Dual Use of Smokeless Tobacco and Cigarettes:A Public Health Warning Sign

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68th Annual Kansas Public Health Association ConferenceWichita, KansasSeptember 22, 2011

Terry F. Pechacek, PhDAssociate Director for Science

Centers for Disease Control and PreventionOffice on Smoking and Health

The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

The responsibility for all of the presented material rests exclusively with the author.

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Presentation Overview The problem: stalled in a steady

state Trends in smoking Overview of smokeless tobacco Trends in use of tobacco products Trends in smokeless tobacco use Trends in dual use Conclusions & implications

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A Steady State

Too Few SmokersQuitting

Too Many YouthStarting to Smoke

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The Problem Slowing of decline in youth

smoking rate Slowing of decline in adult

smoking rate decline Increasing smoking initiation

rates Increasing rates of smokeless

tobacco use among high school boys and young adult men

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Emerging Changes in Tobacco Use Use of other tobacco products

besides cigarettes Pattern of using two or more

tobacco products Dual use of cigarettes and

smokeless tobacco is special concern

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The Bottom Line

Progress in reducing tobacco use among both youth and adults has slowed in recent years

Smokeless use and dual use are part of the problem

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When will we take the handle off the tobacco pump?

1854 - Dr. John Snow removed the pump handle from Broad Street water pump to stop a Cholera Epidemic in London

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Product, Price, Promotion, Placement*

PRODUCT – Certain features of tobacco products appeal to youth & young adults

PRICE – Youth and young adults are especially price sensitive

PROMOTION – Youth are more sensitive to advertising and promotional campaigns

PLACEMENT – Strategic placement of youth-oriented images and brands in media, advertising, and retail environments

*Source: Cummings KM, Morley CP, Horan JK, Steger C, Leavell N-R. Marketing to America’s Youth: evidence from corporate documents. Tobacco Control 2002;11(Suppl 1):i5-i17.

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Overview Cigarette Use Smokeless Tobacco Use Dual Tobacco Use

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Cigarette Use

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0

10

20

30

40

50

60

Year

Current Cigarette Smoking* Among Adults By Sex, U.S.—1955-2010

*Estimates since 1992 include some-day smoking. Sources: 1955 Current Population Survey; 1965-2006 National Health Interview Survey 2010

Males

Females

54.2

21.5

24.5

17.3

Per

cent

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Average Annual Rates of ChangeNHIS 1974-2010

1974 adj. (37.8%) – 2010 (19.4%) = -0.51% 1974 (37.1%) – 1990 (25.5%) = -0.73% 1990 adj. (26.2%) – 1997 (24.7%) = -0.21% 1997 (24.7%) – 2004 (20.9%) = -0.54% 2004 (20.9%) – 2010 (19.4%) = -0.25% 1990 adj. (26.2%) – 2010 (19.4%) = -0.34%

*adj (definition change in 1992 – adjusted estimates used in analysis of rates of change)

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Prevalence (%) of daily and less than daily smoking among U.S. adults (ages 18+ years old) -- 2002-2009 NHIS, BRFSS, and NSDUH20

0220

0320

0420

0520

0620

0720

0820

09

2002

2003

2004

2005

2006

2007

2008

2009

0

2

4

6

8

10

12

14

16

18

20

NHIS NSDUH BRFSS

DAILY SMOKING

*

* Confidence intervals around 2002 and 2009 estimates do not overlap.

LESS THAN DAILY SMOKING

*

*

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• Persons who reported smoking at least 100 cigarettes during their lifetime and who, at the time of the survey, reported smoking cigarettes every day.

• Source: CDC. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—US, 2005-2010. MMWR 60 (Early Release); 1-6

Percentage of daily smokers* aged ≥18 years, by number of cigarettes smoked per day (CPD) and

year, NHIS, United States, 2005--2010

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Current High School Cigarette Smoking And Projected Rates If Decline Had Continued, U.S. 1991-2009

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

5

10

15

20

25

30

35

40

45YRBS HS SMK* Projected HS SMK**

Year

Perc

ent

8%

*High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey, 1991-2009.**Projected High School students who smoked 1 or more days of past 30 days if 1997-2003 decline had been maintained.

3 million fewer youth and youngAdults would be smokers

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Past Year Initiation of Cigarette Use Among Youth and Young Adults: 2004 to

2009

6.8 6.6 6.65.9 6.2 6.2

7.1 7.4

8.77.9 8.3 8.6

0123456789

10

2004 2005 2006 2007 2008 2009

12-17 Years Old18-25 Years Old

Source: SAMHSA and NSDUH, 2004, 2005, 2006, 2007, 2008, 2009

* Initiation is defined as smoking cigarettes for the first time in the past year.

