Abstract
Objectives. To examine patterns of smokeless tobacco (SLT) use, by type, in wave 1 (2013–2014) of the Population Assessment of Tobacco and Health Study in the United States.
Methods. We analyzed data from 32 320 adults (aged ≥ 18 years) to assess the use of pouched snus and other SLT products (loose snus, moist snuff, dip, spit, and chewing tobacco).
Results. Overall, SLT use was most common among men, younger adults, non-Hispanic Whites, and nonurban respondents. Pouched snus users were more likely to report nondaily and polytobacco use than users of other SLT products. Respondents who used SLT some days were more likely to be current established cigarette smokers than those who used SLT every day (57.9% vs 20.2%). Furthermore, current established smokers who used SLT some days were more likely to smoke every day and had a higher median number of cigarettes smoked per day than smokers who used SLT every day.
Conclusions. Polytobacco use, especially cigarette smoking, is common among SLT users. Pouched snus users are more likely to report nondaily snus use and polytobacco use than users of other SLT products.
Although cigarette smoking continues to decline in the United States, the prevalence of smokeless tobacco (SLT) use has remained relatively unchanged over the past decade.1,2 The 2012–2013 National Adult Tobacco Survey estimated that 2.6% of adults aged 18 years or older were current (everyday or some-day) users of SLT,3 and SLT use was more common among young adults, men, non-Hispanic Whites, and nonmetropolitan area residents.1,3
New SLT products have recently been introduced into the United States and have grown in market share. In particular, snus, a Swedish-style moist snuff tobacco, almost doubled its share in the SLT market in the United States between 2009 and 2010 alone.4 Despite the rapidly changing SLT market, national data on newer SLT product use and detailed information on user behavior are limited.5
The Population Assessment of Tobacco and Health (PATH) Study was established in 2011 to generate longitudinal epidemiological data on tobacco use behavior and health among the US population.6 The PATH Study includes a detailed assessment of tobacco products with pictures to prompt recall, and was designed to assess snus use separately from use of other SLT products. Because virtually all snus sold in the United States is in pouched form,4 the PATH wave 1 instrument (fielded between 2013 and 2014) collected information on pouched snus. In PATH wave 1 data, 0.8% of US adults reported pouched snus use and 3.1% reported other SLT use currently some days or every day.7
To further understand population-level use across SLT product types, we analyzed PATH wave 1 adult data to explore the use of different SLT product types, including SLT user characteristics, other concurrent product use by SLT users, and self-reported reasons for SLT use. We focused on adults because of the relatively low prevalence of SLT use in youths (1.6% reported past-30-day use, including pouched snus) in the PATH Study.7
METHODS
Data are from wave 1 of the PATH Study,8 which used a 4-stage stratified area probability sample design, with a 2-phase design for sampling the adult cohort at the final stage. The PATH Study oversampled adult tobacco users, young adults aged 18 to 24 years, and African Americans, and applied weighting procedures to compensate for different probabilities of sampling and nonresponse to allow estimates to be representative of the civilian, noninstitutionalized US population.
We analyzed data from 32 320 adult participants (aged ≥ 18 years) who responded to questions about tobacco product use, including cigarettes, e-cigarettes, cigars, pipes, hookah, pouched snus, other SLT (loose snus, moist snuff, dip, spit, and chewing tobacco), and dissolvable tobacco. The PATH Study conducted interviews via audio computer-assisted self-interviews available in English and Spanish. The PATH Study design and methods have been previously described.6
Measures
Smokeless tobacco classification.
The PATH Study described SLT as a product “which you put in your mouth. Frequently you chew, suck or spit while using smokeless tobacco, although there is no need to do so for some types. Snus, for instance, is a type of smokeless tobacco that comes in a small pouch that you put inside your lip.” The PATH Study showed respondents pictures of SLT products.
To distinguish pouched snus from other SLT products, the PATH Study first asked participants, “Have you ever used any of the following smokeless tobacco products, even one or two times? Choose all that apply: (1) Snus pouches; (2) Loose snus, moist snuff, dip, spit, or chewing tobacco; (3) I have never used a smokeless tobacco product.” It then asked respondents who have ever used snus pouches, “Did you use the brand called Skoal Bandits?” Skoal Bandits is a nonsnus SLT product that comes in pouches, and participants could choose whether they “used only Skoal Bandits,” “used both Skoal Bandits and other brands of snus pouches,” or “did not use Skoal Bandits.” On the basis of these 2 questions, we classified respondents as ever users of pouched snus or ever users of other SLT (including Skoal Bandits). A flowchart summarizing the skip pattern of the questionnaire is included in Figure A (available as a supplement to the online version of this article at http://www.ajph.org).
