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

'No-Barriers' tobacco product? Selling smokeless tobacco to women, people of colour and the LGBTQ+ community in the USA

BACKGROUND

In both Sweden and the USA, smokeless tobacco (ST) is legal and used predominantly by men. Starting in the 1970s, US tobacco companies attempted to expand the ST market to women, African Americans, Hispanic Americans and lesbian, gay, bisexual, transgender, queer and other sexual orientation (LGBTQ+) people.

DESIGN

We analysed industry documents from the Truth Tobacco Industry Documents Library triangulating findings with recent ST advertising and publicly available literature.

FINDINGS

We found tobacco companies used design innovations such as pouched moist snuff, snus and dissolvable products to expand the market. In addition, diverse advertising campaigns targeted women, people of colour (Hispanic, African American) and LGBTQ+ communities with identity-targeted messages emphasising novelty, convenience, cleanliness and use in smoke-free environments. However, stereotypes of ST users as rural white males endured, perpetuated by continued marketing aimed at this customer base, which created cognitive dissonance and stymied marketer's hopes that pouch products would 'democratize' ST.

CONCLUSION

These failed campaigns suggest novel products such as nicotine pouch products may provide a 'clean slate' to similarly target women and other low-ST-using groups. Based on this history, the risk of new tobacco and nicotine products to increase health disparities should be closely monitored.

The Kentucky SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use

BACKGROUND

Smokeless tobacco (SLT) prevalence was decreasing in Kentucky before 2007, but has since increased. This study examines the impact of policies on cigarette and SLT use by applying the SimSmoke tobacco control policy simulation model.

METHODS

Using data from the large-scale Tobacco Use Supplement of the Current Population Survey (TUS-CPS) and information on state-specific tobacco policies, Kentucky SimSmoke is updated and extended to incorporate exclusive SLT and dual cigarette and SLT use. The model is validated using survey data through 2017. The model was used to estimate the impact on smoking and SLT prevalence and attributable deaths of policies implemented between 1993 and 2018 and the impact of stronger future policies implemented in 2018 and maintained through 2060.

RESULTS

SimSmoke generally reflects trends in exclusive cigarette use from the TUS-CPS and the Behavioral Risk Factor Surveillance System (BRFSS), but underestimated the increase in SLT prevalence in recent years. SimSmoke projects that policies implemented between 1993 and 2018 reduced male and female cigarette use by 23.7% and 23.0%, and male and female SLT use by 4.9% by 2018, averting 9018 tobacco-attributable deaths by 2018, increasing to 89 547 by 2060. The largest reductions in cigarette and SLT use were attributed to cigarette price increases. Strengthening tobacco control policies could reduce smoking prevalence by 41% and 40%, and reduce SLT prevalence by 33% and 25% for males and females by 2060.

CONCLUSION

Our results suggest that cigarette-oriented policies were effective in reducing SLT use but have been less successful in recent years. Future use rates can be further reduced through more restrictive statewide policies, which also target non-combustible nicotine products.

Women and Lung Cancer

The world is witnessing a global epidemic of lung cancer in women. Cigarette smoking remains the dominant risk factor in both sexes, but multiple observations suggest that important sex-related distinctions in lung cancer exist. These include differences in histologic distribution, prevalence in never-smokers, frequency of activating EGFR mutations, likelihood of DNA adduct accumulation, and survival outcomes. Important questions such as whether women are more susceptible to carcinogenic effects of smoking or derive more benefit from lung cancer screening merit more study. A deeper understanding of sex-related differences in lung cancer may lead to improved outcomes for both women and men.

The Prevalence and Correlates of Fissured Tongue Among Outpatients in Andkhoy City, Afghanistan: A Cross-Sectional Study

BACKGROUND

Fissured tongue is a common manifestation of the tongue, marked by the presence of multiple prominent grooves or fissures on the dorsal surface of the tongue. However, there is a lack of studies focusing on the prevalence and factors associated with fissured tongue among patients attending an outpatient clinic in Afghanistan.

AIM

The purpose of the current study was to determine the prevalence and factors associated with fissured tongue and its effects on the general health of adult outpatients in Afghanistan.

PATIENTS AND METHODS

The cross-sectional survey was conducted among outpatient populations in Andkhoy City, Afghanistan, between September 2019 and December 2019. A convenience technique was applied by including 1182 patient aged 18-80 years. Socio-economic status, smoking, nass use (smokeless tobacco use) and medical data were collected using face-to-face interviews. We used logistic regression analysis to identify factors associated with fissured tongue. A convenience technique was applied by including patient aged 18-80 years.

RESULTS

The studied population consisted of 1182 participants, of whom 573 (48.5%) were males and 609 (51.5%) females. The prevalence of fissured tongue was 27.2% (95% CI: 24.7-29.9%) with males having significantly higher prevalence than females (47.5%, 95% CI: 43.3-51.6% versus 8.2%, 95% CI: 6.2-10.7%, p<0.001). Male participants (OR=7.1, 95% CI: 4.8-10.3), diabetes mellitus (OR=1.6, 95% CI: 1.1-2.3) and smokeless tobacco use (OR=12.0, 95% CI: 8.1-17.6) were the only variables independently associated with fissured tongue.

CONCLUSION

This study suggested that there was a high rate of fissured tongue among an outpatient clinic in Andkhoy, Afghanistan. Male gender, diabetes mellitus, and nass consumption were associated with fissured tongue. Therefore, these factors might usefully be targeted in local health promotion, prevention and early intervention programs.

Exposure to tobacco marketing in bars predicts subsequent use of multiple tobacco products among non-tobacco-using college students

BACKGROUND

Due to other marketing restrictions, one venue where tobacco companies concentrate their marketing efforts to reach young adults is bars/nightclubs.

OBJECTIVE

This study examined the relationship between exposure to tobacco marketing in bars/nightclubs and number of alternative tobacco/nicotine products used 6 months later among college students.

METHODS

Participants were 1,406 students aged 18-29 years old who reported going to bars or nightclubs at least rarely (M age=21.95; 67% female; 46% non-Hispanic white). Students completed an online survey in fall 2014/spring 2015 (wave 1) and again 6 months later (wave 2). Multilevel Poisson regression models were used to assess the relationship between exposure to three types of marketing at bars/nightclubs at wave 1 (tobacco/nicotine product advertisements; free samples; industry representatives) and number of tobacco products used (range=0-5) at wave 2, controlling for school type (2 year vs 4 year), age, sex, race/ethnicity and frequency of bar visits. An interaction between the number of wave 1 products and each marketing variable was tested.

RESULTS

Greater exposure to free samples and tobacco industry representatives at bars/nightclubs predicted a greater number of products used 6 months later, but only among wave 1 non-tobacco users and not among tobacco users. Exposure to advertisements at bars/nightclubs did not predict the number of products used 6 months later.

CONCLUSION

Tobacco companies claim that marketing is targeted to those who already use the product, not to non-users. However, the current study indicates tobacco marketing in bars and nightclubs may encourage use among non-users and has no influence on current users.

Changes in Black-White Difference in Lung Cancer Incidence among Young Adults

Background

We previously reported that lung cancer incidence between Blacks and Whites younger than 40 years of age converged in women and approached convergence in men. Whether this pattern has continued in contemporary young birth cohorts is unclear.

Methods

We examined 5-year age-specific lung cancer incidence in Blacks and Whites younger than 55 years of age by sex and calculated the Black-to-White incidence rate ratios (IRRs) and smoking prevalence ratios by birth cohort using nationwide incidence data from 1997 to 2016 and smoking data from 1970 to 2016 from the National Health Interview Survey.

Results

Five-year age-specific incidence decreased in successive Black and White men born since circa 1947 and women born since circa 1957, with the declines steeper in Blacks than Whites. Consequently, the Black-to-White IRRs became unity in men born 1967-1972 and reversed in women born since circa 1967. For example, the Black-to-White IRRs in ages 40-44 years born between 1957 and 1972 declined from 1.92 (95% confidence interval [CI] = 1.82 to 2.03) to 1.03 (95% CI = 0.93 to 1.13) in men and from 1.32 (95% CI = 1.24 to 1.40) to 0.71 (95% CI = 0.64 to 0.78) in women. Similarly, the historically higher sex-specific smoking prevalence in Blacks than Whites disappeared in men and reversed in women born since circa 1965. The exception to these patterns is that the incidence became higher in Black men than White men born circa 1977-1982.

