Judgments, Awareness, and the Use of Snus Among Adults in the United States

Abstract

Introduction:

Alternative tobacco products, such as snus, are emerging in the U.S. market. Understanding correlates of awareness and use, particularly judgments about harm and addictiveness, can inform public health communications about these products.

Methods:

Data were collected from a web panel representative of the U.S. population in March 2013 (N = 2,067). The survey assessed awareness and use of snus among adults. Absolute and comparative snus judgments, intentions, smoking status, and sociodemographic variables were measured. Bivariate and multivariable logistic regression analyses were conducted to examine associations between these variables and snus awareness and use.

Results:

Nearly 36% of the population was aware of snus, and 5.2% reported ever using snus. Current cigarette smokers were about 4 times more likely as nonsmokers to report snus awareness and use. Sociodemographic correlates of snus awareness and use included being male, employed full time, and younger. Compared with respondents who perceived snus to be as harmful and as addictive as cigarettes, those who perceived snus to be less harmful and less addictive than cigarettes were more likely to have used snus.

Conclusions:

Current smokers are more likely to be aware of and have used snus. Multiple tobacco product use poses a significant challenge for public health efforts to reduce tobacco-associated morbidity and mortality. Perceptions that snus is less harmful and less addictive compared with cigarettes are associated with snus use. These judgments can inform public health communications about emerging tobacco products and multiple product use.

INTRODUCTION

Snus is a smokeless tobacco product that has been sold for many years in Sweden and was introduced in the U.S. market in 2006. Snus comes in a small pouch (like a small teabag) which is placed in the cheek or between the teeth and gums for extended periods of time. Snus users do not chew or spit when using snus. Despite well-documented health risks, the prevalence of current smokeless tobacco use among U.S. adults aged 18 years and older is 3.4%, and 1.4% of adults use snus (King, Dube, & Tynan, 2012). Sales of pouched forms of moist snuff increased by 333.8% between 2005 and 2011, with snus sales doubling between 2009 and 2010 and snus brands emerging among the top 10 selling moist snuff brands after just 2 years on the U.S. market (Delnevo et al., 2014).

Judgments about tobacco product harm and addictiveness are associated with tobacco use behavior and are particularly important to understand in the context of novel tobacco products (Popova & Ling, 2013a; Zhu et al., 2013). Product judgments can be measured on an absolute scale (e.g., how harmful/addictive is product X) or on a comparative scale (e.g., how harmful/addictive is product X compared with product Y), and recent studies of snus demonstrate the value of using both types of measures to understand consumer judgments (Popova & Ling, 2013a). The purpose of this study is to investigate U.S. adults’ judgments on the absolute harms of snus and comparative harms relative to cigarettes and examine associations among sociodemographics, judgments about snus harms, and snus awareness and use. We build from recent studies examining snus judgments, awareness, and use by investigating these issues in a U.S. population-based sample.

METHODS

Data were collected through GFK Knowledge Networks. Ten questions pertaining to tobacco were submitted and selected as part of a crowdsourced survey research challenge conducted by RTI International (see Supplementary Material) (Brabham, Ribisl, Kirchner, & Bernhardt, 2014). Households were sampled from the KnowledgePanel®, a probability-based web panel representative of U.S. noninstitutionalized adults aged 18 years and older. The survey was fielded in March 2013. The analytic sample included 2,067 adults. Statistical analyses included bivariate chi-square and t tests, and multivariable logistic regression analyses. Statistical weights incorporating selection probabilities and population benchmarks from the Current Population Survey were used to calculate population estimates.

Measures

The survey is included in Supplementary Material. Respondents were first provided with a description of snus. Snus awareness, intentions, and ever use were then assessed. Participants reported their perceived absolute harm and addictiveness of snus. To operationalize absolute snus judgments, participants were categorized as endorsing snus as (a) both harmful and addictive (agree/strongly agree to both items), (b) either harmful or addictive (agree/strongly agree to one item), or (c) neither harmful nor addictive (disagree/strongly disagree to both items). Participants also reported their perceived relative harm and addictiveness of snus compared with cigarettes. To operationalize comparative snus judgments, participants were categorized as endorsing beliefs that (a) snus was harmful and addictive compared with cigarettes (about the same/more/much more to both items), (b) either harmful or addictive compared with cigarettes (about the same/more/much more to one item), or (c) less harmful and less addictive compared with cigarettes (much less/less to both items). Participants were classified as current smokers (everyday and someday) or nonsmokers (never and former). Measures of gender, age, race/ethnicity, marital status, employment status, and education were included.

