The prevalence of smokeless tobacco use in native children in northern Saskatchewan, Canada

We used a self-administered questionnaire to develop a profile of smokeless tobacco use among 1,170 Canadian native children aged 7 to 21 years attending schools situated in remote communities in northern Saskatchewan. Nearly 30% of the sample were current users of smokeless tobacco; more than 50% of users began to use these products before the age of 12 years. More males than females chewed tobacco or dipped snuff. The results revealed a relatively high prevalence of smokeless tobacco users among the present sample of native children and were found to be consistent with data from other studies of similarly aged native populations. The results also showed a prevailing pattern of addiction among the users of smokeless tobacco. It is suggested that educational programs aimed at preventing or reducing the use of tobacco products among native populations be intensified and as well, these programs would benefit from the active participation of trained native personnel.     

American Indian youth and substance abuse: tobacco use problems, risk factors and preventive interventions

After reviewing the special problems of smoked and smokelesstobacco use among American Indian people, this paper notestherisks of early and regular substance use by Indian youth. Theoreticaland empirical explanations for tobacco and substance use amongIndian youth are then recounted. Based on those explanations,the authors outline the wisdom of interventions to prevent tobaccoand other substance use among American Indian young people.Briefly, the authors describe their own original efforts todesign such preventive interventions. The paper concludes bycalling for additional research on the measurement and preventionof smoked and smokeless tobacco, alcohol and drug abuse amongIndian children and adolescents.     

Snuffing tobacco out of sport.

Use of oral snuff has risen sharply among baseball players following a tobacco industry marketing campaign that linked smokeless tobacco with athletic performance and virility. Millions of adolescents have copied these professional role models and, today, are at risk of developing oral cancer and other mouth disorders. New policies and programs are needed to break the powerful grip that the tobacco industry has on professional sport. Health agencies, including the National Cancer Institute and the National Institute for Dental Research, have teamed up with major league baseball to help players quit and reduce public use of oral tobacco. If these efforts are successful, our national pastime will once again become America's classroom for teaching health and fitness, not nicotine addiction.     

Smokeless Tobacco: How Exposed are Our Schoolchildren?

The use of smokeless tobacco (ST) is linked to poor health outcomes, including oral and esophageal cancers. Adolescents who use ST are also more likely to use cigarettes and develop lung cancer later in life. Evidence shows that proximity to tobacco retailers increases youth initiation of use. We assessed availability of ST in neighborhoods surrounding ten high schools in New York City. Three hundred and twenty-one retailers were visited. Sixty-three percent of likely tobacco-selling businesses surrounding schools sold cigarettes. About 20 % sold snus, while 3 % sold snuff. Culturally-linked ST products, such as paan and gutka, were largely confined to ethnic neighborhoods, while snuff was more prevalent in neighborhoods with predominantly US born residents. A variety of ST products are easily accessible to adolescents and are located within close proximity to schools, perhaps facilitating use, as has been documented with youth smoking. Further research is needed on adolescent use of culturally-linked ST products. This research can serve as a foundation for development of interventions to reduce ST use among adolescents and for policy recommendations.     

Health consequences of using smokeless tobacco: summary of the Advisory Committee's report to the Surgeon General

On March 25, 1986, the Surgeon General of the Public Health Service released a report that detailed the results of the first comprehensive, indepth review of the relationship between smokeless tobacco use and health. This review, prepared under the auspices of the Surgeon General's Advisory Committee on the Health Consequences of Using Smokeless Tobacco, is summarized in this article. In the United States, smokeless tobacco is used predominantly in the forms of chewing tobacco and snuff. During the past 20 years, the production and consumption of these products have risen significantly in marked contrast to the decline in smokeless tobacco use during the first half of the century. National estimates indicate that more than 12 million persons age 12 and older in the United States used some form of smokeless tobacco in 1985, and half of these were regular users. The highest rates of smokeless tobacco use occurred among adolescent and young adult males. Examination of the relevant epidemiologic, experimental, and clinical data revealed that oral use of smokeless tobacco is a significant health risk. This behavior can cause cancer in humans, and the evidence is strongest for cancer of the oral cavity, particularly at the site of tobacco placement. Smokeless tobacco use can also lead to the development of noncancerous oral conditions, particularly, oral leukoplakias and gingival recession. Further, the levels of nicotine in the body resulting from smokeless tobacco can lead to nicotine addiction and dependence.     

