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. 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% Results: NSDUH 2007

16. Covariate CCT User % Exc. ST User % Exc. SmokerNon Tobacco User Total % Age (years) 12 – 17 5.210.116.668.2100 18 – 25 7.85.740.545.9100 26 – 34 5.25.143.746.0100 35 or Older 1.64.129.065.3100 Race Ethnicity White * 3.96.030.160.0100 African American * 0.3 44.854.6100 American Indian /Alaska Natives * 1.89.838.949.4100 Other * 1.12.238.458.4100 Hispanic 1.81.133.563.6100 Tobacco Use Characteristics of Male respondents – NSDUH 2007 Results: NSDUH 2007 * Non Hispanic

17. Results: NSDUH 2007

19. Tobacco Use Characteristics of Male respondents – NSDUH 2007 Covariate CCT User % Exc. ST User % Exc. Smoker % Non Tobacco User % Total % Marital Status Married 1.94.825.368.0100 Widowed 0.93.920.774.4100 Divorced/Separated 3.73.847.345.3100 Never Married 5.64.941.648.0100 General Health Excellent 3.15.024.667.3100 Very Good 3.45.629.861.2100 Good 3.23.437.655.8100 Fair/Poor 2.64.240.452.8100

20. Results: NSDUH 2007 Age (Years)OR (95% CI) 12 - 171.27 (1.26 – 1.28) 18 – 253.39 (3.38 – 3.41) 26 – 342.54 (2.53 – 2.55) 35 or OlderReferent

21. Results: NSDUH 2007 Race/EthnicityOR (95% CI) WhiteReferent African American1.36 (1.34 – 1.39) American Indian/ Alaska Native0.28 (0.27 – 0.29) Other0.73 (0.72 – 0.74) Hispanic2.49 (2.47 – 2.51)

22. Results: NSDUH 2007 Education LevelOR (95% CI) Less than High School2.46 (2.44 – 2.47) High School Graduate1.71 (1.70 – 1.71) Some College/College GraduateReferent

23. Results: NSDUH 2007 Marital StatusOR (95% CI) MarriedReferent Widowed0.56 (0.55 – 0.57) Divorced/Separated2.43 (2.42 – 2.45) Never Married2.88 (2.87 – 2.89)

24. Results: NSDUH 2007 General HealthOR (95% CI) ExcellentReferent Very Good0.97 (0.97 – 0.97) Good1.51 (1.50 – 1.51) Fair/Poor0.99 (0.98 – 1.00)

25. Results: NSDUH 2007 Employment StatusOR (95% CI) Full TimeReferent Part Time1.21 (1.20 – 1.21) Unemployed1.57 (1.56 – 1.58) Other0.61 (0.60 – 0.61)

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. 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) Results: BRFSS 2008

29. Covariate CCT User n (%) Exc. ST User n (%) Exc. Smoker n (%) Non Tobacco User n (%) Total n Age (years) 18 – 2573 (5.0)107 (7.3)371 (25.3)915 (62.4)1466 26 – 3486 (3.0)284 (10.0)688 (24.3)1769 (62.6)2827 35 or Older339 (1.2)1804 (6.25)5025 (17.4)21695 (75.17)28863 Race Ethnicity White * 445 (1.6)2039 (7.3)4807 (17.2)20534 (73.8)27825 African American * 12 (0.6)33 (1.5)557 (26.1)1531 (71.8)2133 American Indian /Alaska Natives * 6 (1.6)25 (6.6)130 (34.2)219 (57.6)380 Other * 14 (1.5)57 (6.2)199 (2.1)647 (70.6)917 Hispanic19 (1.1)40 (2.2)369 (20.501374 (76.2)1802 Tobacco Use Characteristics of Male respondents – BRFSS 2008* * Data from participating states † Non Hispanic Results: BRFSS 2008

30. * Data from participating states Results: BRFSS 2008

31. Covariate CCT User n (%) Exc. ST User n (%) Exc. Smoker n (%) Non Tobacco User n (%) Total n Marital Status Married254 (1.2)1513 (7.0)2986 (13.0)16742 (77.9)21495 Widowed17 (0.8)115 (5.4)323 (15.3)1659 (78.5)2114 Divorced/Separated101 (2.1)318 (6.5)1525 (31.3)2928 (60.1)4872 Never Married126 (2.6)258 (5.4)1247 (26.3)3119 (65.7)4750 General Health Excellent61 (1.1)403 (7.0)632 (11.1)4621 (80.8)5717 Very Good155 (1.5)731 (6.9)1662 (15.8)7988 (75.8)10536 Good166 (1.8)655 (6.2)2202 (21.0)7475 (71.2)10498 Fair/Poor115 (1.8)403 (6.2)1595 (24.7)4343 (67.3)6456 * Data from participating states Tobacco Use Characteristics of Male respondents – BRFSS 2008* Results: BRFSS 2008

32. Age (Years)OR (95% CI) 18 – 253.63 (2.64 – 5.00) 26 – 341.61 (1.23 – 2.11) 35 or OlderReferent Results: BRFSS 2008

33. Race/EthnicityOR (95% CI) WhiteReferent African American1.67 (0.85 – 3.25) American Indian/ Alaska Native1.10 (0.44 – 2.70) Other1.12 (0.62 – 2.04) Hispanic2.18 (1.25 – 3.79) Results: BRFSS 2008

34. Education LevelOR (95% CI) Less than High School1.68 (1.25 – 2.27) High School Graduate1.64 (1.33 – 2.03) Some College/College GraduateReferent Results: BRFSS 2008

35. Marital StatusOR (95% CI) MarriedReferent Widowed0.88 (0.52 – 1.49) Divorced/Separated1.89 (1.46 – 2.45) Never Married2.91 (2.26 – 3.80) Results: BRFSS 2008

36. General HealthOR (95% CI) ExcellentReferent Very Good1.40 (1.02 – 1.93) Good1.67 (1.22 – 2.30) Fair/Poor1.88 (1.34 – 2.65) 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 Tobacco User2003 % 2008 % % ChangeAnnual Percent Change CCT User 1.81 1.47↓ 18.55↓ 4.08 Exclusive ST User 5.716.75 ↑ 18.10 ↑ 3.61 Exclusive Smoker 23.3217.58 ↓ 24.61 ↓ 6.84 Non User69.16 74.20 ↑ 7.29

39. Results: Trends in Tobacco Use

40. 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. Conclusion

41. 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) Conclusion

42. 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 Conclusion

43. 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 Conclusion

44. 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. Conclusion

45. 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% Conclusion

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

47. 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 Conclusion