Use of Conventional and Novel Smokeless Products Among US Adolescents

WHAT’S KNOWN ON THIS SUBJECT: Despite declines in , use among youth has remained AUTHORS: Israel T. Agaku, DMD, MPH,a Olalekan A. Ayo- a,b unchanged in the United States. Modified or novel smokeless Yusuf, BDS, MPH, PhD, Constantine I. Vardavas, MD, MPH, PhD,a Hillel R. Alpert, ScM, ScD,a and Gregory N. Connolly, tobacco products are being increasingly promoted to youth in the DMD, MPHa United States as an alternative to smoking. aCenter for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, WHAT THIS STUDY ADDS: Among US students in grades 6 through Massachusetts; and bDepartment of Community Dentistry, 12, 5.0% used or chewing or dipping tobacco, whereas 2.2% University of Pretoria, Pretoria, South Africa used or dissolvable tobacco products. Approximately two- KEY WORDS thirds of smokeless tobacco users concurrently smoked smokeless, adolescents, smoking, tobacco, cigarette, harm combustible tobacco; risk perception of all tobacco products was reduction, protective of smokeless tobacco use. ABBREVIATIONS aOR—adjusted odds ratio CI—confidence interval Dr Agaku conceptualized and designed the study, carried out the initial analyses, and drafted the initial manuscript; Dr Ayo-Yusuf participated in analysis and critically reviewed and revised the abstract manuscript; Drs Vardavas, Alpert, and Connolly critically OBJECTIVES: To assess the prevalence and correlates of use of con- reviewed and revised the manuscript; and all authors approved the final manuscript as submitted. ventional and novel smokeless tobacco products among a national Dr Agaku initiated the reported research while affiliated with sample of US middle and high school students. the Center for Global Tobacco Control at Harvard University. He METHODS: Data from the 2011 National Youth Tobacco Survey were is currently affiliated with the Centers for Disease Control and analyzed to determine national estimates of current use of conven- Prevention’sOffice on Smoking and Health. The research in this report was completed and submitted outside of the official tional (“”, “snuff,” or “dip”), novel (“snus” and “dis- duties of his current position and does not reflect the official solvable tobacco products”), and any smokeless tobacco products policies or positions of the Centers for Disease Control and (novel and/or conventional products) within the past 30 days. Prevention. RESULTS: The overall prevalence of current use of any smokeless tobacco www.pediatrics.org/cgi/doi/10.1542/peds.2013-0843 product was 5.6% (n = 960). Among all students, 5.0% used chewing doi:10.1542/peds.2013-0843 tobacco, snuff, or dip; 1.9% used snus; and 0.3% used dissolvable tobacco Accepted for publication Jun 20, 2013 products. Among users of any smokeless tobacco, 64.0% used only Address correspondence to Israel T. Agaku, DMD, MPH, Center for Global Tobacco Control, Department of Social and Behavioral conventional products, 26.8% were concurrent users of novel plus con- Sciences, Harvard School of Public Health, 677 Huntington ventional products, whereas 9.2% exclusively used novel products. Ap- Avenue, Boston, MA. 02115 E-mail: [email protected] proximately 72.1% of current any smokeless tobacco users concurrently PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). smoked combustible tobacco products, and only 40.1% expressed an Copyright © 2013 by the American Academy of Pediatrics intention to quit all tobacco use. Regression analyses indicated that peer FINANCIAL DISCLOSURE: The authors have indicated they have (adjusted odds ratio [aOR]: 9.56; 95% confidence interval [CI]: 7.14–12.80) no financial relationships relevant to this article to disclose. and household (aOR: 3.32; 95% CI: 2.23–4.95) smokeless tobacco use were FUNDING: Supported by the National Cancer Institute (grants associated with smokeless tobacco use, whereas believing that all forms NCI 3R01 CA125224-03s1rev++ and NCI 2R01 CA087477-09A2). of tobacco are harmful was protective (aOR: 0.55; 95% CI: 0.38–0.79). Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated CONCLUSIONS: Conventional smokeless tobacco products remain the they have no conflicts of interest to disclose. predominant form of smokeless tobacco use. Most users of novel smokeless tobacco products also concurrently smoked combustible tobacco products. Smokeless tobacco use was associated with lower perception of harm from all tobacco products and protobacco social influences, indicating the need to change youth perceptions about the use of all tobacco products and to engage pediatricians in tobacco use prevention and cessation interventions. Pediatrics 2013;132:e578–e586

