Dual Trajectories of Cigarette Smoking and Smokeless Tobacco Use From Adolescence to Midlife Among Males in a Midwestern US Community Sample

Patterns of poly tobacco use among adults in the Population Assessment of Tobacco and Health (PATH) study, 2013-2017: a multistate Markov transition analysis

BACKGROUND

A better understanding of sociodemographic transition patterns between single, dual and poly tobacco product use may help improve tobacco control policy interventions.

METHODS

HRs of transition between never, non-current (no past 30-day use), cigarette, e-cigarette, other combustible, smokeless tobacco (SLT), dual and poly tobacco use states in adults were estimated for age, sex, race/ethnicity, education and income using a multistate model for waves 1-4 of the Population Assessment of Tobacco and Health study (2013-2017), a US-based cohort study, accounting for complex survey design.

RESULTS

Sole cigarette and SLT use were persistent, with 77% and 78% of adults continuing use after one wave. Other use states were more transient, with 29%-48% of adults reporting the same pattern after one wave. If single-product users transitioned, it was most likely to non-current use while dual or poly cigarette users were most likely to transition to exclusive cigarette use. Males were more likely than females to initiate combustible product use after a history of no use, and after a period of tobacco use cessation. Hispanic and non-Hispanic black participants initiated cigarette use at higher rates than non-Hispanic white participants, and had higher rates of experimentation with tobacco products between study waves. Lower socioeconomic status was associated with higher rates of transition into combustible tobacco use.

CONCLUSIONS

Dual and poly tobacco use is largely transient, while single-use patterns are more stable over time. Transitions differ by age, sex, race/ethnicity, education and income, which may influence the impact of current and future tobacco control efforts.

Life-Course Associations Between Smoking and Depressive Symptoms. A 30-Year Finnish Follow-up Study

INTRODUCTION

Relatively little is known about whether the association between smoking and depressive symptoms changes with age and how the trajectories of smoking and depressive symptoms are intertwined during the life course. In this population-based study, these associations were examined from young adulthood to middle age.

METHODS

Participants of a Finnish cohort study (N = 1955) were assessed at the ages of 22, 32, 42, and 52 using questionnaires covering daily smoking (yes/no) and the short 13-item Beck Depression Inventory. Longitudinal latent class and longitudinal latent profile analyses were used to identify life course trajectories of smoking and depressive symptoms.

RESULTS

The proportions of daily smokers decreased, while levels of depressive symptoms increased among both females and males from age 22 to 52 years. Smoking was associated with higher levels of depressive symptoms from age 22 to 42 years, while not at 52. Associations among males prevailed when adjusting for education, marital status, and alcohol use. Four life course classes of daily smoking (nonsmokers, decreasing prevalence of smoking, persistent smokers, and increasing prevalence of smoking) and four trajectories of depressive symptoms (low, increasing/moderate, decreasing/moderate, and high) were identified. In males, persistent daily smokers (relative risk ratio (RRR) = 4.5, 95% confidence interval (CI): 2.2 to 9.2) and those in the class with increasing smoking prevalence (RRR = 3.2, 95% CI: 1.1 to 9.1) had an increased risk of belonging to the high depressive symptoms profile. In females these associations were nonsignificant.

CONCLUSIONS

Compared to females, the relationship between smoking and depressive symptoms seems more robust among males during adulthood. Specifically, males smoking persistently from young adulthood to middle age have an increased risk of high depressive symptoms trajectory.

IMPLICATIONS

This population-based cohort with 30 years of follow-up showed that the life course trajectories of daily smoking and depressive symptoms are associated. Persistent daily smokers and those starting late had an increased risk of belonging to the profile with constantly high levels of depressive symptoms during the life course. However, these associations were statistically significant only in males. Actions should be strengthened, especially in males, to prevent smoking initiation, to help smoking cessation, and to identify and treat depression in smokers with significant depressive symptoms.

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.

Trends in Exclusive, Dual and Polytobacco Use among U.S. Adults, 2014-2019: Results from Two Nationally Representative Surveys

Although increases in the variety of tobacco products available to consumers have led to investigations of dual/polytobacco use patterns, few studies have documented trends in these patterns over time. We used data from the 2014/2015 and 2018/2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) and the 2015–2019 National Health Interview Survey (NHIS) to estimate trends in the following use patterns: exclusive use of cigarettes, electronic nicotine delivery systems (ENDS), other combustibles (cigars/cigarillos/little filtered cigars and traditional pipes/hookah), and smokeless tobacco (four categories); dual use (two product groups) of each product group with cigarettes (three categories); polyuse with cigarettes (all four product groups; one category); and dual/polyuse without cigarettes (one category). We estimated trends in product use patterns overall and by age, sex, and race/ethnicity using two-sample tests for differences in linear proportions. From 2014/2015 to 2018/2019, exclusive ENDS use increased, whereas cigarettes and ENDS dual use decreased. Furthermore, polyuse with cigarettes decreased, whereas dual/polyuse without cigarettes increased, with trends varying by age, sex, and race/ethnicity. Our findings suggest that patterns of dual/polyuse with and without cigarettes have changed in recent years, indicating the need for further surveillance of concurrent tobacco product use patterns.