Perc

ent

Year

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2002 2003 2004 2005 2006 2007 2008 2009 20100.0

0.5

1.0

1.5

2.0

2.5

1.3 1.4 1.4 1.4 1.51.3 1.4 1.5 1.4

0.60.6 0.7 0.8

0.9

0.91.0

1.01.0

Past Year Cigarette Initiates among Persons Aged 12 or Older, by Age at First Use: 2002-2010

Numbers in Millions

17

1.9+2.0+

2.1+2.3

2.4 2.4

2.2

Initiated at Age 18 or Older

Initiated Prior to Age 18

+ Difference between this estimate and the 2010 estimate is statistically significant at the .05 level.

Note: Due to rounding, the stacked bar totals may not add to the overall total.

2.52.4

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Overview of Smokeless Tobacco

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Types of Smokeless Tobacco Chewing tobacco Dry snuff Moist snuff Dissolvables

– Lozenges, orbs, sticks, strips

Substance Abuse and Mental Health Services Agency, Office of Applied Studies. The NSDUH Report: Smokeless tobacco use, initiation, and relationship to cigarette smoking: 2002 to 2007. Rockville, Maryland: SAMHSA, March 5, 2009.

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New Smokeless Products Have Broader Appeal Spitless Discreet Flavored Packaged in novel, attractive ways Blur the line between tobacco

& non-tobacco products Cigarette brand extensions Heavily promoted

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Smokeless Tobacco: Health Effects Contains at least 28 carcinogens Oral cancer Esophageal cancer Pancreatic cancer Fatal heart attacks Premature birth & low birthweight

International Agency for Research on Cancer. Smokeless tobacco and some tobacco-specific N-nitrosamines. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 89. Lyon, France: IARC, 2007.European Commission Health & Consumer Protection Directorate-General, Scientific Committee on Emerging and Newly Identified Health Risks. Health effects of smokeless tobacco products. Brussels, Belgium: European Commission, 2008.National Toxicology Program. NTP report on carcinogens background document for smokeless tobacco. National Toxicology Program, 1997.

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Smokeless Tobacco: Addiction Contains nicotine Highly addictive Increasing intensity of use “Graduation” to brands with higher

nicotine levels

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Major Cigarette Manufacturers Now Dominate Smokeless Market

Reynolds American acquired the Conwood Company in 2006– Grizzly, Kodiak, Hawken

Altria acquired the U.S. Smokeless Tobacco Company in 2008– Copenhagen, Skoal, Red Seal, Husky

Reynolds and Altria have also introduced their own brands.

Implications– Increased resources for promotion– Ability to draw on existing retail programs– Smokeless extensions of cigarette brands

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Advertising Expenditures In 2006, U.S. smokeless manufacturers spent

$354 million on advertising and promotion Up from $251 million in 2005 Preceded acquisitions of main smokeless

manufacturers by Reynolds and Altria Compares to $10.5 billion spent on cigarette and

smokeless products advertising in 2008

Federal Trade Commission. Smokeless Tobacco Report for the Year 2006; Cigarette Report for 2006.

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Potential Promotion Messages Use smokeless to sustain nicotine

addiction in smoke-free places Complement cigarette use with use

of smokeless extension of same brand Use smokeless as aid in cessation Switch to smokeless as safer

alternative (harm reduction) Switch to smokeless as more socially

acceptable alternative Common denominator: many of these messages

appear to target smokers

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Snus ads “Boldly go everywhere” “Bar-friendly” “Encore-friendly” “Fancy hotel-friendly” “Enjoy taxicabs,

subways, and bar hopping”

26

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Snus Ads Advertisements picturing smokefree places like

airplanes and concert venues “Pleasure for wherever”

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Potential Trajectories of Smokeless & Cigarette Use

Smokers switch to smokeless, then quit all tobacco use

Smokers switch to smokeless, subsequently become exclusive long-term smokeless users

Smokers initiate smokeless use while continuing to use cigarettes (dual use)

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Potential Adverse Population Effects Increased initiation of smokeless tobacco use

– Some users could later switch to cigarettes Increased relapse of former smokers to tobacco

use– Could take up smokeless use, then relapse

back to cigarettes Continued smoking by smokers who would

otherwise have quit– Instead of using no tobacco products, end up

smoking and using other tobacco products

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Health Implications of Dual Use Prolonging smoking substantially

increases risk Duration is a stronger determinant of risk

than intensity Use of smokeless in addition to cigarette

adds further layer of risk Combined effects are unknown,

worrisome

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Trends in Use of Any & Multiple

Tobacco Products

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Percentage of High School Students Who Reported Current Cigarette and Tobacco

