Concurrent Tobacco Use: A Study
of Socio-demographic Correlates
Nasir Mushtaq, MPH
Laura A Beebe, PhD
University of Oklahoma Health Sciences Center
Background
• Most common types of tobacco use
• Cigarette Smoking – 19.8% adults (CDC 2008)
• Smokeless Tobacco – 3.5% (NSDUH 2005)
• Worldwide, tobacco use causes 5 million deaths per
year (WHO 2008)
• In the United States, only Smoking causes
• 443,000 deaths each year
• 8.6 million serious illnesses
Background
• Smokeless Tobacco
– Chewing Tobacco
– Snuff
• Health Effects
– Oral lesions
– Oral, esophageal, larynx, and lung cancer
– Cardio-vascular disease
Background
• Smokeless Tobacco
– Nationally 3% of adults are ST users
• Male – 6%
• Female – 0.4%
– Southern and north central states
– More prevalent among American Indian/Alaska
Natives (9%) followed by Whites (4%) and African
Americans (2%)
– 8% of high school students are current ST users
Background
Tobacco Industry
Advertising and promotional expenditures
– ST (Five largest tobacco manufacturers)
• 2005 – $ 250.8 million
• 2006 – $ 354.1 million
– Cigarette
• 2005 – $ 13.1 billion
• 2006 – $ 12.5 billion
Background
• ST as harm reduction
“TobaccoHarmReduction.org”
“Switching from cigarettes to smokeless tobacco is a proven way to lower
your risk -- it is almost as good for you as quitting entirely”
– Reduce the harm: Go smoke free
– Public health is all about harm reduction
– Smokers have more choices than just quitting or
dying
Background
•
Smoke free policy
1992 – 3% hospitals
2008 – more than 45% hospitals
2009 – 70 % of workforce work in smoke free environment
2008 – 1% colleges and universities tobacco free
Background
• Concurrent Tobacco Use (CDC 2000 & NHSDA 2001)
– ST users who also smoke
23 – 29%
– Smokers who also use ST
2.6 – 4 .9%
– Concurrent tobacco use among general
population
0.6 – 0.8% (estimated)
Purpose
• To investigate socio-demographic variation
between concurrent tobacco users and exclusive
ST users
• To assess changes in different types of tobacco
use from 2003 to 2008
Methods
• Data
– National Survey on Drug Use and Health (NSDUH) 2007
– Behavioral Risk Factors Surveillance Surveys (BRFSS) 2008
(Delaware, Florida, Indiana, Louisiana, Nebraska, North Carolina,
Tennessee, Texas, West Virginia, Wisconsin, Wyoming)
– Behavioral Risk Factors Surveillance Surveys (BRFSS) 2003
Delaware, Indiana, Nebraska, North Carolina, Texas, Wyoming
Methods
• Variables
– Smokeless Tobacco (ST) use
• Currently use chewing tobacco or snuff every day or some days
– Smoking
• NSDUH – Smoked at least 100 cigarettes in entire lifetime and
smoked within the past 30 days
• BRFSS - Smoked 100 cigarettes in entire lifetime and currently
smoke someday or every day
– Concurrent Tobacco (CCT) use
• Current Smokeless Tobacco (ST) user and current smoker
Methods
• Variables
– Socio-demographic factors
•
•
•
•
•
•
Age (Categories)
Race/Ethnicity (Five Categories)
Education Level (Three Categories)
General Health (Four Categories)
Marital Status (Four Categories)
Employment Status (Four Categories)
Methods
• Analysis
– Frequencies and probabilities
– Chi square test
– Logistic Regression
• Crude Odds Ratios and 95% confidence intervals
• Average Annual Percent Change
α = 0.05
Results
National Survey on Drug Use and Health
(NSDUH 2007)
Results: NSDUH 2007
• ST use reported by 6.4%
• Prevalence of current smoking – 35.5%
• Current ST users who are current smokers
40.3%
• Current smokers who are current ST Users
8.9%
• Concurrent tobacco use – 3.2%
Results: NSDUH 2007
Tobacco Use Characteristics of Male respondents – NSDUH 2007
CCT User
%
Exc. ST User
%
Exc. Smoker
Non Tobacco
User
Total
%
12 – 17
5.2
10.1
16.6
68.2
100
18 – 25
7.8
5.7
40.5
45.9
100
26 – 34
5.2
5.1
43.7
46.0
100
35 or Older