Lifelong smoking trajectories of Northern Finns are characterized by sociodemographic and lifestyle differences in a 46-year follow-up

Smoking remains among the leading causes of mortality worldwide. Obtaining a comprehensive understanding of a population’s smoking behaviour is essential for tobacco control. Here, we aim to characterize lifelong smoking patterns and explore underlying sociodemographic and lifestyle factors in a population-based birth cohort population followed up for 46 years. Our analysis is based on 5797 individuals from the Northern Finland Birth Cohort 1966 who self-reported their tobacco smoking behaviour at the ages of 14, 31 and 46. Data on sex, education, employment, body mass index, physical activity, alcohol consumption, and substance addiction were also collected at the follow-ups. We profile each individual’s annual smoking history from the age of 5 to 47, and conduct a latent class trajectory analysis on the data. We then characterize the identified smoking trajectory classes in terms of the background variables, and compare the heaviest smokers with other classes in order to reveal specific predictors of non-smoking and discontinued smoking. Six smoking trajectories are identified in our sample: never-smokers (class size 41.0%), youth smokers (12.6%), young adult quitters (10.8%), late adult quitters (10.5%), late starters (4.3%), and lifetime smokers (20.7%). Smoking is generally associated with male sex, lower socioeconomic status and unhealthier lifestyle. Multivariable between-class comparisons identify unemployment (odds ratio [OR] 1.28–1.45) and physical inactivity (OR 1.20–1.52) as significant predictors of lifetime smoking relative to any other class. Female sex increases the odds of never-smoking and youth smoking (OR 1.29–1.33), and male sex increases the odds of adult quitting (OR 1.30–1.41), relative to lifetime smoking. We expect future initiatives to benefit from our data by exploiting the identified predictors as direct targets of intervention, or as a means of identifying individuals who may benefit from such interventions.

Cigarette smokers' concurrent use of smokeless tobacco: dual use patterns and nicotine exposure

BACKGROUND

The concurrent use of cigarettes with other tobacco products, such as smokeless tobacco (SLT), is increasingly common. Extant work with cigarette smokers who also use SLT is based heavily on retrospective reports and between-group comparisons. The purpose of this study was to assess prospectively the patterns of dual users' product use and nicotine exposure on days when cigarettes were smoked exclusively (single use) versus concurrently with SLT (dual use).

DESIGN

Forty-six dual cigarette-SLT users recorded their product use in real time via ecological momentary assessment for a 2-week longitudinal design. They responded to questions about situational factors (eg, location, mood) using this same diary, and collected saliva samples each night for later cotinine measurement. At the end of this 2-week period, users reported on their reasons for and beliefs about SLT use.

RESULTS

Cotinine levels were significantly higher on dual versus single use days (mean±SEM=374.48±41.08 ng/mL vs 300.17±28.13 ng/mL, respectively; p<0.01), and the number of cigarettes logged was higher on dual versus single use days (11.13±0.98 vs 9.13±1.11, respectively; p<0.01). Product use was distinguished by situational factors, with the strongest predictor being location of use. Moreover, the most common reason for initiating (56.52%) and continuing (67.39%) SLT use was to circumvent indoor smoking restrictions.

CONCLUSIONS

Results support the idea of product supplementation rather than replacement among this convenience sample of dual users. For smokers whose primary motivation for SLT use involves situations where they would otherwise be tobacco free, the potential benefits of clean indoor air laws may be diminished.

Impact of snus use in teenage boys on tobacco use in young adulthood; a cohort from the HUNT Study Norway

Background

As smoking rates decreased, the use of Swedish snus (smokeless tobacco) concordantly increased in Norway. The role of snus as possible contributor to the reduction of smoking has been widely discussed. Our aim was to quantitate transitions in snus use, smoking and dual use of snus and cigarettes in a young male population.

Methods

This prospective cohort study includes 1346 boys participating in the Nord-Trøndelag Health Study in Young-HUNT1 1995–97, age 13–19 and in HUNT3 2006–08, age 23–30. Participants reported on tobacco use at both points of time. Models with binominal regression were applied to examine relative risks (RRs), of adolescent ever snus users, dual users or smokers (reference: never tobacco use), to be current snus only users, smokers (including dual users), or tobacco free in adulthood.

Results

Current tobacco use in this male cohort increased from 27% in adolescence to 49% in adulthood, increasing more for snus only use and dual use than for smoking only.

The adjusted RR (95% CI) of becoming a smoker as young adult, was 2.2 (CI 1.7–2.7) for adolescent snus users, 3.6 (CI 3.0–4.3) for adolescent dual users, and 2.7 (CI 2.2–3.3) for adolescent smokers. RR to become snus only users as adults was 3.1 (2.5–3.9) for adolescent dual users, 2.8 (2.2–3.4) for adolescent snus users and 1.5 (1.0–2.2) for adolescent smokers. The adjusted RR for the transition from adolescent tobacco use to no tobacco use in adulthood was similar for snus users and smokers with RR 0.5 (CI 0.4–0.7), but considerably lower for dual users with RR 0.2 (CI 0.2–0.3).

