Concurrent Tobacco Use: A Study of Socio-demographic Correlates

Nasir Mushtaq, MPHLaura 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 smoke23 – 29%

– Smokers who also use ST2.6 – 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) 2003Delaware, 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)

• 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 Users8.9%

• Concurrent tobacco use – 3.2%

Results: NSDUH 2007

Covariate CCT User %

Exc. ST User %

Exc. Smoker Non Tobacco User

Total%

Age (years)

12 – 17 5.2 10.1 16.6 68.2 10018 – 25 7.8 5.7 40.5 45.9 10026 – 34 5.2 5.1 43.7 46.0 10035 or Older 1.6 4.1 29.0 65.3 100Race Ethnicity

White * 3.9 6.0 30.1 60.0 100African American * 0.3 0.3 44.8 54.6 100American Indian/Alaska Natives* 1.8 9.8 38.9 49.4 100Other* 1.1 2.2 38.4 58.4 100Hispanic 1.8 1.1 33.5 63.6 100

Tobacco Use Characteristics of Male respondents – NSDUH 2007

Results: NSDUH 2007

* Non Hispanic

Results: NSDUH 2007

Results: NSDUH 2007

Results: NSDUH 2007Tobacco Use Characteristics of Male respondents – NSDUH 2007

Covariate CCT User %

Exc. ST User %

Exc. Smoker %

Non Tobacco User %

Total %

Marital Status

Married 1.9 4.8 25.3 68.0 100Widowed 0.9 3.9 20.7 74.4 100Divorced/Separated 3.7 3.8 47.3 45.3 100Never Married 5.6 4.9 41.6 48.0 100General Health

Excellent 3.1 5.0 24.6 67.3 100Very Good 3.4 5.6 29.8 61.2 100Good 3.2 3.4 37.6 55.8 100Fair/Poor 2.6 4.2 40.4 52.8 100

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 OR (95% CI)

White 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 OR (95% CI)

Married 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)

• 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

Covariate CCT User n (%)

Exc. ST User n (%)

Exc. Smoker n (%)

Non Tobacco User n (%)

Total n

Age (years)

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

Race Ethnicity

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

Tobacco Use Characteristics of Male respondents – BRFSS 2008*

* Data from participating states

† Non Hispanic

Results: BRFSS 2008

* Data from participating states

Results: BRFSS 2008

Covariate CCT User n (%)

Exc. ST User n (%)

Exc. Smoker n (%)

Non Tobacco User n (%)

Total n

Marital Status

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

General Health

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

* Data from participating states

Tobacco Use Characteristics of Male respondents – BRFSS 2008*

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 OR (95% CI)

White 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 OR (95% CI)

Married 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 OR (95% CI)

Excellent 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: BRFSS 2008

Results:

Trends in Tobacco Use

Behavioral Risk Factor Surveillance SurveysBRFSS 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)

1.97% 1.60% 1.47% 1.30% 1.05% 0.97%

6.33%7.56% 8.12% 9.03%

10.78%

32.87%

23.06%

20.01%

16.18%

11.35% 11.57%

9.85%

0%

5%

10%

15%

20%

25%

30%

35%

2003 2008 2010 2013 2018 2020

Year

Perc

enta

ge

Concurrrent Tobacco User

Exclus ive ST User

Exclus ive Smokers

• 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 socio-demographic 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

Conclusion