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Conventional smokeless tobacco prod- school students by using data from the (including flavored cigarettes uctssuchasdrysnuff,moistsnuff,plug/ 2011 National Youth Tobacco Survey.10 and roll-your-own cigarettes), cigars twist, and loose-leaf chewing tobacco (including clove cigars and flavored have evolved greatly over the years to METHODS little cigars), bidis (small, hand-rolled enhance their social acceptability, ap- cigarettes), kreteks (clove cigarettes), Study Sample/Population peal, and ease of use. Moreover, the pipes, and water pipes/hookahs. increased proliferation of state and The National Youth Tobacco Survey is Currentuse of electronic cigarettesand local laws prohibiting a biennial, nationally representative other unspecified “new tobacco prod- in indoor public areas and workplaces survey of US middle and high school ucts” on $1 days during the past 30 10 has prompted the to students. In the 2011 survey, 18 866 days was also assessed. promote smokeless tobacco as an al- students from 178 schools (school ternative for smokers to access nico- response rate = 83.2%; student par- Quit Intentions ticipation rate = 87.4%) completed tine in situations in which smoking is An intention to quit among current to- a self-administered questionnaire in not allowed.1,2 Whereas cigarette smok- bacco users was defined as any re- a classroom setting, yielding an overall ing has been on the decline, smokeless sponse other than “I am not thinking response rate of 72.7%. This current tobacco use among US youth has about quitting the use of all tobacco” to study was conducted with the use of 3 the question “Are you seriously think- remained stable in recent years, and fi publicly available, deidenti ed data ing about quitting the use of all to- a substantial number of new or modi- and was institutional review board fi bacco?” ed smokeless tobacco products have exempted as nonhuman subject re- entered the US market.4 Swedish-style search. Access to Smokeless Tobacco snus and dissolvable tobacco products Access to smokeless tobacco was are novel smokeless tobacco products Measures/Definitions “ introduced into the US market in 2006 assessed with the question During the Smokeless Tobacco Use and 2008, respectively.5,6 Both novel past 30 days, how did you get your own ” smokeless tobacco products differ Current smokeless tobacco use was chewing tobacco, snuff, or dip? Are- fi sponse of “I bought it myself” was from conventional smokeless tobacco de ned as a response other than “ ” “ categorized as a purchase, whereas products in that they are lower in 0 days to the question During the past 30 days, on how many days did you a response of “I took it from a store or tobacco-specific and do use chewing tobacco, snuff, or dip?” or another person” was categorized as not require spitting.6 More so, their responses of “snus” or “dissolvable stealing. Responses of “I had someone design allows for their discreet use.6,7 tobacco products” to the question else buy it for me,”“I borrowed or Whereas some have argued that these “During the past 30 days, which of the bummed it,” or “Someone gave it to me low- novel smokeless to- following tobacco products did you use without my asking” were merged to- bacco products may confer relatively on at least 1 day?” gether as having obtained smokeless lower risk of tobacco-related disease Snus products such as Camel or tobacco through someone else. compared with cigarettes,8,9 this as- Marlboro snus and dissolvable tobacco Point of purchase of smokeless tobacco sumption of may only products such as Ariva, Stonewall, was assessed by using the question hold true at a population level if these Camel orbs, Camel sticks, or Camel “During the past 30 days, where did you novel smokeless tobacco products are strips were categorized as novel buy your own chewing tobacco, snuff, used exclusively by large numbers of smokeless tobacco products, whereas or dip?” Responses of “a gas station,” adolescents who would have otherwise chewing tobacco, snuff, or dip products “a convenience store,”“a grocery been smoking. were regarded as conventional smok- store,” or “a drugstore” were merged Despite these potential population-level eless tobacco products. as having bought smokeless tobacco effects, little nationwide data are avail- from a retail store. Purchases through able regarding the behavioral char- Combustible and Other Tobacco a vending machine were assessed acteristics of smokeless tobacco use Products separately, as were Internet/mail pur- among US youth. Hence, this study Current use of any combustible tobacco chases. assessed the patterns of use of con- product was defined as use of at least Ease of access to tobacco products was ventional and novel smokeless tobacco 1 of the following tobacco products assessed with the question “How easy products among US middle and high on $1 days during the past 30 days: would it be for you to get tobacco

