The Impact of Graphic Health Warning Labels on Smokeless Tobacco Packets on Motivation to Quit among Current Users: A Cross-Sectional Study

FigureSmokeless tobacco causes cancers of the oral cavity, esophagus, and pancreas.1 CDC analyzed National Health Interview Survey (NHIS) data to estimate the proportion of U.S. working adults who used smokeless tobacco in 2005 and 2010, by industry and occupation. This report describes the results of that analysis, which showed no statistically significant change in the prevalence of smokeless tobacco use among workers from 2005 (2.7%) to 2010 (3.0%). In 2010, smokeless tobacco use was highest among adults age 25 to 44 (3.9%), males (5.6%), non-Hispanic whites (4.0%), those with no more than a high school education (3.9%), and those living in the South (3.9%). By industry, the prevalence of smokeless tobacco use ranged from 1.5 percent in education services to 18.8 percent in mining industries, and by occupation from 1.3 percent in office and administrative support to 10.8 percent in construction and extraction. These findings highlight opportunities for reducing the health and economic burdens of tobacco use among U.S. workers, especially those in certain industries and occupations where use of smokeless tobacco is especially common. CDC recommends best practices for comprehensive tobacco-control programs, including effective employer interventions, such as providing employee health insurance coverage for proven cessation treatments, offering easily accessible help for those who want to quit, and establishing and enforcing tobacco-free workplace policies.2 NHIS is an annual, nationally representative, in-person survey of the noninstitutionalized U.S. civilian population. Questions about cigarette smoking are directed to one randomly selected adult in each surveyed family. In 2005 and 2010, data on cigarette smoking were collected from 31,428 and 27,157 persons, respectively. The same participants responded to a supplemental questionnaire that contained questions regarding the use of smokeless tobacco (i.e., chewing tobacco and snuff). The survey response rates for the adult core and supplemental questionnaire combined were 69.0 percent in 2005 and 60.8 percent in 2010. Survey participants were considered currently working if, when asked about their employment status during the week before their interview, they responded, “working at a job or business,” “with a job or business but not at work,” or “working, but not for pay, at a family-owned job or business.” (A total of 19,445 and 15,649 survey respondents were classified as currently working in 2005 and 2010, respectively.) Information on participants' current industry and occupation was coded by trained coders and grouped into 21 industry groups and 23 occupation groups. Current cigarette smokers were defined as respondents who reported having smoked at least 100 cigarettes during their lifetime and who reported currently smoking every day or some days. Current smokeless tobacco users were defined as those who reported using chewing tobacco or snuff at least 20 times in their lifetime and who reported currently using chewing tobacco or snuff every day or some days. Dual users were persons who were both current cigarette smokers and smokeless tobacco users. Sample weights were used to account for the complex sample design. Estimates with a relative standard error of 30 percent or more are not reported. Two-tailed t-tests were used to determine statistically significant differences between point estimates. The estimated number of adults age 18 and over who were working during the week before the interview was 141 million in 2005 and 139 million in 2010. Current smokeless tobacco use prevalence among working adults did not significantly differ from 2005 (2.7%) to 2010 (3.0%). The prevalence of smokeless tobacco use among working adults was highest among those 18 to 24 (3.6%) in 2005 and those 25 to 44 (3.9%) in 2010, and among males (4.9% and 5.6%, in 2005 and 2010, respectively), non-Hispanic whites (3.5% and 4.0%), those with no more than a high school education (3.6% and 3.9%), and those living in the Midwest (3.8% and 3.3%) or South (3.1% and 3.9%). Current cigarette smoking prevalence among working adults age 18 and over was 22.2 percent in 2005 and 19.1 percent in 2010. Among working adults who currently smoke cigarettes, the proportion who currently used smokeless tobacco (i.e., dual users) was 4.1 percent in 2005 and 4.2 percent in 2010. In 2010, dual use was greatest among the following subgroups of working adult smokers: those aged 18 to 24 (6.3%), males (7.3%), non-Hispanic whites (3.9%), those with no more than a high school education (4.5%), those with an annual household income of at least $75,000 (4.8%), and those living in the Midwest (5.3%). Among adult workers, the average number of cigarettes smoked per day was significantly higher among dual users (15.5) compared with those who used cigarettes only (12.1). 