Definition of smokeless tobacco user groups.
The PATH Study asked participants a series of questions for each tobacco product, including whether they had ever used the product, even 1 or 2 puffs or times; whether they now smoke or use the product every day, some days, or not at all; whether they ever used the product “fairly regularly”; and how much of the product they have used in their lifetime. On the basis of their responses, we defined user categories for pouched snus or other SLT:
never/ever user: “has never/ever used the product, even one or two times”;
current user: “has ever used the product and now uses every day (current everyday user) or some days (current some-day user)”;
current established user: “has ever used the product fairly regularly and now uses every day (current established everyday user) or some days (current established some-day user)”;
current experimental user: “has never used the product fairly regularly but now uses every day or some days”; and
former user: “has ever used the product and now does not use at all.”
We defined use of any type of SLT as use of pouched snus, other SLT, or both. We categorized frequency of any type of SLT use as: “use of any SLT every day,” including current everyday use of pouched snus, other SLT, or both; “use of any type of SLT some days,” including current some-day use of pouched snus, other SLT or both, but not current everyday use of either product; “former use of any SLT,” including former use of pouched snus or other SLT, but not current use of either product; and “never use of any SLT.”
The PATH Study assessed number of days using SLT, by type, in the past 30 days by asking, “On how many of the past 30 days did you use [smokeless/pouched snus]?” Daily SLT users in the past 30 days included current established everyday users and current established some-day users who reported product use on 30 days in the past 30 days. The study assessed the number of SLT or snus pouches per day by asking, “On average, about how many times/snus pouches do you now use each day?” (for current established everyday users) or “On average, on those days you used, how many times/snus pouches did you usually use each day?” (for current established some-day users). It also asked participants, “How old were you when you first used [product], even one or two times?” and “How old were you when you first started using [product] fairly regularly?”
Poly use with other tobacco products.
Polytobacco use is defined as current use (ever used the product and now uses every day or some days) of any tobacco product (cigarettes, e-cigarettes, cigars, hookah, pipes, dissolvable tobacco) in addition to SLT. We constructed 3 mutually exclusive categories for cigarette smoking: (1) “current established cigarette smokers,” who smoked at least 100 cigarettes in their lifetime and now smoke every day (current established everyday smokers) or some days (current established some-day smokers); (2) “former established cigarette smokers,” who smoked at least 100 cigarettes in their lifetime and now do not smoke at all; (3) “never established cigarette smokers,” who smoked fewer than 100 cigarettes in their lifetime, including never smoking cigarettes, even 1 or 2 puffs. The PATH Study assessed number of cigarettes smoked per day by asking, “On average, about how many cigarettes do you now smoke each day?”
Demographic measures.
Demographic variables included age (18–24, 25–34, 35–49, and ≥ 50 years based on imputed values as necessary), sex, race/ethnicity (non-Hispanic Whites vs other racial/ethnic groups), educational attainment (less than high school or some high school—no diploma; general education development [GED] diploma; high-school graduate—diploma; some college or associate’s degree; completed college or beyond), and residential area (urban vs nonurban). We defined urbanicity on the basis of primary sampling area or unit, which is designated as “not urban” if at least 70% of its size for sampling comprises counties that do not belong to a Core-Based Statistical Area (counties or equivalent entities with at least 1 core of at least 10 000 population, plus adjacent counties with a high degree of social and economic integration), and designated as “urban” otherwise.
Statistical Analysis
We weighted estimates to represent the civilian, noninstitutionalized US adult population, and estimated variances by using the balanced repeated replication method9 with Fay’s adjustment set to 0.3 to increase estimate stability.10 We conducted all analyses with SAS 9.3 software (SAS Institute Inc, Cary, NC).
We estimated prevalence of SLT use (any type of SLT, pouched snus, or other SLT) overall and within demographic subgroups (Table 1). Because of the use of dual SLT types (pouched snus and other SLT) among SLT users, we assessed the distributions (weighted percentage and 95% confidence interval [CI]) of demographic and tobacco use variables in 3 SLT user groups: (1) current established pouched snus users, excluding current users of other SLT, (2) current established users of other SLT products, excluding current pouched snus users, and (3) current established users of both pouched snus and other SLT products (dual SLT types; Tables 2 and 3). For continuous variables, we reported median values and 95% CIs; for categorical variables, we reported percentages and 95% CIs. We evaluated differences in categorical characteristics among the 3 SLT user groups with the Rao–Scott χ2 test.
