Chapter 1. PREVALENCE AND TRENDS OF SMOKELESS TOBACCO USE IN THE UNITED STATES Introduction ........0.00.0.00 0.000000 5 Product Characteristics.....000000200000.0..0 0.0.0 c eee. 5 Trends in ProductionandSales.......................... 5 Categories of Products ............................. 7 Temporal Trends..........0000000000 000000. c cece, 7 Trends in Self-Reported Use: Survey Data................. 7 National Survey Data.............0.0.....00........ 7 State and Local Survey Data ....................... 15 Conclusions..............00.00 00.0.0. eee 24 Research Needs ........0.0.000 00.0.0 c cece ete 25 INTRODUCTION This chapter defines the various forms of smokeless tobacco that are used in the United States and examines the data that pertain to trends in prevalence and patterns of use. Trends in smokeless tobacco produc- tion and sales and self-reported use are considered. Methodological con- siderations are discussed and research needs are identified. Tobacco was used by pre-Columbian American Indians in smokeless forms as well as smoked (1). Cultivated by American colonists, tobacco became a major commodity in trade with Europe. Until the end of the 19th century, the use of smokeless tobacco products was widespread in the United States. Its use declined rapidly in this century with the advent of antispitting laws, loss of social acceptability, and increased popularity of cigarette smoking (1,2). Use was primarily confined to rural and agricultural areas and to occupational settings where smok- ing was not allowed, such as mining and some industries (3,4). In the Southeastern United States, especially in rural areas, oral use of dry snuff remained popular among women (5,6). PRODUCT CHARACTERISTICS Today, smokeless tobacco is produced in two general forms: chewing tobacco and snuff (7-10). Chewing tobacco is chewed or held in the cheek or lower lip. Three primary types of chewing tobacco are marketed: looseleaf, plug, and twist. Snuff has a much finer consistency than chewing tobacco and is held in place in the mouth without chewing. It is marketed in both dry and moist forms. Although smokeless tobacco is not subject to combustion and is usually used orally in the United States, products differ with regard to several factors, including type of tobacco plant used, parts of the tobacco plant used, method of curing, moisture content, and additives. For example, looseleaf chewing tobacco is made from air-cured, cigar-type leaves from tobacco that is grown in Pennsylvania and Wisconsin. In contrast, dry snuff is made primarily from fire-cured dark tobacco that is grown in Kentucky and Tennessee. Plug tobacco and snuff come in dry and moist forms, Many smokeless tobacco products are sweetened with sugar or molasses. Many are flavored; licorice is a common additive for chewing tobacco, while mint and wintergreen often are used to flavor snuff. Table 1 describes the types of smokeless tobacco and how they are used and packaged (7-10). TRENDS IN PRODUCTION AND SALES United States Department of Agriculture (USDA) records on the annual production and sales of smokeless tobacco serve as indicators of the population’s consumption. Changes in consumption can be inferred from changes in production and sales. Because sales figures closely resemble those for production, only production will be reported. TABLE 1.—Characteristics of Smokeless Tobacco Products Product Description How Used Packaging* CHEWING TOBACCO Looseleaf Made from air-cured, cigar leaf tobaccos of Pennsylvania A piece of tobacco, 3/4 to 1] inch in Pouch, typically 3 ounces. A few brands and Wisconsin. Consists of stripped and processed tobacco —_ diameter, is tucked between the gum and market a 1.5-ounce pouch. leaves. The leaves are stemmed, cut, or granulated and are jaw, usually to the back of the mouth. loosely packed to form small strips of shredded tobacco. , Most brands are sweetened and flavored with licorice. Plug Made from enriched tobacco leaves (Burley and bright Chewed or held in the cheek or lower lip. A compressed brick or flat block wrapped tobacco and cigar tobacco} or fragments wrapped in fine May be held in the mouth for several inside natural tobacco leaves. Packaged tobacco and pressed into bricks. May be firm (less than 15 hours. in clear plastic. Packages