10 Industry Groups, 8 Occupation Groups Reliable 2010 estimates of smokeless tobacco use were available for workers in 10 industry groups. The prevalence of smokeless tobacco use in 2010 was highest among workers in the mining (18.8%), wholesale trade (8.9%), and construction (7.9%) industries. Reliable estimates of dual use among smoking workers were available only for construction (10.2%) and manufacturing (7.1%). Reliable 2010 estimates of smokeless tobacco use were available for workers in eight occupation groups. The prevalence of smokeless tobacco use in 2010 was highest among workers in construction and extraction (10.8%) and installation, maintenance, and repair (9.0%) occupations. No respondents in health care support occupations reported smokeless tobacco use. Reliable estimates of dual use among smoking workers were available only for construction and extraction (14.5%) and production (5.7%) occupations. In 2010, the prevalence of smokeless tobacco use among working adults (3.0%) exceeded the Healthy People 2020 target of no more than 0.3 percent for all U.S. adults, as did nearly all demographic and industry and occupation subgroups for which results are presented in this report. Although current cigarette smoking prevalence among working adults was significantly lower in 2010 (19.1%) than in 2005 (22.2%), the prevalence of smokeless tobacco use did not significantly differ from 2005 (2.7%) to 2010 (3.0%). The lack of reduction in smokeless tobacco use might be attributable to the introduction of novel smokeless tobacco products into the U.S. marketplace (e.g., snus and dissolvable tobacco), as well as increased expenditures on smokeless tobacco marketing in recent years.3,4 Tobacco industry advertising encourages cigarette smokers to use smokeless tobacco as an alternative in locations where smoking is not permitted.5,6 Additionally, research indicates that cigarette smokers might switch to smokeless tobacco for the purposes of harm reduction or smoking cessation.7 However, smokeless tobacco is not a safe alternative to combustible tobacco, and no conclusive scientific evidence currently exists showing that switching to smokeless tobacco promotes long-term cigarette smoking cessation.8 Because persons who concurrently use smokeless tobacco and cigarettes are less likely to report planning to quit than adults who smoke cigarettes exclusively,9 evidence-based interventions to reduce all forms of tobacco use are warranted. High-impact antitobacco media messages, comprehensive smoke-free policies, increased tobacco prices, and other interventions that prevent initiation and encourage cessation of tobacco products, in concert with sustained, comprehensive state tobacco control programs funded at CDC-recommended levels, are critical to decreasing tobacco use and reducing the health burden and economic impact of tobacco-related diseases in the United States.2 Limitations The findings in this report are subject to at least four limitations: First, because tobacco use information was self-reported and was not validated by biochemical tests, the extent of underreporting or overreporting of tobacco use could not be determined. Self-reported current cigarette smoking status has been shown to have a high validity,10 but the validity of self-reported smokeless tobacco use has not been established. Second, a limited sample size prevented the presentation of reliable estimates for some subpopulations. Third, the NHIS response rates of 69.0 and 60.8 percent might have resulted in nonresponse bias. Finally, the prevalence of smokeless tobacco use might be underestimated because certain smokeless tobacco products (e.g., snus) were not included in the NHIS questionnaire. Summary Health professionals can play an important role in assessing smokeless tobacco use and advising users to quit. Results from this report identify industry and occupation groups with a high prevalence of smokeless tobacco use where evidence-based cessation interventions could be effective in reducing tobacco use. Employers can help reduce tobacco use among employees by making their workplaces tobacco-free—which allow no use of any tobacco products (including cigarettes, cigars, pipes, smokeless tobacco products, or of electronic cigarettes—by anyone at any time. providing employees with information on the health risks of tobacco use and the benefits of quitting, and sponsoring workplace-based tobacco cessation services, including employer-sponsored health insurance that covers proven treatments for tobacco use and dependence.2 Such efforts can help to achieve the Healthy People 2020 objective to reduce smokeless tobacco use by adults to no more than 0.3 percent by 2020. Reprinted (slightly adapted) from Morbidity and Mortality Weekly Report 2014; 63;477-482.

