Trends in Tobacco Use among 9th Graders in Sweden, 1991-2020

Tobacco use was measured with self-reports of lifetime use of cigarettes and snus to examine trends in tobacco use among Swedish 9th graders over the period 1991-2020. Annual school surveys with nationally representative samples of 9th-grade students in Sweden covering the period 1991-2020 with a total sample of 163,617 students. We distinguished between the use of cigarettes only, use of snus only, dual use (use of both cigarettes and snus), and total tobacco use (use of any of these tobacco products). In addition to a graphical description of trends in the various measures of tobacco use, the correlation between these trends was calculated with the Pearson correlation coefficient (Rxy). The prevalence of total tobacco use declined from 72% in 1991 to 36% in 2020. The declining trend in total tobacco use was positively correlated with the trend in dual use (Rxy = 0.98) and the trend in cigarette use only (Rxy = 0.87). The trend in total tobacco use was, on the other hand, negatively correlated with snus use only (Rxy = -0.41), and snus use only was negatively correlated with cigarette use only (Rxy = -0.71). The situation became different after 2017 when total tobacco use increased as a result of an increasing prevalence of snus use. The sharp decline in tobacco use among 9th graders in Sweden over the past three decades is driven by declining cigarette use. The correlations between the various forms of tobacco use suggest that snus use may have contributed to the decline in cigarette use and, by that, overall tobacco use. The situation changed after 2017 when a sharp rise in snus use seems to have increased total tobacco use among adolescents in Sweden. A possible explanation behind this development is the introduction of a new form of snus called "All white snus", which was introduced in Sweden in 2014.

Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review

PURPOSE

While smoking is declining among young people, smokeless tobacco use is increasing. Identifying who is using smokeless tobacco and why is essential in preventing smokeless tobacco use. This study aimed to comprehensively explore the factors of young people's use of smokeless tobacco in western countries and identify research gaps.

METHODS

We conducted a systematic scoping review of studies that examined factors associated with smokeless tobacco use among young people (ages 13-29) from western countries published between January 2011 and September 2021. Searches were conducted in CINAHL, Medline, and Scopus. Studies on adults, total tobacco use (i.e., did not differentiate between tobacco product types), dual and multiple uses of tobacco, and studies on smokeless tobacco cessation programs were excluded.

RESULTS

A total of 160 studies were included in this scoping review. The studies were primarily undertaken in the US and the Scandinavian countries, and the majority explored smokeless tobacco use without distinguishing between the specific types. Smokeless tobacco users were more likely to be male, non-Hispanic white, engaging in physical activity, and using other substances, including cigarettes and alcohol. The role of friends and family were identified as critical factors that were related to the use of smokeless tobacco.

CONCLUSIONS

This scoping review suggests that preventative measures against smokeless tobacco use should focus on peer and family members' roles and that these measures may benefit from targeting males. Additional research, including systematic reviews on this area to validate the identified associated factors, would improve the understanding of smokeless tobacco use.

Multiple Tobacco Product Use Conceptual Framework: A 2021 Update on Evidence

INTRODUCTION

One-third of adults in the United States who use tobacco regularly use two or more types of tobacco products. As the use of e-cigarettes and other noncombusted tobacco products increases-making multiple tobacco product (MTP) use increasingly common-it is essential to evaluate the complex factors that affect product use.

AIMS AND METHODS

In this update to our 2019 conceptual framework, we review and evaluate recent literature and expand the model to include ways in which MTP use may be affected by market factors such as the introduction of new products and socioenvironmental factors like marketing and advertising.

RESULTS AND CONCLUSIONS

MTP use patterns are complex, dynamic, and multiply determined by factors at the level of individuals, products, situations or contexts, and marketplace. Substitution, or using one product with the intent of decreasing use of another, and complementarity, or using multiple products for different reasons or purposes, explain patterns in MTP use. Moreover, substitution and complementarity may inform our understanding of how market changes targeted at one product, for instance, new product standards, bans, product pricing, and taxation, affect consumption of other tobacco products. New data from natural experiments and novel laboratory-based techniques add additional data and expand the framework.

IMPLICATIONS

A substantial proportion of people who use tobacco use more than one product. This review synthesizes and evaluates recent evidence on the diverse factors that affect MTP use in addition to expanding our framework. Our review is accompanied by suggested research questions that can guide future study.

A Conceptual Framework for Understanding Multiple Tobacco Product Use and the Impact of Regulatory Action

INTRODUCTION

Over 35% of the adult tobacco-using population regularly use more than one tobacco product. Although rates of tobacco use in the United States have declined over the last decade, rates of multiple tobacco product (MTP) have either remained stable (among adults) or increased (among youth).