range from 7 to percent moisture) or moist (15 percent or greater 13 ounces. Also sold by the piece. moisture). Most plug tobacco is sweetened and flavored with licorice. Twist Handmade of dark, air-cured leaf tobacco treated with a Similar to plug. A pliable but dry rope. Sold by the piece, tarlike tobacco leaf extract and twisted into strands that packaged in plastic bags. No standard are dried. Majority is sold without flavoring and weight. Sold in small (approximately 1-2 sweeteners. ounces) and larger sizes based on the number of leaves in the twist. SNUFF Moist Made from air-cured and fire-cured tobacco. Consists of A small amount (“pinch”) is placed Cans and plastic containers, typically 1.2 tobacco stems and leaves that are processed into fine par- between the lip or cheek and gum and is ounces. ticles or strips. Some products are flavored. Has a typically held for 30 minutes or longer moisture content of up to 50 percent. per pinch. Dry Most dry snuff is made from fire-cured tobaccos of Ken- Same as moist snuff. May also be sniffed. | Metal cans or glass containers, vary from tucky and Tennessee. After initial curing, the tobacco is fermented further and processed into a dry powdered form. Products vary in strength and flavoring. Generally has a moisture content of less than 10 percent. 1.15 to 7 ounces per container. * Product weight (includes moisture). Categories of Products The USDA reports production and sales by product category {i.e., chewing tobacco and snuff). The definitions of categories changed in 1981. Prior to 1981, total figures for chewing tobacco were derived by summing data for the subcategories of plug, twist, looseleaf, and fine- cut; snuff was a separate category. However, fine-cut tobacco is used in moist snuff. To reflect this fact, after 1981 USDA shifted fine-cut from the category of chewing tobacco to moist snuff. To observe and clarify temporal trends for the purposes of this review, the data presented in figure 1 reflect a uniform category system across years. In these records, fine-cut tobacco is counted consistently as snuff (11-17). Temporal Trends Figure 1 depicts temporal trends in the quantities of smokeless tobacco that were manufactured in the United States from 1961 to 1985. Be tween 1944 and 1968, total smokeless tobacco production declined 38.4 percent from 150.2 to 92.5 million pounds. Subsequent increases in pro- duction reached 135.6 million pounds in 1985. Between 1970 and 1985, total snuff production increased 56 percent from 31.3 to 48.7 million pounds. This increase was due to changes in the production of moist snuff; the manufacture of dry snuff declined (3). The difference in trends in the production of moist and dry snuff is shown in figure 1 for the years 1981 through 1985. Separate production data are not available for the two types of snuff prior to 1981. Between 1970 and 1981, however, the production of fine-cut tobacco, used in the manufacture of some moist snuff, increased threefold from 4.8 to 15.2 million pounds. Between 1970 and 1985, the production of chewing tobacco increased 36 percent from 63.9 to 86.9 million pounds. This increase was due to the production of looseleaf tobacco, which increased 87.3 percent from 39.5 to 74.0 million pounds. The production of plug and twist tobacco declined during this period. TRENDS IN SELF-REPORTED USE: SURVEY DATA National Survey Data National data from 1964 to 1985 are available from eight different na- tional probability surveys and a national survey of college students. The majority of the data pertain to persons over the age of 17. The prin- cipal characteristics of these surveys are shown in table 2. Office on Smoking and Health Surveys Early data on the use of chewing tobacco and snuff are available from the 1964, 1966, 1970, and 1975 Adult Use of Tobacco Surveys that were 7 FIGURE 1.—Manufacturing Trends: Quantities of Smokeless Tobacco Manufactured in the United States From 1961 to 1985 Expressed in Million Pounds 1409 10-4 Number Yr Milion = d Pounds ai 4044 s wr 10% Sete . TT TT A a eee 61 62 63 64 65 G6 G7 6B G9 70 71 72 73 74 75 76 77 7879 BO 8! 82 8384 5 Year o——® _= Total Smokeless Tobacco ee vesancaeee @ = Chewing Tobacco ere = Snuff om m me = Most Snull Om me = Dry Sout TABLE 2.