Smokeless tobacco use by youth in the U.S

Promoting Tobacco Use Among Students: The U.S. Smokeless Tobacco Company College Marketing Program

OBJECTIVES/HYPOTHESIS

From the 1970s-1990s the U.S. Smokeless Tobacco Company (USST) conducted aggressive campaigns to solicit college students to buy their smokeless tobacco (ST) products. The scope, scale, methods, and impact of this youth marketing campaign have yet to be analyzed in the academic literature.

STUDY DESIGN

Historical research study.

METHODS

Internal industry documents describing the USST campaigns were obtained via the University of California, San Francisco's repository of tobacco company records. Marketing materials were obtained from Stanford University's Research Into the Impact of Tobacco Advertising (SRITA) collection of 657 USST advertisements.

RESULTS

USST's College Marketing Program (1978-mid 1980s) sponsored events in some 350 campuses and hired student representatives in at least 175 colleges and universities across America. College representatives were trained to provide free samples to fellow students. Over a typical school year approximately a quarter million Happy Days, Skoal, and Skoal Bandits samples were handed out to undergraduates. USST paid their student representatives well and offered them a variety of incentives based upon sales growth. During the 1990s, USST's Skoal Music program engaged students on campuses and at "spring break" venues such as Daytona Beach.

CONCLUSIONS

Targeting of college students on campus was a common tobacco industry practice between the 1940s and early 1960s. From the 1970s through 1990s USST resurrected the method and pursued it with vigor including: distribution of free samples; sponsored events and concerts, branded intramural teams; visits by sports celebrities; logo wearables and merchandise; contests and incentives; and displays and promotions in stores on and surrounding campuses. Laryngoscope, 131:E1860-E1872, 2021.

Reviewing smokeless tobacco epidemiology, carcinogenesis, and cessation strategy for otolaryngologists

OBJECTIVES/OBJECTIVES

We aimed to provide an otolaryngologist-targeted summary regarding the epidemiology, carcinogenesis, and cessation strategies for smokeless tobacco usage.

STUDY DESIGN

Evidence-based literature review.

METHODS

We reviewed the current evidence-based literature concerning trends in smokeless tobacco use, associations with neoplastic change, and therapeutic interventions to assist with sustained abstinence. In complement, we present an actual case of laryngeal squamous cell carcinoma in the setting of chronic tobacco-dentifrice usage in a lifelong nonsmoker.

RESULTS

This report provides a synopsis of epidemiological data and evidence-based recommendations for general, pharmaceutical, and behavioral cessation strategies.

CONCLUSIONS

Smokeless tobacco use continues to be prevalent among patients seen by otolaryngologists, particularly of various Indian and Southeast Asian descent. The data presented in this article will aid in the identification of at risk patients. The provided recommended cessation strategies will tool otolaryngologists for patient counseling and management, ultimately aimed at improving health outcomes. Laryngoscope, 128:2067-2071, 2018.

High School Students' Perceived Self-Efficacy in Physical and Mental Health

Self-efficacy, a central construct of the Bandura social cognitive theory, formed the background for developing a measure of adolescent health expectations, the School Health Efficacy Questionnaire. The scale taps perceived self-efficacy in both physical and mental health. It showed strong factorial validity, although the factor structure is somewhat different for males and females. Subscales derived from the factor analyses gave high reliabilities. A series of MANOVAs and multiple regressions produced results predicted from self-efficacy theory, and supported the instrument's construct validity. Because low efficacy expectations may lead to self-harmful behaviors, such as poor personal relationships or substance abuse, health educators should consider ways to enhance adolescent appraisals of their capabilities.

Patterns and predictors of smokeless tobacco use among adults in Bangladesh: findings from the International Tobacco Control (ITC) Bangladesh survey

BACKGROUND

Although smokeless tobacco (SLT) use is prevalent in South Asian countries including Bangladesh, information about the pattern and correlates of SLT use is scarce. This study described the pattern and predictors of SLT use among Bangladeshi adults.