Conclusions

The historically higher lung cancer incidence in young Blacks than young Whites in the United States has disappeared in men and reversed in women, coinciding with smoking patterns, though incidence again became higher in Black men than White men born circa 1977-1982.

Retail marketing for chewing tobacco in Los Angeles, California

INTRODUCTION

Retail marketing for chewing tobacco may be different across racial/ethnic neighborhoods, possibly leading to diverging patterns of use and disparate health risks relating to consumption. This study aimed to compare the frequencies of available chewing tobacco, available flavored chewing tobacco, price promotions, and exterior advertisements in tobacco retail stores in Los Angeles, California.

METHODS

In-person observational audits from tobacco retail stores (n=679) located in predominantly non-Hispanic White (n=196), non-Hispanic Black/African American (n=194), Hispanic/Latino (n=189), or Korean American (n=100) neighborhoods were conducted between January 2016 and April 2017.

RESULTS

There were statistically significant associations (p<0.001) between racial/ethnic neighborhood and chewing tobacco marketing, where retailers located in non-Hispanic White neighborhoods sold and advertised chewing tobacco and flavored chewing tobacco, used price promotions, and displayed exterior advertisements more frequently than retailers located in African American, Korean American, and Hispanic/Latino neighborhoods.

CONCLUSIONS

Stronger restrictions on chewing tobacco, price promotions and flavored versions could mitigate exposure and access to these products in the retail environment.

Predictors of Smokeless Tobacco Susceptibility, Initiation, and Progression Over Time Among Adolescents in a Rural Cohort

BACKGROUND

Use of smokeless tobacco (ST, moist snuff and chewing tobacco) is elevated among male rural youth, particularly participants in certain sports, including baseball.

OBJECTIVES

This study aimed to assess factors associated with adolescent male athletes' ST-related behaviors over time, including: baseline use, initiation, and progression in use intensity in a school-based longitudinal cohort.

METHODS

Baseline and one-year follow-up questionnaires assessed sociodemographic characteristics, environmental factors, and tobacco-related perceptions and behaviors among 9- to12th-grade interscholastic baseball players in 36 rural California schools. Population characteristics were compared among ST use categories (never, experimental, and experienced users). Multivariable models using generalized estimating equations were estimated for outcomes among baseline ST never-users (ST susceptibility and future initiation) and experimenters (ST expectations and progression in ST use).

RESULTS

Of 594 participants, over half (57%) had ever tried a tobacco product and the most common products tried were ST (36%) and electronic cigarettes (36%). Being older, perceiving less ST harm, being Non-Hispanic White, using alcohol or other tobacco products, having family or friends who use ST, and being receptive to advertising were associated with greater baseline ST use. Baseline alcohol consumption, lower perceived ST harm, peer use, and susceptibility and expectations were predictive of ST initiation and/or progression at one-year follow-up. Conclusion/Importance: Certain environmental, socio-demographic, cognitive, and behavioral factors predict ST susceptibility and later initiation and progression in use. Interventions addressing these factors have potential to prevent ST uptake and continued use within this high-risk adolescent population.

A study on the prevalence and correlates of nicotine dependence among adolescents of Burdwan Town, West Bengal

CONTEXT

Tobacco will cause one billion deaths in the 21^st century. The use of tobacco causes dependence both psychological and physical.

AIMS

To find out the level of nicotine dependence and it correlates among adolescents.

SETTINGS AND DESIGN

A community-based, cross-sectional, observational study was conducted in the Burdwan town, West Bengal, among 1354 adolescent tobacco users.

MATERIALS AND METHODS

Data were collected by direct interview using a pretested, predesigned, semistructured schedule containing the Fagerström Test for Nicotine Dependence (FTND) questionnaire.

STATISTICAL ANALYSIS

Pearson's Chi-square test, Student's unpaired t-test, one-way analysis of variance, Pearson's product-moment correlation coefficient, and multivariable linear regression were used. All the statistical analyses were performed using SPSS version 19.0.

RESULTS

The mean FTND score was significantly higher among adolescents aged >15 years, males, Hindu, tobacco users from joint family, who belonged to lower socioeconomic status, who started using tobacco at the age of 10-12 years, using tobacco for ≥5 years, who were not married, were illiterate, working, and not aware of the injurious effect of tobacco to health.

CONCLUSIONS

A suitable individualized approach should be used for those who want to quit tobacco depending on their FTND score.

Nass use and associated factors among outpatients in northern Afghanistan: A cross-sectional study in Andkhoy City

INTRODUCTION

Tobacco use is one of the main risk factors for a number of chronic diseases, including cancer, lung diseases, and cardiovascular diseases. Nass is a form of smokeless tobacco. It is used most commonly in Central Asia, Afghanistan, Pakistan, and Iran, and is significantly associated with oral and oesophageal cancers. The aim of this study was to determine the prevalence of nass use and its associated factors among patients attending an outpatient clinic in Afghanistan.

METHODS

This cross-sectional study was performed in an outpatient clinic in Andkhoy, Afghanistan, from April to July 2017. The study included 387 consecutive patients. The data collection tool was a questionnaire, which includes three main items: demographic, physical, and biomedical measurements. We performed binary logistic regression to identify independent risk factors of nass use.

RESULTS

The study included 387 participants, of whom 225 were males (58.1%) and 162 were females (41.9%). The overall prevalence of nass use was 48.8% (95% CI: 43.8–53.9%), with the Turkmen ethnic group having significantly higher prevalence than other ethnic groups (58.2%, 95% CI: 50.8–65.3% vs 41.8%, 95% CI: 34.7–49.2%). The mean and standard deviation of the age was 63.9 (17.2) years for nass users and 42.3 (17.4) years for non-users.

Based on a multivariate analysis, family history of nass use (OR=31.4, 95% CI: 12.5–78.5), illiteracy (OR=8.9, 95% CI: 2.5–31.2), rural residence (OR=2.0, 95% CI: 1.0–3.9), and unemployment (OR=5.4, 95% CI: 1.4–21.4) were associated with nass use.

CONCLUSIONS

Our results indicate that about half of the participants were nass users, and nass use associated factors were family history of nass use, illiteracy, unemployment, and rural residency in outpatient clinics in Afghanistan. More surveillance data are needed on a national level to inform the development of strategies for the prevention and control of nass consumption in Afghanistan.

Deployment and Smokeless Tobacco Use Among Active Duty Service Members in the U.S. Military

Introduction

The prevalence of smokeless tobacco use among U.S. active duty service members has been much higher than in the U.S. general population. The association between deployment and smokeless tobacco use has not been well studied. We investigated the association between deployment and smokeless tobacco use among U.S. active duty service members. We also evaluated the modification effects from other factors related to smokeless tobacco use on the deployment-smokeless tobacco use association.

Materials and Methods

Eligible active duty service members stationed at two military installations (Fort Bragg, NC, USA and Lackland Air Force Base, TX, USA) were recruited from July 2015 to May 2016. Each participant completed a self-administered questionnaire. Multivariable logistic regression was used to assess the association between deployment and smokeless tobacco use and estimated odds ratio (OR) and 95% confidence interval (CI). Stratified analysis was performed to evaluate modification effects from other commonly known factors related to smokeless tobacco use in military, specifically, cigarette smoking status, use among family members (family history of use), perception of harm, and use among military peers.

Results

Out of 2,465 study participants who completed the questionnaire, 548 were smokeless tobacco users. Service members who had been deployed to a combat zone had 1.39 fold (95% CI = 1.03–1.87) increased odds of using smokeless tobacco than those who never deployed to a combat zone. The odds of smokeless tobacco use among those who had been deployed once, twice, three times and four or more times to a combat zone were 1.27 (95% CI = 0.91–1.78), 1.30 (95% CI = 0.85–1.99), 2.49 (95% CI = 1.45–4.28), and 2.88 (95% CI = 1.71–4.86), respectively, with a significant dose–response trend (p for trend &lt;0.0001). Further, subjects who served in combat units during deployment exhibited more than two-fold increased odds of use as compared with those who had never been deployed (OR = 2.03, 95% CI = 1.41–2.93). In stratified analysis, the association between deployment and smokeless tobacco use was only present among subjects who never smoked cigarettes, those without family history of smokeless tobacco use, and those who had low perception of harm of use.