METHODS

In this paper, we review the literature and propose a framework for understanding both MTP use and how regulatory actions on any single tobacco product (STP) may influence the use of other tobacco products.

RESULTS AND CONCLUSIONS

Within the framework, Product, Person, and Context/Situational factors (and their interactions) influence product cross-substitution and thus patterns of use of MTPs. In addition, we propose that Context/Situation effects specifically increase the complexity of MTP-use patterns resulting in "dynamic complementarity" in addition to substitution-like relationships between tobacco products. Experimentation with, and use of, various tobacco products results in reinforcement histories that affect which products are used, in what contexts, and by whom, which in turn has downstream impacts on toxicant exposure and health. We conclude our analysis with an examination of how regulation of STPs can have impacts on the use of other STP and MTP use and provide research questions for further examining MTP use.

IMPLICATIONS

Though rates of tobacco use have declined in the United States, over 35% of the adult tobacco-using population regularly uses more than one tobacco product. This paper provides a framework for understanding MTP use and how regulatory actions on any STP may influence the use of other tobacco products. We conclude our analysis by providing research questions for further examining MTP use.

Tobacco use and the interplay of internalizing, externalizing and substance use problems: A latent class analysis of data from the Population Assessment of Tobacco and Health Study

BACKGROUND

Cigarette smoking is disproportionately high among adults with two or more psychiatric disorders (psychiatric comorbidities), yet research on non-cigarette tobacco use among this population is scant. Additionally, most studies on tobacco use this among this population rely on psychiatric diagnoses rather than individual symptoms, potentially excluding individuals with symptom-specific issues that increase their risk for tobacco use but do not meet the criteria for diagnosis. The objectives of this study were to identify unique classes of individuals based on symptoms of psychiatric disorders and to assess differences in demographic characteristics and tobacco use behaviors between classes.

METHODS

This study used data from Wave 2 of the Population Assessment of Tobacco and Health Study adult dataset. Latent class analysis was used to classify individuals based on internalizing, externalizing and substance use problems. Bivariate and multivariable models examined the association between latent class membership and current use of cigarettes, cigar products, electronic nicotine delivery systems, pipe, hookah and smokeless tobacco products. Poly tobacco use was also examined.

RESULTS

Three latent classes were identified. The "normative" class reported low prevalence of all symptoms, the "severe internalizing and non-violent externalizing" class reported severe internalizing problems and non-violent externalizing problems and the "severe" class reported high prevalence of all symptoms. Tobacco use was highest for the "severe" class and lowest for the "normative" class across products.

CONCLUSIONS

Individuals in the "severe" class may be at elevated risk of tobacco-related morbidity and mortality and would likely benefit from targeted tobacco control interventions.

Alarming development of dual snus and cigarette usage among young Finnish males

Background

The consumption of tobacco products has evolved to include more complex combinations of different products. We investigated the tobacco habits of a representative population of young Finnish male conscripts in order to evaluate the prevalence of dual use of cigarettes and snus as well as the transition from one tobacco product to another. In addition, we evaluated the correlation between the level of education and the use of cigarettes and snus.

Methods

A questionnaire-based survey was carried out in three out of 17 garrisons among conscripts during their first week of service in 2014. A total of 1971 male conscripts were selected by simple random sampling of the 9013 males in the selected garrisons. Of them 1916 participated and filled in the questionnaire. The response rate was 97.2%. The questionnaire consisted of 25 questions including age, gender, basic education, use of tobacco products as well as questions assessing nicotine dependency.

Results

The amount of dual users of cigarettes and snus was 21%. There was a higher probability of dual use of cigarettes and snus among smokers compared to snus users (p < 0.001). One third (35%) of former smokers reported daily snus use and over 40% of the former snus users smoked daily. One third (34%) of the participants reported snus usage and 14% of the study subjects used snus daily. 40% of the study population were smokers and over 25% smoked daily. Of the participants with basic educational background 57% smoked daily (p < 0.001), however, no association between snus and level of education was found (p = 0.69).

Conclusions

This study provides better understanding of the complex tobacco habits of young adult males. The simultaneous usage of multiple tobacco products as well as the high tendency to transition from one tobacco product to another should be taken into consideration when planning cessation interventions in health care settings and tobacco control policies at societal levels.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7519-1) contains supplementary material, which is available to authorized users.