Coaches' attitudes toward smokeless tobacco and intentions to intervene with athletes

Smokeless tobacco use among athletes is alarming. Most of these athletes report beginning smokeless tobacco use in middle or high school. West Virginia has significantly higher rates of smokeless tobacco use among adolescent and adult males than the general population. Since West Virginia athletes may be particularly vulnerable to smokeless tobacco use, West Virginia coaches can be critical agents in smokeless tobacco prevention and intervention. This study surveyed West Virginia middle and high school coaches' 1) attitudes toward smokeless tobacco, 2) actions toward athletes who use smokeless tobacco, 3) intentions to provide intervention for users, and 4) tobacco use history. Results indicated coaches had unfavorable attitudes toward smokeless tobacco, perceived it as a problem, and were willing to help athletes quit. These findings provide support for development of training programs for middle and high school coaches to act as smokeless tobacco intervention agents.     

Use of smokeless tobacco among children and adolescents in the United States

Data collected by National Cancer Institute grantees on the use of smokeless tobacco by youth are reported. Self-reports were collected from over 43,000 students from grades 4 through 11 in 16 locations in the United States and 1 location in Canada. Lifetime and recent use of smokeless tobacco are reported by location, sex, grade level, and ethnic group. Use of smokeless tobacco increased with grade level. Typically, 40 to 60% of males had tried smokeless tobacco, and in most locations, 10 to 20% of older male youths reported recent use. With the exception of Native Americans, rates of use among females were lower than those among males. Use was highest among Native Americans and lowest among blacks and Asians. Smokeless tobacco use by Hispanics was comparable to that by whites. Collectively, the data indicate that large numbers of male youths in many areas of the United States are using smokeless tobacco. In light of recent research on the health consequences of using smokeless tobacco, the health of these youth may be endangered.     

Parental influence on adolescents' intention to use smokeless tobacco

This study examined the role of parents in the initiation ofsmokeless tobacco use by adolescent and pre-adolescent males.The subjects were 106 6th–9th grade students who werenot current smokeless tobacco users. Questionnaires were administeredmeasuring subjects intention to use smokeless tobacco, theirexpectations of how their parents would respond if they discoveredthem using smokeless tobacco, parents' use of smokeless tobaccoand the existence of parental rules against using smokelesstobacco. Multi-variate analyses of variance revealed that subjectswho intended to use smokeless tobacco expected a less aversiveresponse by parents (i.e., less likelihood of punishment, lessparental anger and disappointment) than did those who did notintend to use. In addition, intenders were more likely to havefathers who used smokeless tobacco, and were less likely toreport parental rules prohibiting the use of smokeless tobacco.The implications for smokeless tobacco prevention programs arediscussed.     

Patterns of cigarette and smokeless tobacco use among children and adolescents

Although cigarette and smokeless tobacco use are recognized as major problems among school-age youth, few nationwide or statewide data exist on the prevalence and patterns of use. To determine the patterns of tobacco use among children and adolescents in Missouri, self-report information was obtained from a representative sample of 5,431 students in grades 5, 8, and 12. Both cigarette smoking and smokeless tobacco use were more common among males than females for each grade level except the 12th, where 30% of females and 28% of males had smoked during the previous week. Smoking prevalence was considerably lower among blacks than whites. Smokeless tobacco use was rare among both blacks and females. Smokeless tobacco use was more common than cigarette smoking in rural areas, where 17% of 8th-grade males and 31% of 12th-grade males had used smokeless tobacco during the previous week. The mean age at first use of cigarettes was slightly lower in the rural than the urban area, whereas the mean age of initial smokeless tobacco use was more than a year earlier in the rural area. Data regarding the perceived difficulty of quitting smoking and quit rates suggested that adolescent females have more difficulty quitting smoking than males. Male smokeless tobacco users appeared to be more addicted than male cigarette smokers. Smokeless tobacco brand preference indicated that users may switch to progressively stronger types of smokeless tobacco as they get older and a nicotine tolerance is developed. The current study emphasizes the urgent need for carefully targeted tobacco prevention and cessation efforts among school-age youth.     