TABLE 1—
Prevalence of Current Established Smokeless Tobacco Use, Overall and by Demographic Subgroups: Population Assessment of Tobacco and Health Study Wave 1 (2013–2014) Adult Sample, United States
| Pouched Snusa |
Loose Snus, Moist Snuff, Dip, Spit, and Chewing Tobaccob |
Any Smokeless Tobaccoc |
||||
| Characteristic | No. | Weighted % (95% CI) | No. | Weighted % (95% CI) | No. | Weighted % (95% CI) |
| Overall | 273 | 0.4 (0.4, 0.5) | 1 597 | 2.7 (2.5, 2.9) | 1 720 | 2.9 (2.7, 3.1) |
| Age, y | ||||||
| 18–24 | 109 | 1.0 (0.8, 1.2) | 451 | 3.7 (3.3, 4.1) | 488 | 4.0 (3.6, 4.5) |
| 25–34 | 74 | 0.8 (0.6, 0.9) | 333 | 3.6 (3.1, 4.0) | 372 | 4.0 (3.5, 4.5) |
| 35–49 | 70 | 0.6 (0.4, 0.7) | 468 | 3.5 (3.0, 3.9) | 502 | 3.7 (3.3, 4.1) |
| ≥ 50 | 20 | 0.1 (0.0, 0.1) | 345 | 1.5 (1.3, 1.7) | 358 | 1.6 (1.4, 1.8) |
| Sexd | ||||||
| Male | 260 | 0.9 (0.7, 1.0) | 1 522 | 5.3 (4.9, 5.7) | 1 635 | 5.7 (5.3, 6.1) |
| Female | 13 | e | 73 | 0.2 (0.2, 0.3) | 83 | 0.2 (0.2, 0.3) |
| Race/ethnicityd | ||||||
| Non-Hispanic White | 237 | 0.6 (0.5, 0.7) | 1 346 | 3.6 (3.3, 3.8) | 1 452 | 3.9 (3.6, 4.1) |
| Other racial/ethnic groups | 34 | 0.1 (0.1, 0.2) | 220 | 0.9 (0.7, 1.0) | 236 | 0.9 (0.8, 1.1) |
| Educationd | ||||||
| < high school or some high school, no diploma | 26 | 0.3 (0.1, 0.4) | 201 | 2.8 (2.3, 3.2) | 212 | 2.9 (2.4, 3.3) |
| GED diploma | 30 | 1.0 (0.6, 1.4) | 144 | 4.7 (3.8, 5.6) | 153 | 5.0 (4.1, 5.9) |
| High-school graduate—diploma | 71 | 0.5 (0.4, 0.7) | 478 | 3.6 (3.1, 4.1) | 515 | 3.9 (3.4, 4.4) |
| Some college or associate’s degree | 111 | 0.5 (0.4, 0.7) | 560 | 2.8 (2.4, 3.1) | 605 | 3.0 (2.7, 3.3) |
| Completed college or beyond | 34 | 0.2 (0.1, 0.3) | 201 | 1.2 (1.0, 1.5) | 222 | 1.4 (1.2, 1.6) |
| Urbanicity | ||||||
| Urban | 244 | 0.4 (0.4, 0.5) | 1 299 | 2.3 (2.1, 2.5) | 1 412 | 2.5 (2.3, 2.8) |
| Nonurban | 29 | 0.6 (0.3, 1.0) | 298 | 7.9 (6.2, 9.6) | 308 | 8.1 (6.5, 9.8) |
Note. CI = confidence interval; GED = general education development. The sample size was n = 32 320.
This group includes current established pouched snus users who may or may not use other smokeless tobacco products currently.
This group includes current established users of other smokeless tobacco products who may or may not use pouched snus currently. Because of the skip pattern design in the questionnaire, adults who responded that they had never used other smokeless tobacco products but used “both Skoal Bandits and other brands of snus pouches” (n = 191) were routed through questions for pouched snus only. They were classified as noncurrent users of other smokeless tobacco. Results remained similar when these 191 individuals were excluded from the analyses (overall prevalence = 2.7%; 95% CI = 2.5%, 2.9%).
This group includes respondents who are either current established pouched snus users or current established other smokeless tobacco product users.