Association of snus experimentation in late adolescence with daily cigarette smoking in early adulthood: A longitudinal study among Finnish men

Aims: Swedish smokeless tobacco (snus) is a lower-risk tobacco product than cigarette smoking for individuals. However, the public health impact of snus use is less well studied. Critically, it is uncertain whether use of snus leads to the onset of smoking. This study aimed to investigate prospectively the association between snus experimentation in late adolescence and daily cigarette smoking in early adulthood among Finnish young men. Methods: Data were obtained from 1090 young men within the population-based FinnTwin12 cohort. At baseline (mean age 17 years), we assessed lifetime use of cigarettes and snus, plus other potential predictors of cigarette smoking. At follow-up (mean age 24 years), participants were categorized according to their current smoking status. The final analyses were conducted among 375 young men who were never smokers at baseline with adequate data on follow-up smoking status and other potential predictors of cigarette smoking. Results: Age-adjusted logistic regressions showed an increased risk of becoming a daily smoker at follow-up among those participants who had at least tried snus but had never smoked cigarettes at baseline (odds ratio (OR) 6.48, 95% confidence interval (CI) 2.02-20.7), compared with those who had never used snus. When additionally adjusted for monthly alcohol intoxication, maternal smoking, and peer drug use, the association between snus experimentation and later daily cigarette smoking was attenuated, but remained significant (OR 3.94, 95% CI 1.22-12.7). Conclusions: Our data support the proposition that snus experimentation during late adolescence is longitudinally associated with daily cigarette smoking in early adulthood. Although a causal association cannot be inferred with certainty, snus experimentation might constitute an indicator of the propensity to proceed to regular snus use and initiation of use of other tobacco or nicotine products.

Young adult dual combusted cigarette and e-cigarette users' anticipated responses to hypothetical e-cigarette market restrictions

Introduction: The aim of this exploratory study was to assess young adult dual e-cigarette (EC) and combusted cigarette (CC) users' anticipated responses to hypothetical market restrictions regarding key EC characteristics. Methods: Data came from 240 young adult dual EC and CC users recruited via Amazon Mechanical Turk in June 2017. Descriptive statistics were used to report sociodemographic, CC smoking, and EC use characteristics. McNemar's chi-square tests and chi-square tests were used to assess differences between groups in terms of anticipated responses to hypothetical EC market restrictions. Results: Hypothetical regulations resulted in reported intentions to reduce EC use and increase CC use; the greatest impact was found for restrictions regarding e-liquid nicotine content, followed by flavor and ability to modify EC devices. Moreover, individuals reporting use of flavored e-liquid, high nicotine content e-liquid, and customizable EC were most likely to report intentions to reduce EC use and increase CC use. Conclusions: This work provides preliminary evidence that restrictive regulations regarding key EC characteristics may increase intentions to increase CC use among young adult dual EC and CC users.

Use of moist oral snuff (snus) and pancreatic cancer: Pooled analysis of nine prospective observational studies

While smoking is a well-established risk factor for pancreatic cancer, the effect of smokeless tobacco is less well understood. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between Swedish snus use and the risk of pancreatic cancer. A total of 424,152 male participants from nine cohort studies were followed up for risk of pancreatic cancer through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors. During 9,276,054 person-years of observation, 1,447 men developed pancreatic cancer. Compared to never-snus use, current snus use was not associated with risk of pancreatic cancer (HR 0.96, 95% CI 0.83-1.11) after adjustment for smoking. Swedish snus use does not appear to be implicated in the development of pancreatic cancer in men. Tobacco smoke constituents other than nicotine or its metabolites may account for the relationship between smoking and pancreatic cancer.

Adolescent tobacco use practices and user profiles in a mature Swedish moist snuff (snus) market: Results from a school-based cross-sectional study

AIMS

The aim of this work was to study the diversity of tobacco use among Norwegian adolescent tobacco users and to investigate how different user groups compared with each other in terms of lifestyle and risk correlates. Swedish moist snuff (snus) use has increased dramatically in Norway over the last few years and is now more prevalent than smoking in younger age groups.

METHODS

The participants were 736 15-year-old tobacco users obtained from a large school-based cross-sectional survey (response rate 73%). Leisure time activity and risk behaviour factors were extracted by principal components analysis. Associations between tobacco use, leisure activities, risk behaviours, alcohol use and sex were studied bivariately and by logistic regression.