Conclusions

The use of snus, with or without concurrent smoking, carried a high risk of adult smoking as well as adult snus only use. Dual use seemed to promote the opportunity to become snus only users in adulthood, but made it also more difficult to quit. The benefit of snus use for harm reduction is not evident in our cohort, as the combination of smoking and dual use resulted in high smoking rates among the young adults.

School-based behavioral intervention to reduce the habit of smokeless tobacco and betel quid use in high-risk youth in Karachi: A randomized controlled trial

There have been recent surges in the use of smokeless tobacco (SLT) and betel quid (BQ) chew among adolescents in South East Asian countries, with an increase, on average, of 7% to 15% between 2004 and 2013, necessitating interventional investigations to modify this behavior. The current intervention was aimed towards changing adolescents' perceptions regarding the harmful effects of SLT and BQ use and encouraging them to quit. This randomized control trial involved 2140 adolescents from 26 private and public-sector schools in Karachi, Pakistan. After randomization, 1185 individuals were placed in the intervention group and administered a behavior changing intervention (BCI), while 955 individuals constituted the control group. A generalized estimating equation was employed to measure differences in repeated measures for both groups. The beta coefficients were reported after adjusting the covariates with the 95% confidence interval, and the p-value was considered significant at <0.050. Cohen's d was employed to report the effect size of the intervention. The BCI resulted in a 0.176-unit (95% CI 0.078-0.274, p-value <0.001) increase in knowledge scores regarding the health hazards of SLT and BQ, a 0.141-unit (95% CI 0.090-0.192, p-value <0.001) increase in use perception scores, and a 0.067-unit (95% CI 0.006-0.129, p-value 0.031) increase in quit perception scores in the intervention group compared with those in the control group. A knowledge related module (p-value 0.024) and quit preparation module (p-value 0.005) were found to be helpful by adolescents in either changing their perceptions regarding SLT and/or BQ chew use or in quitting. The role of BCI is promising in improving adolescents' knowledge and changing their perceptions in a positive manner regarding their harmful SLT and BQ use. Convincing results may be achieved if interventions are tailored, with an emphasis on the identification of the products that are used by adolescents in addition to highlighting their ill effects and how students may manage to quit them. If included in the schools' curricula, this BCI method may help in developing schools that are free of SLT and BQ use. Trial registration: ClinicalTrials.gov NCT03488095.

Young or adult users of multiple tobacco/nicotine products urgently need to be informed of meaningful differences in product risks

Previously, it has been argued that health information efforts need to inform the public about meaningful differential risks from tobacco/nicotine products. The fact of multiple product use by the same individual further supports this need. When the majority of youth, for example, who use smokeless tobacco are also current tobacco smokers, it makes little sense to mount a smokeless prevention campaign that fails to include clear messages about the much greater risks from smoking. In April 2016, The Food & Drug Administration (FDA) announced a $36 million campaign for youth that "smokeless doesn't mean harmless." Research shows the public (a) already knows that smokeless tobacco is not harmless, but are (b) also largely unaware that cigarettes are much more harmful than smokeless. Though not harmless, smokeless tobacco has been estimated to be over 90% less harmful than cigarettes. 'Gateway' fears are made moot by current use of multiple tobacco/nicotine products. When multi-tobacco product use is commonplace among users, usable information on significant differences in risk is crucial for both adult and younger users. The FDA and like campaigns and health information websites should follow established ethical principles and accepted communication methods to inform the public of less-harmful tobacco/nicotine products as well as the greater harms of smoking, in keeping with the Surgeon-General's advice that reductions in smoking in particular will bring about the greatest public health advances.

Maternal trajectories of cigarette use as a function of maternal age and race

BACKGROUND

Patterns of smoking vary as a function of age and race. The goals of this study were to identify trajectories of maternal cigarette use over a 17-year span, and to determine if maternal age at first birth and race were associated with smoking trajectories.

METHODS

Pregnant women (N=690) were recruited at an urban prenatal clinic. The women (13-42years old; 62% African-American, 38% White) were interviewed about cigarette use during pregnancy and 6, 10, 14, and 16years postpartum. Growth mixture modeling (GMM) was used to identify trajectories. Regressions were used to determine if maternal age at first birth and race predicted trajectory class membership.

RESULTS

A GMM of maternal cigarette use delineated 5 groups: none/unlikely to use (33%), decreasing likelihood of use (6%), late desistance (5%), increasing likelihood of use (17%), and chronic use (39%). Women who became mothers at a younger age were more likely to be classified as late desisters or increasingly likely to smoke. White mothers were more likely to be chronic smokers. Different smoking trajectories and predictors of trajectories were identified for the African-American and White mothers. Covariates including prenatal substance use, hostility, education, and economic hardship also differentiated smoking trajectories.

CONCLUSIONS

Both prevention and treatment of smoking should be targeted to specific groups by age of first pregnancy and race. Pregnant smokers should be provided with more information and resources to help them avoid cigarettes during pregnancy and maintain abstinence after pregnancy.