco should be encouraged as an option for smoking cessation in adult smokers, particularly for those who have failed to stop smoking using NRT or other methods.

Epidemiologic perspectives on smokeless tobacco marketing and population harm

Moist snuff is the most popular form of orally-used smokeless tobacco in North America and parts of Europe. Because moist snuff use conveys lower risks for morbidity or mortality than does cigarette smoking, its use has been proposed as a tobacco harm-reduction strategy. This article critically reviews new and published epidemiologic evidence on health effects of moist snuff and its patterns of use relative to smoking in the United States, Sweden, and Norway. The available evidence suggests that: (1) moist snuff is a human carcinogen and toxin, (2) increased promotion of moist snuff has led to increased sales in those countries, (3) the uptake of moist snuff in these three countries during the past several decades has occurred primarily among adolescent and young adult men, (4) increased prevalence of snuff use has not been associated consistently with a reduction in smoking initiation or prevalence, (5) moist snuff use apparently plays a very minor role in smoking cessation in the U.S. and an inconsistent role in Sweden, (6) U.S. states with the lowest smoking prevalence also tend to have the lowest prevalence of snuff use, (7) there are no data on the efficacy of snuff as a smoking-cessation method, (8) the prevalence of cigarette smoking is relatively high among people who use snuff, and (9) snuff use is more consistently associated with partial substitution for smoking than with complete substitution. The evidence base for promotion of snuff use as a public health strategy is weak and inconsistent.

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.

Smokeless tobacco brand switching: a means to reduce toxicant exposure?

The purpose of this study was to examine the effects of smokeless tobacco (ST) brand switching on biomarkers of ST exposure and on ST use. Subjects seeking treatment to reduce their use were randomized to ST brand switching with controlled ST topography, brand switching with ad libitum ST use, or a waitlist control with subsequent randomization to one of these two conditions. The waitlist control group was included to assess whether changes were a consequence of time effect. During the intervention, Copenhagen or Kodiak ST users were asked to switch to products that were sequentially lower in nicotine content: Skoal Long Cut Straight or Wintergreen for 4 weeks and then Skoal Bandits for the subsequent 4 weeks. Measures were obtained during the course of treatment and at 12-week follow-up. Significant reductions in total urinary cotinine and 4-(methylnitrosamino)-L-(3-pyridyl)-L-butanol (NNAL) plus its glucuronides (total NNAL) were observed with no significant differences between the controlled topography and ad libitum conditions. Significant reductions were also observed in the amount and duration of dips with a significant intervention effect for durational measures. At 12 weeks, the 7-day biochemically-verified tobacco abstinent rate was 26% in the ad libitum group. ST brand switching may be a feasible alternative intervention for ST users interested in quitting but unwilling to stop ST use completely.

Defining participant exposure measures in Web-based health behavior change programs

BACKGROUND

Published research on the use of Web-based behavior change programs is growing rapidly. One of the observations characterized as problematic in these studies is that participants often make relatively few website visits and spend only a brief time accessing the program. Properly structured websites permit the unobtrusive measurement of the ways in which participants access (are exposed to) program content. Research on participant exposure to Web-based programs is not merely of interest to technologists, but represents an important opportunity to better understand the broader theme of program engagement and to guide the development of more effective interventions.

OBJECTIVES

The current paper seeks to provide working definitions and describe initial patterns of various measures of participant exposure to ChewFree.com, a large randomized controlled trial of a Web-based program for smokeless tobacco cessation.

METHODS

We examined measures of participant exposure to either an Enhanced condition Web-based program (interactive, tailored, and rich-media program) or a Basic condition control website (static, text-based material). Specific measures focused on email prompting, participant visits (number, duration, and pattern of use over time), and Web page viewing (number of views, types of pages viewed, and Web forum postings).

RESULTS

Participants in the ChewFree.com Enhanced condition made more visits and spent more time accessing their assigned website than did participants assigned to the Basic condition website. In addition, exposure data demonstrated that Basic condition users thoroughly accessed program content, indicating that the condition provided a meaningful, face-valid control to the Enhanced condition.

CONCLUSIONS

We recommend that researchers conducting evaluations of Web-based interventions consider the collection and analysis of exposure measures in the broader context of program engagement in order to assess whether participants obtain sufficient exposure to relevant program content.

The epidemiology of tobacco use and dependence

Tobacco use continues to be a public health issue of great importance. Acute and critical care nurses in particular have a unique opportunity to become a cornerstone for the nation's tobacco control efforts through integration of prevention and cessation interventions as part of patient care. This article provides readers with a working knowledge of tobacco use and dependence as background reading for the subsequent articles presented in this special issue addressing tobacco cessation in acute and critical care settings.

