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Issues in Comprehensive Pediatric Nursing, 26:13–21, 2003Copyright 2003 Taylor & Francis0146-0862/03 $12.00 + .00DOI: 10.1080/01460860390183047
CHEWING TOBACCO USE: PERCEPTIONSAND KNOWLEDGE IN RURALADOLESCENT YOUTHS
CHRISTIE CAMPBELL-GROSSMAN, PhD, RNDIANE BRAGE HUDSON, PhD, RNMARGARET OFE FLECK, MSN, RNUniversity of Nebraska Medical Center,College of Nursing, Lincoln, Nebraska, USA
The purposes of this pilot study were to describe the incidence of chewing tobaccouse among rural midwestern adolescents and to describe rural midwestern adolescents’perceptions and knowledge about chewing tobacco use. A Smokeless Tobacco UseSurvey was administered to 34 adolescent subjects who attended 5th–8th grades intwo rural towns. None of the subjects reported trying chewing tobacco products.However, a group of male subjects who stated they may chew tobacco sometime inthe future, performed less well on the test about chewing tobacco facts and percep-tions of use, indicating some education needs are warranted. Risk factors and deterrentfactors to using chewing tobacco are reported.
Received 10 June 2002; accepted 20 September 2002.Address correspondence to Christie Campbell-Grossman, University of Nebraska Medical
Center, College of Nursing, P.O. Box 880620, Lincoln, NE 68588-0620, USA. E-mail:[email protected]
The use of chewing tobacco among youths has been increasing since1970 (Boyle, Claxton, & Forster, 1997). Chewing tobacco is called “smoke-less tobacco,” with other popular terms such as “snuff” and “chew” refer-ring to how the tobacco product is processed. Snuff is finely groundtobacco often placed between the lip and gums. Chew is a more coarselyshredded tobacco, commonly placed between the check and gums (Hirsch-felder, 1999). The majority of young adolescents using chewing tobaccoare Caucasian, male, and from a rural area (Newman, 1999). Each yearapproximately 824,000 young people aged 11 to 19 years in the United
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States experiment with chewing tobacco, with more than one-third ofthose who experiment becoming regular users within 1 to 2 years ofbeginning use (Tomar & Giovino, 1998).
Most of the tobacco use research has focused on cigarette smoking,risk factors, and methods of smoking cessation. Much less research existson the use of chewing tobacco products. Particularly lacking are dataaddressing adolescents’ knowledge and perceptions regarding use andnonuse of chewing tobacco. Although smoking tobacco and chewing to-bacco both may result in nicotine addiction, investigators have reportedthat experimentation with chewing tobacco typically begins at an earlierage (age 10) than experimentation with cigarettes (age 12 to 14), whichmeans that prevention programs need to be designed for elementary school-aged children (Boyle et al., 1997; Gottlieb, Pope, Rickert, & Hardin,1993). The purposes of this pilot study were to describe the incidence ofchewing tobacco use among rural midwestern adolescents and to describerural midwestern adolescents’ perceptions and knowledge about chewingtobacco use.
THEORETICAL FRAMEWORK
Tobacco use acquisition was the theoretical framework for the study (Fray,1993; Robinson, Klesge, Zbikowski, & Glaser, 1997) modified to focusspecifically on chewing tobacco products. The five stages identified inthis framework include:
1. Preparatory stage in which the individual is exposed to the con-cept of chewing tobacco use and levels of receptiveness and accep-tance of tobacco use are developed.
2. Trying stage in which the individual has a few experiences withusing chewing tobacco.
3. Experimentation stage in which the individual repeatedly uses chewingtobacco, but on an irregular basis.
4. Regular usage stage in which the individual uses chewing tobaccoacross a wide variety of situational contexts.
5. Nicotine dependence.
According to this theory, adolescents’ perceptions of chewing tobaccouse may be important in each of the five stages. Knowledge may be moreimportant in the first three stages. Perception is defined as a level ofawareness and understanding the impact of certain choices. Knowledge isdefined as the facts or information needed to make a successful choice(Fray, 1993; Robinson et al., 1997).
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LITERATURE REVIEW
Tomar and Giovino (1998) studied 2,769 males between the ages of 11and 19 for four years for tobacco use. The cumulative incidence duringthis four-year period revealed that 21% of participants classified them-selves as experimenters, and 8% classified themselves as regular users ofchewing tobacco. A total of 73% of the regular male users were Cauca-sian, and 59% of experimenters and regular users were between the agesof 11 and 17. Experimentation with chewing tobacco was related to anumber of factors, including personal factors (e.g., risk taking, physicalfighting, and less satisfaction in school) and weak family structure orsupport (e.g., spending more than 10-hr per week unsupervised and aone-parent family). Regular use of chewing tobacco was related to adultrole modeling, peer influences, and certain sports team membership (Tomar& Giovino, 1998, Boyle et al., 1997).
