Characteristics of smokeless tobacco users seeking treatment

Measuring tobacco dependence in the general population: Evaluation of the Cigarette Dependence Scale (CDS-12) and its adaptation to smokeless tobacco use (STDS-12) in two Swedish surveys

Aims: The 12-item Cigarette Dependence Scale (CDS-12) is an instrument suitable to assess tobacco dependence in non-clinical populations. The aim of this study was twofold: a) to evaluate the scale’s performance in a smoking population including non-daily smokers; b) to explore the scale’s adaptation to the assessment of dependence on smokeless tobacco. Methods: In a cross-sectional study we investigated performance and construct validity of the CDS-12 and of its adaptation to smokeless tobacco (STDS-12) in two Swedish population samples. The first sample consisted of young adults (1246 ever daily smokers and 1086 ever daily snus (the Swedish type of moist oral snuff) users between 19 and 28 years of age). The second sample included 1229 current smokers and 855 current users of snus between 16 and 84 years of age. Score distribution, internal consistency, factor structure, and associations with other indicators of tobacco dependence were analysed. Results: Both scales had a small amount of missing answers (below 2% in most items) and had acceptable internal consistency. Factor analyses suggested a one-factor model. CDS-12 score and proportions classified as dependent were significantly higher among daily smokers compared to non-daily smokers, positively correlated with the number of cigarettes, and negatively with quit attempts as well as their duration. The same pattern was seen for STDS-12, apart from correlation with quit attempts. Conclusions: Both the CDS-12 and its adaptation to smokeless tobacco, tested for the first time in this study, appear to perform well in population-based samples including young and non-daily tobacco users.

Measurement of multiple nicotine dependence domains among cigarette, non-cigarette and poly-tobacco users: Insights from item response theory

BACKGROUND

Nicotine dependence (ND) is a key construct that organizes physiological and behavioral symptoms associated with persistent nicotine intake. Measurement of ND has focused primarily on cigarette smokers. Thus, validation of brief instruments that apply to a broad spectrum of tobacco product users is needed.

METHODS

We examined multiple domains of ND in a longitudinal national study of the United States population, the United States National Epidemiological Survey of Alcohol and Related Conditions (NESARC). We used methods based in item response theory to identify and validate increasingly brief measures of ND that included symptoms to assess ND similarly among cigarette, cigar, smokeless, and poly tobacco users.

RESULTS

Confirmatory factor analytic models supported a single, primary dimension underlying symptoms of ND across tobacco use groups. Differential Item Functioning (DIF) analysis generated little support for systematic differences in response to symptoms of ND across tobacco use groups. We established significant concurrent and predictive validity of brief 3- and 5-symptom indices for measuring ND.

CONCLUSIONS

Measuring ND across tobacco use groups with a common set of symptoms facilitates evaluation of tobacco use in an evolving marketplace of tobacco and nicotine products.

Evaluating strategies and costs to recruit smokeless tobacco users

We recruited smokeless tobacco users throughout Minnesota to participate in a trial testing telephone counseling versus a written self-help manual for cessation. This paper describes the recruitment strategies applied on a state-wide basis. We established a recruitment tracking system to monitor weekly rates of screened callers and returned consents, allowing us to adjust future recruitment efforts. Screening was completed with 783 callers, with 406 subjects enrolled. Overall 44% of initial contacts and 52% of those screened enrolled in the study. The overall average cost per consented subject was $99. Sports talk radio, small print ads, and newspaper articles based on press releases were consistently effective channels for recruitment. The overall cost was expensive but reflected the geographic diversity of recruitment and the prevalence of oral snuff use.

Progression of oral snuff use among Finnish 13-16-year-old students and its relation to smoking behaviour

AIMS

To examine the progression of oral moist snuff use among adolescents and its relation to smoking behaviour and nicotine addiction.

DESIGN AND SETTING

A 3-year smoking prevention study in 27 schools of Helsinki, Finland, starting with the seventh grade to the ninth grade.

PARTICIPANTS AND MEASUREMENTS

Pupils (n=2816) completed questionnaires four times, which included information on smoking behaviour, snuff experiments, nicotine addiction (Fagerström Tolerance Questionnaire) and other activities.

FINDINGS

The prevalence of snuff experimentation rose among boys from 7% in the seventh grade to 43% 3 years later in the ninth grade, and among girls from 2% to 13% for the corresponding period. Among boys, smoking predicted later snuff use in all assessments and snuff experimentation predicted later weekly smoking. The impact of snuff experimentation upon later smoking experimentation was smaller than vice versa. Among boys active in sports, smoking was less common but snuff use was more common. Combined use was common; by the end of the follow-up only 10% of weekly smokers had not tried oral snuff. Nicotine dependence scores increased linearly with snuff use among weekly smokers.

CONCLUSIONS

Despite the European Union sales ban on oral snuff products since 1995, in Finland snuff use is common among boys. Although combined use of snuff and cigarettes is associated with higher levels of nicotine dependence among adolescent boys, the direction of causality is not known. Unlike cigarette smoking, oral snuff use was tried among boys who spent their free time with sports-related activities.