RESULTS

In total, 41.5% of the tobacco users were dual users (smokers and snus users). Problem behaviour and risk-taking lifestyles were associated with tobacco use frequency and high-frequency dual use, with a low risk profile for all types of occasional users (snus, cigarettes or dual users), a medium risk profile for all types of daily single-product users, including those who occasionally used the other product (i.e. dual users) and a high-risk profile for those who used both products daily (daily dual users).

CONCLUSIONS

Fragmented use patterns in adolescence undermine the dichotomy often applied between smokers and snus users. For associations with lifestyle and risk correlates, use frequency and high-frequency dual use seem to be more important than the choice of product.

Multiple tobacco product use among young adult bar patrons in New Mexico

INTRODUCTION

Use of non-cigarette tobacco products is common, and e-cigarette use is increasing among young adults. We aimed to identify use of other tobacco products among young adult bar patrons in the context of a bar-based intervention to decrease cigarette smoking.

METHODS

2291 cross-sectional surveys were collected from young adults in bars in Albuquerque, New Mexico using time-location sampling between 2011 and 2013 (N=1142 in 2011, N=1149 in 2012-2013), 2 and 3years into an intervention to reduce cigarette use, and analyzed in 2014-2015. Participants reported current (i.e. past 30-day) use of cigarettes, snus, dip, cigarillos, hookah, and e-cigarettes, demographics, and tobacco-related attitudes. Multiple imputation was used to account for planned missing data. Logistic regression determined correlates of multiple tobacco product use.

RESULTS

Cigarette smoking in the population decreased during the intervention from 43% to 37%. Over 60% of current cigarette smokers reported poly-use, most frequently with e-cigarettes (46%) and hookah (44%), followed by cigarillos (24%), dip (15%), and snus (14%) in 2012-2013. Among cigarette smokers, current e-cigarette use increased, while use of other products decreased during the intervention. Odds of poly-use (versus smoking cigarettes only) were greater among males and those reporting past 30-day binge drinking, and lower in those who strongly believed secondhand smoke exposure is harmful.

CONCLUSIONS

Among young adult bar patrons in Albuquerque, New Mexico, most cigarette smokers reported currently using at least one other tobacco product. Public health interventions should address use of all tobacco products, use of which may rise despite decreased cigarette use.

The Case for Requiring Graphic Warning Labels on Smokeless Tobacco Product Packages

On November 10, 2015, the U.S. Food and Drug Administration approved, for the first time, the sale of smokeless tobacco products authorized under the new premarket tobacco application pathway. This Food and Drug Administration regulatory decision draws attention to the growing worldwide use of smokeless tobacco products in general. Use of these tobacco products is particularly popular in low- and middle-income countries of Asia. Due to aggressive and strategic marketing to children, young adults, and current smokers, rates of smokeless tobacco use in men of all ages are on the rise in United States and elsewhere. The tobacco industry also continues to market these products to current cigarette smokers for use in the growing number of "smoke-free environments." Smokeless tobacco products are associated with cancers of the upper aerodigestive tract, particularly the oral cavity, esophagus, and pancreas; cardiovascular diseases; small-for-gestational-age infants; premature births; increased risk of apnea; and stillbirth. There is no convincing evidence regarding the efficacy of smokeless tobacco, including snus, to promote smoking cessation. Rather, studies from Europe and the United States demonstrate that smokeless tobacco use may facilitate regular cigarette smoking by acting as a gateway drug, especially for children. Caution is warranted before proposing smokeless tobacco as a harm-reduction strategy, in part because of the potential for further promoting smokeless tobacco in low- and middle-income countries where use is already widespread. Continued vigilance through comprehensive surveillance is warranted. We strongly recommend the use of graphic warning labels as a "no regrets" strategy for all smokeless tobacco products marketed globally.

Dual use of electronic and tobacco cigarettes among adolescents: a cross-sectional study in Poland

OBJECTIVES

Electronic cigarettes (e-cigarettes) are gaining in popularity among youth. While these products may be beneficial in adult smokers, the effect on young users of electronic and tobacco cigarettes (dual users) is unknown. The objective of this study was to assess the frequency of dual use among adolescents and to compare tobacco cigarette consumption among dual and exclusive tobacco cigarette users.

METHODS

A cross-sectional survey of a sample of 2213 Polish students aged 16-18 conducted between December 2013 and February 2014.

RESULTS

Overall, 21.8 % of students were dual users. Dual users were more likely to smoke tobacco cigarettes on a daily basis [adjusted odds ratio, AOR 3.54 (95 % CI 2.34-5.36) and less likely to smoke fewer cigarettes per day (AOR 0.27 (95 % CI 0.12-0.57)] than exclusive tobacco cigarette users.