The impact of chewing tobacco use on the individuals’ health is welldocumented. Overwhelming evidence indicates that the nicotine foundin all tobacco products, including chewing tobacco, is addicting (U.S.Department of Health and Human Services, 1994). The amount ofnicotine obtained from a single administration of chewing tobacco isequal to, or greater than, the nicotine obtained from smoking a cigarette(U.S. Department of Health and Human Services, 2000). The use ofchewing tobacco has demonstrated health risks that include increasedrisk of oral-pharyngeal cancer, coronary artery disease, peptic ulcers, andneuromuscular disease (U.S. Department of Health and Human Ser-vices, 2000). Recent national statistics show that chewing tobacco use inadults remains constant or is decreasing, whereas chewing tobaccouse among adolescents is increasing, with age of initiating chewing to-bacco use becoming younger (U.S. Department of Health and HumanServices, 2000).
Most researchers have studied the incidence, correlates, and predictorsof experimentation and regular use of tobacco products (predominatelycigarettes), but few researchers have studied adolescents’ knowledge andperceptions of chewing tobacco use. The following research questionswere addressed in this research study:
1. What is the extent of chewing tobacco use among young adoles-cents in two midwestern rural schools?
2. What stages of acquisition of chewing tobacco use are present amongyoung adolescents in the two midwestern rural schools (Fray,1993;Robinson et al., 1997)?
3. What are young adolescents’ perceptions and knowledge about chew-ing tobacco use in two midwestern rural schools?
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4. What are young adolescents’ risk factors and deterrent factors thatprevent chewing tobacco use in two midwestern rural schools?
METHODS
Design
A descriptive survey design was used to study young adolescents’ knowl-edge and perceptions of chewing tobacco use. A Chewing Tobacco Ques-tionnaire was developed and administered to 34 adolescents in the 5th,6th, 7th, and 8th grades in two rural midwestern schools. The researchstudy was approved by the Institutional Review Board at a universitymedical center.
Sample
Informed consent and assent were obtained from a convenience sampleof 34 adolescent students and their parents/guardians. Subjects ranged inage from 10 to 14 years (M age = 11.9, SD = 1.43) and represented tworural communities. The rural setting for this research was defined as thepublic schools in two small towns (population ≤ 5,000) at least 100 milesfrom a city (population ≥ 100,000), in a central midwestern state. Thisself-selected sample was predominately male (n = 25, 70%). One femalewas Hispanic, and the remaining sample (n = 33, 98%) reported Cauca-sian ethnicity. All four grade levels were represented with a report of 9subjects (26%) from the 5th grade, 11 subjects (32%) from the 6th grade,5 subjects (15%) from the 7th grade, and 9 subjects (26%) from the 8thgrade.
In this sample, 17 subjects (50%) lived in the towns, and 17 subjects(50%) lived in the country. Also, 6 subjects (18%) had parents who farmedor ranched; 7 subjects (20%) did not live with their parent(s), but only1 of the 7 subjects lived with a guardian who was not an extended familymember.
Procedure
After permission was obtained from each school board, a letter explain-ing the purpose of the research was sent home with all students in grades5–8 in the two participating schools. An introduction to the study, de-scription of the survey questionnaire, and expectations of the studentswere enclosed. Individuals who volunteered to participate in the studyreturned signed youth assent forms and parental/guardian consent formsbefore data collection began. Those who chose not to participate returned
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a card indicating this choice. Two follow-up letters encouraging a re-sponse were sent to those potential subjects who did not initially respond.The total response rate was 18% (n = 34) with 18 subjects agreeing toparticipate from one school and 16 subjects agreeing to participate fromanother school.
A researcher administered the written questionnaires to subjects at theirschools during school hours. The researcher was present to distribute andcollect the questionnaires and answer questions. Data collection was com-pleted in 20 to 30 min. Due to illness, two questionnaires were completedin subjects’ homes and mailed to the researchers.
Instrument
The Chewing Tobacco Survey, which was developed by the researchers,is a 45-item, short-answer instrument with three sections on chewingtobacco use. The first section (30 items) collected demographic informa-tion that may be associated with youth risk factors and is based on theCenter for Disease Control (CDC) Behavior Risk Factor Surveillance(Tomar & Giovino, 1998). The second section (5 items) assessed thesubjects’ stage of receptivity to chewing tobacco use (Fray, 1993). Theseitems were presented in a 4-5 level Likert scale format and evaluated thesubjects’ present use of chewing tobacco products, frequency of use, re-ceptivity to quit if presently using, or intent to use sometime in the futureif not using chewing tobacco products at this time. Regular use of chew-ing tobacco products was defined by these investigators as once a weekuse or more frequently.