Most smokeless tobacco use is not a causal gateway to cigarettes: using order of product use to evaluate causation in a national US sample

AIMS

To evaluate non-causal and causal patterns of smokeless tobacco (SLT) and cigarette use; to assess the prevalence of 'non-gateway' and possible 'gateway' patterns of SLT use.

DESIGN AND SETTING

Data from the Cancer Control Supplement to the 1987 National Health Interview Survey, a representative survey of non-institutionalized adults in the United States. From reported age at first use, participants were categorized by type and sequence of tobacco product use. SUDAAN 8.0.1 was used for statistical analyses.

PARTICIPANTS

Males aged 18-34 (n = 3454), weighted to provide estimates of the US population. A subsample of males aged 23-34 (n = 2614) was analyzed to minimize the possibility of future product switching.

MEASUREMENTS

Smoking status, smokeless tobacco (snuff, chewing tobacco, both) use status, age at regular use of cigarettes, age at first use of smokeless tobacco.

FINDINGS

Of those 23-34-year-olds who had ever used SLT with or without cigarettes, 77.2% (95% CI: 71.3, 83.3) were classifiable as non-gateway users in that 35.0% (95% CI: 29.9, 40.1) had only used SLT and 42.2% (95% CI: 36.8, 47.7) had used cigarettes first. Cigarette use in younger cohorts was less common, despite increased SLT use. Those who used cigarettes before moist snuff were 2.1 times more likely to have quit smoking (95% CI 1.21,6.39) than cigarette-only users.

CONCLUSIONS

The large majority of SLT users are non-gateway users. Causal gateway effects should be of minor concern for policy. SLT may be more likely to prevent smoking than cause it.

Who enrolls in a self-help cessation program for smokeless tobacco?

To further our understanding of the representativeness of the smokeless tobacco (SLT) user recruited to various treatment settings, and to suggest gaps in services available to SLT users, we first compared participants who enrolled in a self-help cessation program with two samples of nontreatment-seeking SLT users: SLT users identified through a random digit dialing (RDD) survey, and SLT users who came to 1 of 75 dental practices for a routine cleaning visit. We found that those in the self-help SLT cessation program were older, more educated, more likely to have made a serious quit attempt, and used more SLT weekly than those who did not seek treatment. Secondly, we compared SLT users seeking treatment in three different treatment settings varying in accessibility and intensity: self-help study participants, SLT users enrolled in a clinic-based study, and callers to the California Help Line for SLT cessation. Participants differed across the three studies on demographics, some measures of dependence, and history of SLT use.

Adolescents, Doping Agents, and Drug Use: A Community Study

Use of doping agents among Norwegian adolescents was investigated, with special emphasis on the association between doping agent use and use of tobacco, alcohol and drugs. The sample consisted of all 14 to 17 year olds in the public and private school systems in Oslo. The response rate was 94.3 % (n = 10,828). Two and three-tenths percent of the boys and 1.3% of the girls reported a life-time ever use of doping agents. Use of doping agents did not vary according to socio-demographic variables, living area in the city, or ethnic background. Multivariate analyses showed that there was an association between doping agent use and family factors (parental alcohol exposure and poor monitoring). Doping agent users often used commercial gymnasiums; they also reported use of smokeless tobacco and high levels of alcohol problems. The associations between doping agent use and use of amphetamines, MDMA, and heroin were particularly strong. Surprisingly, the association between doping agent use and use of cannabis only was negative. In particular, the link to the use of heroin should be noted, as this may imply needle sharing and the spread of hepatitis and HIV.

Evidence that smokeless tobacco use is a gateway for smoking initiation in young adult males

BACKGROUND

This study was designed to test the hypothesis that smokeless tobacco (SLT) serves as a gateway drug for smoking among young adult males. Methods. A cohort (n = 7,865) of U.S. Air Force recruits who claimed to have never smoked cigarettes was followed prospectively for 1 year. The participants were male, 32.9% were ethnic minorities, and their average age was 19.84 years (SD = 2.29). Among recruits entering basic military training, 403 (5.1%) reported current SLT use and 198 (2.5%) reported a past history of SLT use.

RESULTS

At the 1-year follow-up current SLT users were 233% more likely to have initiated smoking than nonusers (odds ratio = 2.33, 95% CI = 1.84-2.94). Similarly, recruits who reported past SLT use were 227% more likely to begin smoking than participants who had never used SLT (odds ratio = 2.27, 95% CI = 1.64-3.15). SLT use remained a potent predictor of smoking initiation in a multivariate logistic model that included demographic factors and other risk factors for initiation.

CONCLUSIONS

SLT use appears to be an important predictor of smoking initiation among young adult males. This study suggests that smoking prevention and cessation programs should also include strategies related to SLT use.

Smokeless tobacco cessation

Smokeless tobacco use is increasing in the United States, especially among young men, but there are few resources to assist users in quitting their use of moist snuff or chewing tobacco. This article reviews some unique aspects of smokeless tobacco use and provides a systematic four-step clinical plan for providing cessation. The authors provide clear suggestions, measures, and aids for getting the user ready to quit, planning their quit, quitting, and staying quit. The procedures and measures have been validated in randomized clinical trials and provide empirical support for the recommended cessation procedures. Finally, a review of brief cessation interventions in the context of health care is provided.