CONCLUSIONS

The frequency of dual use was higher than exclusive use of a single product among Polish adolescents. Young dual users do not smoke a lower number of tobacco cigarettes per day than exclusive tobacco cigarette users.

Use of snus, its association with smoking and alcohol consumption, and related attitudes among adolescents: the Finnish National School Health Promotion Study

Background

The relationship between the use of snus and lifestyle-related habits – especially in adolescence, when these behaviours begin and become established – is not widely studied. Our aim was to analyse associations between snus use and habits of and attitudes towards smoking and alcohol consumption among Finnish adolescents.

Methods

The study is a part of the National School Health Promotion Study in Finland. The study population consisted of a representative sample of Finnish adolescents (n = 183 226). A questionnaire enquired about pupils’ use of snus, habits of and attitudes towards smoking and alcohol consumption, as well as their (age, gender, school type) and their parents’ (education and smoking) background factors. Chi-square tests and logistic regression models served in the statistical analyses.

Results

Of the adolescents, 18 % had used snus (2 % daily, 16 % experimented) while 82 % never had. Snus use was more common among boys than girls (p < 0.05). Concerning smoking, 19 % were daily and 15 % occasional smokers. Regarding alcohol, 11 % consumed it weekly and 57 % monthly or less frequently. More than two thirds of the adolescents held positive attitudes towards smoking (71 %), and alcohol (67 %). Male gender (OR = 9.9; 95 % CI 9.4–10.4), current (OR = 32.8; 95 % CI 26.1–41.1) or former (OR = 10.1; 95 % CI 8.0–12.9) smoking, weekly consumption of alcohol (OR = 27.4; 95 % CI 21.0–35.8), positive attitude towards smoking (OR = 1.4; 95 % CI 1.3–1.6), and higher parental education (OR = 1.4; 95 % CI 1.3–1.4) associated significantly with adolescents’ current snus use, whereas parental smoking did not.

Conclusion

Current snus use among adolescents may signal an accumulation of other lifestyle-related risky behaviours such as current or past smoking and alcohol consumption as well as a positive attitude towards smoking. In addition to these possible co-existing health-related risk factors, health promotion activities should take into account gender and school differences in order to target preventive messages to youth more effectively.

Oral cavity and oropharyngeal squamous cell carcinoma--an update

Oral cavity squamous cell carcinoma (OC-SCC) is the most common malignancy of the head and neck (excluding nonmelanoma skin cancer). Recent trends have shown a dramatic rise in the incidence of oropharyngeal squamous cell carcinoma (OP-SCC), with a marked increase in lesions related to human papillomavirus infection. This update presents the latest evidence regarding OC-SCC and OP-SCC. In particular, the authors compare and contrast tumors at these two sites with respect to epidemiology, etiopathogenesis, clinicopathologic presentation, clinical assessment, imaging, management, and prognosis. It is important for clinicians to be aware of differences between OC-SCC and OP-SCC so that appropriate patient education and multidisciplinary care can be provided to optimize outcomes.

Prevalence and factors associated with use of smokeless tobacco in young Swiss men

BACKGROUND

Smokeless tobacco is of increasing interest to public health researchers and policy makers. This study aims to measure prevalence of smokeless tobacco use (nasal dry snuff, snus and chewing tobacco) among young Swiss men, and to describe its correlates.

METHODS

We invited 13 245 young men to participate in this survey on socio-economic and substance use data. Response rate was 45.2%. We included 5720 participants. Descriptive statistics and multivariable-adjusted logistic regression were performed.

RESULTS

Mean age of participants was 19.5 years. Self-reported use once a month or more often was 8% for nasal dry snuff, 3% for snus and negligible for chewing tobacco. In multivariable-adjusted logistic regression, the odds for nasal dry snuff use increased in non daily smokers [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.90-3.05], compared with non smokers, participants reporting risky weekly drinking volume (OR 3.93, 95% CI 1.86-8.32), compared with abstinents, and binge drinking once a month or more often (OR 7.41, 95% CI 4.11-13.38), compared with never binge drinking. Nasal dry snuff use was positively associated with higher BMI, average or above family income and German language, compared with French, and negatively associated with academic higher education, compared with non higher education, and occasional cannabis use, compared with no cannabis use. Correlates of snus were similar to those of nasal dry snuff.

CONCLUSION

One in 12 young Swiss men use nasal dry snuff and 3% use snus. Consumption of smokeless tobacco is associated with a cluster of other risky behaviours, especially binge drinking.