Smokeless tobacco use and oral pathology in a professional baseball organization.

BACKGROUND. Smokeless tobacco has been implicated as a risk factor for numerous oral conditions. Since baseball players are known to have a high incidence of smokeless tobacco use, they are an excellent group in which to study the effects of smokeless tobacco on the oral cavity. We report our findings in 206 of 220 eligible men during spring training of a professional baseball organization. Major and minor league ballplayers, coaches, and management personnel were included. METHODS. Participants completed a 2-page, 23-item questionnaire on smokeless tobacco use. This was followed by a detailed examination for oral leukoplakia, periodontal disease, and dental caries performed by a physician who was blinded to the results of the questionnaire. Oral leukoplakia was graded I, II, or III according to severity. RESULTS. Eighty-eight of 206 participants (42.7%) reported current use of smokeless tobacco; 62 of these men used smokeless tobacco year round, while 26 used smokeless tobacco only during the baseball season. The 88 smokeless tobacco users often used more than one form of tobacco. Moist snuff was the most common form (73.9% of users) followed by loose leaf tobacco (53.4%) and plug tobacco (9.1%). Oral leukoplakia was found in 25 of 88 current users (28.4%). Only the year-round users, however, had an incidence rate (37.1%) that was significantly different from all others (odds ratio = 9.35, 95% CI = 3.46 to 26.21). Year-round users were also more likely to have a higher grade of oral leukoplakia. Periodontal disease and dental caries were no more prevalent among smokeless tobacco users than nonusers. CONCLUSIONS. We conclude that the use of smokeless tobacco products is a significant risk factor for the development of oral leukoplakia, and that this risk is greatest in those individuals who use smokeless tobacco continuously throughout the year.     

Middle school students' perceived access to cigarettes in Virginia

OBJECTIVE: To examine correlates of perceived access to cigarettes at home, school, and the store among youth. METHODS: Virginia middle school youth were surveyed before beginning tobacco prevention programs. Multivariate analyses examined household smoking, peer smoking, and perceived community tobacco use for their relationship to perceived access at home, school, and the store. RESULTS: Perceived access at home was associated with parent, sibling, and friend smoking. Perceived access at school and stores was associated with perceived peer and community smoking. CONCLUSIONS: Youth tobacco prevention programs should target the commercial and social sources of tobacco access to reduce experimentation, adoption, and addiction among youth.     

Inhaltliche, konzeptionelle und organisatorische Bedingungen einer erfolgreichen schulischen Prävention des Rauchens

The US Centers for Disease Control and Prevention have published guidelines for school health programs to prevent tobacco use and addiction [Centers for Disease Control and Prevention (1994) Guidelines for school health programs to prevent tobacco use and addiction. MMWR 43 (No. RR-2): 1–18]. Seven recommendations summarize strategies that are effective in preventing tobacco use among youth. To ensure the greatest impact, schools should (1) develop and enforce a school policy on tobacco use, (2) provide instruction about (a) short- and long-term negative physiological and social consequences of tobacco use, (b) social influences on tobacco use, (c) peer norms regarding tobacco use, (d) refusal skills, and (e) life skills, (3) provide education on tobacco use prevention from kindergarten through 12th grade, (4) provide program-specific training for teachers,(5) involve parents or families in support of school-based programs to prevent tobacco use, (6) support cessation efforts among students and all school staff who use tobacco, and (7) assess the tobacco use prevention program at regular intervals. This paper examines opportunities and barriers for the implementation of these recommendations in German schools. It is concluded that the US Centers for Disease Control and Prevention guidelines should also be applied in Germany.     