Respondents with missing values of the demographic variables were dropped from the analyses.
Estimates suppressed.
TABLE 2—
Demographic Characteristics Among Current Established Smokeless Tobacco Users, by Smokeless Tobacco Product Type: Population Assessment of Tobacco and Health Study Wave 1 (2013–2014) Adult Sample, United States
| Current Established Pouched Snus Users, Excluding Current Users of Other SLTa (n = 101) |
Current Established Users of Other SLT, Excluding Current Pouched Snus Users (n = 1355) |
Current Established Users of Pouched Snus and Other SLT (n = 150) |
||||
| Characteristicsa | No. | Weighted Estimate (95% CI) | No. | Weighted Estimate (95% CI) | No. | Weighted Estimate (95% CI) |
| Age group, % | ||||||
| 18–24 y | 28 | 19.2 (12.3, 26.0) | 341 | 15.5 (13.3, 17.8) | 72 | 35.9 (28.3, 43.5) |
| 25–34 y | 30 | 29.9 (20.4, 39.5) | 274 | 23.0 (20.3, 25.8) | 35 | 28.7 (20.2, 37.2) |
| 35–49 y | 30 | 35.1 (25.0, 45.3) | 415 | 33.6 (30.3, 36.8) | 36 | 30.8 (21.8, 39.8) |
| ≥ 50 y | 13 | 15.7 (8.1, 23.4) | 325 | 27.8 (25.2, 30.5) | 7 | b |
| Sex, % | ||||||
| Male | 92 | b | 1 288 | 95.7 (94.3, 97.1) | 147 | b |
| Female | 9 | b | 65 | 4.3 (2.9, 5.7) | 3 | b |
| Race/ethnicity, % | ||||||
| Non-Hispanic White | 87 | 89.4 (83.7, 95.1) | 1 138 | 88.7 (86.8, 90.6) | 131 | 90.4 (85.4, 95.4) |
| Other racial/ethnic groups | 13 | 10.6 (4.9, 16.3) | 187 | 11.3 (9.4, 13.2) | 18 | 9.6 (4.6, 14.6) |
| Education, % | ||||||
| < high school or some high school, no diploma | 7 | b | 174 | 12.5 (10.4, 14.6) | 15 | 7.6 (3.1, 12.1) |
| GED diploma | 7 | b | 114 | 8.4 (6.8, 10.1) | 21 | 14.1 (8.2, 20.0) |
| High-school graduate—diploma | 30 | 33.4 (20.8, 45.9) | 421 | 34.4 (30.5, 38.4) | 34 | 25.2 (15.5, 34.8) |
| Some college or associate’s degree | 39 | 36.2 (26.3, 46.1) | 455 | 31.0 (28.3, 33.7) | 66 | 42.6 (34.1, 51.2) |
| Completed college or beyond | 18 | 16.8 (9.2, 24.4) | 180 | 13.6 (11.6, 15.6) | 13 | 10.5 (5.0, 15.9) |
| Urbanicity, % | ||||||
| Urban | 91 | b | 1 088 | 81.3 (78.0, 84.6) | 131 | b |
| Nonurban | 10 | b | 267 | 18.7 (15.4, 22.0) | 19 | b |
| Age of first SLT use, median y | ||||||
| Pouched snus | 101 | 24.5 (20.1, 28.9) | NA | NA | 150 | 18.0 (16.2, 19.7) |
| Other SLT | NA | NA | 1 352 | 15.3 (15.0, 15.5) | 150 | 15.0 (14.4, 15.6) |
| Age of regular SLT use, median y | ||||||
| Pouched snus | 101 | 26.6 (22.7, 30.6) | NA | NA | 150 | 21.0 (17.7, 24.2) |
| Other SLT | NA | NA | 1 353 | 17.3 (17.1, 17.5) | 150 | 16.3 (15.3, 17.2) |
Note. CI = confidence interval; GED = general education development; NA = not applicable; SLT = smokeless tobacco.
Because of the skip pattern in the data collection instrument, this group included 19 respondents who responded that they had never used other SLT but used “both Skoal Bandits and other brands of snus pouches.” Excluding this subset of the sample from analyses did not change the estimates substantially.
Estimates suppressed.
