Concurrent Tobacco Use: A Study of Socio-demographic Correlates

1. Concurrent Tobacco Use: A Study of Socio-demographic Correlates Nasir Mushtaq, MPH Laura A Beebe, PhD University of Oklahoma Health Sciences Center

2. 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

3. Background • Smokeless Tobacco • Chewing Tobacco • Snuff • Health Effects • Oral lesions • Oral, esophageal, larynx, and lung cancer • Cardio-vascular disease

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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)

13. Methods • Analysis • Frequencies and probabilities • Chi square test • Logistic Regression • Crude Odds Ratios and 95% confidence intervals • Average Annual Percent Change α = 0.05

14. Results National Survey on Drug Use and Health (NSDUH 2007)

15. 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%

16. Results: NSDUH 2007 Tobacco Use Characteristics of Male respondents – NSDUH 2007 * Non Hispanic

17. Results: NSDUH 2007

18. Results: NSDUH 2007

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

20. Results: NSDUH 2007

21. Results: NSDUH 2007

22. Results: NSDUH 2007

23. Results: NSDUH 2007

24. Results: NSDUH 2007

25. Results: NSDUH 2007

26. Results: NSDUH 2007

27. Results Behavioral Risk Factor Surveillance Surveys (BRFSS 2008) (Delaware, Florida, Indiana, Louisiana, Nebraska, North Carolina, Tennessee, Texas, West Virginia, Wisconsin, Wyoming)

28. 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)

29. Results: BRFSS 2008 Tobacco Use Characteristics of Male respondents – BRFSS 2008* * Data from participating states † Non Hispanic

30. Results: BRFSS 2008 * Data from participating states

31. Results: BRFSS 2008 Tobacco Use Characteristics of Male respondents – BRFSS 2008* * Data from participating states

32. Results: BRFSS 2008

33. Results: BRFSS 2008

34. Results: BRFSS 2008

35. Results: BRFSS 2008

36. Results: BRFSS 2008

37. Results: Trends in Tobacco Use Behavioral Risk Factor Surveillance Surveys BRFSS 2003 & BRFSS 2008 Delaware, Indiana, Nebraska, North Carolina, Texas, Wyoming

38. Results: Trends in Tobacco Use

39. Results: Trends in Tobacco Use

40. 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.

41. 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)

42. 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

43. 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

44. 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.

45. 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%

46. Conclusion • Study found increase in ST use among smokers • Smoke free environment? • Harm reduction? • Lack of clear direction of the shift in tobacco product

47. 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