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. 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. 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. 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. 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.

Smokeless tobacco (SLT) use, particularly gutka and khaini, is a significant public health concern in India, mainly in rural areas. This prospective cohort study aimed to investigate the association between SLT use and oral cancer incidence among rural Indian men. A cohort of 300 rural Indian men without a history of oral cancer was recruited and followed for five years. Baseline data on SLT use (type, frequency, and duration) and other risk factors were collected. Annual oral examinations and medical record reviews were conducted to identify incident cases of oral cancer. Incidence rates, relative risks, and hazard ratios (HR) were calculated to assess the association between SLT use and oral cancer. Among the 300 participants, 185 (61.7%) were SLT users at baseline. During follow-up, 25 incident cases of oral cancer were diagnosed. The incidence rate of oral cancer was significantly higher among SLT users (24.3 per 1,000 person-years) compared to non-users (5.4 per 1,000 person-years). After adjusting for confounders, the HR for oral cancer associated with SLT use was 4.51 (95% CI: 2.03-9.98), indicating a significantly increased risk. A dose-response relationship was observed, with higher frequency and longer duration of SLT use associated with increased risk. This study provides strong evidence for a significant association between SLT use and increased risk of oral cancer among rural Indian men. The findings underscore the urgent need for targeted interventions to reduce SLT use and promote oral cancer awareness in this high-risk population.

Background: Cigarette smoking is one of the strongest modifiable risk factors for peripheral artery disease (PAD), a disease which affects over 200 million people worldwide. Though cigarette use has decreased across time, use of cigars, pipes and smokeless tobacco remains unchanged or slightly increased. The association of PAD and non-cigarette tobacco use is not well described. Thus, we tested the hypothesis that the use of cigars, pipes or smokeless tobacco is associated with incident PAD even after adjustment for cigarette use. Methods: A total of 14,395 Atherosclerosis Risk in Communities (ARIC) Study participants with no history of prevalent PAD were followed from 1987 to 2015 for PAD events (hospitalizations with PAD diagnosis or leg revascularization). Baseline pipe, cigar smoking and smokeless tobacco use was self-reported. Multivariable-adjusted Cox proportional hazards regression was used. Results: At enrollment the 14,395 participants included in the study were on average (SD) 54 (6) years old, 55% female and 27% African American; 489 (3.4%) were current users of smokeless tobacco and 481 (3.3%) current users of cigars or pipes. A total of 1,289 incident PAD events occurred during a median of 25.9 years of follow-up. After adjustment for demographics and cigarette smoking status, risk of incident PAD was higher among current (versus never) users of smokeless tobacco [HR (95% CI): 1.66 (1.29-2.12)], though this association was attenuated with adjustment for CVD risk factors (Table). Cigar and pipe use were not associated with PAD incidence, regardless of degree of adjustment (Table). Conclusion: Active use of smokeless tobacco was associated with increased risk for incident PAD compared to non-use, independent of cigarette smoking, although this relationship was not statistically significant after adjustment for cardiovascular risk factors. No association was observed with use of pipes or cigars. Use of smokeless tobacco may increase PAD risk and could be a potential target for intervention.

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. 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. 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 <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. 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.

The global impact of tobacco control policies on smokeless tobacco use: a systematic review

BackgroundThe aim of the study was to investigate the practice and pattern of smokeless tobacco (SLT) use as well as the knowledge and perception about its ill effects among rural Bangladeshi adolescents.MethodsA cross-sectional survey was conducted among students aged 13–18 years in two rural secondary schools in Bangladesh in August 2015. Data were collected through a self-administered questionnaire which consists of topics derived from the Social Cognitive Theory and Health Belief Model (personal characteristics, environmental factors, self-efficacy, outcome expectancies, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action). Data analysis was performed using SPSS version 24. A descriptive analysis was conducted to determine the current pattern of SLT use and knowledge about its ill effects. A chi-square test and Fisher exact test were conducted to explore associations between variables. Lastly, a logistic regression model was used to locate the predictors for current SLT use.ResultsA total of 790 students participated in the study. Among them, 9.5% (75) had used SLT at least once and 3.7% (29) were current SLT users. Males had a higher incidence of SLT use compared with females. The majority of students (77.3%) initiated SLT use between 10–13 years of age. ‘Zarda’ was the most common type of SLT used and most of the current users (86%) were able to buy SLT without age restrictions. Most of the current users (90%) wanted to quit SLT immediately; however, professional help was not available in schools. Overall, students had a good knowledge about the harmful effects of SLT with 54.8% (428) of respondents scoring in the good knowledge category. However, the majority of never SLT users (55.4%; 396) had a good knowledge compared to ever SLT users (42.7%; 32). Significant predictors of current SLT use included being a student aged 14 years and above (OR = 6.58, 95% CI [2.23–28.31]) as well as the variables of self-efficacy (OR = 5.78, 95% CI [1.46–19.65]), perceived barriers (OR = 0.30, 95% CI [0.10–0.74]), perceived benefit (OR = 0.21, 95% CI [0.05–1.03]) and perceived severity (OR = 0.36, 95% CI [0.16–0.91]).DiscussionThis study demonstrates the need for comprehensive prevention and control programme in rural schools targeting young adolescents. Effective measure should be taken to reshape the attitude of rural adolescents towards self-confidence and competence, as to prevent SLT use.