TABLE 3—
Patterns of Smokeless Tobacco and Other Tobacco Use Among Current Established Smokeless Tobacco Users, by Smokeless Tobacco Type: Population Assessment of Tobacco and Health Study Wave 1 (2013–2014) Adult Sample, United States
| Current Established Pouched Snus Users, Excluding Current Users of Other SLTa (n = 101) |
Current Established Users of Other SLT, Excluding Current Pouched Snus Users (n = 1355) |
Current Established Users of Pouched Snus and Other SLT (n = 150) |
||||
| Characteristics | No. | Weighted Estimate (95% CI) | No. | Weighted Estimate (95% CI) | No. | Weighted Estimate (95% CI) |
| Daily SLT use in the past 30 d, % | ||||||
| Pouched snus | 40 | 41.6 (29.1, 54.1) | NA | NA | 31 | 21.5 (15.1, 27.9) |
| Other SLT | NA | NA | 894 | 66.9 (64.3, 69.5) | 72 | 47.4 (38.1, 56.7) |
| Current use of other tobacco products, % | ||||||
| Cigarette (current established) | 46 | 42.6 (30.2, 55.0) | 459 | 31.0 (28.5, 33.5) | 75 | 48.7 (39.4, 58.0) |
| Cigarette (current) | 51 | 45.8 (33.5, 58.0) | 494 | 33.3 (30.5, 36.1) | 82 | 51.8 (42.7, 60.9) |
| E-cigarette | 21 | 21.0 (12.2, 29.8) | 137 | 8.3 (7.0, 9.7) | 46 | 26.3 (19.3, 33.3) |
| Any cigar | 33 | 30.8 (18.9, 42.6) | 332 | 23.7 (21.8, 25.7) | 82 | 53.0 (44.0, 61.9) |
| Hookah | 18 | 15.5 (7.9, 23.0) | 120 | 6.6 (5.0, 8.1) | 36 | 18.8 (12.5, 25.1) |
| Pipe | 10 | b | 73 | 5.2 (4.0, 6.5) | 23 | 14.3 (8.1, 20.4) |
| Any tobacco product | 68 | 64.0 (52.8, 75.1) | 634 | 44.7 (42.1, 47.4) | 115 | 74.9 (66.4, 83.5) |
| Exclusive current established SLT use,c % | 32 | 36.0 (24.9, 47.2) | 693 | 55.3 (52.6, 57.9) | 35 | 25.1 (16.5, 33.6) |
| No. of pouches per day (among daily users of pouched snus in the past 30 d), median | ||||||
| Current cigarette smokers | 13 | 4.9 (3.5, 6.3) | NA | NA | 14 | 4.8 (2.5, 7.2) |
| Noncurrent cigarette smokers | 27 | 9.1 (4.6, 13.5) | NA | NA | 17 | b |
| No. of times per day (among daily users of other SLT in the past 30 d), median | ||||||
| Current cigarette smokers | NA | NA | 211 | 5.0 (4.4, 5.5) | 30 | b |
| Noncurrent cigarette smokers | NA | NA | 682 | 5.8 (5.4, 6.2) | 42 | 4.9 (3.5, 6.2) |
Note. CI = confidence interval; NA = not applicable; SLT = smokeless tobacco.
Because of the skip pattern in the data collection instrument, this group included 19 respondents who responded that they had never used other SLT but used “both Skoal Bandits and other brands of snus pouches.” Excluding this subset of the sample from analyses did not change the estimates substantially.
Estimates suppressed.
Exclusive current established SLT users include current established users of pouched snus or other SLT who currently do not use any of the other tobacco products (cigarettes, e-cigarettes, any cigars, hookah, pipe, or dissolvable tobacco) every day or some days.
We excluded individuals with missing values from the analyses. We suppressed estimates if relative standard error was greater than or equal to 30%; for dichotomous variables, we suppressed estimates if relative standard error for proportion or (1-proportion) was greater than or equal to 30%.
RESULTS
On the basis of all PATH wave 1 adult samples, an estimated 16.5% of adults reported ever use of any SLT type, and 2.9% reported current established use. The prevalence estimate of current established use was 0.4% for pouched snus and 2.7% for other SLT (Table 1).
Current established use of any SLT type was most common in younger adults (4.0% for ages 18–24 and 25–34 years), men (5.7%), non-Hispanic Whites (3.9%), and respondents with GED diplomas (5.0%; Table 1). The current established use of other SLT was more common in nonurban (7.9%) than urban (2.3%) areas (Table 1).