Use,* 1991-2009

43.440.2

33.9

27.5 28.425.7 26

27.530.5

34.8 36.4 34.8

28.5

21.9 2320 19.5

0

5

10

15

20

25

30

35

40

45

50

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Any Tobacco Use† Cigarette Use

Source: National Youth Risk Behavior Survey, 1991 – 2009* Smoked cigarettes on > 1 of the 30 days preceding the survey† Current cigarette use, current smokeless tobacco use, or current cigar use

Perc

ent

Year

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Large Cigarweigh > 1.36 grams

Wide variety of cigar products

Small cigars weigh less than or equal to 1.36 grams

Features common to cigarettes, such as shape, length (70 to 100 mm), and use of filter tips

CigarilloConsidered a “large” cigar for taxation purpose

Source: Cristine Delnevo, UMDNJ School of Public Health

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Per Capita Consumption of Cigars (Number of Sticks) – 2000-2010

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

10

20

30

40

50

60

Cigars-SmallCigars-Large

Source: US Department of Treasury; Alcohol and Tobacco Tax and Trade Bureau

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Trends in Smokeless Tobacco

Use

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Who Uses Smokeless Tobacco? Males Teens and young adults Rural residents Residents of the South and Midwest American Indians

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Substance Abuse and Mental Health Services Agency, Office of Applied Studies. The NSDUH Report: Smokeless tobacco use, initiation, and relationship to cigarette smoking: 2002 to 2007. Rockville, Maryland: SAMHSA, March 5, 2009.

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Percentage of High School Students, by Sex, Who Reported Current Smokeless

Tobacco Use,* 1995-2009

Source: National Youth Risk Behavior Surveillance Surveys, 1995 – 2009* Used chewing tobacco, snuff, or dip on 1 of the 30 days preceding the survey

Perc

ent

Year

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Percentage of Male High School Students Who Reported Current

Smokeless Tobacco Use* by Ethnicity, 1995-2009

Source: National Youth Risk Behavior Surveillance Survey, 1995 – 2009*Used chewing tobacco, snuff, or dip on 1 of the 30 days preceding the survey **Non-Hispanic

1995 1997 1999 2001 2003 2005 2007 20090

5

10

15

20

25

30

White Male**Black Male**Hispanic MaleWhite Female**Black Female**Hispanic Female

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Percentage of Smokeless Tobacco Use in the Past Month among Persons 18-25

years of age, by sex: 2004-2009

2004 2005 2006 2007 2008 20090

2

4

6

8

10

12Males Females

Source: SAMHSA, 2004-2009, NSDUH

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Percentage of Youth 12-17 and 18-25 Initiating Smokeless Tobacco Use, Among

Those Eligible for Initiation, 2004-2009

0

0.5

1

1.5

2

2.5

3

2004 2005 2006 2007 2008 2009

12-17 Years of Age18-25 Years of Age

Source: SAMHSA, 2004 to 2009, NSDUH

Perc

ent

Year

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Trends in Prevalence of Smokeless Tobacco Use: Grades 8, 10 and 12

Source: Monitoring the Future survey, 2000-2010Question text: “Have you ever used smokeless tobacco?”; “How frequently have you used smokeless tobacco during the past 30 days?”

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

30 Grade 8 Grade 10 Grade 12

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Trends in 30 day Prevalence of smokeless tobacco use by sex: Grade 12

Source: Monitoring the Future survey, 2000-2010Question text: “How much do you think people risk harming themselves (physically or in other ways) if they use smokeless tobacco regularly?”

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 201002468

1012141618 Males Grade 12 Females Grade 12

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Trends in 30 day Prevalence of smokeless tobacco use by Race/Ethnicity: Grade 12

Source: Monitoring the Future survey, 2000-2010Question text: “How much do you think people risk harming themselves (physically or in other ways) if they use smokeless tobacco regularly?”

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2

4

6

8

10

12

14white African American Hispanic

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Trends in Attitudes about Regular Smokeless Tobacco Use: grades 8 and 10

Disapproval

Source: Monitoring the Future survey, 2000-2010Question text: “Do you disapprove of people using smokeless tobacco regularly?”

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 201072

74

76

78

80

82

84Grade 8 Disapproval Grade 10 Disapproval

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Trends in Dual Use

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Percentage of High School Students Who Were Current SLT Users Who Were Also

Current Smokers: 1995-2009

1995 1997 1999 2001 2003 2005 2007 20090

102030405060708090

Total MalesWhite Males Hispanic Males

Source: National Youth Risk Behavior Survey 1995-2009

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Percentage of High School Students Who Reported Current Any Tobacco Use* and Current Poly Tobacco

Use† by Race/Ethnicity and Sex: 2009

Total White Black Hispanic Other Male Female0

2

4

6

8

10

12

14

16

18 Only One Tobacco Product Any Two Tobacco ProductsAll Three Tobacco Products

Source: National Youth Risk Behavior Survey, 2009*Any Tobacco Use: Current use of one or more tobacco products (cigarettes, cigar, SLT).† Poly Tobacco Use: Current use of 2 or more tobacco products (cigarettes, cigar, SLT).