RESULTS

Awareness and Use of Snus

More than one third of the 2,067 respondents (35.5%, n = 714) reported awareness of snus and 5.2% (n = 99) had ever used snus (Table 1). Less than 1% of the sample (n = 7) currently used snus. Among those who had ever used snus, 48.6% were current smokers and 51.4% were nonsmokers. Respondents who were male, younger (≤55 years), non-Hispanic White, employed, who did not have a college education, and who were current smokers were more likely to be aware of snus (all ps < .001). Snus intentions (p = .002) and comparative judgments (p = .001) were also associated with snus awareness. Respondents who were male, younger (≤55 years), and current cigarette smokers were also more likely to have used snus (all ps < .001). Snus intentions, absolute, and comparative snus judgments were also associated with snus use (all ps < .001). Almost 88% of participants rated snus as harmful and addictive and almost 82% rated snus as harmful and addictive compared with cigarettes. When judgments about snus harm and addictiveness were examined separately, only comparative judgments about harm and addictiveness were associated with snus awareness. Both absolute and comparative judgments about snus harm and addictiveness were associated with snus use (all ps < .01).

Table 1.

Sample Characteristics and Bivariate Associations of Snus Awareness and Use (Weighted %, Sample n Unless Otherwise Indicated)

	Sample	Snus awareness		p value	Snus use		p value
		Yes	No		Yes	No
	% (n)	% (n)	% (n)		% (n)	% (n)
Total	2,067	35.5 (714)	64.5 (1,353)		5.2 (99)	94.8 (1,968)
Demographics
Gender				<.001			<.001
Male	48.6 (1,009)	56.4 (404)	44.3 (605)		75.5 (74)	47.1 (935)
Female	51.4 (1,058)	43.6 (310)	55.7 (748)		24.5 (25)	52.9 (1,033)
Age (M, SE)	47.6 (0.51)	44.3 (0.79)	49.3 (0.65)	<.001	37.9 (1.70)	48.0 (0.53)	<.001
18–25 years	14.1 (213)	15.9 (90)	13.2 (123)	<.001	27.0 (22)	13.4 (191)	<.001
26–30 years	8.8 (132)	10.5 (56)	7.9 (76)		18.3 (14)	8.3 (118)
31–45 years	24.7 (473)	26.7 (190)	23.6 (283)		24.9 (27)	24.7 (446)
46–55 years	17.4 (413)	21.0 (165)	15.5 (248)		19.0 (24)	17.4 (389)
≥56 years	34.9 (836)	25.9 (213)	39.8 (623)		10.5 (12)	36.2 (824)
Race/ethnicity				.017			.095
Non-Hispanic White	67.0 (1,577)	74.0 (580)	63.2 (997)		68.7 (79)	66.9 (1,498)
Non-Hispanic Black	12.0 (181)	6.6 (40)	14.9 (141)		2.2 (3)	12.5 (178)
Non-Hispanic Other	8.8 (141)	6.9 (43)	9.8 (98)		14.0 (8)	8.5 (133)
Hispanic	12.2 (168)	12.5 (51)	12.1 (117)		15.1 (9)	12.1 (159)
Marital status				.465			.202
Married/partnered	60.5 (1,351)	59.1 (466)	61.2 (885)		52.5 (60)	60.9 (1,291)
Unmarried	39.5 (703)	40.9 (244)	38.8 (459)		47.5 (38)	39.1 (665)
Employment				.007			.074
Employed	50.1 (1,060)	55.2 (412)	47.3 (648)		61.9 (66)	49.5 (994)
Not employed	49.9 (995)	44.8 (298)	52.7 (697)		38.1 (33)	50.5 (962)
Education				<.001			.171
High school/GED or less	36.2 (646)	38.5 (247)	34.8 (399)		33.7 (33)	36.3 (613)
Some college/technical training	32.2 (655)	35.2 (246)	30.6 (409)		37.0 (34)	32.0 (621)
College degree	15.0 (340)	15.2 (112)	14.9 (228)		21.4 (24)	14.7 (316)
Graduate degree	16.6 (418)	11.1 (107)	19.7 (311)		7.8 (8)	17.1 (410)
Cigarette smoking				<.001			<.001
Current smoker	16.8 (329)	30.0 (217)	9.5 (112)		48.6 (49)	15.1 (280)
Nonsmoker	83.2 (1,728)	70.0 (495)	90.5 (1,233)		51.4 (49)	84.9 (1,679)
Snus intentions (M, SE range, 1–5)	1.3 (0.02)	1.4 (0.04)	1.2 (0.03)	.002	2.3 (0.15)	1.2 (0.02)	<.001
Absolute snus judgment				.591			<.001
Harmful and addictive	87.8 (1,834)	86.6 (616)	88.4 (1,218)		72.3 (71)	88.6 (1,763)
Harmful or addictive	6.8 (138)	7.2 (59)	6.7 (79)		11.8 (16)	6.6 (122)
Not harmful and not addictive	5.4 (95)	6.2 (39)	4.9 (56)		15.9 (12)	4.8 (83)
Comparative snus judgment				.001			<.001
Harmful and addictive	81.7 (1,661)	76.5 (529)	84.5 (1,132)		54.7 (52)	83.2 (1,609)
Harmful or addictive	12.0 (260)	15.1 (120)	10.4 (140)		22.4 (27)	11.4 (233)
Less harmful and less addictive	6.3 (146)	8.4 (65)	5.1 (81)		22.9 (20)	5.4 (125)