The last section included 10 true/false items that evaluated their sub-jects’ knowledge and perceptions of chewing tobacco use and risks. Knowl-edge (8 items) was represented in this section as actual facts and iden-tification of misconceptions about chewing tobacco use by others andeffects on the body. Knowledge items include such statements as: “Ath-letes chew tobacco so it must be safe.” “Most guys chew tobacco, at leastonce in a while.” Perception (2 items) was measured in this section byidentifying misconceptions related to identification with the product. Per-ception items were statements such as: “Chewing tobacco and using snuffmakes me look tough” and “Chewing tobacco and using snuff makes melook older.” The total 10 items were keyed as correct or incorrect, withtotal test scores ranging from 0 to 10.
The Chewing Tobacco Survey was developed from a review of theliterature. Three research experts on chewing tobacco risk factorsand three experts in youth development behaviors reviewed the instru-ment for content, context, and face validity. A pilot group of 9 age-appropriate young adolescents completed the questionnaire and verbalized
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suggestions for improving clarity. Suggestions for revising the instrumentwere incorporated.
Data Analyses
Descriptive statistics were used to analyze the demographic data. De-scriptive statistics, Fisher’s Exact Test for correlations, and Student’st-tests were completed on results from other sections of the instrument.
RESULTS
Unfortunately, the extent of chewing tobacco use among young adoles-cents in two midwestern rural schools was not clearly determined fromthis small convenience sample. None of the subjects in this sample re-ported he or she had tried chewing tobacco products and only 11 subjects(32%) reported they had friends who used chewing tobacco. Verbal feed-back from subjects indicated these friends were typically in high school.
Indications are that first stage of acquisition with chewing tobacco usewas present. In the first stage, the individual is exposed to the concept ofchewing tobacco use, and attitudes toward use begin to develop. Expo-sure to the use of chewing tobacco was evident in this sample. Fourteensubjects (41%) had a father or brother who chewed tobacco, 12 subjects(35%) had observed extended family members who chewed, and 11 sub-jects (32%) had friends who chewed. Open-ended comments from the7th and 8th graders were more accepting of others who used chewingtobacco compared with the 5th and 6th graders. The second stage ofacquisition is the trying stage in which the individual experiments withthe tobacco product. Although none of the sample admitted to using chew-ing tobacco, attitudes toward future use varied. Also, 8 males (24% oftotal sample) indicated they may try chewing tobacco in the future; 26subjects (76%) reported they will never try chewing tobacco.
Young adolescents’ perceptions and knowledge of chewing tobaccouse was evident when answering the open-ended question, “Why notchew tobacco?” in a focus group discussion following the administrationof the questionnaire. Negative verbal feedback from subjects was asser-tive, graphic, and often described a loved one who was suffering fromhealth complications resulting from tobacco use. The total correct scoreon the 10-point knowledge and perception section that evaluated sub-jects’ knowledge and perceptions of risk was high (M score = 8.7, SD =1.22, n = 34). There was a significant difference in test scores betweenthose who said they may chew in the future and those who said theywould never chew in the future (t = 7.72, p = .009). Those adolescentswho may chew in the future had lower test scores (M = 8.25, SD = 1.83,
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n = 8) compared with those who reported they will never chew tobacco(M = 8.85, SD = .97, n = 26).
Risk factors included participation in team sports (n = 28, 82%) andhaving one or more family members who chewed tobacco (n = 14, 41%).Deterrent factors included being involved in activities outside of school(n = 19, 56%), having responsibilities for chores at home (n = 27, 79%),and “liking” or“ loving school” (n = 30, 88%). The majority of subjectscame from relatively stable households, living with one or both parents(n = 27, 79%). Also, 30 subjects (88%) agreed their mothers would be“very upset,” and 25 subjects (73.5%) said their fathers would be “veryupset ”if they chewed tobacco.
DISCUSSION
Users of chewing tobacco products have a distinct profile as comparedwith users of cigarettes; they are younger and more likely to be malesfrom rural areas, and more likely to engage in sports activities (Botvin etal., 1989; Gottlieb et al., 1993; Tomar & Giovino, 1998). Although asimilar subject profile was found in this study, no users of chewing to-bacco were identified. This finding may be a result of a sample bias withonly the nonusers agreeing to participate in this study. Users may notwant to obtain their parents consent to participate, even though the re-search results were anonymous.