Conclusions

Military deployment was associated with smokeless tobacco use among active service members. However, the influence of military deployment on smokeless tobacco use was not equally strong on all service members. Subjects who never smoked cigarettes, who had no family history of use and who had low perception of harm were the most susceptible subgroups to deployment-related smokeless tobacco use. This study has implications to identify high-risk subgroups to reduce smokeless tobacco use in the U.S. military.

Cigarette and Smokeless Tobacco Perception Differences of Rural Male Youth

Objectives

Compare cigarette and smokeless tobacco (ST) perceptions within a youth population where ST use is common.

Methods

Male baseball players (N = 594) at 36 rural high schools in California rated separately 20 potential risks or benefits associated with cigarettes or ST, along with global harm ratings. Informed by principal components analysis, 3 composite categories were created: oral/rule-breaking risks (eg, mouth cancer, getting in trouble), systemic risks (eg, heart attack), and benefits (eg, relaxation). Standardized composite scores and harm ratings were compared by product and by tobacco use status.

Results

Cigarettes were perceived as likely to impart oral/rule-breaking risks and systemic risks, unlikely to cause benefits, and as very harmful overall. ST was perceived similarly as cigarettes regarding oral/rule-breaking risks, but less likely to cause systemic risks, and more beneficial. Most participants rated cigarettes as more harmful than ST. Similar patterns existed in all tobacco use groups, including non-users and dual-users.

Conclusions

In this population, cigarettes were perceived as very harmful. ST was perceived similarly to cigarettes only for some risks and as less harmful overall. Communication for rural adolescents should consider multifaceted aspects of ST risk.

The US SimSmoke tobacco control policy model of smokeless tobacco and cigarette use

Background

Smokeless tobacco (SLT) prevalence had been declining in the US prior to 2002 but has since increased. Knowledge about the impact of tobacco control policies on SLT and cigarette use is limited. This study examines the interrelationship between policies, cigarette use, and SLT use by applying the SimSmoke tobacco control policy simulation model.

Methods

Using data from large-scale Tobacco Use Supplement and information on policies implemented, US SimSmoke was updated and extended to incorporate SLT use. The model distinguishes between exclusive SLT and dual use of SLT and cigarettes, and considers the effect of implementing individual and combined tobacco control policies on smoking and SLT use, and on deaths attributable to their use. After validating against Tobacco Use Supplement (TUS) survey data through 2015, the model was used to estimate the impact of policies implemented between 1993 and 2017.

Results

SimSmoke reflected trends in exclusive cigarette use from the TUS, but over-estimated the reductions, especially among 18–24 year olds, until 2002 and under-estimated the reductions from 2011 to 2015. By 2015, SimSmoke projections of exclusive SLT and dual use were close to TUS estimates, but under-estimated reductions in both from 1993 to 2002 and failed to estimate the growth in male exclusive SLT use, especially among 18–24 year olds, from 2011 to 2015. SimSmoke projects that policies implemented between 1993 and 2017 reduced exclusive cigarette use by about 35%, dual use by 32.5% and SLT use by 16.5%, yielding a reduction of 7.5 million tobacco-attributable deaths by 2067. The largest reductions were attributed to tax increases.

Conclusions

Our results indicate that cigarette-oriented policies may be effective in also reducing the use of other tobacco products. However, further information is needed on the effect of tobacco control policies on exclusive and dual SLT use and the role of industry.

Higher Lung Cancer Incidence in Young Women Than Young Men in the United States

BACKGROUND

Previous studies showed a higher incidence of lung cancer among young women than among young men in the United States. Whether this pattern has continued in contemporary birth cohorts and, if so, whether it can be fully explained by sex differences in smoking behaviors are unknown.

METHODS

We examined the nationwide population-based incidence of lung cancer according to sex, race or ethnic group, age group (30 to 34, 35 to 39, 40 to 44, 45 to 49, and 50 to 54 years), year of birth (1945 to 1980), and calendar period of diagnosis (1995-1999, 2000-2004, 2005-2009, and 2010-2014), and we calculated female-to-male incidence rate ratios. We also examined the prevalence of cigarette smoking, using data from the National Health Interview Survey from 1970 to 2016.

RESULTS

Over the past two decades, the age-specific incidence of lung cancer has generally decreased among both men and women 30 to 54 years of age in all races and ethnic groups, but the declines among men have been steeper. Consequently, among non-Hispanic whites, the female-to-male incidence rate ratios increased, exceeding 1.0 in the age groups of 30 to 34, 35 to 39, 40 to 44, and 45 to 49 years. For example, the female-to-male incidence rate ratio among whites 40 to 44 years of age increased from 0.88 (95% confidence interval [CI], 0.84 to 0.92) during the 1995-1999 period to 1.17 (95% CI, 1.11 to 1.23) during the 2010-2014 period. The crossover in sex-specific rates occurred among non-Hispanic whites born since 1965. Sex-specific incidence rates converged among non-Hispanic blacks, Hispanics, and non-Hispanic Asians and Pacific Islanders but crossed over from a higher incidence among men to a higher incidence among women only among Hispanics. The prevalence of cigarette smoking among women born since 1965 has approached, but generally not exceeded, the prevalence among men.

CONCLUSIONS

The patterns of historically higher incidence rates of lung cancer among men than among women have reversed among non-Hispanic whites and Hispanics born since the mid-1960s, and they are not fully explained by sex differences in smoking behaviors. Future studies are needed to identify reasons for the higher incidence of lung cancer among young women. (Funded by the American Cancer Society.).

Association Between Receptivity to Tobacco Advertising and Progression to Tobacco Use in Youth and Young Adults in the PATH Study

IMPORTANCE

Cigarette marketing contributes to initiation of cigarette smoking among young people, which has led to restrictions on use of cigarette advertising. However, little is known about other tobacco advertising and progression to tobacco use in youth and young adults.

OBJECTIVE

To investigate whether receptivity to tobacco advertising among youth and young adults is associated with progression (being a susceptible never user or ever user) to use of the product advertised, as well as conventional cigarette smoking.

DESIGN, SETTING, AND PARTICIPANTS

The Population Assessment of Tobacco and Health (PATH) Study at wave 1 (2013-2014) and 1-year follow-up at wave 2 (2014-2015) was conducted in a US population-based sample of never tobacco users aged 12 to 24 years from wave 1 of the PATH Study (N = 10 989). Household interviews using audio computer-assisted self-interviews were conducted.

EXPOSURES

Advertising for conventional cigarettes, electronic cigarettes (e-cigarettes), cigars, and smokeless tobacco products at wave 1.

MAIN OUTCOMES AND MEASURES

Progression to susceptibility or ever tobacco use at 1-year follow-up in wave 2.

RESULTS

Of the 10 989 participants (5410 male [weighted percentage, 48.3%]; 5579 female [weighted percentage, 51.7%]), receptivity to any tobacco advertising at wave 1 was high for those aged 12 to 14 years (44.0%; 95% confidence limit [CL], 42.6%-45.4%) but highest for those aged 18 to 21 years (68.7%; 95% CL, 64.9%-72.2%). e-Cigarette advertising had the highest receptivity among all age groups. For those aged 12 to 17 years, susceptibility to use a product at wave 1 was significantly associated with product use at wave 2 for conventional cigarettes, e-cigarettes, cigars, and smokeless tobacco products. Among committed never users aged 12 to 17 years at wave 1, any receptivity was associated with progression toward use of the product at wave 2 (conventional cigarettes: adjusted odds ratio [AOR], 1.43; 95% CL, 1.23-1.65; e-cigarettes: AOR, 1.62; 95% CL, 1.41-1.85; cigars: AOR, 2.01; 95% CL, 1.62-2.49; and smokeless [males only]: AOR, 1.42; 95% CL, 1.07-1.89) and with use of the product (conventional cigarettes: AOR, 1.54; 95% CL, 1.03-2.32; e-cigarettes: AOR, 1.45; 95% CL, 1.19-1.75; cigars: AOR, 2.07; 95% CL, 1.26-3.40). Compared with those not receptive to any product advertising, receptivity to e-cigarette advertising, but not to cigarette advertising, was independently associated with those aged 12 to 21 years having used a cigarette at wave 2 (AOR, 1.60; 95% CL, 1.08-2.38).

CONCLUSIONS AND RELEVANCE

Receptivity to tobacco advertising was significantly associated with progression toward use in adolescents. Receptivity was highest for e-cigarette advertising and was associated with trying a cigarette.