Note. GED = general educational development.

Multivariable Analyses

Regression analysis estimated the association between snus awareness and demographics, smoking status, intentions, and absolute and comparative judgments (Table 2). After adjusting for other variables in the model, males (vs. females), those employed full time (vs. not employed), those with a high school education or less or some college/technical training (vs. graduate degree), and those who were younger than 56 years (vs. ≥56 years) were significantly more likely to be aware of snus. Current cigarette smokers were nearly four times more likely than nonsmokers to report snus awareness.

Table 2.

Multivariable Logistic Regression Analysis of Snus Awareness and Snus Use

	Snus awareness		Snus use
	OR (95% CI)	p value	OR (95% CI)	p value
Demographics
Gender		.001		.011
Male	1.51 (1.18–1.94)		2.45 (1.23–4.90)
Female	Ref.		Ref.
Age		.003		.004
18–25 years	1.95 (1.24–3.06)		5.27 (1.56–16.79)
26–30 years	1.81 (1.10–2.98)		4.78 (1.52–15.58)
31–45 years	1.52 (1.09–2.13)		1.30 (0.46–3.66)
46–55 years	1.79 (1.25–2.55)		2.40 (0.83–6.89)
≥ 56 years	Ref.		Ref.
Race/ethnicity		<.001		.051
Non-Hispanic White	Ref.		Ref.
Non-Hispanic Black	0.32 (020–0.53)		0.16 (0.04–0.62)
Non-Hispanic other race	0.58 (0.33–1.00)		1.47 (0.43–4.94)
Hispanic	0.83 (0.54–1.30)		1.00 (0.32–3.11)
Marital status		.706		.552
Married/partnered	0.95 (0.72–1.25)		0.81 (0.40–1.63)
Unmarried	Ref.		Ref.
Employment		.015		.014
Employed	1.41 (1.07–1.85)		2.39 (1.19–4.80)
Not employed	Ref.		Ref.
Education		.030		.466
High school/GED or less	1.76 (1.18–2.62)		1.37 (0.37–5.14)
Some college/technical training	1.81 (1.17–2.51)		1.66 (0.45–6.09)
College degree	1.52 (0.99–2.30)		2.33 (0.62–8.78)
Graduate degree	Ref.		Ref.
Cigarette smoking		<.001		<.001
Current smoker	3.73 (2.65–5.25)		4.26 (2.19–8.77)
Nonsmoker	Ref.		Ref.
Snus intentions	1.17 (0.98–1.40)	.078	2.35 (1.86–2.97)	<.001
Absolute snus judgment		.779		.548
Harmful and addictive	Ref.		Ref.
Harmful or addictive	0.86 (0.52–1.40)		1.52 (0.67–3.45)
Not harmful and not addictive	0.88 (0.45–1.70)		1.37 (0.42–4.45)
Comparative snus judgment		.261		.017
Harmful and addictive	Ref.		Ref.
Harmful or addictive	1.22 (0.87–1.70)		1.58 (0.81–3.07)
Less harmful and less addictive	1.42 (0.84–2.39)		3.96 (1.53–10.28)
Hosmer–Lemeshow model χ2	6.35 [8 df]	.608	3.26 [8 df]	.917

Note. OR = odds ratio; CI = confidence interval; GED = general educational development.

