Patterns of Smokeless Tobacco Use by Young Adolescents

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Patterns

of Smokeless

Tobacco

Use

by Young

Adolescents

Anita Gottlieb, RNP, MA; Sandra K. Pope, MPH; Vaughn I. Rickert, PsyD; and Brian H. Hardin, MD

ABSTRACT. The use of smokeless tobacco products by

adolescents has reportedly increased. The purpose of this

study was to examine the use of smokeless tobacco by young adolescents across geographic locations and to

look at patterns of use and variables associated with

con-tinued use beyond experimentation. Participants were

2018 students in sixth through ninth grades. Forty-five

percent were male and 76% were white. Use of smokeless

tobacco products was reported by 12% of the total

pop-ulation, and 25% reported smoking. Smokeless tobacco

use was associated with cigarette smoking, alcohol use,

and parental substance abuse. Those reporting alcohol

use were more than four times more likely to be users of

smokeless tobacco than nondrinkers. We found increased

age, being male, being white, smoking, drinking,

per-ceived effects of .smokeless tobacco use, and friends’

smoking behavior to be significantly associated with

continued use beyond experimentation. Smokeless

to-bacco use was reportedly greater in rural areas.

Adoles-cents who reported initiating use between 6 and 8 years

of age were using on a more frequent basis than those

who had initiated use when older. This study

demon-strated the need for targeting elementary schools for

educational interventions aimed at reducing smokeless

tobacco use. Pediatrics 1993;91:75-78; adolescents,

smoke-less tobacco, high-risk behavior.

Smokeless tobacco use has not received the same

adverse publicity as smoking tobacco and as a result

is frequently considered “the lesser of the two evils.”

However, use of smokeless tobacco is not without

negative consequences. Research has shown nicotine

exposure from a single chew of smokeless tobacco to

be equal to or greater than that from smoking one

cigarette.1 Smokeless tobacco users are at four times

greater risk for oral-pharyngeal cancer than

nonus-ers2 and at increased risk for coronary artery disease,

peptic ulcers, and neuromuscular disease.3

Use of chewing tobacco and snuff has remained

constant among adults, while use by adolescents has

reportedly increased.2’4’5 Although the increased use

of smokeless tobacco by adolescents is not well

un-derstood, the promotion of smokeless tobacco

prod-ucts by celebrities and sports figures has been

cred-ited with contributing to its popularity.6 Regional

and national studies of patterns of adolescent

smoke-less tobacco use have found white males to be the

most frequent users.7 Among adolescents aged 12 to

From the University of Arkansas for Medical Sciences and Arkansas Chil-dren’s Hospital, Little Rock.

Received for publication Apr 20, 1992; accepted Jul 9, 1992.

Reprint requests to (AG.) Arkansas Children’s Hospital, Division of

Ado-lescent Medicine, 800 Marshall St. Little Rock, AR 72202.

Acad-emy of Pediatrics.

17 years, 25% of males and 3% of females have used

some form of smokeless tobacco.8 Use by peers and

parents have also been identified as factors

influenc-ing adolescents to use these products.91 The use of

smokeless tobacco by teenagers has been found to be

higher in rural compared with urban areas and in

small communities where there is a tradition of

smokeless tobacco use.6’ 7,9 Most research has

tar-geted older teenagers and has not assessed patterns

of initiation or factors related to continued use by the

younger adolescent. A limitation of past research is

that investigators have looked at the dichotomy of

rural vs urban areas without evaluating the diversity

of the rural settings. This study examined the use of

smokeless tobacco by young adolescents across

geo-graphic locations from very rural to urban. It also

investigated patterns of use and variables associated

with continued use beyond experimentation.

METHODS

Thirty schools, representing the social and geographic diversity of a rural southern state, were contacted to participate in this study. Of those schools, 18 agreed to participate but only 10 were available to complete data collection before the end of the 1989-1990 school year. The populations of the 10 participating schools were representative of the urban, suburban, Highland, and Delta regions of Arkansas52 The urban area was primarily metropolitan with racially balanced public schools. The suburban area consisted of commuter communities with both public and private schools and a primarily white population. The Highland area was rural with light industry and was also primarily white, The Delta region was characterized by farm workers, extreme poverty, and a largely African-American population.

