Smokeless tobacco use and dental care utilization, using a National dataset

Highlights

• •Smokeless tobacco use has serious oral health consequences.
• •Dental professionals can discover lesions early, given the opportunity.
• •Dental visit utilization has been declining.
• •Dental visit utilization is less frequent among those who use smokeless tobacco.

Abstract

Background

Smokeless tobacco use has serious oral health consequences. The purpose of this current research is to determine the level of dental care utilization among individuals with smokeless tobacco use as compared with individuals who do not use smokeless tobacco.

Method

The U.S. national dataset, 2020 Behavioral Risk Factor Surveillance System (BRFSS), was the data source for the cross-sectional study. Smokeless tobacco use and having a dental visit within the previous year were determined from the BRFSS questionnaire. There were 94,821participants included. Chi square and logistic regression analyses were conducted.

Results

There was a significant relationship with smokeless tobacco use and not having a dental visit within the previous year even after adjusting for sex, race/ethnicity, age, education, income, health insurance, smoking, and region. The adjusted odds ratio was 1.42 (95 %CI: 1.17, 1.69; p = 0.0002).

Conclusion

Individuals who use smokeless tobacco products are less likely to have a dental visit within the previous year.

1. Introduction

1.1. Smokeless tobacco prevalence and health consequences

Smokeless tobacco is tobacco that is held in the mouth rather than burned/inhaled. Some people chew the tobacco, while others suck (dip) it (CDC, 2022). Smokeless tobacco has several forms based on how the tobacco is cut and packaged. Chewing tobacco is sold as leaves of tobacco, bricks or plugs of tobacco, or twists of rope (CDC, 2022). Snuff is available as a powder or very finely processed cuts of tobacco which are sold as dry snuff or moist snuff in dissolvable lozenges, pouches (snus), strips and similar packaging (CDC, 2022). There are approximately 2.3 % of U.S. adults who use smokeless tobacco (CDC, 2022). The prevalence in men is 4.5 % as compared with 0.3 % of women; and, the prevalence is the highest in Wyoming (8.8 %) followed by West Virginia (8.3 %) (CDC, 2022). The health consequences of smokeless tobacco use include exposure to carcinogenic tobacco-specific nitrosamines; heavy metals such as arsenic (Muthukrishnan and Warnakulasuriya (2018) Jul), polonium-210, beryllium, cadmium, chromium, cobalt, lead, nickel, mercury, and highly addictive nicotine (CDC, 2021). Smokeless tobacco use increases the risk for cancer of the pancreas, esophagus, and mouth; early delivery, stillbirth, and fetal brain development (CDC, 2021).

1.2. Smokeless tobacco and dental professionals

Significant oral tissue damage is associated with smokeless tobacco products resulting in oral outcomes from staining and denuding of teeth of attached gingiva to periodontal disease, tooth loss, leukoplakia/erythroplakia/erythroleukoplakia; submucous fibrosis; oral squamous cell carcinoma, verrucous carcinoma, and other oral potentially malignant disorders (Muthukrishnan & Warnakulasuriya, 2018). In a global systematic review, researchers determined that the poorest population segments bore the greatest burden of smokeless tobacco use (Sinha et al. (2018) Nov 15). Similarly, in another study, U.S. males who used smokeless tobacco, aged 25–34 years, lost 4.1 quality adjusted life years due to smokeless tobacco (Xu et al. (2021) Sep). The authors suggested that the quality adjusted life years could be minimized through prevention of initiation and early help with cessation (Xu, et al., 2021).

As many consequences of smokeless tobacco use have dental/oral/craniofacial consequences, dental professionals can have a significant role in smokeless tobacco discussions during oral examinations (Nethan et al. (2018) Oct). Dental visits are critical in discovery of tissue changes due to smokes tobacco as well as for the discussion of not initiating use or in providing the help for smokeless tobacco cessation efforts.