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Sequence of Initiation of Smokeless Tobacco and Cigarette Use among Persons Who Had Ever Used Both Smokeless Tobacco and Cigarettes: 2004 to 2007

Source: SAMHSA, 2004 to 2007 NSDUHs

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Percentages of Cigarette Use among Past Month Smokeless Tobacco Users, by

Age Group: 2002 to 2009

Source: SAMSHA, 2002-2009 NSDUHs

Total

Aged 12 to 17

Aged 18 to 25

Aged 26 or Older

0 10 20 30 40 50 60 70

39

51.8

65.8

29.9

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Conclusions & Implications

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Conclusions New smokeless products have broader

appeal These products are being heavily marketed,

including to smokers Smokeless tobacco use is on the increase Many smokeless users also smoke cigarettes Smokeless use and dual use are

concentrated in white teen boys and white young adult men

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Cause for Concern Exclusive smokeless tobacco use pose

significant health risks in itself Dual use of smokeless tobacco and

cigarettes poses additional risks Dual use may delay smoking cessation or

make it more difficult– Prolong duration of smoking– Keep people in the smoking population

Duration of smoking is the most important determinant of risk

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Cause for Concern Dual use may also facilitate pattern of light

smoking among young adults–Nondaily smoking– “Social” or “recreational smoking”

This pattern poses particular challenges to cessation

People may not perceive themselves to be smokers

Part of a broader pattern of polytobacco use Other product combinations may pose risks

too

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Implications Emerging trends in smokeless and dual use

threaten to reverse progress towards reducing tobacco use and its health burden

We need to keep a close eye on these trends and monitor their population impact

We need to monitor use of all tobacco products, not just cigarettes

We need to monitor use of combinations of tobacco products, rather than monitoring use of each product in isolation

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When will we take the handle off the tobacco pump?

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End GoalWhat is the final destination?

Tobacco Use is a Minor Public Health Nuisance

Timeline: This Generation (not by 22nd century)

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AZ

WY

ORID

MT

UTNV

WA

CA

TX

AROK

ND

LA

KS

IANE

SD

CO

NM

MO

MN

TN

AL

KY

OH

MS

MI

IN

GA

FL

PA

ME

NY

WV VA

NC

SC

VT

CT

D.C.

RI

NJ

MDDE

NHMA

IL

WI

AK

HI

Ban in worksites,restaurants, and bars (n=26)

Ban in two of three locations (n=4)

Laws in effect as of June 1, 2011*

Less comprehensiveor no restrictions (n=21)

Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.

State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars

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AZ

WY

ORID

MT

UTNV

WA

CA

TX

AROK

ND

LA

KS

IANE

SD

CO

NM

MO

MN

TN

AL

KY

OH

MS

MI

IN

GA

FL

PA

ME

NY

WV VA

NC

SC

VT

D.C.

NJ

MDDE

NHMA

IL

WI

AK

HI 50-99 cents per pack$1.00-$1.49 per pack$1.50-$1.99 per pack$2.00-$2.99 per pack

CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.

<50 cents per pack

Chicago$3.66

NYC$5.85

CTRI $3.46

State Cigarette Excise Tax Rates – 2011

≥ $3.00 per pack

Anchorage$4.20

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Hard hitting media campaigns

http://www.youtube.com/watch?v=SfAxUpeVhCg

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Support for Smokers Who Want to Quit

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Family Smoking Prevention and Tobacco Control Act of 2009

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Immediate impact of a comprehensive approach:

youth and adult smoking rates in NYC

Source: BRFSS 1993 – 2001; NYC Community Health Survey 2002 – 2009; and NYC YRBS 2001 - 2010

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

AdultYouth

Perc

ent

3-yr. average 3-yr. average 3-yr. average

21.6% 21.5% 21.7% 21.5%

19.2% 18.3%

18.9%

17.5%16.9%

15.8%

City and State tax increases

Smoke-freepolicy Media

campaign

17.6%

14.8%

11.2%

8.5% 8.4%

15.8%

State and Federal Tax increases

7%

14%

Terry F. Pechacek, Ph.D.Associate Director for ScienceOffice on Smoking and Health

Phone: (770) 488-5701Fax: (770) 488-5767E-mail: txp2@cdc.govInternet: www.cdc.gov/tobacco

For More Information...

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The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.