PEDIATRICS Volume 132, Number 3, September 2013 e579 Downloaded from www.aappublications.org/news by guest on October 2, 2021 products if you wanted some?” Re- “never” or “rarely” were categorized to- panic, non-Hispanic white, non-Hispanic sponses of “very easy” or “somewhat gether to identify unexposed respondents. black, non-Hispanic Asian, or non-Hispanic easy” were grouped together as a per- Receptivity to tobacco promotional ac- American Indian/Alaska Native), and ceived ease of access (versus “not easy tivities was assessed with 2 questions: school level (middle or high). at all”). “During the past 12 months, did you buy or receive anything that has a to- Statistical Analysis Perception of Harm From All Tobacco bacco company name or picture on it?” National estimates of current use of Products (with “yes” as a positive response in- smokeless tobacco products were cal- The perception that all tobacco prod- dicating receptivity to tobacco pro- culated overall and stratified by socio- ucts are harmful was defined with the motional activities) and “How likely is it demographic characteristics and are question “How strongly do you agree that you would ever use or wear presented as percentages with 95% with the statement ‘All tobacco prod- something that has a tobacco company confidence intervals (CIs). Within-group ucts are dangerous?’” Responses of name or picture on it?” Responses of comparison of estimates was per- “strongly agree” or “agree” were grouped “very likely” or “somewhat likely” to the formed by using x2 statistics; esti- together as a positive perception of latter question categorized the ado- mates with a relative SE of $40% were harm, whereas responses of “disagree” lescent as receptive of tobacco pro- not reported. Logistic regression was or “strongly disagree” were categorized motional activities, whereas responses performed to assess the role of per- together to identify respondents who of “very unlikely” or “somewhat un- ception of harm from all tobacco did not perceive that all tobacco prod- likely” were categorized together to products and social influences on ucts are harmful. identify unreceptive respondents. smokeless tobacco use, adjusting for the following: gender, race/ethnicity, Peer and Household Protobacco Exposure to Health Warning Labels and school level; current use of other Influences Exposure to health warning labels on smoked tobacco products; and re- smokeless tobacco products was as- Protobacco peer influence was as- ceptivity toward tobacco promotional sessed with the question “During the sessed with the following questions: activities (P , .05). “How many of your 4 closest friends past 30 days, how often did you see Finally, a decomposition analysis was use chewing tobacco, snuff, or dip?” a warning label on a smokeless tobacco conducted to assess how much of the ” and “How many of your 4 closest product? Among respondents who saw male-female difference in smokeless friends smoke cigarettes?” Students a smokeless tobacco product during the tobacco use was attributable to gender “ ” who reported having at least 1 friend past 30 days, responses of sometimes, differences in covariates such as soci- “ ” “ ” who used smokeless tobacco or at most of the time, and always were odemographic characteristics (age and least 1 friend who smoked cigarettes categorized as having seen a warning race/ethnicity),perceptionofharmfrom “ ” were categorized as being exposed to label, whereas responses of never or all tobacco products, current use of “ ” pro–smokeless tobacco and prosmok- rarely were categorized together to combustible tobacco products, as well ing peer influences, respectively. identify unexposed respondents. as proximal (protobacco peer and Students who had at least 1 household household influences) and environ- Exposure and Receptivity to Tobacco member who used smokeless tobacco mental (exposure and receptivity to to- Promotional Activities products were categorized as having bacco advertisements) factors. In Exposure to advertisements on a bill- a pro–smokeless tobacco household the decomposition analysis, current board or a retail store was assessed in fluence, whereas those who had at smokelesstobaccousewastheoutcome with the question “During the past 30 least 1 household member who smoked variable, gender was the group variable, days, how often did you see an ad for any combustible tobacco product were and all other covariates were decom- cigarettes or smokeless tobacco that categorized as having a prosmoking posed iteratively. An adaptation of the was outdoors on a billboard or could household influence. Blinder-Oaxaca decomposition analysis be seen from outside a store?” Stu- for nonlinear regression models was dents who responded “sometimes,” Sociodemographic Factors used because of the binary outcome.11 “most of the time,” or “always” were Sociodemographic characteristics as- All analyses were weighted to account categorized as being exposed to pro- sessed included the respondents’ age for the complex survey design and were tobacco advertisements on a billboard (9–11, 12–14, 15–17, or $18 years), performed with Stata version 11 (Sta- or at a store, whereas responses of gender (girl or boy), race/ethnicity (His- taCorp, College Station, TX).