1.3. Purpose of the study

Researchers have noted that despite the use of smokeless tobacco by many people, and its known adverse health consequences, there has been a scarcity of research upon smokeless tobacco as compared with combustible tobacco (Nethan et al. (2018) Oct). For example, in a systematic review of tobacco and peri-implantitis associated with tobacco, the researchers did not find any studies in indexed literature about smokeless tobacco products (Javed et al. (2000). 2019 Oct,). In another systematic review of factors associated with dental service use, smokeless tobacco was not included in the main findings of any of the 31 reviewed studies. (Hajek et al. (2021) Mar 3). In a study of dental visit trends in the U.S., using nationally representative Behavioral and Risk Factor Surveillance Survey (BRFSS) data from 1995 to 2008, although smoking was included, smokeless tobacco use was not (Akinkugbe and Lucas-Perry (2013) Jan 1). It should be noted that dental visits remained consistently lower by 10 % for people who smoked as compared with people who did not smoke between 1995 and 2008 (Akinkugbe, et al., 2013).

As dental professionals may curb smokeless tobacco use through cessation programs (Rindal et al. (2022) Sep 1), it is important to know how dental utilization compares among individuals who with smokeless tobacco use with individuals who do not. The purpose of this current research is to determine the level of dental care utilization among individuals with smokeless tobacco use as compared with individuals who do not use smokeless tobacco. The null hypothesis is that there is no difference in odds of dental visit use between individuals who use smokeless tobacco and individuals who do not use smokeless tobacco.

2. Material and methods

2.1. Ethical statement

The research received acknowledgment from the West Virginia University Institutional Review Board as non-human subject research.

2.2. Study design

The research had a cross-sectional, observational study design of secondary data.

2.3. Data source

The data for this study were extracted from the 2020 BRFSS available at the BRFSS website (BRFSS, 2021). BRFSS is an on-going study that is conducted by phone in the U.S. Each year, over 400,000 U.S. residents respond to questions about health, health risks, prevention, and chronic conditions (2020 BRFSS).

2.4. Measures

The main variables of interest examined in this study were dental visit within the previous year and use of smokeless tobacco. The dental visit variable was extracted from the 2020 BRFSS calculated variable of adults who visited a dentist, dental hygienist, or other dental clinic within the past year (yes, no). The use of smokeless tobacco variable dichotomized to a yes/no variable from the BRFSS question, “Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?”.

3. Theory/calculation

The theory used for this research is the Andersen Behavioral Model of Health Services Use (Andersen, et al., 2007). It is a healthcare utilization model that includes predisposing factors (sex, age, race, etc.), enabling factors (education, income, health insurance, residence, etc.), perceived need (level of risk, perceived benefit, etc.), and personal health practices (smoking, alcohol use, drug use, exercise, etc.). For this study, the variables, sex (male, female); age (18–39 years, 40–49 years, 49, 50 59, 60 64, ≥65); race/ethnicity (white, black/African American, Hispanic, Other); educational level (less than high school, high school, above); income.

(<$10,000, $10,000 to <$25,000, $25,000 to <$75,000, ≥$75,000); smoking (current, former, never); region (Northeast, Midwest, South, West); and insurance (yes, no) were included to satisfy the theory.

Calculations were conducted using SAS® (version 9.4; SAS Institute., Cary, NC: https://www.sas.com). Data frequencies, bivariate analyses with Rao Scott Chi square, and logistic regression analyses were conducted. BRFSS provided weights, clusters, and sampling units were used to account for the BRFSS study design. The alpha level was set at < 0.05.

4. Results

4.1. Sample characteristics

The sample description and the Chi Square relationships with dental visit in the previous year (yes, no) are presented in Table 1. There were 94,821 participants in the study of whom 51.2 % were women; 54.1 % were non-Hispanic white; 35.5 % were ages 18–39 years; and 57.4 % had a high school diploma as the highest level of education. Most (88.5 %) had health insurance; and nearly-two-thirds (64.1 %) had never smoked. There were 65,127 (65.1 %) who had a dental visit within the year.

Table 1.

Bivariate description of dental visit within the year with variables of interest, 2020 BRFSS (n = 94,821).