METHODS

The data for this study were derived from the International Tobacco Control Policy Evaluation Bangladesh (ITC BD) Survey, a prospective cohort survey of a nationally representative sample of smokers and non-smokers, conducted during November 2011 and May 2012. The study included 5522 adults aged 15 or above. We used multiple logistic regression models to identify predictors of SLT use.

RESULTS

Of the respondents (N = 5522), 20% were SLT users. In general, SLT use was significantly higher among women, the illiterate and residents of the Dhaka slums or non-tribal/non-border areas outside Dhaka; SLT use increased with age. Several attitudinal factors were also associated with SLT use. Multivariable logistic regression analyses revealed several predictors of SLT use: being female (OR = 1.96, 95% confidence interval, CI: 1.18-3.24), an increasing age, being a resident of a Dhaka slum (OR = 5.86; 95% CI: 3.73-9.21) or non-tribal/non-border areas outside Dhaka (OR = 3.42; 95% CI: 1.94-6.03), being illiterate (OR = 3.37; 95% CI: 1.99-5.71), holding positive opinion towards societal approval of SLT use (OR = 5.84; 95% CI: 3.38-10.09), holding positive opinion towards SLT use by women (OR = 2.63; 95% CI: 1.53-4.54), believing that SLT is addictive (OR = 2.96; 95% CI: 1.51-5.81), and believing SLT is less harmful than bidi (OR = 2.22; 95% CI: 1.36-3.62).

CONCLUSION

The findings suggest that coordinated efforts of governmental and non-governmental organizations, targeting both smoked tobacco and SLT use reduction and cessation, could be modified to reach each level of population including those who are marginalized, female, less educated and elderly. As most tobacco control programs in Bangladesh target mainly cigarette or bidi smoking, coordinated programs are needed that will also include SLT use within the tobacco control policy and prevention strategies.

Spit (Smokeless) Tobacco Intervention for High School Athletes: results after 1 year

OBJECTIVE

To determine the efficacy of a spit tobacco (ST) intervention designed to promote ST cessation and discourage ST initiation among male high school baseball athletes.

METHODS

This study was a cluster-randomized controlled trial. Forty-four randomly selected high schools in rural California were randomized within strata (prevalence of ST use and number and size of baseball teams) to either the intervention or the control group. Ninety-three percent of eligible baseball athletes participated, yielding 516 subjects in 22 intervention schools and 568 subjects in 22 control schools. Prevalences of sustained ST cessation and ST use initiation over 1 year were assessed by self-report. Multivariate logistic regression models for clustered responses were used to test the null hypotheses of no association between group and the two outcomes, adjusted for the stratified design and baseline imbalances between groups in significant predictors of ST use.

RESULTS

Prevalence of cessation was 27% in intervention high schools and 14% in control high schools (odds ratio (OR)=2.29; 95% confidence interval (CI), 1.36-3.87). The intervention was especially effective in promoting cessation among those who, at baseline, lacked confidence that they could quit (OR=6.4; 95% CI, 1.0-4.3), among freshmen (OR=15; 95% CI, 0.9-260), and among nonsmokers (OR=3.2; 95% CI, 0.9-11). There was no significant difference between groups in the prevalence of ST initiation.

CONCLUSIONS

This intervention was effective in promoting ST cessation, but was ineffective in preventing initiation of ST use by nonusers.

In vitro effects of smokeless tobacco extract on tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) production, and on lymphocyte proliferation

The use of smokeless tobacco (moist snuff) products is associated with mucosal lesions, gingival recession, attachment loss, and oral cancer. Despite numerous reports on the general toxic effects of smokeless tobacco extract, little information is available regarding the specific effects of smokeless tobacco on immune response. Inflammatory cytokines released as a result of smokeless tobacco-induced irritation may play a role in the development of oral mucosal lesions at habitual tobacco placement sites in smokeless tobacco users. Consequently, the purpose of this study was to determine whether an aqueous extract of smokeless tobacco (STE) affects the secretion of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), and the proliferation of lymphocytes. A macrophage cell line (J774-A1) was used to measure the effects of STE on tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) secretion. Mouse splenocytes were used to assess the effects of STE on lymphocyte proliferation. We found that STE at low concentrations enhanced the production of both TNF-alpha and IL-1beta. Furthermore, STE at similar concentrations enhanced mitogen-induced murine splenocyte proliferation. Overall, these data suggest that smokeless tobacco upregulated two key proinflammatory cytokines and also induces lymphocyte proliferation.