Tobacco-related morbidity and nicotine dependence: An experience in an urban slum of Burdwan district, West Bengal, India

Tobacco use causes many diseases irrespective of age and sex. More the addiction, more is the occurrence of morbidity in terms of frequency and severity. This community-based study was conducted to find out any relationship between the morbidity associated with tobacco use and nicotine dependence. In an urban slum - Alamganj, district Burdwan, West Bengal, India, from January to October 2012 among 128 current adult tobacco users using Fagerström test for nicotine dependence (FTND) questionnaire. Tobacco users were maximally suffering from chronic obstructive pulmonary disease (COPD) (27.27%), gastritis (25.45%), and leukoplakia (25.45%). For individual diseases, the difference in FTND score was significantly high in cases of gastritis, hypertension, and COPDs. All types of morbidity were more common in the group of high nicotine dependence. FTND score can be suitably used to assess nicotine dependence of the tobacco users, who can be counseled accordingly to reduce the tobacco-related morbidity and mortality.

Beyond the brotherhood: Skoal Bandits' role in the evolution of marketing moist smokeless tobacco pouches

Background

Since 2006, "snus" smokeless tobacco has been sold in the U.S.. However, U.S. Smokeless Tobacco (USST) and Swedish Match developed and marketed pouched moist snuff tobacco (MST) since 1973.

Methods

Analysis of previously secret tobacco documents, advertisements and trade press.

Results

USST partnered with Swedish Match, forming United Scandia International to develop pouch products as part of the "Lotus Project." Pouched MST was not commonly used, either in Sweden or the U.S. prior to the Lotus Project's innovation in 1973. The project aimed to transform smokeless tobacco from being perceived as an "unsightly habit of old men" into a relevant, socially acceptable urban activity, targeting 15-35 year-old men. While USST's initial pouched product "Good Luck," never gained mainstream traction, Skoal Bandits captured significant market share after its 1983 introduction. Internal market research found that smokers generally used Skoal Bandits in smokefree environments, yet continued to smoke cigarettes in other contexts. Over time, pouch products increasingly featured increased flavor, size, nicotine strength and user imagery variation.

Conclusions

Marlboro and Camel Snus advertising mirrors historical advertising for Skoal Bandits, designed to recruit new users and smokers subjected to smokefree places. Despite serious efforts, pouched MST marketing has been unable to dispel its association with traditional smokeless tobacco stereotypes as macho and rural. Public education efforts to discourage new users and dual use of MST and cigarettes should emphasize that "new" pouch products are simply repackaging "old" smokeless tobacco.

ST product characteristics and relationships with perceptions and behaviors among rural adolescent males: a qualitative study

Although smoking declines in the United States, the prevalence of male adolescent smokeless tobacco (ST; moist snuff and chewing tobacco) use remains unchanged. ST product characteristics, such as flavoring, packaging, and branding, could influence adolescents' ST initiation and continued use. This qualitative study examines the potential role of product characteristics in shaping ST-related perceptions and behaviors among rural adolescent males. Semi-structured individual interviews were conducted at three California rural high schools. ST users were asked about their experiences and perceptions related to product characteristics. Interviews were transcribed, coded, and analyzed using a general inductive approach. Participants associated flavored ST with appealing non-tobacco products, such as chewing gum and alcohol. Availability of different varieties and flavors stimulated interest and curiosity in sampling or switching between ST products. Time-limited promotional flavors and packaging also enhanced product appeal. Adolescent ST users preferred certain brands based on perceived brand features and perceived nicotine content, associating higher-strength brands as better suited for experienced ST users. Brand preferences frequently reflected perceived ST brand popularity within peer groups. Based on these observations, potential ST regulation and health education campaigns to address misconceptions about ST characteristics could influence adolescents' ST-related perceptions and reduce ST use among this vulnerable population.

Individual, social and environmental determinants of smokeless tobacco and betel quid use amongst adolescents of Karachi: a school-based cross-sectional survey

BACKGROUND

With 600 million people using betel quid (BQ) globally, and smokeless tobacco (SLT) use being more wide-spread; the duo is an uphill public health concern in South Asian countries. SLT and/or BQ use increases the risk for morbidity and mortality from oral cancer. Because SLT and/or BQ use is initiated during adolescence, it renders this group more vulnerable; and particular attention is needed to curb SLT and/or BQ use to reduce related disease burden. We aimed to observe the differential individual, social and environmental features amongst SLT and/or BQ users to determine the key influencers of its use in adolescents.

METHODS

This study was a cross-sectional survey of 2140 adolescents from secondary schools of Karachi, Pakistan. The main outcome measure was SLT and/or BQ use based on their consumption in the past 30 days. Univariate and multivariate regression binary logistic analyses were employed while reporting results in both crude form and adjusted odds ratio (after adjusting for all remaining individual, social and environmental level variables) with 95% confidence level. A p-value of < .05 was considered significant for all analyses.

RESULTS

The overall prevalence of SLT and/or BQ use was 42.6% (n = 912) of the total sample. The SLT and/or BQ consumer group had more males than females. A significant proportion of user (n = 558, 61.2%) was found in co-education schools. Students whose peers (OR = 6.79, 95% CI 4.67-9.87, p-value <0.001) and/or either of the parents (OR = 2.16, 95% CI 1.73-2.65, p-value <0.001) used SLT and/or BQ, alongside, adolescents who had not attended knowledge based sessions in schools regarding harmful effects of SLT and/or BQ were more likely to consume it. It's availability with outside school hawkers increased the odds of its use by 6 times, as indicated by both univariate and multivariate models after adjusting for the remaining variables.

CONCLUSION

In conclusion, students studying in co-education, parents and peers use, lack of knowledge based sessions on harmful health effects of SLT and/or BQ, and easy availability of the product from hawkers outside school all contribute towards enhanced risk of SLT and/or BQ use in adolescents.

Rising incidence of oral tongue cancer among white men and women in the United States, 1973-2012

BACKGROUND

Despite significant reductions in tobacco use in the US, oral tongue cancer incidence has reportedly increased in recent years, particularly in young white women. We conducted age-period-cohort analyses to identify birth cohorts that have experienced increased oral tongue cancer incidence, and compared these with trends for oropharyngeal cancer, a cancer caused by human papillomavirus (HPV) that has also recently increased.

METHODS

We utilized cancer incidence data (1973-2012) from 18 registries maintained by the NCI SEER Program. Incidence trends were evaluated using log-linear joinpoint regression and age-period-cohort modeling was utilized to simultaneously evaluate effects of age, calendar year, and birth year on incidence trends.

RESULTS

Incidence of oral tongue cancer increased significantly among white women during 1973-2012 (0.6% annual increase, p<0.001) and white men during 2008-2012 (5.1% annual increase, p=0.004). The increase was most apparent among younger white individuals (<50years; annual increase of 0.7% for men [p=0.02] and 1.7% for women [p<0.001] during 1973-2012). Furthermore, the magnitude of the increase during 1973-2012 was similar between young white men and women (2.3 vs. 1.8 cases per million, respectively). Incidence trends for oropharyngeal cancer were similar to trends for oral tongue cancer and similar birth cohorts (born after the 1940s) experienced rising incidence of these cancers (p-value: white men=0.12, white women=0.42), although the magnitude of increase was greater for oropharyngeal cancer.

CONCLUSIONS

The incidence of oral tongue and oropharyngeal cancer has significantly increased among young white men and women within the same birth cohorts in the US.

Nicotine dependence and its correlates among the adult tobacco users in a slum of Burdwan district, West Bengal, India

Background

Tobacco kills half of its users, with smoking and smokeless tobacco killing nearly 6 million people worldwide - one death every 6 s in each year. Use of tobacco over time causes a physical and psychological addiction due to the presence of nicotine. To find out the level of nicotine dependence among adult (18 years and above) tobacco users and the factors responsible for it.

Materials and Methods

A cross-sectional community-based study was conducted among 128 current tobacco users in an urban slum of Burdwan District, West Bengal, India. Study tools comprised of predesigned, pretested, semi-structured schedule, containing Fagerström test for nicotine dependence (FTND) questionnaire. Data were collected by interview after getting consent from the participants. Chi-square test, unpaired student t-test, ANOVA, correlation coefficient, and linear regression was calculated. SPSS software (Statistical Package for the Social Sciences Inc, Chicago, IL, USA). was used for analysis.