	All Number	All percentage	Dental Visit Number	Dental visit weighted percentage	No dental visit Number	No dental visit weighted percentage	p-value
	94,821	100	65 127	65.1	29,694	34.9
Smokeless Tobacco use							<0.0001
Yes	2929	2.6	1487	51.0	63,640	49.0
No	91,892	97.4	1422	65.5	28,252	34.5
Sex							<0.0001
Female	51,269	52.1	36,641	67.8	14,628	32.2
Male	43,552	47.9	28,486	62.1	15,066	37.9
Race/ethnicity							<0.0001
Non-Hispanic white	59,944	64.1	49,632	70.1	20,312	29.9
Non-Hispanic black	5959	11.1	3447	59.7	2512	40.3
Hispanic	7897	21.4	4742	56.5	3155	43.5
Other	11,021	13.4	7306	63.2	3715	36.8
Age in years							<0.0001
18–39	22,614	35.5	14,538	61.1	8076	38.9
40–49	12,974	15.2	8871	64.1	4103	35.9
50–59	15,998	16.8	11,053	67.1	4945	32.9
60–64	9911	8.7	6924	68.2	2987	31.8
≥65	31,660	22.2	22,528	69.2	9132	30.8
Education							<0.0001
Less than High School	5625	13.6	2326	45.8	3299	54.2
High School	52,456	57.4	33,521	63.2	18,935	36.8
Additional education	36,484	28.7	29,117	78.2	7367	21.8
Income in thousand dollars							<0.0001
<10	2955	5.2	1338	46.2	1617	53.8
≥10 to < 25	14,979	16.2	7564	50.6	7415	49.4
≥25 to < 75	31,392	30.4	21,108	61.6	10,284	28.4
≥75	30,262	33.0	24,689	78.0	573	22.0
Health Insurance							<0.0001
Yes	87,346	88.5	61,770	68.2	22,576	31.8
No	7017	10.8	3076	39.9	3941	60.1
Smoking							<0.0001
Current	12,634	12.6	6045	46.8	6589	53.2
Former	24,902	22.8	16,783	64.7	8119	35.3
Never	56,775	64.1	41,949	68.8	14,826	32.2
Region							<0.0001
Northeast	18,858	20.9	13,199	67.0	5659	33.0
Midwest	36,495	22.0	24,967	66.8	11,528	33.2
South	12,037	15.1	7286	59.8	4741	40.2
West	27,441	42.0	19,675	65.2	7766	34.8

4.2. Bivariate associations

Among participants who used smokeless tobacco, 51.0 % had a dental visit as compared with 65.5 % of participants who did not use smokeless tobacco (p < 0.0001). Other significant bivariate associations with dental visit were with sex, race, age, education, income, health insurance, smoking, and region.

4.3. Logistic regression analyses results

The logistic regression analyses of smokeless tobacco use on no dental visit within the previous year are presented in Table 2. The unadjusted odds ratio for no dental visit was 1.81 (95 % CI: 1.55, 2.14; p < 0.0001) for participants who used smokeless tobacco. It remained significant in the model adjusted for sex, race/ethnicity, age, education, income, health insurance, smoking, and region. The adjusted odds ratio was 1.42 (95 % CI: 1.17, 1.69; p = 0.0002).

Table 2.

Logistic Regression of Smokeless Tobacco Use on No Dental Visit within the Previous Year, BRFSS, 2020 (n = 94,821).