Patterns of use of smokeless tobacco and the unidimensional model of drug involvement

The present study tested whether smokeless tobacco (ST) fits a unidimensional model of drug involvement and tried to locate ST along the dimension that underlies drug use. The latent trait analysis was employed to quantify drug involvement in a sample of high school students. Analyses showed that although ST use fits the unidimensional model of drug involvement, the place of ST use along the continuum of drug involvement is not stable and differs by gender and ethnicity. Particularly for males, ST use is likely to be preceded by soft drug use and followed by hard drug use; for females, however, ST use is closely associated with hard drug use. The analyses also revealed that the fit of the unidimensional model and the location of ST use along the dimension vary with different ethnic groups.

Prevalence, patterns, and correlates of spit tobacco use in a college athlete population

We surveyed varsity athletes (N = 1,328) in 16 California colleges about their patterns of spit (smokeless) tobacco (ST) use, related habits, reasons for use, and preferred methods for quitting. Prevalence of use was analyzed by sport and demographic characteristics, and patterns of use in players using snuff exclusively, using chewing tobacco exclusively, and those using both were compared. Odds ratios and 95% confidence intervals were calculated, adjusting for ethnic group. Prevalence was highest in Whites (44%) and Native Americans (48%) and lowest in African Americans (11%), and higher in varsity baseball (52%) than varsity football players (26%), in players attending rural colleges, and among those who ever smoked cigarettes or used alcohol. Forty-one percent of ST users initiated regular use during their high school years. Athletes who used snuff exclusively used it more intensively and for more years than those who used chewing tobacco exclusively. Snuff users indicated a greater perceived need for ST, but also were more ready to quit. These data suggest ST programs with prevention and cessation components are appropriate for high school as well as college athletes. Such interventions should focus on baseball players, distinguish snuff from chewing tobacco users in planning quit strategies, integrate intervention programs for cigarette smoking and alcohol consumption, provide training in refusal skills, and attempt to change social norms in support of ST use by integrating popular peers and significant others (e.g., wives/girlfriends) to endorse nonuse of ST.

Planning a spit tobacco cessation intervention: identification of beliefs associated with addiction

We examine the relationship between beliefs regarding spit tobacco (ST) use and addiction among 473 male college athletes who currently use ST. Beliefs were assessed using methods prescribed by the Theory of Reasoned Action. Independent associations between beliefs and addiction, defined by self-reported amount of ST used per week, were found via multivariate polychotomous regression modeling. We found that with increasing addiction level, athletes were significantly more likely to believe that "ST helps me relax," "ST keeps me alert," "ST tastes good," and "ST is addicting." All athletes believed that clinicians, parents, and girlfriends do not approve of their ST use, but that male peers, coaches, and professional athletes are fairly indifferent about it. To increase quit rates, highly addicted ST users may require an intensive cessation program including nicotine replacement to overcome symptoms of withdrawal, oral substitutes for the enjoyable taste of ST, and the support of male peers and athletes who influence their social norms.