Results

High level of nicotine dependence was maximally seen among increased in age group, prolonged duration of use and daily users. Age, duration of tobacco use and habit of tobacco use had a significant positive correlation with FTND score while starting age of tobacco had a significant negative correlation. Then in multivariable linear regression, starting age of tobacco use, habit of tobacco use and duration of tobacco use emerged as a significant predictor of FTND score and could explain 27.3% of total variation in FTND score.

Conclusions

Suitable plan for quitting may be developed based on the FTND score of an individual, the most important determinant of quitting.

Tobacco Use and Cancer Risk in the Agricultural Health Study

Background: Cigarettes are well known to cause cancer, but less is known about the risks of other tobacco products and use of more than one product.Methods: We examined cancer incidence in relation to exclusive use of six tobacco products [cigarettes, other combustibles (pipe, cigar, cigarillo), and smokeless tobacco (chewing tobacco, snuff)] in the Agricultural Health Study. We also examined the added cancer risks associated with use of cigarettes and other tobacco products.Results: In our study population of 84,015, ever use of smokeless tobacco was higher than the general United States population, whereas cigarette use was lower and other combustible product use was about the same. The strongest associations for exclusive ever use were for lung cancer [cigarettes HR = 15.48; 95% confidence interval (CI), 11.95-20.06; other combustible tobacco HR = 3.44; 95% CI, 1.53-7.71; smokeless tobacco HR = 2.21; 95% CI, 1.11-4.42]. Compared with exclusive cigarette smokers, cigarette smokers who additionally ever-used another combustible product had higher risks of smoking-related cancers (HR = 1.16; 95% CI, 1.04-1.30), especially among those who smoked cigarettes for more than 15 years.Conclusions and Impact: Cigarette smokers who additionally ever used smokeless tobacco had cancer risks similar to exclusive cigarette smokers. Users of cigarettes and other combustible tobacco may have higher risks of certain cancers than exclusive cigarette users. Cancer Epidemiol Biomarkers Prev; 26(5); 769-78. ©2016 AACR.

Smokeless Tobacco and Stroke - A Clinico-epidemiological Follow-up Study in A Tertiary Care Hospital

INTRODUCTION

Among the modifiable risk factors for stroke, tobacco smoking is well recognized. In some studies the use of Smokeless Tobacco (ST) has also been contributed as a risk factor for ischemic stroke. Use of ST is very common in South-East Asia. The form of ST varies according to the geographical and cultural variation.

AIM

To study the various clinical symptoms and radiological findings of stroke due to different types of ST.

MATERIALS AND METHODS

This was a prospective hospital based study carried out over a period of 2 years. All the cases within age group of 16 - 60 years and with a clinical and radiological diagnosis of acute stroke were included in the study. The Fagerström Test for Nicotine Dependence for ST of more than 6 was taken as the inclusion criteria. Patients having other addictions like smoked tobacco, alcohol, etc., and with important risk factors like hypertension, diabetes, dyslipidemia were excluded. The cases were extensively investigated and followed up for at least 6 months. Analysis was done using the Statistical Package for Social Sciences (SPSS- version 16.0). Descriptive statistics like percentage, mean were used wherever appropriate.

RESULTS

During a period of 2 years, a total of 54 patients were studied. Forty two (77.7%) were males and 12(22.3%) were females. The mean age at presentation was 42.72(± 8.6) years and among all 96.3% patients were diagnosed as ischemic stroke. Among ST, pan was most commonly used in 21(38.9%) patients with an average of 14.6(±3.27) years of addiction. Hemiplegia was the predominant symptom on presentation (46, 85.2%). According to Oxfordshire Stroke Classification, partial anterior circulation infarct was most common in 20(38.4%). The mean Modified Rankin scale after 5 days of hospital stay was 3.83(±1.03) and after 6 months of follow-up was 2.1(±0.8). Patients were counseled for deaddiction and after 6 months follow-up 48(88.8%) patients had quit ST.

CONCLUSION

ST is an important etiological factor for young ischemic stroke. This is the first study depicting clinical symptomatology of ST addicted ischemic stroke patients from India. Considering the increasing prevalence of ST use in south-east Asia, further long term studies are needed from this region.

Magazine hyped: Trends in tobacco advertising and readership characteristics, 2010-2014

We tracked magazine advertisements for seven tobacco products in U.S. magazines from 2010 to 2014 and examined magazine readership characteristics that are associated with advertising placement in 2014. Advertising data came from Kantar Media's Intelligence and readership data came from a 2014 Experian's nationally representative survey of 4667 adult tobacco users. At magazine level, we aggregated total and product-specific number of advertisements and expenditures by year and calculated readership demographics. We used linear and poisson regression models to examine trends in number of tobacco advertisements and expenditures and readership characteristics associated with number of tobacco advertisements in 2014. Analyses were conducted in 2015. There were 5317 tobacco advertisements with expenditures of $796 million that appeared in 322 magazines during 2010-2014. Cigarette advertisements accounted for 2928 (55%), followed by e-cigarettes (n=862, 16%), and snus (n=534, 10%). Advertisements increased by 2.79ad/year for cigarettes, 1.94ad/year for e-cigarettes, and 0.78ad/year for chewing tobacco (p<0.05). In 2014, number of advertisements was associated with select readership characteristics (p<0.05). For every 10% increase in 18-39year-old readers, advertisement rate increased by 1.48 times for cigarettes, 3.44 times for e-cigarettes, and 2.15 times for chewing tobacco. For every 10% increase in readers who earn ≤$24,999, advertisement rate increased by 1.37 times for cigarettes and 1.70 times for e-cigarettes. Magazine tobacco advertising has increased especially for cigarettes and is targeted toward certain demographic subgroups. Regulating tobacco magazine advertising should be integral to tobacco control policies.

Trends and Factors Related to Smokeless Tobacco Use in the United States

BACKGROUND

While declines in smoking prevalence in the United States have been well documented, trends in smokeless tobacco (SLT) use are less clear. This study updates previous analyses of US SLT use prevalence to better understand trends and factors related to SLT use.

METHODS

We used the Tobacco Use Supplement of the Current Population Survey (TUS-CPS) to examine trends and factors related to SLT use using joinpoint and logistic regression models. SLT consumption from 1985 to 2011 was obtained from the 2011 Federal Trade Commission Smokeless Tobacco Report. Sensitivity analyses were conducted for assessing the impact of varying frequency definitions of SLT use.

RESULTS

Decreasing trends in smoking and SLT prevalence overall were observed from 1992 to 2003 independently of use definition. SLT prevalence in the total adult population significantly decreased at an annual percent change (APC) of 4.5% per year from 1992 to 2003, but has been approximately constant ever since. Similar patterns were also found in adult males (APC = -4.4%) and young males (APC = -9.5%). SLT per capita consumption decreased significantly from 1991 to 1999 (APC = -2.2%), but has since decreased at only 0.35% per year (1999-2011). SLT use was found to be associated with former smoker status, younger age, white race, living in rural areas, residence in the South, lower education and unemployment, adjusting for other factors.

CONCLUSIONS

Declines in SLT use were found in the United States, suggesting tobacco control has had positive impacts, but these have slowed since 2003. Targeting tobacco control policies to at-risk demographic groups is needed to further reduce SLT use in the United States.

IMPLICATIONS

This study confirms that the declines in SLT use prevalence stopped in 2003 across different demographic groups, consistent with trends in SLT consumption. In addition, the longer period of analysis in comparison with earlier studies allows for quantitative characterization of SLT use trends using joinpoint regression. The study also shows the impact of different SLT use definitions in determining tobacco product use prevalence and trends.

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.

Risk Factors Associated With Hookah Use

BACKGROUND

Potential harms associated with hookah smoking are largely unrecognized and it is emerging as a trendy behavior. To help inform policy and preventive interventions, we used responses from a population survey of US adults to examine risk factors associated with hookah involvement.

METHOD

An online survey of 17 522 US adults was conducted in 2013. The nationally representative sample was drawn from GfK Group's KnowledgePanel plus off-panel recruitment. Multinomial logistic regression was used to examine the relationships between tobacco use patterns across multiple products (cigarettes, cigars, and dissolvables), perceived harms towards regular pipe/hookah use, and demographic characteristics with hookah involvement (never used, ever used with/without reusing intent).