Demographic Characteristics, by Smokeless Tobacco Type
Current use of dual SLT types (pouched snus and other SLT) was common: 60.6% of current established pouched snus users reported current use of other SLT, and 13.5% of current established other SLT users reported current use of pouched snus. Young adults aged 18 to 24 years were the most prevalent dual SLT type users (35.9%), whereas adults aged 35 to 49 years were the most prevalent single SLT type users (35.1% of pouched snus users; 33.6% of other SLT users; Table 2).
Reported median age of first use or regular use was higher for pouched snus users than other SLT users, regardless of whether users currently used single (first use: 24.5 vs 15.3 years; regular use: 26.6 vs 17.3 years) or dual SLT types (first use: 18.0 vs 15.0 years; regular use: 21.0 vs 16.3 years; Table 2).
Polytobacco Use by Smokeless Tobacco Type and Frequency
Users of different SLT types showed distinct tobacco use behaviors (Table 3). Among single SLT type users, 41.6% of pouched snus users reported daily use in the past 30 days compared with 66.9% of other SLT users. Polytobacco use was also common, especially among those who used dual SLT types (74.9%) or pouched snus only (64.0%) compared with those who used other SLT only (44.7%). Cigarettes were the most commonly used product reported by SLT users. Among single SLT type users, the amount of SLT use (median number of snus pouches or SLT times per day) was similar between daily SLT users (past 30 days) who currently smoked cigarettes and those who did not (Table 3); however, there were fewer daily SLT users among current established SLT users who currently smoked cigarettes versus those who did not (22.4% vs 58.8% for pouched snus; 41.2% vs 79.7% for other SLT; Table A, available as a supplement to the online version of this article at http://www.ajph.org).
We further examined the percentage of current, former, and never established smokers, by SLT type and frequency of SLT use (Table 4). By SLT type, current established cigarette smoking was most common among current established dual SLT type users (48.7%), followed by pouched snus–only users (42.6%), other SLT–only users (31.1%), and never SLT users (15.0%). The percentage of former established cigarette smoking was similar between users of different SLT types (from 27.7% to 28.4%) but lower in never SLT users (18.0%). The percentage of current established cigarette smoking reported by some-day SLT users was higher (57.9%) than that reported by everyday (20.2%), former (33.1%), and never (15.0%) SLT users. By contrast, everyday SLT users were more likely to be former established cigarette smokers (34.4%) than some-day (13.4%) or never (18.0%) SLT users.
TABLE 4—
Percentage of Adults Reporting Current Established, Former Established, and Never Established Cigarette Smoking, by Smokeless Tobacco Type and Frequency of Smokeless Tobacco Use: Population Assessment of Tobacco and Health Study Wave 1 (2013–2014) Adult Sample, United States
| Current Established Cigarette Smoking |
Former Established Cigarette Smoking |
Never Established Cigarette Smoking |
||||
| Variable | No. | Weighted % (95% CI) | No. | Weighted % (95% CI) | No. | Weighted % (95% CI) |
| By SLT type | ||||||
| Current established users of other SLT, excluding current pouched snus users (n = 1350) | 459 | 31.1 (28.6, 33.7) | 347 | 28.4 (25.9, 30.9) | 544 | 40.5 (37.7, 43.2) |
| Current established pouched snus users, excluding current users of other SLT (n = 100) | 46 | 42.6 (30.2, 55.0) | 23 | 27.7 (17.5, 37.8) | 31 | 29.7 (19.9, 39.4) |
| Current established users of pouched snus and other SLT (n = 150) | 75 | 48.7 (39.4, 58.0) | 34 | 28.1 (18.5, 37.6) | 41 | 23.2 (16.0, 30.5) |
| Never users of any SLT (n = 24 768) | 7 793 | 15.0 (14.5, 15.5) | 3 252 | 18.0 (17.1, 18.8) | 13 723 | 67.0 (65.9, 68.1) |
| By frequency of SLT use | ||||||
| Users of any SLT every day (n = 1028) | 235 | 20.2 (18.0, 22.5) | 324 | 34.4 (31.5, 37.3) | 469 | 45.4 (42.1, 48.6) |
| Users of any SLT some days (n = 1017) | 622 | 57.9 (54.3, 61.5) | 113 | 13.4 (10.9, 15.9) | 282 | 28.7 (25.1, 32.3) |
| Former users of SLT (n = 5216) | 2 691 | 33.1 (31.4, 34.9) | 1 208 | 32.6 (30.4, 34.7) | 1 317 | 34.3 (32.1, 36.5) |
| Never users of SLT (n = 24 768) | 7 793 | 15.0 (14.5, 15.5) | 3 252 | 18.0 (17.1, 18.8) | 13 723 | 67.0 (65.9, 68.1) |
Note. CI = confidence interval; SLT = smokeless tobacco.