Completed questionnaires were obtained from 2018 students in the sixth through ninth grades. The sample consisted of 864% of the total student enrollment and 88.9% of the available population when considering the mean daily absenteeism rate, The consent form was read aloud to each class and students were given the opportunity to have their questions answered prior to receiving the questionnaire. Written consent was obtained and separated from the questionnaire to preserve confidentiality. Teachers were asked to remain in the room but were not involved in data collec-tion. Students were allowed a maximum of 60 minutes to complete the questionnaire. Additional time and assistance were made available for students who had difficulty reading. Data were an-alyzed from scanned answer sheets and incomplete computer forms were compared to hand written questionnaires to maximize data accuracy.

Questionnaire

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Yes No 501 1463 24 22 20 18 w 16 05 i 14 C Os e 12 Os E3 8 6 4 2 0

Figure. Use of smokeless tobacco products by area. U, urban;

l, suburban; LI, Highland; L, Delta.

76 SMOKELESS TOBACCO USE

smokeless tobacco products were assessed across three general

domains, which included participant, family, and peer character-istics.

Statistical Analyses

The sample population was described using standard univari-ate methods. Bivariate analyses ( tests) were used to compare adolescents who used smokeless tobacco products two or more times with those who did not use the product. To control for the effects of confounding, multivariate logistic regression, fitted by the method of maximum likelihood, was used to examine the inherent relationship of each variable with smokeless tobacco use.

We used 2 tests to examine patterns of smokeless tobacco use for those participants reporting use within the previous month

and to examine factors associated with continued use of smokeless tobacco products beyond experimentation (using only once in one’s life). Logistic regression analyses were used to examine fur-ther the independent effects of each variable on continued use of smokeless tobacco products beyond experimentation. Statistical

significance was set at P < 05 for all analyses.

RESULTS

The overall sample population included 2018

ad-olescents. Seven hundred fourteen (35%) were from

urban areas, 571 (28%) from suburban area, 461 (23%)

from the rural Highland, and 272 (14%) from the

rural Delta. Forty-five percent of the participants

were male and 76% were white. Age was evenly

distributed, with approximately one quarter of the

sample in each of the four age groups (11 through 12,

13, 14, and 15 through 16 years). Use of a smokeless

tobacco product two or more times was reported by

242 adolescents (12% of the total sample population),

and smoking cigarettes three or more times was

re-ported by twice as many, or 505 (25%). The Figure

demonstrates use of smokeless tobacco within each

area and shows a greater percentage of the

adoles-cents from the Highland area reporting use than from

any of the other areas.

The personal and parental characteristics of

ado-lescents using smokeless tobacco products in our

sample are illustrated in Table I. When compared

with nonusers, users of these products were

associ-ated with increasing age, being male, being white,

and having a lower grade-point average.

Addition-ally, users of smokeless tobacco products were more

likely to report personal cigarette and alcohol use

and parental substance use than were nonusers.

TABLE 1. Percentage of Smokeless Tobacco Users in a Sample

of Young Adolescents*

Age’F 11-12 y 13 y 14 y 15-16 y Sext

Characteristics Total No. % of Smokeless

Tobacco Users Male Female Racet Black Nonblack Grade-point average <C C Smokest DrinksF Yes No

Parents smoke or drinks

Neither

Either or both Parents use snuffi

None

Either or both

Believes effects of snuff to bet Serious Mild Good 587 519 457 410 7.3 11.6 14.0 18.3 873 1100 24.9 2.1 457 1517 3,7 14.8 397 1562 20.4 10.2 29.7 6.3 846 1087 22.6 4.4 605 1371 8.8 13.8 1705 240 10.6 23.8 1618 311 22 9.6 23.5 54.5 *Smokeless tobacco users defined as those who had used chewing

tobacco or snuff two or more times. 1’ P < .0005

P< 005.

When questioned regarding the health effects of

smokeless tobacco use, users were more likely than

nonusers to report that it was “good for you” or had

only mild side effects.

Logistic regression was used to examine factors

independently associated with smokeless tobacco

us-ers compared with nonusers while controlling for the

confounding effects of the other factors in the model

such as gender. Odds ratios for age, gender, race, and

other significant variables are presented in Table 2.