1.6
4.1
29.0
65.3
100
White *
3.9
6.0
30.1
60.0
100
African American *
0.3
0.3
44.8
54.6
100
American Indian/Alaska Natives*
1.8
9.8
38.9
49.4
100
Other*
1.1
2.2
38.4
58.4
100
Hispanic
1.8
1.1
33.5
63.6
100
Covariate
Age (years)
Race Ethnicity
* Non Hispanic
Results: NSDUH 2007
Results: NSDUH 2007
Results: NSDUH 2007
Tobacco Use Characteristics of Male respondents – NSDUH 2007
CCT User
%
Exc. ST User
%
Exc. Smoker
%
Non Tobacco User
%
Total
%
Married
1.9
4.8
25.3
68.0
100
Widowed
0.9
3.9
20.7
74.4
100
Divorced/Separated
3.7
3.8
47.3
45.3
100
Never Married
5.6
4.9
41.6
48.0
100
Excellent
3.1
5.0
24.6
67.3
100
Very Good
3.4
5.6
29.8
61.2
100
Good
3.2
3.4
37.6
55.8
100
Fair/Poor
2.6
4.2
40.4
52.8
100
Covariate
Marital Status
General Health
Results: NSDUH 2007
Age (Years)
OR (95% CI)
12 - 17
1.27 (1.26 – 1.28)
18 – 25
3.39 (3.38 – 3.41)
26 – 34
2.54 (2.53 – 2.55)
35 or Older
Referent
Results: NSDUH 2007
Race/Ethnicity
White
OR (95% CI)
Referent
African American
1.36 (1.34 – 1.39)
American Indian/ Alaska Native
0.28 (0.27 – 0.29)
Other
0.73 (0.72 – 0.74)
Hispanic
2.49 (2.47 – 2.51)
Results: NSDUH 2007
Education Level
OR (95% CI)
Less than High School
2.46 (2.44 – 2.47)
High School Graduate
1.71 (1.70 – 1.71)
Some College/College Graduate
Referent
Results: NSDUH 2007
Marital Status
Married
OR (95% CI)
Referent
Widowed
0.56 (0.55 – 0.57)
Divorced/Separated
2.43 (2.42 – 2.45)
Never Married
2.88 (2.87 – 2.89)
Results: NSDUH 2007
General Health
OR (95% CI)
Excellent
Referent
Very Good
0.97 (0.97 – 0.97)
Good
1.51 (1.50 – 1.51)
Fair/Poor
0.99 (0.98 – 1.00)
Results: NSDUH 2007
Employment Status
OR (95% CI)
Full Time
Referent
Part Time
1.21 (1.20 – 1.21)
Unemployed
1.57 (1.56 – 1.58)
Other
0.61 (0.60 – 0.61)
Results: NSDUH 2007
Results
Behavioral Risk Factor Surveillance Surveys
(BRFSS 2008)
(Delaware, Florida, Indiana, Louisiana, Nebraska, North
Carolina, Tennessee, Texas, West Virginia, Wisconsin,
Wyoming)
Results: BRFSS 2008
• Tobacco Use






Concurrent tobacco use – 1.5% (499)
Exclusive ST user – 6.6% (2206)
Exclusive Smoker – 18.3% (6106)
Non tobacco user – 73.5% (33315)
Current ST users who smoke – 18.5%
Current smokers who use ST – 7.55%
• Other Characteristics




Non Hispanic White – 83.9% (28823)
Age 35 year or older – 87.1% (30006)
Some college or college graduate – 56.6% (19546)
Married – 64.6% (22290)
Results: BRFSS 2008
Tobacco Use Characteristics of Male respondents – BRFSS 2008*
CCT User
n (%)
Exc. ST User
n (%)
Exc. Smoker
n (%)
Non Tobacco
User n (%)
Total
n
18 – 25
73 (5.0)
107 (7.3)
371 (25.3)
915 (62.4)
1466
26 – 34
86 (3.0)
284 (10.0)
688 (24.3)
1769 (62.6)
2827
35 or Older
339 (1.2)
1804 (6.25)
5025 (17.4)
21695 (75.17)
28863
White *
445 (1.6)
2039 (7.3)
4807 (17.2)
20534 (73.8)
27825
African American *
12 (0.6)
33 (1.5)
557 (26.1)
1531 (71.8)
2133
American Indian/Alaska Natives*
6 (1.6)
25 (6.6)
130 (34.2)
219 (57.6)
380
Other*
14 (1.5)
57 (6.2)
199 (2.1)
647 (70.6)
917
Hispanic
19 (1.1)
40 (2.2)
369 (20.50
1374 (76.2)
1802
Covariate
Age (years)
Race Ethnicity
* Data from participating states
† Non Hispanic
Results: BRFSS 2008
* Data from participating states
Results: BRFSS 2008
Tobacco Use Characteristics of Male respondents – BRFSS 2008*
CCT User
n (%)
Exc. ST User
n (%)
Exc. Smoker
n (%)
Non Tobacco User
n (%)
Total
n
Married
254 (1.2)
1513 (7.0)
2986 (13.0)
16742 (77.9)
21495
Widowed
17 (0.8)
115 (5.4)
323 (15.3)
1659 (78.5)
2114
Divorced/Separated
101 (2.1)
318 (6.5)
1525 (31.3)
2928 (60.1)
4872
Never Married
126 (2.6)
258 (5.4)
1247 (26.3)
3119 (65.7)
4750
Excellent
61 (1.1)
403 (7.0)
632 (11.1)
4621 (80.8)
5717
Very Good
155 (1.5)
731 (6.9)
1662 (15.8)
7988 (75.8)
10536
Good
166 (1.8)
655 (6.2)
2202 (21.0)
7475 (71.2)
10498
Fair/Poor
115 (1.8)
403 (6.2)