We also assessed the percentage of current established cigarette smokers who smoked cigarettes every day and number of cigarettes smoked per day, by current SLT use status (Figures B and C, available as supplements to the online version of this article at http://www.ajph.org). Current established smokers who used SLT some days were more likely to smoke every day (82.9%) than those who used SLT every day (56.0%; Figure B). Furthermore, among everyday smokers, those who used SLT some days reported the highest median number of cigarettes per day (19.2 cigarettes per day), followed by those who currently did not use any SLT (14.4 cigarettes per day), and those who used SLT every day (13.5 cigarettes per day; Figure C).
Lastly, we assessed the endorsed reasons for SLT use among current established SLT users, by ever cigarette smoking (Tables B and C, available as supplements to the online version of this article at http://www.ajph.org). Among ever smokers, the most common reason for using SLT was that they could use SLT when or where smoking cigarettes is not allowed (pouched snus: 85.0%; other SLT: 79.5%). Other commonly reported reasons for SLT use included that the products “come in flavors” (pouched snus: 82.9%; other SLT: 66.9%), “are less harmful to people around me than cigarettes” (pouched snus: 60.1%; other SLT: 60.5%), and “are affordable” (pouched snus: 56.2%; other SLT: 50.4%; Table B). Similar results were reported among current established other SLT users who never smoked (Table C), although the number was limited for pouched snus users who never smoked.
DISCUSSION
According to the PATH wave 1 adult data, SLT use was most common among men, younger adults, non-Hispanic Whites, and respondents in nonurban areas. These findings are generally consistent with data reported in other national surveys, although surveys use different populations and tobacco use definitions.1,3
One of the unique features of the PATH Study is the detailed assessment of SLT use by product type. This enabled analysis of the use of pouched snus separately from other SLT products. Among current established SLT users, ages of first use and regular use were older for pouched snus than for other SLT products. However, users may have started traditional SLT before pouched snus was introduced into the US market. Whether users have a preference for the SLT type with which to initiate product use remains to be seen. Data also indicated that most pouched snus users reported nondaily pouched snus use and polytobacco use, whereas users of other SLT products were more likely to use the products daily and exclusively (among single SLT–type users). Because these products are used differently in the population, they may have different implications for population health, such as product transition, switching, or even health risk.
Polytobacco use (particularly cigarette smoking) was common among current SLT users. In general, current established SLT users were more likely to be current established cigarette smokers than were those who had never used any SLT, and the highest percentage of current established smokers was observed among those who used dual SLT types (almost 50%). Current some-day SLT users were more likely to be current established smokers (compared with current everyday SLT users and never SLT users), and current everyday SLT users were more likely to be former established smokers. Furthermore, the most commonly endorsed reason for SLT use by SLT users who ever smoked was that they “can use at times when or in places where smoking cigarette is not allowed.” This suggests that SLT users may have used SLT to either supplement cigarette smoking to maintain access to nicotine or substitute for cigarette smoking. However, with PATH wave 1 data alone, we are unable to prospectively assess whether SLT use is associated with smoking maintenance or product switching among cigarette smokers, and it is possible that the PATH Study instrument may not include all possible reasons for use. Information from future PATH Study waves will allow further assessment of SLT use trajectories and their impact on population tobacco use behaviors.
Nearly 83% of current established cigarette smokers who currently used SLT some days reported using cigarettes every day, which is similar to the percentage of smokers who currently do not use any SLT (about 80%) but higher than smokers who currently use SLT every day (56%). This is consistent with a previous study showing that men who used moist snuff some days were more likely to be current daily smokers than those who used moist snuff daily.11 Furthermore, current established everyday smokers who used SLT some days reported higher cigarettes per day than did those who currently used SLT every day or not at all. These results suggest that, depending on how smokers use SLT, SLT use may not necessarily be associated with reduced cigarette or overall tobacco use. Although everyday smokers who used SLT every day smoked slightly fewer cigarettes per day than those who currently did not use SLT, users were also exposed to nicotine from SLT use. Additional data, such as nicotine metabolites via biological samples, are needed to investigate whether nicotine exposure differs between smokers who use SLT versus those who do not.