Prevalence rates of smokeless tobacco (SLT) use and late initiation among firefighters (ie, starting use as an adult after joining the fire service) are remarkably high, 10.5% and 26.0%, respectively. The purpose of this study is to examine characteristics associated with late SLT initiation in a sample comprised of male career firefighters from two large cohort studies. We examined correlates of late SLT initiation in a secondary analysis of data combining the baseline evaluations of two published firefighter health studies with 1474 male career firefighters in the United States. Fourteen percent of participants were current SLT users. Among this group, the unadjusted rate of firefighters who initiated SLT use after joining the fire service was 15.9%, while the age-standardized rate was 38.2%; this is substantially higher than the national adjusted late initiation rate among adult males (0.8%). In addition, firefighters demonstrated higher rates of late SLT initiation (15.9% unadjusted; 18.4% age-standardized) when compared to males in the military overall (13.8%). The exceptionally high prevalence of SLT use overall and late initiation in the fire service suggest that joining the fire service in the United States is a risk factor for SLT use. There is a need to develop interventions aimed at reducing SLT use in the fire service that are specifically tailored for this occupational group. The high prevalence of late SLT initiation (ie, starting use as an adult after joining the fire service) among firefighters should be addressed by both researchers and fire service organizations given the significant health risks associated with SLT and its impact on occupational readiness. There is a need for developing intervention programs aimed at reducing SLT use in the fire service. Interventions would need to be specifically tailored for this occupational group and their unique culture, given that joining the fire service appears to be a risk factor for SLT initiation among firefighters who did not use tobacco prior to joining the fire service.

BackgroundAlthough the Framework Convention on Tobacco Control prioritizes monitoring of tobacco use by population-based surveys, information about the prevalence and patterns of tobacco use in sub-Saharan Africa is limited. We provide country-level prevalence estimates for smoking and smokeless tobacco (SLT) use and assess their social determinants.MethodsWe analyzed population-based data of the most recent Demographic Health Surveys performed between 2006 and 2013 involving men and women in 30 sub-Saharan African countries. Weighted country-level prevalence rates were estimated for ‘current smoking’ (cigarettes, pipe, cigars, etc.) and ‘current SLT use’ (chewing, snuff, etc.). From the pooled datasets for men and women, social determinants of smoking and SLT use were assessed through multivariate analyses using a dummy country variable as a control and by including a within-country sample weight for each country.ResultsAmong men, smoking prevalence rates were high in Sierra Leone (37.7%), Lesotho (34.1%), and Madagascar (28.5%); low (<10%) in Ethiopia, Benin, Ghana, Nigeria, and Sao Tome & Principe; the prevalence of SLT use was <10% in all countries except for Madagascar (24.7%) and Mozambique (10.9%). Among women, smoking and SLT prevalence rates were <5% in most countries except for Burundi (9.9%), Sierra Leone (6%), and Namibia (5.9%) (smoking), and Madagascar (19.6%) and Lesotho (9.1%) (SLT use). The proportion of females who smoked was lower than SLT users in most countries. Older age was strongly associated with both smoking and SLT use among men and women. Smoking among both men and women was weakly associated, but SLT use was strongly associated, with education. Similarly, smoking among men and women was weakly associated, but SLT use was strongly associated, with the wealth index. Smoking and SLT use were also associated with marital status among both men and women, as well as with occupation (agriculturists and unskilled workers).ConclusionsPrevalence of smoking among women was much lower than in men, although the social patterns of tobacco use were similar to those in men. Tobacco control strategies should target the poor, not/least educated, and agricultural and unskilled workers, who are the most vulnerable social groups in sub-Saharan Africa.