RESULT

Nearly one in five (16%) of the respondents had smoked hookah at least once in their life ("ever users"). Ever users of hookah were at higher risk of having used cigarettes, cigars, and dissolvable tobacco products (all P < .01). Odds for hookah use were greater for those who perceived regular pipe/hookah use as less dangerous (P < .05). Odds for hookah involvement were higher among young adults (P < .001), individuals with higher educational attainment (P < .01), and Hispanics/Latinos (P < .05).

CONCLUSIONS

Information about the public health harms associated with hookah smoking should be delivered to individuals at-risk for hookah smoking. It is likely that misconceptions about the safety of hookah smoking could be driving, at least in-part, its increase in popularity.

A literature review on prevalence of gender differences and intersections with other vulnerabilities to tobacco use in the United States, 2004-2014

This report describes results from a systematic literature review examining gender differences in U.S. prevalence rates of current use of tobacco and nicotine delivery products and how they intersect with other vulnerabilities to tobacco use. We searched PubMed on gender differences in tobacco use across the years 2004-2014. For inclusion, reports had to be in English, in a peer-reviewed journal or federal government report, report prevalence rates for current use of a tobacco product in males and females, and use a U.S. nationally representative sample. Prevalence rates were generally higher in males than in females across all products. This pattern remained stable despite changes over time in overall prevalence rates. Gender differences generally were robust when intersecting with other vulnerabilities, although decreases in the magnitude of gender differences were noted among younger and older users, and among educational levels and race/ethnic groups associated with the highest or lowest prevalence rates. Overall, these results document a pervasive association of gender with vulnerability to tobacco use that acts additively with other vulnerabilities. These vulnerabilities should be considered whenever formulating tobacco control and regulatory policies.

Trends in Multiple Tobacco Product Use, Among High School Students

OBJECTIVE

The purpose of this study was to identify trends of tobacco use, among all students and current tobacco users, in a nationally representative sample of high school students from 1999 to 2013.

METHODS

Trends in individual and concurrent use of cigarettes, cigars, and smokeless tobacco (SLT) products were tested using 8 repeated cross-sections of the YRBS between 1999 and 2013. Tests for effect modification of race/ethnicity and sex were conducted for each trend.

RESULTS

Among all students, there were significant non-linear changes detected for the concurrent use of all 3 products, and the dual use of cigarettes and cigars. Girls significantly increased their use of SLT. Among users, significant changes were detected for each individual product and all combinations. Female users significantly increased their concurrent use of cigarettes and cigars and concurrent use of cigarettes and SLT. Male users significantly decreased their use of cigarettes and cigars.

CONCLUSION

While the decrease in the youth prevalence of cigarette use is a public health success, there is concern about the increase in non-cigarette products, among tobacco users. These changes further drive increases in the concurrent use of tobacco products, adding to the potential health burden.

Polytobacco Use of Cigarettes, Cigars, Chewing Tobacco, and Snuff Among US Adults

INTRODUCTION

Tobacco use prevalence has been commonly estimated on a product by product basis and the extent of polytobacco use among current users of each tobacco product is not well understood. This study aimed to examine the prevalence, trends, and correlates of polytobacco use among current users of cigarettes, cigars, chewing tobacco, and snuff in US adults aged ≥18.

METHODS

We used pooled data from the 1998, 2000, 2005, and 2010 Cancer Control Supplements of the National Health Interview Survey (N = 123 399 adults). Multivariate logistic regression models were estimated to determine significant factors associated with polytobacco use.

RESULTS

In 2010, the prevalence of polytobacco use was 8.6% among current cigarette smokers, 50.3% among current cigar users, 54.8% among current chewing tobacco users, and 42.5% among current snuff users. After controlling for other covariates, gender and race/ethnicity did not show consistent associations with poly-use across these four groups of current tobacco users; however, a positive association of young adulthood, less than high school education, and binge drinking with poly-use was consistently found among all these groups.

CONCLUSIONS

Polytobacco use is extremely popular among current users of non-cigarette tobacco products. Polytobacco use patterns differ across sociodemographic subpopulations, and the gender and racial/ethnic profiles in poly-users vary across different groups of current tobacco users. Tobacco control strategies need to consider the interrelationships in the use of different tobacco products and the diverse profiles of poly-users in order to develop tailored tobacco prevention and intervention policies to further reduce the burden of tobacco use.

Risk Factors Associated With Hookah Use

BACKGROUND

Potential harms associated with hookah smoking are largely unrecognized and it is emerging as a trendy behavior. To help inform policy and preventive interventions, we used responses from a population survey of US adults to examine risk factors associated with hookah involvement.

METHOD

An online survey of 17 522 US adults was conducted in 2013. The nationally representative sample was drawn from GfK Group's KnowledgePanel plus off-panel recruitment. Multinomial logistic regression was used to examine the relationships between tobacco use patterns across multiple products (cigarettes, cigars, and dissolvables), perceived harms towards regular pipe/hookah use, and demographic characteristics with hookah involvement (never used, ever used with/without reusing intent).

RESULT

Nearly one in five (16%) of the respondents had smoked hookah at least once in their life ("ever users"). Ever users of hookah were at higher risk of having used cigarettes, cigars, and dissolvable tobacco products (all P < .01). Odds for hookah use were greater for those who perceived regular pipe/hookah use as less dangerous (P < .05). Odds for hookah involvement were higher among young adults (P < .001), individuals with higher educational attainment (P < .01), and Hispanics/Latinos (P < .05).

CONCLUSIONS

Information about the public health harms associated with hookah smoking should be delivered to individuals at-risk for hookah smoking. It is likely that misconceptions about the safety of hookah smoking could be driving, at least in-part, its increase in popularity.

Psychiatric correlates of snuff and chewing tobacco use

Compared to the association between cigarette smoking and psychiatric disorders, relatively little is known about the relationship between smokeless tobacco use and psychiatric disorders. To identify the psychiatric correlates of smokeless tobacco use, the analysis used a national representative sample from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) wave 1. Smokeless tobacco use was classified as exclusive snuff use, exclusive chewing tobacco, and dual use of both snuff and chewing tobacco at some time in the smokeless tobacco user's life. Lifetime psychiatric disorders were obtained via structured diagnostic interviews. The results show that the prevalence of lifetime exclusive snuff use, exclusive chewing tobacco, and dual use of both snuff and chewing tobacco was 2.16%, 2.52%, and 2.79%, respectively. After controlling for sociodemographic variables and cigarette smoking, the odds of exclusive chewing tobacco in persons with panic disorder and specific phobia were 1.53 and 1.41 times the odds in persons without those disorders, respectively. The odds of exclusive snuff use, exclusive chewing tobacco, and dual use of both products for individuals with alcohol use disorder were 1.97, 2.01, and 2.99 times the odds for those without alcohol use disorder, respectively. Respondents with cannabis use disorder were 1.44 times more likely to use snuff exclusively than those without cannabis use disorder. Respondents with inhalant/solvent use disorder were associated with 3.33 times the odds of exclusive chewing tobacco. In conclusion, this study highlights the specific links of anxiety disorder, alcohol, cannabis, and inhalant/solvent use disorders with different types of smokeless tobacco use.

Adolescent and adult perceptions of traditional and novel smokeless tobacco products and packaging in rural Ohio

OBJECTIVE

As smokeless tobacco (ST) marketing increases and new products emerge on the market, very little is known about consumer perceptions of ST products. To inform development of future ST counter-marketing approaches, this qualitative study examined consumer perceptions of traditional and novel ST products and packaging.

METHODS

Focus groups and qualitative interviews were held with adolescent (n=23; mean age of 17 years) and adult (n=38; mean age of 29 years) male ST users from rural Ohio counties. Participants were shown a variety of traditional (eg, Copenhagen, Timber Wolf) and novel (eg, Camel Snus, Orbs) ST products and asked about perceptions of these products and their packaging. Transcriptions were coded independently for common themes by two individuals.

FINDINGS

Adolescents and adults generally had similar beliefs and reactions about ST products. While participants were familiar with a variety of traditional ST products, Copenhagen was the most frequently used product. Perceptions of quality and price of traditional products were closely tied to product taste and packaging material. Colours, design and size of ST packaging appealed to participants and influenced decisions to purchase. Adults believed novel ST products had a weak taste and were targeted at untraditional ST users. While the vast majority was unfamiliar with dissolvable tobacco, adolescents noted that they would be more convenient to use during school than traditional ST.

CONCLUSIONS

Packaging has a significant role in shaping perceptions of ST and consumer behaviour. Regulation of product packaging such as shape, size and images should be part of comprehensive tobacco control.