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RESULTS Study Participants = 686) n (

In total, 49.0% of all students were girls b 4.7) 7.5) 2.3) 3.3) 6.7) 2.4) 6.5) 5.6) 10.0) 3.9) 2.5) 4.6) 2.0) 6.8) – – – – – – – – – – – – – and 43.3% were in middle school. Par- – ticipants’ race/ethnic composition was 2.2 (0.6 5.1 (3.4 as follows: non-Hispanic white (60.2%),

non-Hispanic black (14.8%), non- Tobacco Products Combining Use of Any Smokeless Hispanic Asian (3.5%), Hispanic (20.2%), Tobacco Product Plus Combustible 40%. and non-Hispanic American Indian/ $ Alaska Native (0.8%).

Prevalence = 221) 1.9) 4.0 (3.3 0.6) 1.9 (1.4 1.5) 2.0 (0.7 3.0) 5.6 (4.5 0.9) 2.0 (1.5 2.9) 5.4 (4.3 2.6) 4.6 (3.6 4.4) 7.8 (5.7 0.9) 1.6 (0.6 1.3) 4.1 (3.5 0.5) 1.6 (1.3 3.5) 6.3 (5.2 – – – – – – – – – – – – The overall prevalence of current any n smokeless tobacco product use was 0.8 (0.1 0.5 (0.2

fi avored cigarettes and roll-your-own cigarettes), cigars (including clove cigars 5.6%. By speci c smokeless tobacco Products ( fl products, 5.0% of all students used Combining Use of Snus or chewing tobacco, snuff, or dip; 1.9% or Chewing or Dipping Tobacco used snus; and 0.3% used dissolvable Dissolvable Tobacco Products Plus Snuff tobacco products. — , estimate not reported because relative SE was = 65)

As depicted in Table 1, the prevalence of n 0.4) 1.5 (1.1 0.4) 0.4 (0.3 0.5) 2.4 (1.7 0.3) 0.6 (0.3 0.4) 2.2 (1.6 0.3) 2.0 (1.4 1.2) 3.2 (1.9 0.8) 0.9 (0.6 0.3) 0.3 (0.2 0.6) 2.7 (2.0 – – – – – – – – – current smokeless tobacco use in- – — — creased with age and was lowest —— among respondents aged 9 to 11 years Using Dissolvable (2.2%; 95% CI: 0.9%–3.6%) and highest Tobacco Products ( among those aged $18 years (10.8%; 1 days during the past 30 days: cigarettes (including 2.4) 0.3 (0.2 1.1) 0.2 (0.1 1.8) 3.5) 0.4 (0.2 1.2) 0.2 (0.1 3.4) 0.3 (0.1 3.2) 0.2 (0.1 4.9) 0.6 (0.1 1.0) 1.8) 0.5 (0.3 0.9) 0.2 (0.1 5.7) 4.0) 0.4 (0.3 95% CI: 8.1%–13.5%). The prevalence of $ – – – – – – – – – – – – – —— — current smokeless tobacco use was =313) n ( significantly higher among boys (9.0%; Using Snus

95% CI: 7.2%–10.7%) compared with 1 day during the past 30 days: snus, dissolvable tobacco products, snuff, or chewing or dipping tobacco. $ girls (2.0%; 95% CI: 1.7%–2.4%) and = 838) 6.0) 1.9 (1.5 2.6) 0.8 (0.6 3.2) 1.0 (0.2 8.7) 2.8 (2.1 2.9) 0.9 (0.6 8.4) 2.7 (2.0 7.6) 2.5 (1.8 12.7) 3.6 (2.3 3.3) 0.6 (0.2 4.8) 1.5 (1.3 3.5) 1.9) 0.7 (0.5 11.1) 3.3 (0.8 10.1) 3.2 (2.3 – – – – – – – – – – – – – higher among high school students – n (7.7%; 95% CI: 6.2%–9.3%) compared with middle school students (2.6%; 95% Products ( – or Dipping Tobacco

CI: 2.1% 3.1%). By race/ethnicity, the Using Snuff or Chewing prevalence of current smokeless to- bacco use was lowest among non- Hispanic blacks (2.2%; 95% CI: 1.1%– = 960) 6.6) 5.0 (4.1 3.1) 2.2 (1.7 3.6) 1.9 (0.7 9.3) 7.2 (5.6 3.4) 2.4 (1.9 9.0) 6.9 (5.4 8.1) 6.2 (4.8 13.5) 10.1 (7.4 3.4) 2.2 (1.0 5.7) 4.1 (3.4 4.4) 2.1 (0.6 2.4) 1.6 (1.2 11.6) 6.8 (2.6 10.7) 8.4 (6.8 ned as use of at least 1 of the following tobacco products on – – – – – – – – – – – – – 3.4%), whereas non-Hispanic whites – n fi ( (6.7%; 95% CI: 5.3%–8.1%) and non- a Hispanic American Indian/Alaska Natives (7.4%; 95% CI: 3.3%–11.6%) Product ned as use of at least 1 of the following tobacco products on