	Odds Ratio	95 % Confidence Interval	p-value	Adjusted odds ratio	95 % Confidence Interval	p-value
Smokeless Tobacco use			<0.0001			0.0002
Yes	1.81	1.55, 2,14	<0.0001	1.42	1.17, 1.69
No	Reference			Reference
Sex						<0.0001
Female				Reference
Male				1.24	1.14, 1.35
Race/ethnicity
Non-Hispanic white				Reference
Non-Hispanic black				1.26	1.12, 1.42	<0.0001
Hispanic				1.17	1.02, 1.34	0.0027
Other				1.45	1.26, 1.67	<0.0001
Age in years
18–39				1.24	1.11, 1.38	<0.0001
40–49				1.18	1.03, 1.35	0.0206
50–59				1.05	0.92, 1.20	0.4445
60–64				0.97	0.85, 1.12	0.6468
≥65				Reference
Education
Less than High School				2.17	1.87, 2.51	<0.0001
High School				1.49	1.36, 1.63	<0.0001
Additional education				Reference
Income in thousand dollars
<10				2.42	1.88, 3.11	<0.0001
≥10 to < 25				2.22	1.95, 2.54	<0.0001
≥25 to < 75				1.73	1.55, 1.93	<0.0001
≥75				Reference
Health Insurance						<0.0001
Yes				Reference
No				2.09	1.83, 2.38
Smoking
Current				1.98	1.77, 1.44	<0.0001
Former				1.30	1.18, 1.44	<0.0001
Never				Reference
Region
Northeast				0.98	0.88, 1.08	0.6526
Midwest				1.00	0.91, 1.11	0.9729
South				1.18	1.05, 1.32	0.0047
West				Reference

5. Discussion

5.1. Study result summary and similar research

There were 2.6 % of adult U.S. residents who used smokeless tobacco in 2020. They were less likely to have a dental visit within the previous year than adult U.S. residents who did not use smokeless tobacco (p = 0.0002). Among people who used smokeless tobacco, 49.0 % had not attended a dental visit within the previous year as compared with 34.5 % of participants who did not use smokeless tobacco; a 14.5 % difference. Although there are no similar studies of smokeless tobacco use and dental visits in the literature with which to specifically compare with this study, there was a 19.37 % difference among women who were not pregnant and used tobacco as compared with women who were not pregnant and did not use tobacco (Naavaal et al. (2019) Dec 1); and, there was a 10 % difference in dental visits between people who smoke and people who do not smoke (Akinkugbe, et al., 2013).

Overall dental visits per year have been fluctuating due to many factors from the expansion of Medicaid that increased dental visits to the COVID-19 pandemic that contracted dental visits. In 2019, 34.7 % of U.S. residents had not had a dental visit within the previous year while in 2020, that number increased to 37.0 % (NCHS. (2022)). However, an assessment (2013–2014) of people who used smokeless tobacco indicated 51.3 % had not seen a dentist in the previous year (Vora and Chaffee (2019) May 1), and in this study, there were 49.0 %. The trend between 2013 and 2020 data for people who used smokeless tobacco has not appreciably changed despite Medicaid expansion and the COVID-19 pandemic. Adults in the U.S. who use smokeless tobacco are less likely to have a dental visit within the previous year. Other researchers have indicated that tobacco use has shifted from cigarettes to other uses of tobacco and the evidence base is less established for smokeless tobacco use (Levy et al., 2017). This current research is novel in that it helps to identify a break in the link in tobacco cessation program access and oral examinations to a vulnerable group—if people who use smokeless tobacco are not seeking dental care as other members of the population, they are at greater risk of more advanced cancers upon diagnosis, greater harm from dental diseases, and are less likely to have cessation counseling.

Although this study had the strength of using nationally representative data, it is also constrained by the variables available. For example, rural residency would have been a variable which would have strengthened the results.

5.2. Policy implications

Much attention has been placed upon dental healthcare providers to learn pharmacotherapeutic and behavioral interventions for tobacco cessation. These efforts are hampered if the people who need them the most are not presenting for routine care. Additionally, invasive cancers of the tongue and other oral tissues, often associated with smokeless tobacco use, cannot be diagnosed in a timely manner if the individuals who use smokeless tobacco do not have routine dental visits. There is a need for expanded public service announcements to encourage dental visits, particularly for individuals who use tobacco products.

6. Conclusions

Individuals who use smokeless tobacco products are less likely to have a dental visit within the previous year.

Funding

Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health, though not financially, under Award Number 5U54GM104942-04. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

CRediT authorship contribution statement

R. Constance Wiener: Conceptualization, Methodology, Visualization.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

The data is available from the BRFSS website at: CDC-2020 BFRSS Survey Data and Documentation