Predictors of quitting behaviour with special reference to nicotine dependence among adult tobacco-users in a slum of Burdwan district, West Bengal, India

BACKGROUND & OBJECTIVES

Information on predictors of quitting behaviour in adult tobacco users is scarce in Indian context. Hence, this study was undertaken to assess the intention of tobacco-users towards quitting and its predictors with reference to nicotine dependence.

METHODS

A community-based observational, cross-sectional study was conducted on 128 adult tobacco-users (89.8% male) with mean age of 41.1 ± 15.7 yr selected by complete enumeration method. Data were collected by interview using pre-designed, pre-tested schedule. Nicotine dependence was assessed by Fagerstrφm Test for Nicotine Dependence (FTND) questionnaire.

RESULT

Of the 128 users, 63.3 per cent had intention to quit. Majority of the tobacco users who did not intend to quit belonged to the age group of > 40 yr (66.0%), were illiterate (55.3%), started tobacco use at 11 - 15 yr of age (57.4%), had been using tobacco for 20 yr or more (70.2%), were daily tobacco users (91.5%), and highly dependent on nicotine (80.9%). Tobacco users having high FTND score and who started tobacco use early in life were 1.83 and 3.30 times more unintended to quit, respectively.

INTERPRETATION & CONCLUSIONS

Suitable plan for quitting should be developed depending on the FTND score of an individual, the most important determinant of quitting that would be beneficial for categorization of the treatment leading to successful quitting.

Monitoring tobacco-specific N-nitrosamines and nicotine in novel smokeless tobacco products: findings from round II of the new product watch

INTRODUCTION

Analysis of novel smokeless tobacco products purchased in Round I of the New Product Watch (NPW)-a national tobacco monitoring network-demonstrated that some tobacco constituents vary not only across various brands but also regionally and over time within the same product. In this study, we analyzed snus and dissolvable tobacco products that were purchased in Round II of the NPW.

METHODS

We analyzed tobacco-specific N-nitrosamines (TSNA) and nicotine in snus and dissolvable tobacco products that were purchased in various regions of the country during the spring and summer of 2011. The results were compared against the Round I data, across different U.S. regions, and among products.

RESULTS

A total of 216 samples were received from different states representing 6 regions of the country. Compared with the previous analyses, TSNA levels increased significantly in Marlboro and Camel Snus and some dissolvable Camel products. The levels of unprotonated nicotine in Marlboro Snus and Camel Snus in this study were not different from Round I but varied significantly by regions; the differences between the highest and the lowest average regional levels were ~3.2-fold in Marlboro Snus ~1.7-fold in Camel Snus.

CONCLUSIONS

Our results indicate that some novel smokeless tobacco products contain TSNA at the levels found in the conventional moist snuff. Observation of regional variations in unprotonated nicotine content in both Round I and Round II of NPW suggest that manufacturers may tailor the levels of this constituent consistently to different regions.

Tobacco use among HIV-infected individuals in a rural community in Yunnan Province, China

OBJECTIVE

To examine the prevalence and correlates of smoking versus tobacco chewing, and potential gender differences in tobacco use among HIV-infected individuals in a rural community in Yunnan Province, China.

METHOD

A cross-sectional design using face-to-face interviews.

RESULTS

Among the participants, 301 (66.2%) were male; 79 (17.4%) were ethnic Han, 310 (68.1%) were Jingpo minority, 62 (13.6%) were Dai minority; 17.8% had no formal education and 55.6% had only primary school education; 15.4% were never married; 40% reported drinking in the past 30 days; 55.4% had ever used drugs; and 67% were currently receiving antiretroviral therapy (ART). The mean age of the study participants was 38.1 years (SD=8.8). About 62% were current cigarette smokers. Current cigarette smoking was positively associated with being male (OR=142.43, 95% CI: 35.61-569.72) and current drinking (OR=7.64, 95% CI: 2.68-21.81), as well as having ever used drugs (OR=4.03, 95% CI: 1.31-12.35). Among current smokers, 67.6% were heavy smokers (smoked at least 20 cigarettes per day). Those who were older than 46 years of age (OR=9.68, 95% CI: 1.41-66.59) and current drinkers (OR=2.75, 95% CI: 1.56-4.83) were more likely to be heavy smokers. Approximately 9% were currently used chewing tobacco. Those who were female (OR=41.29, 95% CI: 8.53-199.93) and current drinkers (OR=3.22, 95% CI: 1.02-10.16) were more likely to use chewing tobacco. All who used chewing tobacco were ethnic minorities.

CONCLUSIONS

Cigarette smoking and use of chewing tobacco were highly prevalent among HIV-infected individuals in rural Yunnan, underscoring the urgent need for tobacco prevention and intervention programs tailored for this population.

Factors associated with smokeless tobacco use and dual use among blue collar workers

OBJECTIVES

To examine demographic and substance use factors associated with exclusive smokeless tobacco use (SLT) and dual use of both cigarettes and SLT among blue-collar workers.

DESIGN AND SAMPLE

This cross-sectional study used data from the United States 2009 National Survey on Drug Use and Health. The sample (n = 5,392) was restricted to respondents who were classified as blue collar workers by self-report primary job title.

MEASURES

Various demographic variables, tobacco use and other substance use variables were examined.

RESULTS

Respondents in this blue collar sample were 87% male and 64% Non-Hispanic White. An estimated 9.5% (SE = 0.6) of respondents were current SLT users; 5.3% (SE = 0.4) were current exclusive SLT users, and 4.2% (SE = 0.4) were current dual users of both SLT and cigarettes. Factors related to exclusive SLT use were gender, marital status, age, race/ethnicity, type of blue-collar occupation, current binge drinking, and current marijuana use. Significant factors related to dual use were gender, marital status, age, race/ethnicity, type of blue-collar occupation, current cigar smoking, current binge drinking, and current illicit drug use.

CONCLUSIONS

Rates of SLT use and dual use are high among U.S. blue-collar workers, indicating a need for targeted, workplace cessation interventions. These interventions may also serve as a gateway for addressing other substance use behaviors in this population.

Hookah use among adolescents in the United States: results of a national survey

INTRODUCTION

U.S. adolescents increasingly use alternative tobacco products (ATPs), including hookah. No study has previously assessed correlates of adolescent hookah use in a nationally representative sample.

METHODS

Cross-sectional, nationally representative data of adolescents from the 2011 National Youth Tobacco Survey (NYTS) were used. Student demographics and their use of, exposure to, and beliefs about tobacco were examined as correlates of hookah use.

RESULTS

Of adolescents nationwide, 7.3% reported ever trying hookah and 2.6% reported using hookah within the past month. Increasing age was associated with trying hookah, but not current hookah use. Sex was unassociated with hookah use. Asians were most likely to have tried hookah; Hispanics and those of another race reported greater current hookah use. Hookah use increased with perceived ease of access to and willingness to try tobacco. Students with a hookah user at home were more likely to have tried hookah and to currently use hookah. Current cigarette use was not associated with current hookah use (odds ratio [OR] = 1.3, 95% CI = 0.8-2.1), but was associated with trying hookah (OR = 1.5, 95% CI = 1.1-2.2). Non-cigarette tobacco use was associated with trying hookah (OR = 2.7, 95% CI = 2.1-3.5) and current hookah use (OR = 4.8, 95% CI = 2.7-8.7).

CONCLUSIONS

A sizeable minority of U.S. adolescents use hookah, particularly those living with hookah users, those who use other ATPs, and those who perceive tobacco as easily accessible. Current cigarette use was not associated with current hookah use. Future studies assessing the dangers of hookah use and interventions to curb this emerging problem appear warranted.

Smokeless tobacco and cardiovascular disease in low and middle income countries

Smoking is an important cardiovascular risk factor, however, use of smokeless tobacco has not been well studied. Smokeless tobacco use is high in countries of South and Southeast Asia, Africa and Northern Europe. Meta-analyses of prospective studies of smokeless tobacco users in Europe reported a relative risk for fatal coronary heart disease of 1.13 (confidence intervals 1.06-1.21) and fatal stroke of 1.40 (1.28-1.54) while in Asian countries it was 1.26 (1.12-1.40). Case-control studies reported significantly greater risk for acute coronary events in smokeless tobacco users (odds ratio 2.23, 1.41-3.52), which was lower than smokers (2.89, 2.11-3.96), and subjects who both chewed and smoked, had the greatest risk (4.09, 2.98-5.61). There is a greater prevalence of hypertension and metabolic syndrome in users of smokeless tobacco. Smokeless tobacco use leads to accelerated atherothrombosis similar to smoking. There is an urgent need for public health and clinical interventions to reduce smokeless tobacco addiction.

