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Use of Conventional and Novel Smokeless Tobacco Products Among US Adolescents

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Use of Conventional and Novel Smokeless Tobacco Products Among US Adolescents Use of Conventional and Novel Smokeless Tobacco Products Among US Adolescents WHAT’S KNOWN ON THIS SUBJECT: Despite declines in cigarette smoking, smokeless tobacco 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 snuff or chewing or dipping tobacco, whereas 2.2% University of Pretoria, Pretoria, South Africa used snus 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, addiction 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 (“chewing tobacco”, “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 e578 AGAKU et al Downloaded from www.aappublications.org/news by guest on October 2, 2021 ARTICLE Conventional smokeless tobacco prod- school students by using data from the cigarettes (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 tobacco smoking 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 tobacco industry 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 nitrosamines 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-nitrosamine 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 harm reduction 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.
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