Correlates of exclusive or combined use of cigarettes and smokeless tobacco among male adolescents

Past studies which examined correlates of smokeless tobacco or cigarette use have investigated use of one tobacco product regardless of use of the other product. Thus, the etiology of exclusive use of the two tobacco products is not clear. The present study investigated the relationship of problem-prone-related variables to exclusive versus overlapping use of smokeless tobacco and cigarettes. Two samples of southern California male students (eighth-grade and high school) were divided into groups according to their tobacco use status: neither product, cigarettes only, smokeless tobacco only, or both tobacco products. Generally, triers and monthly users of both tobacco products reported a higher risk-taking preference, greater susceptibility to peer social influence to use tobacco products, and greater likelihood to have tried marijuana and alcohol than did subjects who were not users of either tobacco product. Adolescents who used either product, but not both, reported similar scores on most of the variables examined, which fell in between combined or nonuse categories. These results suggest that the number of tobacco products used, not the specific product, is associated with problem-prone attributes.

Project towards no tobacco use: 1-year behavior outcomes

OBJECTIVES

We present 1-year follow-up data from a school-based tobacco use prevention project designed to test the effectiveness of three main components of social influence programs. The components teach refusal skills, awareness of social misperceptions about tobacco use, and misconceptions about physical consequences.

METHODS

Four different curricula were developed and tested in a randomized experiment involving 48 junior high schools. The outcome variables examined were changes in initial and weekly cigarette and smokeless tobacco use 1 year after the intervention.

RESULTS

Analyses indicated that each of the component programs were effective in decreasing both the initial and the weekly use of cigarettes except for the curriculum in which refusal skills were taught. Also, each curriculum was effective in decreasing the initial use of smokeless tobacco except for the one aimed at correcting social misperceptions. Only the combined curriculum showed an effect on the weekly use of smokeless tobacco.

CONCLUSIONS

The combined intervention was the most effective overall in reducing the initial and weekly use of cigarettes and smokeless tobacco. This suggests that different reasons for use exist and need to be counteracted simultaneously. However, since single programs were also effective in reducing all but weekly smokeless tobacco use, any of these components may be worthwhile prevention tools.

Immunostimulatory potential of smokeless tobacco extract in in vitro cultures of murine lymphoid tissues

Despite numerous studies on the general toxicologic effects of smokeless tobacco (ST) little immunotoxicologic information is available. As a first step in assessing the potential activity of ST on the immune system, the effects of an aqueous extract of ST was studied in in vitro cultures of mouse lymphoid cells. There was a significant increase in the proliferation of spleen cells cultured with different concentrations of ST extract. The polyclonal IgM antibody responses as determined by protein A plaque assay were also elevated in ST stimulated spleen cell cultures. Similar immunostimulatory results were seen in the mesenteric lymph node cell cultures also. ST extract was able to stimulate the spleen cells of the immune defective CBA/N mice. The mitogenic ability of ST extract may not be due to lipopolysaccharide (LPS) contamination as determined by its response in the LPS resistant C3H/HeJ mice spleen cells. ST extract was mitogenic not only to B cells but also to T cells. However the magnitude of response was less in T cells than in B cells. The proliferation of T cells was not accompanied by secretion of IL-2 or expression of IL-2 receptors on T cells. However there was an increase of IL-1 activity in spleen cells cultured with ST extract. Finally, activation of B or T lymphocytes by ST did not result in the elevation of intracellular calcium levels. Since ST is consumed orally, the chronic immunostimulation by ST in oral mucosal lymphoid tissues may be associated with the increased incidence of gingivitis, leukoplakia and oral cancer seen in human ST users.

Psychological profile of college students who use smokeless tobacco

The purpose of this study was to develop a psychological profile of smokeless tobacco users. We surveyed 1991 college students regarding their use of tobacco products. Twenty-one percent of the white males used smokeless tobacco compared to only 10.4% of blacks, 5.4% of Hispanics, and 5.4% of others, primarily Asians. Although the prevalence of smokeless tobacco use reported by Asians was relatively low, their rate of reported smoking was over twice as high as any other ethnic group, 43.6%. The most important reasons for beginning to use smokeless tobacco were to "see if I would enjoy it," "most friends used it," and "try something new." The personality profile of the smokeless tobacco users differed from that of smokers and non-users of tobacco. College students with the highest probability of being a smokeless tobacco user were white males who scored higher in extraversion and neuroticism but lower on state anxiety than non-users.