BackgroundAlthough smokeless tobacco (SLT) use is prevalent in South Asian countries including Bangladesh, information about the pattern and correlates of SLT use is scarce. This study described the pattern and predictors of SLT use among Bangladeshi adults.MethodsThe data for this study were derived from the International Tobacco Control Policy Evaluation Bangladesh (ITC BD) Survey, a prospective cohort survey of a nationally representative sample of smokers and non-smokers, conducted during November 2011 and May 2012. The study included 5522 adults aged 15 or above. We used multiple logistic regression models to identify predictors of SLT use.ResultsOf the respondents (N = 5522), 20% were SLT users. In general, SLT use was significantly higher among women, the illiterate and residents of the Dhaka slums or non-tribal/non-border areas outside Dhaka; SLT use increased with age. Several attitudinal factors were also associated with SLT use. Multivariable logistic regression analyses revealed several predictors of SLT use: being female (OR = 1.96, 95% confidence interval, CI: 1.18–3.24), an increasing age, being a resident of a Dhaka slum (OR = 5.86; 95% CI: 3.73–9.21) or non-tribal/non-border areas outside Dhaka (OR = 3.42; 95% CI: 1.94–6.03), being illiterate (OR = 3.37; 95% CI: 1.99–5.71), holding positive opinion towards societal approval of SLT use (OR = 5.84; 95% CI: 3.38–10.09), holding positive opinion towards SLT use by women (OR = 2.63; 95% CI: 1.53–4.54), believing that SLT is addictive (OR = 2.96; 95% CI: 1.51–5.81), and believing SLT is less harmful than bidi (OR = 2.22; 95% CI: 1.36–3.62).ConclusionThe findings suggest that coordinated efforts of governmental and non-governmental organizations, targeting both smoked tobacco and SLT use reduction and cessation, could be modified to reach each level of population including those who are marginalized, female, less educated and elderly. As most tobacco control programs in Bangladesh target mainly cigarette or bidi smoking, coordinated programs are needed that will also include SLT use within the tobacco control policy and prevention strategies.

Compared with smoking, there is much less information about smokeless tobacco (ST) use in the United States. The purpose of this study is to characterize and compare ST use among American men in 2000 and 2005. We used US National Health Interview Surveys from 2000 and 2005 to estimate the prevalence of ST use, describe the demographic and socioeconomic profile of ST users and evaluate ST use according to product type and with respect to smoking. The prevalence of ST use among American men was 4.4% in 2000 and 4.3% in 2005. Almost all ST users were white, about half were 25-44 years old and 80% lived in the South or Midwest, commonly in small metropolitan and rural areas. Educational and income levels of ST users were lower than those of never users of tobacco. One-third of ST users also smoked; cigarette consumption was lower among dual users than among exclusive smokers. In 2005, 1.3 million current ST users were former smokers but 3.2 million smokers were former ST users. ST users were evenly distributed between snuff (43%) and chewing tobacco (44%) in 2000 and 13% used both products. By 2005 snuff use was clearly dominant. The prevalence of ST use among men is low but stable; dual use of cigarettes and ST is common, and snuff has become the dominant ST product.

Tobacco use is widely prevalent in different forms in Nepal. These habits are deeply rooted among different age groups and gender. There is no information available on all aspects of smokeless tobacco (SLT) use and its implications in Nepal. To review the types of SLT products available in Nepal, prevalence of SLT use, correlates of SLT use, SLT-related harm, and existing gaps in information and policy implications. This review is mainly based on information from literature, and some WHO and other documents. The prevalence of smokeless tobacco use is high, particularly among males and disadvantaged groups. SLT users have multiple habits of tobacco chewing, smoking and drinking. Despite SLT products being manufactured in the unorganized sector, they are also largely imported from India. People have easy access to various SLT products. There is a general lack of information on the health hazards of SLT use to the population. This calls for research on the issue. In order to succeed in reducing SLT use in Nepal, addressing the challenges of enforcing the Tobacco Control Act through a multisectoral approach and developing capacity of sectors other than health is of vital importance.

Purpose: To identify and compare the determinants of different types of tobacco use among rural youths and discuss the implication of these differences for youth tobacco use cessation. Methods: Ninth grade participants (n = 883) were 95% white, between 13 and 19 years old with a mean age of 14.6 years. Students were classified into four exclusive groups: non–tobacco use, smoking only, smokeless tobacco (ST) use only, and conjoint smoking and ST use. The influences of 14 specific risk factors on tobacco use were investigated for each group using separate multiple logistic regression analyses. Results: Among participants, 20% were smokers only, 6% were ST users only, and 10% were conjoint users. Students who had more friends (odds ratio [OR] =] 2.75) and siblings (OR = 1.96) who smoke, family problems (OR = 1.70), and favorable attitudes toward tobacco use (OR = 1.12) were more likely to smoke than were other students. Among students who used only ST, gender was a primary determinant (95% were male). Excluding gender, sibling ST use (OR = 4.28), friends' ST use (OR = 1.71), and favorable attitudes (OR = 1.11) were the most significant risk factors. Male students were also more likely to use both cigarettes and ST (OR = 8.62). In addition, among students who used both tobacco products, siblings' and friends' ST use were significant (OR = 3.09 and 2.13, respectively), as well as family problems (OR = 2.41) and attitude (OR = 1.15). Unlike smokers only or ST users only, lack of knowledge about tobacco was a significant determinant among conjoint users (OR = 1.39). Conclusions: Findings revealed that 7 of 14 factors were significant predictors of tobacco use. Some factors predicted smoking only, ST only, and conjoint use; however, the pattern of predictors varied for these three categories. Implications for these findings as they relate to tobacco use interventions are discussed.