The use of chewing tobacco and snuff in Canada, 1986

This paper reviews current data relating to the use of smokeless tobacco products in Canada. Sources of data include production, disposition, and sales statistics; special population surveys, and estimates obtained from the 1986 Labour Force Survey smoking supplement. In Canada, the use of smokeless tobacco products is confined to the male population. About 0.7% of males over age 15 use chewing tobacco and 0.4% use snuff. The pattern of use is similar to that of the United States in the early 70s. Prevalence rates for both substances tend to be higher in older age groups. Men employed in outdoor occupations are more likely to use chewing tobacco or snuff. Chewing tobacco use tends to be more prevalent in eastern Canada and snuff use in western Canada. The low national prevalence estimates conceal the relatively high usage rates among sub-populations. Among Inuit youth in the Northwest Territories in 1982, 25% of the 10-14 age group used smokeless tobacco.     

Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office.

OBJECTIVES. Primary care medical clinics are good settings for smoking interventions. This study extends this strategy with a smokeless tobacco intervention delivered by dentists and dental hygienists in the course of routine dental care. METHODS. Male users of moist snuff and chewing tobacco (n = 518) were identified by questionnaire in clinic waiting rooms and then randomly assigned to either usual care or intervention. The intervention included a routine oral examination with special attention to the part of the mouth in which tobacco was kept and an explanation of the health risks of using smokeless tobacco. After receiving unequivocal advice to stop using tobacco, each patient viewed a 9-minute videotape, received a self-help manual, and was briefly counseled by the dental hygienist. RESULTS. Long-term success was defined as no smokeless tobacco use at both 3- and 12-month follow-ups, with those lost to follow-up counted as smokeless tobacco users. The intervention increased the proportion of patients who quit by about one half (12.5% vs 18.4%, P < .05). CONCLUSIONS. These results demonstrate the efficacy of a brief dental office intervention for the general population of smokeless tobacco users.     

Effects of a Fact Sheet on beliefs about the harmfulness of alternative nicotine delivery systems compared with cigarettes

ABSTRACT: BACKGROUND: This study explored the value of providing information in a Fact Sheet to correct misperceptions about the relative harmfulness of nicotine replacement products (NRT) and smokeless tobacco (ST), when compared to cigarette smoking. METHODS: Four convenience samples from different countries Australia, UK, Sweden and USA) were surveyed concerning their beliefs about the relative harmfulness of smokeless tobacco and NRT. Study participants were given the Fact Sheet that explained that nicotine, as used by consumers, is not particularly harmful and explained why. They were resurveyed one week later regarding their beliefs about the relative harmfulness of smokeless tobacco and NRT and future intentions to use the products. RESULTS: In all four samples knowledge increased by similar amounts and beliefs regarding the lower harmfulness of smokeless tobacco increased. However, misconceptions remained common and responses to belief measures were not always consistent. Likelihood of use of ST increased in all four samples after exposure to the Fact Sheet, but interest in NRT use only increased in the US sample. CONCLUSIONS: A Fact Sheet such as this one can help address misconceptions about NRT and smokeless tobacco, at least in the short term. However, as is true of most educational interventions, exposure to a single educational session is not sufficient to overcome misperceptions that smokers have about the relative harmfulness of oral versus combustible forms of nicotine delivery.     

Characteristics of users of cigars,bidis, and kreteks and the relationship to cigarette use

BACKGROUND: In the 1990s, youth use of alternative tobacco products including cigars, bidis, and kreteks increased. This article discusses the prevalence of youth use of cigars, bidis, and kreteks, and characteristics of users. METHODS: The Cigar Use Reasons Evaluation (CURE)-a questionnaire assessing alternative tobacco use and associated attitudes and behaviors-was administered to middle and high school students from 12 school districts across Massachusetts. RESULTS: Males were more likely to use all forms of alternative tobacco and females more likely to smoke cigarettes. Hispanics were less likely to smoke kreteks or use smokeless tobacco. Urban students were more likely to smoke bidis or use smokeless tobacco than suburban or rural youth. Most smokeless and alternative tobacco users were lifetime cigarette smokers. There was, however, a significant group of cigar smokers, associated with higher parental education, who were not current cigarette smokers. CONCLUSIONS: Use of alternative tobacco poses a risk to the success of tobacco control efforts. While many alternative tobacco users smoke cigarettes, some alternative tobacco users are current cigarette smokers. Cigar use thus constitutes a potential serious risk for youth who otherwise might not be exposed to tobacco.     