1595 (24.7)
4343 (67.3)
6456
Covariate
Marital Status
General Health
* Data from participating states
Results: BRFSS 2008
Age (Years)
OR (95% CI)
18 – 25
3.63 (2.64 – 5.00)
26 – 34
1.61 (1.23 – 2.11)
35 or Older
Referent
Results: BRFSS 2008
Race/Ethnicity
White
OR (95% CI)
Referent
African American
1.67 (0.85 – 3.25)
American Indian/ Alaska Native
1.10 (0.44 – 2.70)
Other
1.12 (0.62 – 2.04)
Hispanic
2.18 (1.25 – 3.79)
Results: BRFSS 2008
Education Level
OR (95% CI)
Less than High School
1.68 (1.25 – 2.27)
High School Graduate
1.64 (1.33 – 2.03)
Some College/College Graduate
Referent
Results: BRFSS 2008
Marital Status
Married
OR (95% CI)
Referent
Widowed
0.88 (0.52 – 1.49)
Divorced/Separated
1.89 (1.46 – 2.45)
Never Married
2.91 (2.26 – 3.80)
Results: BRFSS 2008
General Health
Excellent
OR (95% CI)
Referent
Very Good
1.40 (1.02 – 1.93)
Good
1.67 (1.22 – 2.30)
Fair/Poor
1.88 (1.34 – 2.65)
Results:
Trends in Tobacco Use
Behavioral Risk Factor Surveillance Surveys
BRFSS 2003 & BRFSS 2008
Delaware, Indiana, Nebraska, North Carolina, Texas, Wyoming
Results: Trends in Tobacco Use
Tobacco User
2003
%
2008
%
% Change
Annual Percent
Change
CCT User
1.81
1.47
↓ 18.55
↓ 4.08
Exclusive ST User
5.71
6.75
↑ 18.10
↑ 3.61
Exclusive Smoker
23.32
17.58
↓ 24.61
↓ 6.84
Non User
69.16
74.20
↑ 7.29
Results: Trends in Tobacco Use
Predicted Change in Tobacco Use in 12 Years (Men)
35%
32.87%
Concurrrent Tobacco User
Exclusive ST User
30%
Exclusive Smokers
23.06%
Percentage
25%
20.01%
20%
16.18%
15%
11.35%
10%
5%
10.78%
11.57%
9.85%
9.03%
7.56%
8.12%
1.97%
1.60%
1.47%
1.30%
1.05%
0.97%
2003
2008
2010
2013
2018
2020
6.33%
0%
Year
Conclusion
• Based on NSDUH, prevalence of concurrent
tobacco use has increased from 2001 to 2007.
• Based on BRFSS (6 state sub-sample),
prevalence of concurrent tobacco use has
decreased from 2003 to 2008.
• Based on both surveys, prevalence of
smokeless tobacco use has increased from
2000 to 2008.
Conclusion
• The study identified important sociodemographic factors related to concurrent
tobacco use among ST user men
• Men of younger age are more likely to be
concurrent tobacco user
– Odds of ST user men 18-25 years to be CCT user
were 3.5 times higher
• BRFSS 2008* OR = 3.63 (2.64 – 5.00)
• NSDUH 2007 OR = 3.39 (3.38 – 3.41)
Conclusion
• Race ethnicity was significantly associated
with CCT use
– Hispanic ST user men were twice more likely to be
CCT user as compared to White ST user men
– American Indian/Alaska Natives were more likely
to be exclusive ST user
Conclusion
• Significant association was found between
education level and CCT use
– Prevalence of CCT use was higher among ST user
men with lower education (high school or less)
• ST user men who had good, fair, or poor
health were more likely to use CCT as
compared to those with excellent health
Conclusion
• Divorced or separated ST user men were 1.8
times more likely to be CCT user as compared
to married ST user men
• Among never married these odds were more
than double.
Conclusion
• Decrease in the prevalence of CCT use is still
less than the decrease observed in smoking
prevalence
• If current trend continues until 2020
– ST use – 11.57%
– Smoking – 9.85%
– CCT use – 0.97%
Conclusion
• Study found increase in ST use among smokers
– Smoke free environment?
– Harm reduction?
• Lack of clear direction of the shift in tobacco
product
Conclusion
• Study identified sub groups of the population which
are more likely to use CCT
• Risk of diseases associated with individual tobacco
product might be higher among CCT users
• Tobacco prevention and cessation programs should
address CCT use
• Public health impact of CCT is still unrecognized
• Future research
– Identify other sub groups of the population
– Cessation strategies