Cancer survivors experience treatment-related complications that can be exacerbated by tobacco use. This study reports the prevalence of smokeless and dual tobacco use, compares these rates to the U.S. population, and examines tobacco risk factors among males surviving childhood cancer. Data from the Childhood Cancer Survivor Study (CCSS) 2007 survey were used (N = 3378). Standardized incidence ratios (SIR) were obtained by comparing CCSS data with the National Survey on Drug Use and Health. Logistic regression was used to evaluate associations between risk factors and tobacco use. Among male survivors, 8.3% and 2.3% were current smokeless tobacco and dual tobacco users, respectively. Survivors were less likely than population males to report smokeless tobacco [SIR = 0.64; 95% confidence interval (CI), 0.57-0.72) or dual tobacco (SIR = 0.37; CI, 0.29-0.46) use; however, non-White survivors aged 35 to 49 years were more likely to use smokeless tobacco (SIR = 2.32; CI, 1.27-3.90). Smokeless tobacco use was associated (P < 0.05) with younger age at diagnosis, lower education, being married or divorced/separated, and not living in the Northeastern United State, whereas history of cardiovascular- and/or pulmonary-toxic treatment was protective. Dual tobacco use was associated with younger age at diagnosis, lower education, divorce/separation, and high psychologic distress. Having active heart or circulatory conditions was protective. Although smokeless tobacco/dual tobacco use is generally low among childhood cancer survivors, these findings suggest that tobacco use screening should be expanded to include smokeless tobacco use, and that smokeless tobacco-specific education and cessation interventions should be provided to users. Screening and intervening for smokeless tobacco/dual tobacco use in childhood cancer survivors will reduce tobacco-related morbidity and mortality.

BackgroundSmokeless tobacco use is becoming an increasingly important public health issue in the US and may influence cigarette smoking behavior. Systematic information on transitions between smokeless tobacco and cigarette use in the US is limited.MethodsWe conducted a systematic review of published literature on transitions between smokeless tobacco and cigarette use in the US. We searched PubMed, Web of Science and EbscoHost databases for all published articles from January 2000 to March 2014 that presented estimates of transitions in US youth and adult study populations over time between at least one of the following tobacco use states: exclusive cigarette smoking, exclusive smokeless tobacco use, dual use of both products, and use of neither product. We excluded non-English language studies, studies published before 2000, clinical trials, controlled cessation programs, and clinical studies or evaluations of smokeless tobacco cessation programs.ResultsThe review identified six studies on US populations published since 2000 with longitudinal data on some or all of the transitions that users can undergo between smokeless tobacco and cigarette use. There was considerable heterogeneity across studies in design and tobacco use definitions. Despite these differences, the existing data indicate that switching behaviors from exclusive smoking to exclusive smokeless tobacco use are limited (adults: 0%-1.4%, adolescents: 0.8%-3.8%) but may be more common from exclusive smokeless tobacco use to exclusive smoking (adults: 0.9%-26.6%, adolescents: 16.6%-25.5%). Among adults, exclusive cigarette smoking was generally stable and consistent (79.7% to 87.6%) over follow-up across studies but less stable in adolescents (46.8%-78.7%). Exclusive smokeless tobacco use was less stable than exclusive cigarette smoking over time (adults: 59.4%-76.6%, adolescents: 26.2%-44.8%).ConclusionThis review provides published estimates of the proportions of adults and adolescents transitioning between tobacco use categories from the most recently available studies on longitudinal transitions between smokeless tobacco and cigarettes in the US. These data can be used to track tobacco use behaviors and evaluate their effect on public health; however, the data for these studies were generally collected more than a decade ago. Additional research including nationally representative longitudinal estimates using consistent definitions and designs, would improve understanding of current tobacco transition behaviors.