had the highest prevalence of smoke- fi

less tobacco use. 8) 2.6 (2.1 – 12) 7.7 (6.2 – Concurrent Tobacco Use Among current smokeless tobacco users, the majority reported use of Prevalence and Pattern ofCharacteristics, Current 2011 Use National of Youth Smokeless Tobacco Tobacco Survey Products Among All US Middle and High School Students by Type of Smokeless Tobacco Product and Sociodemographic Characteristic Using Any Smokeless Tobacco level 14 2.8 (2.3 17 7.5 (5.9 11 2.2 (0.9 avored little cigars), bidis, kreteks, pipes, and waterpipes/hookahs. – – conventional smokeless tobacco prod- 18 10.8 (8.1 fl – 9 Middle school (grades 6 High school (grades 9 12 15 White, non-Hispanic 6.7 (5.3 $ Black, non-Hispanic 2.2 (1.1 Hispanic 5.0 (4.3 Asian, non-Hispanic 2.6 (0.9 Female 2.0 (1.7 AI/AN, non-Hispanic 7.4 (3.3 Male 9.0 (7.2 Any smokeless tobacco use was de Current use of any combustible tobacco product was de TABLE 1 Data are presented asa percentages (95% CI). All datab were weighted to account for the complex survey design. AI/AN, American Indian or Alaska Native; and Overall 5.6 (4.6 Age, y School Race/ethnicity ucts (64.0%; n = 617), whereas 26.8% Gender

PEDIATRICS Volume 132, Number 3, September 2013 e581 Downloaded from www.aappublications.org/news by guest on October 2, 2021 e582 TABLE 2 Concurrent Use Pattern of Smokeless Tobacco With Other Tobacco Products, Perceptions, Social Influences, and Adjusted Effect of Characteristics on Current Any Smokeless Tobacco Use, 2011 National Youth Tobacco Survey

GK tal et AGAKU Proportion of Students, % (95% CI) Adjusted Effect on Smokeless Tobacco Use, aORb (95% CI) Characteristic Nonusers of Any Snus or Dissolvable Tobacco Snuff or Chewing or Combined Users of Snus or Users of Any Smokeless Tobacco Product Users Only (n = 114) Dipping Tobacco Users Dissolvable Tobacco Products Smokeless Tobacco Product Only Plus Snuff or Chewing or Dipping Producta (n =17589) (n =617) Tobacco (n = 221) (n =960) Concurrent use of other tobacco products Current smoking of any 13.0 (11.6–14.4) 80.5 (70.6–90.4) 65.2 (59.1–71.4) 82.3 (76.9–87.7) 72.1 (67.4–76.8) 5.91 (4.36–7.99)* (Ref = nonsmokers) combustible tobaccoc