Levels of (S)-N'-nitrosonornicotine in U.S. tobacco products

INTRODUCTION

N'-nitrosonornicotine (NNN), an esophageal and oral carcinogen present in tobacco products, has a chiral center in its structure. Of its two enantiomers, (S)-NNN exhibits higher tumorigenic potency than (R)-NNN. There is no information available on the levels of (S)-NNN in various tobacco products currently marketed in the United States.

METHODS

We used chiral gas chromatography analysis to determine (S)-NNN levels in a convenience sample of 37 tobacco products currently marketed in the United States: conventional smokeless tobacco, novel smokeless tobacco products, and cigarette tobacco filler.

RESULTS

Among all products analyzed here, (S)-NNN averaged 62.9 ± 6.3% (SD) of NNN. The absolute amount of (S)-NNN in conventional moist snuff averaged 1.26 ± 0.5 µg/g tobacco; in novel smokeless products 0.70 ± 0.2 µg/g tobacco; and in cigarette filler 1.36 ± 0.6 µg/g tobacco (all values are per wet weight). For each cigarette brand, the enantiomeric composition of NNN in cigarette smoke was similar to that of the corresponding tobacco filler.

CONCLUSIONS

Our results demonstrate that (S)-NNN is the predominant NNN enantiomer in moist snuff, novel smokeless tobacco products, and cigarettes currently marketed in the United States. Efforts toward the reduction of NNN in U.S. tobacco products should take into account its enantiomeric composition, with particular focus on (S)-NNN as a causative agent for esophageal and oral cancers associated with tobacco use.

Prevalence of oral mucosal lesions among Pre-University students of Kodava population in Coorg District

BACKGROUND

To know the prevalence of oral mucosal lesions among Pre-University students of Kodava population in Coorg District. This survey also aims to find out tobacco or other habits among students and related changes in the oral environment.

MATERIALS & METHODS

900 PU students of Kodava population were included. 300 students from each taluk were randomly selected, after the consent. Questions were asked to reveal the systemic diseases, abnormal oral habits, use of tobacco &alcohol. Each student was examined for oral mucosal lesions and recording was based on WHO oral health assessment form.

RESULTS

Oral mucosal lesions were similar to studies done in other population but with a slightly higher frequency of few lesions. Incidence of substance use was noted, but with no signs of significant changes in the oral mucosa.

CONCLUSION

Prevalence of oral mucosal lesions varies among each population indicating the need for study in each population to format health policy. Substance use was noted among 16-17 yr age group indicates the need for early preventive measures among adolescents to avoid future serious health problems. How to cite this article: Sandeepa N C, Jaishankar H P, Sharath C B, Abhinetra M S, Darshan D D, Nappalli D. Prevalence of oral mucosal lesions among Pre-University students of Kodava population in Coorg District. J Int Oral Health 2013; 5(3):35-41.

The conceptualization and communication of risk among rural appalachian adolescents

This study uses a meta-theoretical perspective for examining risk perceptions and behavior in the rural Appalachian cultural context, an area that remains largely unexplored. The authors conducted in-depth interviews with 113 rural adolescents to describe how youth conceptualize risk and how risk is communicated in the rural environment. Analyses revealed adolescents viewed behavior as risky when they had personal or vicarious experiences resulting in a loss of control or physical harm. Elements of the rural Appalachian culture including activities, familism, and community ties can prevent and promote adolescent risk taking in various forms. This study demonstrates the conceptualization of risk and messages about risk are culturally situated and communicatively devised and enacted. The implications of these findings for adolescent risk prevention programs are discussed.

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.

Tobacco cessation in the dental office

Evidence-based tobacco-cessation guidelines when used by clinicians are effective in reducing tobacco use and obtaining successful quits by patients. Dentists have been encouraged to provide instruction and intervention on tobacco cessation in the dental office. The dental provider is in the unique position to relate oral findings to the patient and to provide advice to tobacco-using patients to quit. In addition, dentists are able to assess patients' self-addiction and level of readiness to quit tobacco use. With this information, dentists can assist in helping patients to stop using tobacco by providing appropriate pharmacotherapeutic aid and thus improve their oral and overall health.

Trends in the use and advertising of discount versus premium snuff

INTRODUCTION

The Conwood Company, a major producer of discount moist snuff, was awarded a $1 billion antitrust settlement in the year 2000 against its leading competitor, the U.S. Smokeless Tobacco Company. The objective of this study was to examine the trends in use and advertising of discount versus premium snuff since the Conwood settlement, a topic seldom addressed in the tobacco control literature.

METHODS

2 sources of data were analyzed in 2011: (a) male snuff users from the 2002-2009 National Surveys on Drug Use and Health (N = 13,172) and (b) total advertisements of moist snuff identified from over 350 consumer magazines dated 2005-2009 (N = 861). For the survey data, demographic and tobacco-related measures were assessed as predictors of use of discount versus premium snuff in logistic regression models. For the advertising data, associations were examined between the snuff category and nicotine content, magazine youth readership, and year of magazine publication.

RESULTS

The prevalence of discount and premium snuff use among males increased and decreased, respectively, from 2002 to 2009. Significant predictors of using discount versus premium snuff were being an adolescent, being an African-American, being a current or former smoker, living in a less populated region of the country, and using snuff frequently. Discount snuff advertising was associated with publication in magazines with a high youth readership.

CONCLUSIONS

Discount snuff has grown in popularity among male adolescents who have been a target of advertising. The tobacco's cheap price and high nicotine content pose a public health problem because of the potential for long-term tobacco use and dependence.

Trends in the use of smokeless tobacco in United States, 2000-2010

OBJECTIVES/HYPOTHESIS

To quantify trends in the use of smokeless tobacco in the United States.

STUDY DESIGN

Longitudinal analysis of national population database.

METHODS

The National Health Interview Surveys for 2000, 2005, and 2010 were analyzed for adult responses to specific questions regarding smokeless tobacco use, which includes chewing tobacco and snuff. Smokeless tobacco lifetime exposure, current use, and frequency of use were determined according to each sampled year, examining for trends over the past decade. Subset analysis for young adults (ages 18-44 years) was conducted. Demographic factors associated with smokeless tobacco use were also determined.

RESULTS

A total of 86,270 adults were surveyed. Among all adults, the proportions of those who had ever tried chewing tobacco were 7.1 ± 0.2%, 8.5 ± 0.2%, and 9.2 ± 0.2% for 2000, 2005, and 2010, respectively (P < .001). Similarly, the proportions of those who had ever tried snuff were 4.4 ± 0.2%, 7.5 ± 0.2%, and 8.4 ± 0.3%, respectively (P < .001). In aggregate, the proportions who were regular users of chewing tobacco remained stable over the survey years: 1.3 ± 0.1%, 1.1 ± 0.1%, and 1.2 ± 0.1%, respectively (P = .382). In contrast, the percentages who were regular users of snuff tobacco increased significantly over the survey years: 1.4 ± 0.1%, 1.6 ± 0.1%, and 2.0 ± 0.1% (P < .001). The proportion of young adults regularly using snuff rose to 2.8 ± 0.2% (P < .001) in 2010. Male sex, non-Hispanic ethnicity, white race, and less than a high school education were characteristics that were strongly associated with smokeless tobacco use.

CONCLUSIONS

There was a trend toward increased smokeless tobacco use, mainly snuff, in the United States in the past decade. This trend was more prominent among young adults and likely will have future health-care implications.

Epidemiology of human papillomavirus-related head and neck cancer

Human papillomavirus (HPV) is now recognized to cause a subset of head and neck squamous cell carcinomas (HNSCC). Although excessive tobacco and alcohol use continue to be important risk factors for HNSCC, epidemiologic studies suggest that more than 25% of HNSCC are now caused by HPV. The incidence of HPV-related HNSCC is increasing, highlighting the need to understand the oral HPV infections causing these cancers. This article reviews the evidence for a causal association between HPV and HNSCC, examines the changing epidemiologic trends of HNSCC, and discusses what is currently known about oral HPV infection, natural history, and transmission.