Ten subjects (29%) identified friends and brothers who chewed to-bacco. Unlike other samples described in the literature, these users ap-pear to have been older (high school age or above). This finding may beindicating a delayed stage of chewing tobacco acquisition, a result of alarge number of deterrent factors that were also identified in the sample.These deterrent factors included involvement in outside activities, re-sponsible for chores at home, success in the school setting, living withone or both parents, and parental disapproval of tobacco products.
Participation in team sports was found to increase the risk of chewingtobacco use in some studies (Botvin et al., 1989; Tomar & Giovino,1998). However, 7 subjects in this study stated they did not chew tobaccobecause it would negatively impact their ability to perform sports, or theywould not be allowed to participate in school sports if they were caughtchewing tobacco. For subjects in this study, it may have been a deterrent.
In this study, the male students who said they may chew tobaccosometime in the future also reported lower scores on the section relatedto knowledge and perception about chewing tobacco use, indicating thatsome educational interventions are warranted. The distinctive characteris-tics of chewing tobacco users and their younger age suggest that thetypical smoking prevention programs currently available may not be
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effective with preventing chewing tobacco use. Because of the findingthat acquisition stage one has begun with this group, educational materi-als need to be targeted specifically for younger males who are exposed tochewing tobacco use, considering both the unique factors and commonrisk factors associated with cigarette smoking prevention programs
RECOMMENDATIONS AND NURSING IMPLICATIONS
Generalizations are tentative because a convenience sample was used inthis study. The findings should be cautiously interpreted because the re-sponse rate was low, indicating possible selection bias. Research withlarger random samples of adolescents from more diverse backgroundsis needed. Longitudinal studies are warranted to determine whether ado-lescents’ perceptions, attitudes, and knowledge of chewing tobacco usechange over time. Additional testing of the Chewing Tobacco Surveyshould occur to further determine reliability and validity.
Results of this pilot study may provide nurses with a greater under-standing of rural midwestern adolescents’ knowledge and perceptions ofchewing tobacco use. Standardized scales should be developed and usedto assess adolescents’ knowledge and perceptions of chewing tobaccouse. The use of the Chewing Tobacco Survey as an assessment tool shouldbe further tested, as it may provide nurses with a better understanding ofthe dimensions of chewing tobacco usage among adolescents.
The assessment findings may assist nurses in developing effective in-terventions for prevention of chewing tobacco use among adolescents.Nurses could collaborate with teachers and counselors to develop theseinterventions. Educators could include educational content about chewingtobacco based on research investigations in their classes to provide ado-lescents with a realistic picture of the consequences of chewing tobaccouse. The common practice of focusing educational content on adoles-cents’ knowledge and perceptions of cigarette smoking as opposed tochewing tobacco may not adequately inform adolescents about the conse-quences of chewing tobacco.
REFERENCES
Botvin, G. J., Baker, E., Tortu, S., Dusenbury, L., & Gessula, J. (1989). Chewingtobacco use among adolescents: Correlates and concurrent predictors. Developmentaland Behavioral Pediatrics, 10(4), 818–186.
Boyle, R. G., Claxton, A. J., & Forster, J. L., (1997). The role of social influences andtobacco availability on adolescent chewing tobacco use. Journal of Adolescent Health,20, 279–285.
Fray, B. R. (1993). Youth tobacco use: Risks, patterns, and control. In J. Slade & C. T.
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Orleans (eds.), Nicotine addictions: Principles and management (pp. 365–384). NewYork: Oxford University Press.
Gottlieb, A., Pope, S. K., Rickert, V. I., & Hardin, B. H. (1993). Patterns of chewingtobacco use by young adolescents. Pediatrics, 91(1), 75–78.
Hirschfelder, A. B. (1999). The Encyclopedia of Smoking and Tobacco (pp. 278–279).Phoenix: Oxyx Press.
Newman, I. (1999, July). Adolescent tobacco use in Nebraska from Nebraska PreventionCenter for Alcohol and Drug Abuse, UNL.
Robinson, L. A., Klesge, R. C., Zbikowski, S. M., & Glaser, R. (1997). Predictors ofrisk for different stages of adolescent smoking in a biracial sample. Journal of Con-sulting and Clinical Psychology, 65(4), 653–662.
Tomar, S. L., & Giovino, G. A. (1998). Incidence and predictors of chewing tobacco useamong US youth. American Journal of Public Health, 88(1), 20–26.
U.S. Department of Health and Human Services (1994), Preventing Tobacco Use AmongYoung People: A Report of the Surgeon General. Atlanta, GA: Centers for DiseaseControl and Prevention, Office on Smoking and Health.
U.S. Department of Health and Human Services. (2000), Healthy People 2010 (confer-ence edition, two volumes). Washington, DC: January 2000.
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