Downloaded from Current use of electronic 0.6 (0.4–0.8) 8.6 (2.6–14.5) 3.9 (1.9–6.0) 19.2 (12.7–25.7) 8.5 (5.9–11.0) 2.95 (1.62–5.37)* (Ref = nonusers) cigarettes Current use of other “new 1.2 (0.9–1.4) — 15.6 (11.1–20.2) 20.0 (13.2–26.9) 16.3 (12.5–20.2) 4.11 (2.47–6.87)* (Ref = nonusers) tobacco products” not specified Beliefs, attitudes, and www.aappublications.org/news perceptions Self-report that it would be 60.6 (57.9–63.4) 93.7 (88.1–99.3) 92.6 (89.0–96.1) 97.1 (94.6–99.6) 93.9 (91.5–96.2) 2.22 (1.35–3.63)* (Ref = not easy) easy or somewhat easy to get tobacco Belief that all tobacco 91.6 (90.8–92.4) 67.6 (57.7–77.4) 67.9 (63.0–72.8) 64.6 (57.6–71.6) 67.0 (63.3–70.7) 0.55 (0.38–0.79)* (Ref = not harmful) products are harmful Exposure to smokeless tobacco health warning labels Saw warning label on 47.9 (45.1–50.8) 64.0 (50.0–78.0) 75.7 (70.8–80.7) 86.3 (81.1–91.5) 78.1 (74.0–82.2) 2.68 (1.93–3.74)* (Ref = never or rarely) smokeless tobacco d byguest on October2,2021 products in past 30 days Exposure and receptivity to tobacco advertisement Exposure to tobacco 51.5 (49.3–53.7) 68.7 (55.8–81.5) 69.9 (64.5–75.3) 73.3 (66.3–80.2) 70.8 (66.5–75.1) 1.24 (0.93–1.65) (Ref = never or rarely) advertisements at billboard or store Likely to use or wear 16.0 (14.9–17.2) 56.9 (46.9–66.9) 57.8 (53.3–62.2) 64.2 (55.2–73.2) 59.4 (55.6–63.3) 1.68 (1.26–2.25)* (Ref = not likely) something with tobacco company name or picture Bought or received 10.5 (9.7–11.3) 39.2 (29.9–48.6) 41.1 (35.7–46.5) 52.1 (43.9–60.2) 44.0 (39.8–48.1) 1.41 (1.01–1.99)* (Ref = no purchase/receipt) something with tobacco company name/picture in past 12 months Protobacco influences One or more close friends 29.7 (27.4–31.9) 73.2 (63.6–82.7) 74.5 (70.0–78.9) 85.3 (79.4–91.2) 77.4 (74.3–80.5) 0.82 (0.59–1.12) (Ref = none) smokes cigarettes One or more close friends 12.9 (11.0–14.8) 41.9 (30.0–53.7) 79.2 (75.0–83.4) 91.6 (87.4–95.9) 79.2 (76.2–82.3) 9.56 (7.14–12.80)* (Ref = none) uses smokeless tobacco ARTICLE

(n = 221) reported combined use of conventional plus novel products such as snus or dissolvable tobacco prod- ucts, and only 9.2% (n = 114) reported (95% CI)

b using only novel smokeless tobacco products. About 72.1% of smokeless tobacco users also smoked combusti- ble tobacco products. Also, 80.5% of 1.27) (Ref = none) 4.95)* (Ref = none) – – Tobacco Use, aOR

Adjusted Effect on Smokeless users of snus or dissolvable tobacco products also smoked combustible to- bacco products. a 62.1) 0.96 (0.73 40.7) 3.32 (2.23 – – Factors Associated With Smokeless

=960) Tobacco Use n Product ( Users of Any Of the covariates assessed, perceiving avored cigarettes and roll-your-own cigarettes), cigars (including clove cigars Smokeless Tobacco fl that all tobacco products are harmful was the only protective factor against smokeless tobacco use (adjusted odds – 73.8) 57.3 (52.4 52.9) 35.6 (30.5

= 221) ratio [aOR]: 0.55; 95% CI: 0.38 0.79), – – n whereas a pro–smokeless tobacco – 40%. peer (aOR: 9.56; 95% CI: 7.14 12.80) and $ Tobacco ( household environment (aOR: 3.32; 95%

Combined Users of Snus or CI: 2.23–4.95) were associated with Dissolvable Tobacco Products Plus Snuff or Chewing or Dipping significantly higher odds of smokeless tobacco use. However, cigarette smok- 60.4) 65.7 (57.7 41.8) 45.5 (38.1

1 days during the past 30 days: cigarettes (including ing by either peers or household – – $ fi

=617) members was not signi cantly associ- Only n ( ated with current smokeless tobacco

Snuff or Chewing or use (Table 2). Dipping Tobacco Users 1 days during the past 30 days: snus, dissolvable tobacco products, or snuff or chewing or dipping tobacco. $

Proportion of Students, % (95% CI) Access and Intention to Quit = 114) n — , estimate not reported because relative SE was Slightly more than half (53.9%) of cur- 58.4) 54.8 (49.2 18.5) 34.9 (28.0 – – rent users of snuff or chewing or dipping tobacco reported that they obtained smokeless tobacco from someone else, 32.2% reported pur- Snus or Dissolvable Tobacco Product Users Only ( chasing it, 3.6% reported stealing from a store or someone else, and 10.3% ned as use of at least 1 of the following tobacco products on fi 38.2) 49.4 (40.5 8.6) 10.9 (3.3 obtained it through other ways not – – specified. Among those who did pur- =17589) Product n ( 7.1 (5.6 chase smokeless tobacco within the 35.6 (32.9

Smokeless Tobacco past 30 days, 70.2% reported that they ned as use of at least 1 of the following tobacco products on fi bought it from a retail store, 4.0% purchased over the Internet/mail, 3.5% purchased from a vending machine,