Project towards no tobacco use: 1-year behavior outcomes.

OBJECTIVES. We present 1-year follow-up data from a school-based tobacco use prevention project designed to test the effectiveness of three main components of social influence programs. The components teach refusal skills, awareness of social misperceptions about tobacco use, and misconceptions about physical consequences. METHODS. Four different curricula were developed and tested in a randomized experiment involving 48 junior high schools. The outcome variables examined were changes in initial and weekly cigarette and smokeless tobacco use 1 year after the intervention. RESULTS. Analyses indicated that each of the component programs were effective in decreasing both the initial and the weekly use of cigarettes except for the curriculum in which refusal skills were taught. Also, each curriculum was effective in decreasing the initial use of smokeless tobacco except for the one aimed at correcting social misperceptions. Only the combined curriculum showed an effect on the weekly use of smokeless tobacco. CONCLUSIONS. The combined intervention was the most effective overall in reducing the initial and weekly use of cigarettes and smokeless tobacco. This suggests that different reasons for use exist and need to be counteracted simultaneously. However, since single programs were also effective in reducing all but weekly smokeless tobacco use, any of these components may be worthwhile prevention tools.     

Predictors of smokeless tobacco use among students: a preliminary multivariate analysis

Smokeless tobacco use is increasing among today's youth. Thepurpose of this study was to determine if certain factors couldpredict the use of smokeless tobacco by 7th and 10th grade studentsin the deep South of the United States of America. In addition,we were interested in finding out if these factors would bedifferent for 7th versus 10th graders. Questionnaires were administeredto 2961 7th and 10th grade students in 16 schools in the South-east(81% response rate). Stepwise multiple logistic regression analysiswas used to model and analyze the predictive power of the independentvariables. Our analysis indicated (i) use of smokeless tobaccoby their ‘best friend’ and (ii) the number of closefriends who use smokeless tobacco were the two most importantfactors of whether an individual was a user or a non-user. Inaddition, predictive factors appear to be different for 7thgrade males as compared to 10th grade males. Conclusions aredrawn as to the relative needs and emphasis of prevention programsin this area of smokeless tobacco use.     

Smokeless Tobacco Use in Adolescents: The Cardiovascular Health in Children (CHIC II) Study

Smokeless tobacco has seen a resurgence of popularity among adolescents despite its association with oral cancer and altered cardiovascular function. This study examined age, gender, ethnicity, self-esteem, physical activity, parental smoking, and socioeconomic status as predictors of smokeless tobacco use among middle school children. Subjects included 1,211 youth (White (64%), Black (24%), Hispanic (6%), and Other (6%); age 12.2) participating in the Cardiovascular Health in Children and Youth (CHIC II) study. All data were collected by questionnaire. Factors related to ever using smokeless tobacco included older age (p < .001), being male (p < .001), lower self-esteem (p < .001), and having parents who currently (p = .02) or formerly (p = .05) smoked. Hispanics reported a higher current usage rate than other ethnic groups (p < .001). White youth in the lowest socioeconomic status were most likely to be experimental users (p = .007), while those in the high socioeconomic status were more likely to be current users (p = .006). Physical activity was not associated with smokeless tobacco use.     

Smokeless Tobacco and Cancer in Women

Smokeless tobacco, particularly snuff, is a recognized risk factor for cancer of the oral cavity. This conclusion rests in large part on epidemiologic studies of oral cancer in women, especially in the American South, where the oral cancer death rate in females has been high. The research focus on studies of women led to the identification of the hazards from smokeless tobacco use; the strategies used are broadly applicable to studies of the etiology of other cancers in both women and men. High levels of nitrosamines, which are potent carcinogens, are found in smokeless tobacco products. Steps should be taken to reverse the alarming increase in their use by men and boys. More research attention also should be directed to understanding new emerging trends in oral cancer mortality among women.