Limitations
Our analyses have several limitations. First, we excluded youth samples (aged 12–17 years) because of the low prevalence of SLT use among youths. Second, sample size is limited in some subgroups (especially for pouched snus), which constrained the statistical precision of the estimates. Because of sample size, we were unable to analyze intensity of SLT use by intensity of smoking (rather than using a yes-or-no smoking category) by subtype. Third, including loose snus with other SLT rather than pouched snus is not accurate for the purpose of separating snus products from other SLT; however, we were unable to recategorize because of the design of the data collection instrument. We expect such misclassification to have minimal impact on analyses, because the majority of snus sold in the United States is pouched.4 Finally, like any self-reported data, respondents may misclassify tobacco products used (although the PATH Study used tobacco product images to mitigate misclassification).
In summary, polytobacco use, especially cigarette smoking, is common among SLT users. Pouched snus users are more likely to report nondaily use and polytobacco use than are users of other SLT products. Future waves of the PATH study will clarify the trajectories of SLT use over time and shed light on whether certain SLT products may be more appealing as substitutes for smoking.
Public Health Implications
The results refine our understanding of SLT product use in the United States, revealing distinct tobacco use patterns by SLT type. Differences in tobacco use behaviors may have an impact on overall population health, such as initiation of tobacco use among nonusers, cessation among tobacco users, and health risk. These results highlight the need to continue monitoring changes in US use of tobacco products, especially novel products, and help to inform tobacco regulatory and control efforts to protect public health.
ACKNOWLEDGMENTS
This project has been funded in whole or in part with federal funds from the National Institute on Drug Abuse, National Institutes of Health, and the Food and Drug Administration, Department of Health and Human Services, under contract HHSN271201100027C.
Note. The views and opinions expressed in this article are those of the authors only and do not necessarily represent the views, official policy, or position of the US Department of Health and Human Services or any of its affiliated institutions or agencies.
HUMAN PARTICIPANT PROTECTION
Westat’s institutional review board approved the study design and protocol and the Office of Management and Budget approved the data collection.
REFERENCES
- 1.Behavioral health trends in the United States. results from the 2014 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2015. HHS publication no. SMA 15-4927, NSDUH Series H-50.
- 2.US Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
- 3.Agaku IT, King BA, Husten CG et al. Tobacco product use among adults—United States, 2012–2013. MMWR Morb Mortal Wkly Rep. 2014;63(25):542–547. [PMC free article] [PubMed] [Google Scholar]
- 4.Delnevo CD, Wackowski OA, Giovenco DP, Manderski MTB, Hrywna M, Ling PM. Examining market trends in the United States smokeless tobacco use: 2005–2011. Tob Control. 2014;23(2):107–112. doi: 10.1136/tobaccocontrol-2012-050739. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tam J, Day HR, Rostron BL, Apelberg BJ. A systematic review of transitions between cigarette and smokeless tobacco product use in the United States. BMC Public Health. 2015;15:258. doi: 10.1186/s12889-015-1594-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hyland A, Ambrose BK, Conway KP et al. Design and methods of the Population Assessment of Tobacco and Health (PATH) study. Tob Control. 2016 doi: 10.1136/tobaccocontrol-2016-052934. Epub ahead of print. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kasza KA, Ambrose BK, Conway KP et al. Tobacco-product use by adults and youths in the United States in 2013 and 2014. N Engl J Med. 2017;376(4):342–353. doi: 10.1056/NEJMsa1607538. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.National Institutes of Health. National Institute on Drug Abuse; Food and Drug Administration, Center for Tobacco Products. Population Assessment of Tobacco and Health (PATH) Study [United States] restricted-use files. ICPSR36231. Ann Arbor, MI: Inter-university Consortium for Political and Social Research; 2016. Available at: http://doi.org/10.3886/ICPSR36231. Accessed April 28, 2017.
- 9.McCarthy PJ. Pseudoreplication: further evaluation and applications of the balanced half-sample technique. Vital Health Stat. 1969;2(2):1–24. [PubMed] [Google Scholar]
- 10.Judkins DR. Fay’s method for variance estimation. J Off Stat. 1990;6(3):223–239. [Google Scholar]
- 11.Tomar SL, Alpert HR, Connolly GN. Patterns of dual use of cigarettes and smokeless tobacco among us males: findings from national surveys. Tob Control. 2010;19(2):104–109. doi: 10.1136/tc.2009.031070. [DOI] [PMC free article] [PubMed] [Google Scholar]