Males were more likely than females to be users and

whites were more than three times more likely to be

users than African-Americans. Additionally,

adoles-cents reporting use of cigarettes were more than

three times more likely to be users of smokeless

to-bacco products than were nonsmokers. Those

report-ing drinking alcohol were more than four times more

likely to be users than were nondrinkers. The

High-land area was the only rural area found to be

signif-icantly associated with use of smokeless tobacco

products. Those living in the Highland area were

twice as likely as those living in the suburban area to

be identified as users of smokeless tobacco products.

Participants who reported use of smokeless

to-bacco products in the month prior to the

administra-tion of the survey (n = 197) were further examined

for characteristics associated with their patterns of

use, as shown in Table 3. The majority of the subjects

reported smokeless tobacco use to be once per week

or less. However, 50% of the adolescents living in the

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* Smokeless tobacco use defined as having used chewing tobacco or snuff two or more times. CI, confidence interval.

t P < .05.

: P < .005.

§J) < .0005.

TABLE 3. Characteristics of Smokeless Tobacco Users and

C/c of Smokeless

Tobacco Users 41.7 43.2 56.6 55.1 58.3 19.5 26.2 52.7 59-4 38.3 57.0 32.7 45.2 57.0 80.0 56.6 38.8 103 139 113 136 372 118 65 427 251 240 335 147 345 128 15 272 214

TABLE 2. Odds Ratios for Smokeless Tobacco

Computed From Logistic Regression Analyses*

Use vs Nonuse

Characteristics Odds Ratios 95’7c CI

Males 18.42 11.35, 29.91

Nonblack 3.44 1.81, 6.52

Area

Suburban 1.00

Urban 1.32 0.81, 2.16

Highlandt 2.16 1.35, 3.48

Delta 1.14 0.58, 2.23

Smoking 3.20 2.20, 4.66

Drinking 4.16 2.78, 6.23

Parents use snufft 1.76 1.13, 2.73

Grade-point average <Cf 1.54 1.04, 2.29

Believes effects of snuff are

Serious 1.00

Mild 2.78 0.77, 10.01

Good for you 934 4.21, 20.71

Their Patterns of Use*

Characteristics Total % Using C7 Using 9 Using

No. of Once/wk 2-3 Times/ Daily

Users or Less wk

Age

11-12 y 44 52.3 15.9 31.8

13 y 56 66.1 14.3 19.6

14 y 44 36.4 22.7 40.9

15-16y 54 51.9 24.1 24.1

Se4

Male 151 45.7 21.2 33.1

Female 46 76.1 10.9 13.0

Areat’

Urban 65 61.5 10.8 27.7

Suburban 41 56.1 24.4 19.5

Highland 68 50.0 23.5 26.5

Delta 24 29.2 20.8 50.0

Age of initiationt

5-8 y 64 48.4 15.6 35.9

9-12 y 61 52.5 14.8 32.8

13-16 y 33 54.5 33.3 12.1

Wish could chew less4

Yes 68 67.6 14.7 17.6

No 72 30.6 26.4 43.1

Need snuff in AM

Yes 34 23.6 20.6 55.9

No 107 57.0 19.6 23.4

*Smokeless tobacco users defined asthose who had used chewing tobacco or snuff two or more times.

tP< .05.

::P < .005.

Delta area reported daily use compared with only

28% or fewer reporting daily use in the three other

areas. Across regions, age of initiation was shown to

be significantly associated with use, with more

ado-lescents who initiated use between 6 and 8 years of

age being daily users than those who reported

initi-ation when they were older. Although not

signifi-cantly different, it is interesting to note that 32% of

the 11- and 12-year-olds who had tried smokeless

tobacco reported daily use.

To determine what factors were associated with

continued use beyond experimentation, bivariate

comparisons were conducted on those adolescents

who reported use of smokeless tobacco products at

least once (n = 492). These analyses found that

in-creased age, being male, and being white were

re-lated to continued use. Additionally, smoking,

drink-ing, perceived effects of smokeless tobacco use, and

friends’ smoking behavior were significantly

associ-ated with continued use (Table 4). When we

con-trolled for confounding effects through logistic

re-gression, gender, race, alcohol use, and friends’

smoking were associated with continued use beyond

experimentation (Table 5). Interestingly, geographic

location was not found to be associated with use

beyond experimentation in either bivariate or

multi-variate analyses.

