1. 1 Olutola Bukola G, Ayo-Yusuf OA University of Pretoria & Office of the Director, School of Oral Health Sciences, University of Limpopo, Medunsa Campus, Pretoria Socio-economic correlates of snuff use in South Africa during 2003 – 2011

2. Introduction 2 While the prevalence of cigarette smoking is reducing in the developed world, the use of SLT is on the increase. It has been suggested that this is as a result of smokers switching to the perceived less dangerous SLT, while others have raised concerns that SLT may serve as an entry point to tobacco smoking. South African cultural practices are such that it is predominantly black women who use SLT, as it is considered a culturally acceptable behaviour and a more socially discreet behaviour than smoking, which is considered a taboo for women. SLT use is socially acceptable among the indigenous black people mainly for ceremonial and medicinal purposes. (Ayo-Yusuf et al, 2006)

3. Smokeless tobacco as a smoking initiator Evidence suggests that ST use is a gateway into smoking The use of smokeless tobacco has been shown to be a potential predictor of smoking initiation and has been associated with a significantly increased risk of adult-onset smoking initiation. SLT users may switch to cigarette as their degree of tolerance to nicotine develops and the nicotine dependence process progresses. 3

4. Smokeless as a form of harm reduction There is a growing interest in using smokeless tobacco (ST) products for tobacco harm reduction (USA and Sweden). Studies have shown that the use of ST by young people may reduce smoking initiation. (Bates et al, 2003; Kozlowski et al, 2003). Evidence from Sweden which has a sizeable market for snus (moist smokeless tobacco) shows that snus plays a protective role. The commercial brands of ST in South Africa deliver more nicotine than other brands from Sweden and other developed countries and such brands may have a higher addiction potential. (Ayo-Yusuf et al, 2004). 4

5. Types of snuff used in South Africa Two types of snuff are available in South Africa.  Industrially-made SLT- “Ntsu”, “Taxi-Red”, “Singleton- Menthol” and “Tobacco-rette original”  Traditional, home-made SLT as ‘snuff’ prepared with local additives, such as ash obtained from burning the mukango vegetable plant. 5

6. Smokeless tobacco use in South Africa

7. More commercialized products, including snus test-marketed in 2005-2007 7

10. SmokelessTobacco outlook by major market: Value (US$) 2008-2013 (Euromonitor, 2008) 2008 2013 % growth* US5,176.78,274.559.8 India5,602.66,550.316.9 Sweden1,204.81,468.721.9 Norway366.1709.993.9 Algeria347.6338.2-2.7 Canada175.5198.413.1 Denmark10.639.7276.1 Germany38.239.02.1 South Africa2.73.324.5 Mexico2.02.15.4 Tunisia1.91.8-4.5 Venezuela0.20.38.1 Slovenia0.2 5.9

11. SLT -Nicotine Nicotine is the addicting agent in tobacco that prevents cessation and sustains long term use. The pH of SLT strongly influences nicotine absorption through the nose and mouth, especially the free base (unionised) nicotine, which is the form most readily absorbed. Nicotine dose obtained from a unit (‘‘dip’’ or‘‘sniff’’) of SLT is primarily determined by characteristics of the product itself and to a lesser extent by the amount of snuff used, and behavioural and physiological factors unique to each user.16 South African commercial brands of SLT have been found to deliver more nicotine than other brands from developed countries, and such brands may therefore have a higher addiction potential. (Ayo-Yusuf et al, 2004). 11

12. Health effects of SLT The levels of carcinogenic tobacco specific nitrosamines in traditional South African SLT products are up to 19 times higher than those in Swedish-style snus. (Ayo-Yusuf & Burns, 2012). The traditional South African SLTs may also contain a considerable amount of toxic combustion products from the ash, which comes from burning of Mukango—used in the mixture. (Fant, 1999; Peltzer et al, 2001). Long term use of oral SLT has been associated with development of oropharyngeal and upper respiratory tract cancers and is a risk factor for cardiovascular disease and adverse reproductive outcome. SLT use may also be a risk factor for the development of chronic bronchitis and may predispose to tuberculosis infections in South Africa. 12

13. Existing legislation or public campaign The prevalence of smoking has decreased in South Africa over the last 20 years but, little attention has been given to the use of snuff. SLT manufacturers in South Africa are required by law (since 1995) to include the phrase ‘‘causes cancer’’ on every can of SLT. (WHO, 2012). They are not mandated by law to disclose the nicotine content of their products. Snuff is much less expensive than cigarettes in South Africa. 13

14. Objective This study therefore sought to determine trends and socio-economic correlates of snuff use among South African adults. 14

15. Methods This secondary data analysis involved three waves of the South African Social Attitude Survey –Survey years and sample sizes were: 2003 (n=2,855), 2007 (2,907) and 2011 (3,003). (N=8765) Using interviewer-administered questionnaire, information obtained included socio-demographic data and current smoking status. Current snuff users were respondents who reported using oral and/or nasal snuff every day or some days. The datasets from the three surveys were then merged. Data analysis included chi-square statistics and multivariable-adjusted logistic regression analysis. 15

16. Characteristics of the study population 16

17. 17 Mostly nasal use, but oral use slightly increased

18. Snuff use among those who smoke negligible, but increased 18

19. Percentage of current snuff use in the study population in relation to various characteristics Characteristics Current snuff use %(n)p-Value GenderMale0.98 (32) <0.001 Female6.02 (286) RaceBlack4.60 (302) <0.001 Others0.38 (16) Age16-240.80 (22) <0.001 25-342.78 (61) 35-442.95 (62) 45-545.80 (70) 55-647.28 (40) 65+10.71 (63) LocationUrban2.93 (165) 0.002 Rural4.97 (153) Current smokingNo4.09 (284) 0.001 Yes1.83 (34) Marital statusSingle2.18 (107) <0.001 Divorce/widow10.62 (92) Married3.84 (114) EducationNo education13.16 (71) <0.001 Grade3.31 (238) >Grade 120.53 (6) 19

20. Trends in snuff use between 2003 and 2011 20

21. Factors associated with current snuff use Characteristics Odds ratio(95% Conf Interval) GenderMale1.0 Female5.8 (3.67-9.23) RaceOthers1.0 Black20.2 (9.90-41.06) Age16-241.0 25-343.06 (1.59-5.91) 35-443.34 (1.61-6.94) 45-546.46 (3.17-13.15) 55-646.29 (2.97-13.32) 65+9.23 (4.22-20.18) Survey year20031.0 20071.28 (0.83-1.96) 20110.56 (0.36-0.87) Marital statusSingle1.0 Divorce/widow1.71 (1.09-2.68) Married1.26 (0.83-1.92) EducationNo education1.0 Grades 1-120.58 (0.36-0.93) >Grade 120.15 (0.06-0.40) 21

22. Conclusion The use of snuff, which is on the decline, remains predominantly among non- smoking women, those of low socioeconomic status and among rural residents. These socioeconomic determinants should be considered when planning snuff use prevention interventions. Although, not significant, the fact that oral tobacco use and dual use tended to have increased following the test marketing of oral tobacco – snus, during 2005-2007, suggest need for vigilance in ensuring tobacco control regulation covers all forms of tobacco. There is nonetheless, need for further studies on the trends in smokeless tobacco use and its relationship with smoking among adolescents from low SES in South Africa. 22

23. . THANK YOU Acknowledgement: This study was supported by the American Cancer Society (Grant A0U146)