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

OBJECTIVES

Smokeless tobacco has many adverse health effects. We analyzed long-term national trends in smokeless tobacco use.

METHODS

We used 1987 to 2000 National Health Interview Survey data for adults aged 18 years and older, 1986 to 2003 data from Monitoring the Future surveys of adolescents, and 1991 to 2003 data from the Youth Risk Behavior Survey for 9th- to 12th-grade students to examine overall and demographic-specific trends.

RESULTS

Smokeless tobacco use among adult and adolescent females was low and showed little change. Smokeless tobacco use among men declined slowly (relative decline=26%), with the largest declines among those aged 18 to 24 years or 65 years and older, Blacks, residents of the South, and persons in more rural areas. Overall and demographic-specific data for adolescent boys indicate that smokeless tobacco use increased for 12th-grade students from 1986 until the early 1990s, but has subsequently declined rapidly in all grades since then (range of relative overall declines=43% to 48%).

CONCLUSIONS

Smokeless tobacco use has declined sharply, especially among adolescent boys. Ongoing prevention and cessation efforts are needed to continue this trend.

Progression of oral snuff use among Finnish 13-16-year-old students and its relation to smoking behaviour

AIMS

To examine the progression of oral moist snuff use among adolescents and its relation to smoking behaviour and nicotine addiction.

DESIGN AND SETTING

A 3-year smoking prevention study in 27 schools of Helsinki, Finland, starting with the seventh grade to the ninth grade.

PARTICIPANTS AND MEASUREMENTS

Pupils (n=2816) completed questionnaires four times, which included information on smoking behaviour, snuff experiments, nicotine addiction (Fagerström Tolerance Questionnaire) and other activities.

FINDINGS

The prevalence of snuff experimentation rose among boys from 7% in the seventh grade to 43% 3 years later in the ninth grade, and among girls from 2% to 13% for the corresponding period. Among boys, smoking predicted later snuff use in all assessments and snuff experimentation predicted later weekly smoking. The impact of snuff experimentation upon later smoking experimentation was smaller than vice versa. Among boys active in sports, smoking was less common but snuff use was more common. Combined use was common; by the end of the follow-up only 10% of weekly smokers had not tried oral snuff. Nicotine dependence scores increased linearly with snuff use among weekly smokers.

CONCLUSIONS

Despite the European Union sales ban on oral snuff products since 1995, in Finland snuff use is common among boys. Although combined use of snuff and cigarettes is associated with higher levels of nicotine dependence among adolescent boys, the direction of causality is not known. Unlike cigarette smoking, oral snuff use was tried among boys who spent their free time with sports-related activities.

A randomised clinical trial of nicotine patches for treatment of spit tobacco addiction among adolescents

BACKGROUND

This study tested the efficacy of nicotine patches in combination with behavioural therapy for the treatment of adolescent spit tobacco addiction. Prior interventions had resulted in mean cessation rates below 15% at one year.

METHODS

This study, the PATCH Project, used a three group, placebo controlled, randomised clinical trial design. The control group received a standard 3-5 minute counselling followed by a two week follow up phone call. The two intervention groups received a six week behavioural intervention; in addition, one group received active nicotine patches while the other group received placebo patches. Both groups received quarterly stage based telephone counselling.

RESULTS

At one year, the usual care group's spit tobacco cessation rate was 11.4% (exact 95% confidence interval (CI) 6.1% to 19.1%), placebo patch 25.0% (95% CI 16.9% to 34.7%), and the active patch 17.3% (95% CI 10.4% to 26.3%). When both patch groups were combined, the cessation rate was 21.2% (95% CI 15.7% to 27.6%). The cessation rates for active and placebo patch were not significantly different (exact two sided p = 0.22), while the combined patch groups had a significantly greater cessation rate than usual care (exact two sided p = 0.04).

CONCLUSIONS

The behavioural intervention proved to be about twice as successful as previous interventions, but the nicotine patch offered no improvement in cessation rates. The behavioural intervention is based on publicly available materials and can be easily adapted for widespread use, particularly in high schools.

Smokeless tobacco: an emerging addiction

Smokeless tobacco (ST) use is an important health issue in the United States, and chronic use leads to significant morbidity. ST users are exposed to levels of nicotine comparable with smokers and experience symptoms of nicotine withdrawal when attempting to stop. Clinical treatment of ST users requires an understanding of the unique characteristics of ST. This article reviews ST products, epidemiology, pharmacology, health risks, and treatment approaches.