.05. whereas 22.3% reported that they , P

uences. purchased it through some other way Continued

Characteristic Nonusers of Any not specified. Moreover, 93.9% of smoke- cant at fi household smokes any combustible tobacco household uses smokeless tobacco avored little cigars), bidis, kreteks, pipes, and waterpipes/hookahs.

fl less tobacco users felt it would be easy One or more persons in One or more persons in Among students who reported seeing a smokeless tobacco product within the past 30 days. Any smokeless tobacco use wasAdjusted de for age, gender, race/ethnicity, school level, current use of smoked tobacco products, receptivity toward protobacco advertisements (as measured by buying or receiving an item with a tobacco name or picture), and protobacco peer and Current use of any combustible tobacco product was de * Signi TABLE 2 All data were weighteda to account for the complexb survey design. Ref, referent category; c d household in fl and to get tobacco if they wanted to.

PEDIATRICS Volume 132, Number 3, September 2013 e583 Downloaded from www.aappublications.org/news by guest on October 2, 2021 An intention to quit all tobacco use was gender differences in household smokeless tobacco products such as reported by 40.1% of smokeless to- members’ use of tobacco products snus or dissolvable tobacco products. bacco users, with those combining the explained only 1.9% of the male-female Most smokeless tobacco users also use of conventional plus novel smoke- gap in smokeless tobacco use (Table 3). smoked combustible tobacco products, less tobacco products reporting sig- In contrast, gender differences in the and ∼4 of 5 users of snus or dissolvable nificantly lower quit intention rates use of combustible tobacco products tobacco products concurrently smoked compared with those who used only (with higher use among boys) combustible tobacco products. novel smokeless tobacco products explained 17.0% of the male-female These findings are generally at odds , (34.2% vs 57.7%; P .05). difference in smokeless tobacco use, with the recent positions in favor of whereas gender differences in proto- novel smokeless tobacco products as Exposure to Health Warning Labels bacco peer relationships (with boys a means of harm reduction. Whereas The prevalence of self-reported expo- having more close friends who used novelsmokelesstobaccoproductssuch sure to warning labels on smokeless smokeless tobacco and cigarettes) as snus or dissolvable tobacco prod- tobacco products was lowest among further explained 19.1% of the male- ucts contain lower levels of tobacco- respondents who used novel smoke- female gap in smokeless tobacco use. specific nitrosamines compared with less tobacco products only (64.0%; 95% In addition, some of the male-female combustible tobacco products or con- CI: 50.0%–78.0%) and highest among difference in smokeless tobacco use ventional smokeless tobacco prod- was explained by gender differences in combined users of novel plus conven- ucts,6 the dual-use patterns found in exposure and receptivity to tobacco tional smokeless tobacco products this study suggest that any harm re- promotional activities (10.7%) and dif- (86.3%; 95% CI: 81.1%–91.5%). Even af- duction that might be associated with ferential perception that all tobacco ter controlling for potential con- these low-nitrosamine novel products products are harmful (6.5%). founders, exposure to warning labels may be negated by the finding that they on smokeless tobacco products was are often used concurrently with high- not protective against smokeless to- DISCUSSION nitrosamine conventional smokeless bacco use (aOR 5 2.68; 95% CI: 1.93– Our results indicate that the overall tobacco products and/or with com- 3.74; Table 2). prevalence of smokeless tobacco use bustible tobacco products. The in- among US youth was 5.6%, which sub- creased popularity and use of high- Explaining Gender Differences stantially differed by gender, age, and nitrosamine moist snuff in recent Only 2.0% of the male-female differ- race/ethnicity. Moreover, this study years further complicates the argu- ence in smokeless tobacco use was identified that the majority of smokeless ment of harm reduction with smoke- explained by gender differences in tobacco users used snuff or chewing or less tobacco products.4 Thus, whereas sociodemographic characteristics such dipping smokeless tobacco products, the evidence is suggestive that switch- as age and race/ethnicity. Similarly, alone or in combination with novel ing from cigarettes to novel smokeless tobacco products might reduce in- TABLE 3 Assessment of Male-Female Differences in Smokeless Tobacco Use, 2011 National Youth dividual risk, promotion of snus or Tobacco Survey dissolvable tobacco products at a pop- Characteristic Male-Female Gap in Smokeless Tobacco Use P ulation level may not have benefits and Explained by Gender Difference in Observed might even cause harm from dual use Characteristics, % (95% CI) with combustible and/or conventional $ – , Use of cigarette or smokeless tobacco by 1 19.11 (15.39 22.84) .001 smokeless tobacco products.6,12,13 The close friend Use of cigarette or smokeless tobacco by $1 1.92 (0.0–4.09) .081 American Academy of Pediatrics has household member thus called for the regulation of novel Exposure and receptivity to tobacco 10.72 (7.05–14.38) ,.001 smokeless tobacco products to pre- advertisements Current use of any combustible tobacco 16.89 (12.93–20.85) ,.001 vent potential harm to children and productsa adolescents.14 Perception that all tobacco products are harmful 6.50 (4.01–8.99) ,.001 Sociodemographic characteristicsb 2.00 (0.73–3.24) .002 The relatively higher prevalence of All data were weighted to account for the complex survey design. smokelesstobaccouseamongboysand a Current use of any combustible tobacco product was defined as use of at least 1 of the following tobacco products on $1 non-Hispanic whites found in our study days during the past 30 days: cigarettes (including flavored cigarettes and roll-your-own cigarettes), cigars (including clove is consistent with reports in the liter- cigars and flavored little cigars), bidis, kreteks, pipes, and waterpipes/hookahs. – b Sociodemographic characteristics assessed included age and race/ethnicity. ature.15 18 In addition, the important