DISCUSSION

In this study, we assessed use of smokeless tobacco

among sixth through ninth graders across diverse

geographic settings in a rural southern state.

Previ-ous studies have noted regional variation related to

the use of smokeless tobacco by both youth and

adults. Rural areas have been found to have the

high-est population of users. We sought to investigate

fur-ther the significance of rural locations and found that

the rural Highland area had a higher percentage of

users than the urban area. However, adolescents

liv-ing in the very rural or Delta area had a lower

per-centage of users than those in the urban area. Thus, it

may be incorrect to assume that all rural areas have

more users than urban areas without considering the

unique cultural, geographic, and economic

dimen-sions of rural locales.

TABLE 4. Comparison of Experimenters vs Users of Smoke-less Tobacco in Young Adolescent Sample*

Aget 11-12 y 13 y 14 y 15-16 y Genders Male Female

Characteristics Total No. of

Experimenters and Users Race4 Black Nonbiack Smokes Yes No Drinks Yes No

Believes effects of snuff to bet’ Serious Mild Good Friends smokes Yes No

* Experimenters defined as those who had tried snuff or chewing tobacco only once; user defined as those who had used snuff or smokeless tobacco two or more times.

t P < .05.

P< .001.

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78 SMOKELESS TOBACCO USE

TABLE 5. Odds Ratios for Variables Associated With

Contin-ued Use of Smokeless Tobacco Products Beyond Experimentation

Computed From Logistic Regression Analyses*

Characteristics Odds Ratio 95% CI

Males 6.01 (3.56, 10.14)

Nonblack 2.75 (1.41, 5.36)

Drinker* 2.52 (1 .59, 3.97)

Friends smoket I .65 (1 .09, 2.52)

* Experimentation defined as trying snuff or chewing tobacco only once. CI, confidence interval.

t P < .05.

1:P < .005.

§P < .0005.

The influence of parents and peers on adolescents

has been shown to be one of the most salient

predic-tors of substance abuse among adolescents.10’11’34 In

support of other studies, we found that the

adoles-cents who reported that their parents smoked, drank

alcohol, or used smokeless tobacco were more likely

to be users of smokeless tobacco products. We also

found that adolescents with friends who smoked

were more likely to continue use above experimen-tation.

The subjects’ perceptions of health consequences

of dipping and chewing were related to use and to

continued use beyond experimentation. Nonusers

were more likely than users to perceive negative

health consequences of using smokeless tobacco.

Also, adolescents who tried smokeless tobacco

prod-ucts once, but did not continue to use them, were

more likely to perceive the negative health

conse-quences of use. This emphasizes the need to provide

health education to children about the negative

ef-fects of using smokeless tobacco products. Targeting

elementary schools, as well as junior high schools, for

preventive education is necessary.

We found a relationship between age of initiation and frequency of use that is consistent with previous research. In particular, our study showed that

ado-lescents who reported initiating use between 6 and 8

years of age were currently using smokeless tobacco

products on a more frequent basis than those who

were older when use was initiated. This finding

sup-ports addiction and dependence developed from use

of smokeless tobacco. Other researchers have also

reported that younger users appear to have a greater

likelihood of developing a regular pattern of use

compared with those who first tried smokeless

to-bacco during adolescence.

Many people believe that the use of smokeless

tobacco products is a safe alternative to smoking.

Hence adults, and subsequently their children, are

using smokeless tobacco products. As health care

providers, our role in preventive medicine needs to

include education to patients and their parents

re-garding the health risks of smokeless tobacco. Our

message must include information that nicotine

present in cigarettes and smokeless tobacco products

causes addiction and that the underlying process of

this addiction is similar to those in other drugs. From

our findings, we recommend providing this

educa-tion at very young ages and targeting urban as well

as rural children. Information regarding the hazards

of smokeless tobacco use needs to be as widely

pub-licized

as

that related to the hazards of cigarette smoking.

ACKNOWLEDGMENTS

We thank Gene Bonner and Kevin Hiegel for their help with data collection and Charlotte Bornemeier for manuscript prepara-tion.

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1993;91;75

Pediatrics

Anita Gottlieb, Sandra K. Pope, Vaughn I. Rickert and Brian H. Hardin