Similar variables were associated with snus use (Table 2): males, respondents aged 18–25 years and 26–30 years, and those who were employed full time were more likely to have used snus. Current smokers were more than four times more likely than nonsmokers to have used snus. Each unit increase in intentions to use snus was associated with a two-fold increase in the odds of using snus. Respondents who perceived snus to be less harmful and less addictive than cigarettes were almost four times more likely to have used snus compared with those who perceived snus to be harmful and addictive compared with cigarettes. There was no significant difference in the odds of using snus among those who perceived snus as either harmful or addictive compared with cigarettes (Table 2).

Snus Judgments Among Smokers

Based on the observed associations between cigarette smoking and snus awareness and use, we examined absolute and comparative snus judgments by smoking status. Across measures of both absolute and comparative snus judgments, smokers perceived snus to be both less harmful and less addictive compared with nonsmokers. Compared with nonsmokers, smokers were more likely to perceive snus as not harmful or not addictive (8.9% vs. 6.5%) and to perceive snus as not harmful and not addictive (9.4% vs. 4.5%, χ² [2 df] = 9.8, p = .008). Smokers were also more likely than nonsmokers to perceive snus as less harmful or less addictive than cigarettes (16.2% vs. 11.2%) and to perceive snus as less harmful and less addictive than cigarettes (8.6% vs. 5.8%, χ² [2 df] = 7.1, p = .028).

DISCUSSION

This study characterized snus awareness and use in a statistically representative sample of U.S. adults. The findings demonstrate that current cigarette smokers are more likely to be aware of and to have used snus. These results could suggest the potential for dual use of snus and cigarettes, which poses a challenge for public health efforts to reduce tobacco-associated morbidity and mortality (Kasza et al., 2013; Lee, Hebert, Nonnemaker, & Kim, 2014; Popova & Ling, 2013b). These results could also imply that current smokers may be interested in switching to snus if they hold certain perceptions of snus compared with cigarettes. Comparative perceptions of harm and addictiveness of snus relative to cigarettes were associated with snus use, although absolute perceptions of snus harm and addictiveness were not associated with snus use in the multivariable model. Finally, the results demonstrate that current smokers hold lower harm and addictive judgments of snus compared with nonsmokers, in line with other research (Lund, 2012).

The multivariable model revealed that current smokers were almost four times more likely than nonsmokers to report having heard of snus and more than four times more likely to report having used snus after adjusting for other factors. Some researchers have called for devising ways to inform the public about the risk continuum of tobacco products (Berridge, 1999; Erickson, 1999) and even promoting snus as a cessation aid (Lund & Scheffels, 2012). The results from the current study suggest that comparative tobacco product harm judgments (e.g., snus is less harmful than cigarettes) is an important factor in the use of tobacco products.

Although absolute judgments about snus harm and addiction were not significantly related to snus awareness or use, harms relative to cigarettes were significantly predictive of having used snus. Those who perceived snus as less harmful and less addictive than cigarettes were almost four times more likely to have reported snus use compared with those who rated snus as harmful and addictive compared with cigarettes. This finding has important implications for health communications regarding tobacco product harm. When asked to compare two products, which is often done in novel tobacco product marketing, people who infer that one product is less harmful and less addictive than another may be susceptible to use. Public health practitioners need to carefully consider how the marketing and communication of tobacco product harm and addiction may influence use.

Important sociodemographic correlates of snus awareness and use were noted in this study and are consistent with previous studies (King et al., 2012; Zhu et al., 2013). Males were more likely to have heard of snus and were about three times more likely to report snus use compared with females. This may indicate that disproportionate marketing of smokeless tobacco to males contributes to snus awareness and use (Delnevo et al., 2014). Non-Hispanic White participants were the most likely to be aware of snus compared with other racial/ethnic groups, but race/ethnicity was not significantly associated with snus use. Similarly, employment and education were significantly related to snus awareness, but not snus use. These findings suggest important subgroups to examine in more depth in future research.

Results of the current study are informative but must be considered in light of several limitations. This study used a probability-based online survey research panel designed to be statistically representative of U.S. adults and cannot generalize to youth. Although these data are self-reported and cross-sectional, future research should examine how comparative tobacco product judgments may predict use in longitudinal samples. Despite these limitations, this study provides important findings in how comparative tobacco product judgments may play an important role in awareness and use and highlights the potential importance of dual use of snus and cigarettes for public health efforts to reduce tobacco use.

SUPPLEMENTARY MATERIAL

Supplementary material can be found online at http://www.ntr.oxfordjournals.org

FUNDING

This work was supported by the National Cancer Institute and the Center for Tobacco Products, U.S. Food and Drug Administration. Data collection was funded by RTI International.

DECLARATION OF INTERESTS

None declared.