e584 AGAKU et al Downloaded from www.aappublications.org/news by guest on October 2, 2021 ARTICLE role of current use of combustible to- underscores the need for stronger patterns of conventional and novel bacco products and pro–smokeless health warnings for smokeless tobacco smokeless tobacco use and access and tobacco peer influence on smokeless products (such as a combination of factors related to use. Nonetheless, the tobacco use was further shown by the graphic and text warnings) and bans or findings in this study are subject to fact that most of the gender difference restrictions on smokeless tobacco a number of limitations due to its de- in smokeless tobacco use was ex- advertisements. sign.First,recallbiasmayhaveresulted plained by these factors. The relatively low quit-intention rates in an underreporting of tobacco use. Although we found that harm percep- among respondents who combined use Also, the cross-sectional study design precludes making inferences on cau- tion of all tobacco products was pro- of conventional plus novel smokeless sality and can only indicate associa- tective of smokeless tobacco use, the tobacco products, coupled with the tions. fact that exposure to health warning finding of the protective effect of risk labels was not protective of smokeless perception of all tobacco products, tobacco use suggests the need for highlights the role that pediatricians CONCLUSIONS more effective warning labels on smoke- can play in providing cessation support less tobacco products. Strikingly, we This study revealed that conventional by educating youth on risks of tobacco noted that a lower proportion of users smokeless tobacco products remain use during pediatricconsultation visits. of novel smokeless tobacco products, the predominant form of smokeless This can also be an opportunity to ei- such as snus or dissolvable tobacco tobacco use and that most users of ther refer an accompanying household products, reported seeing a warning novel smokeless tobacco products also member who might be using smoke- label on a smokeless tobacco product concurrently smoked combustible to- less tobacco or offer cessation support compared with users of conventional bacco products. Moreover, smokeless smokeless tobacco products or with to that member considering that tobacco use was associated with lower ’ respondents who combined use of that household members continued perception of harm from all tobacco conventional plus novel smokeless to- smokeless tobacco use might be as- products and protobacco social influ- bacco products. This finding may sug- sociated with greater odds that the ences, indicating the need to change gest a dilutary effect of the visibility adolescent child may use smokeless adolescents’ perception about the or impact of text-only health labels tobacco too. dangers of all tobacco products and to by the highly colorful packaging of This study used a large, nationally denormalize tobacco use through novel smokeless tobacco products and representative sample to assess evidence-based interventions.

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e586 AGAKU et al Downloaded from www.aappublications.org/news by guest on October 2, 2021 Use of Conventional and Novel Smokeless Tobacco Products Among US Adolescents Israel T. Agaku, Olalekan A. Ayo-Yusuf, Constantine I. Vardavas, Hillel R. Alpert and Gregory N. Connolly Pediatrics 2013;132;e578 DOI: 10.1542/peds.2013-0843 originally published online August 5, 2013;

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 Use of Conventional and Novel Smokeless Tobacco Products Among US Adolescents Israel T. Agaku, Olalekan A. Ayo-Yusuf, Constantine I. Vardavas, Hillel R. Alpert and Gregory N. Connolly Pediatrics 2013;132;e578 DOI: 10.1542/peds.2013-0843 originally published online August 5, 2013;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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