—National Prevalence of Smokeless Tobacco Use: Data Sources Number of Respondents/ Survey Type Date Respondents Households Products Questions Office on Smoking Personal 1964 Adults 2 21 5,794 Snuff and Chewing “Have you ever used—at all regularly?” and Health Interview Tobacco Separately “Do you use—now?”" Office on Smoking Personal 1966 Adults 2 21 5,770 Snuff and Chewing “Have you ever used—at all regularly?” and Health Interview Tobacco Separately “Do you use—now?" Office on Smoking Telephone 1970 Adults > 21 5,200 Snuff and Chewing “Have you ever used—at all regularly?” and Health Tobacco Separately “Do you use—now?" Office on Smoking Telephone 1975 Adults > 21 12,000 Snuff and Chewing “Have you ever used—at all regularly?” and Health Tobacco Separately “Do you use—now?" National Health Interview —_ Personal 1970 Persons 2 17 77,000/ Snuff and Chewing Does presently use any other Survey Supplement Interview 37,000 Tobacco Separately form of smokeless tobacco, such as snuff or (National Center for Including chewing tobacco? Health Statistics) Proxy Simmons Study of Questionnaire 1980 Adults > 18 15,000- Snuff Only 1980 to 1983 ‘Do you use it yourself— Media Markets, 1981 19,000 snuff (smokeless tobacco)?” Simmons Market 1982 1984 to 1985 ‘Do you yourself use any of the Research Bureau, Inc. Iona following tobacco products?" Snuff (ST) 1985 listed as an option. Simmons National Questionnaire 1983 College 2,011- Snuff Only “Please mark which of the items listed below College Study, Students 2,373 you yourself use.” ae poet Inc 1985 218 Snuff (smokeless tobacco) listed as an option. Current Population Survey Personal 1985 Persons > 16 120,000/ Snuff and Chewing Does presently use any other form Supplement—Census Bureau Interview 58,000 Tobacco Separately of tobacco, such as snuff or chewing tobacco? for orice on Smoking Including What other forms of tobacco does and Fea oxy presently use? NIDA Household Personal 1985 Persons > 12 8,000 Snuff and “On the average, in the past 12 months, Survey Interview Chewing how often have you used chewing tobacco Tobacco Combined or snuff or other smokeless tobacco?” TABLE 3.—Use of Smokeless Tobacco in the United States by Individuals Over 21 Years of Age* Percentage of Users Males Females Use Category 1964 1966 1970 1975 1964 1966 1970 1975 Now Use Snuff 20 31 29 25 20 21 #414 «1438 Used to Use Snuff 36 39 42 40 09 10 411 #411 Have Ever Used Snuff t 54.7 72 71 64 29 31 26 2.4 Now Use Chewing Tobacco 5.1 71 56 49 05 O04 O06 06 Used to Use Chewing Tobacco 12.0 13.2 191 161 1.0 11 #18 12 Have Ever Used Chewing Tobaccot 17.2 20.5 24.7 210 15 415 24 «18 * Use’ not further defined with respect to frequency. ft Includes those who used to use, but did not state if they used it currently. Source: National Clearinghouse on Smoking and Health. conducted by the National Clearinghouse for Smoking and Health, cur- rently the Office on Smoking and Health (OSH) (18-20). National prob- ability samples of 5,700 to 12,000 individuals over the age of 21 from randomly selected households were interviewed by telephone regarding the use of tobacco products. Between 1964 and 1975, the prevalence of smokeless tobacco use remained fairly stable. Results are summarized in table 3. Three patterns in these data may be noted: ¢ Less than 5 percent of the population reported using smokeless tobacco. ¢ Nationally, use was higher among males than females. ¢ Among males, the prevalence of use of chewing tobacco was higher than that for snuff. National Health Interview Survey In 1970, the National Center for Health Statistics included a question on current use of snuff and chewing tobacco in its National Health Interview Survey (NHIS) (21). One respondent per household provided information on all household members age 17 and older. Data were col- lected on approximately 77,000 persons in 37,000 households. Esti- mates indicate that 1.4 percent of males used snuff and 3.8 percent used chewing tobacco (table 4). Simmons Market Research Bureau, Inc. National probability data that were collected annually from 1980 through 1985 for the Simmons Study of Media and Markets provide estimates of the prevalence of snuff use among adults who were 18 years of age or older. Sample size ranged from 15,000 to 19,000. Data are summarized in table 5 for the years 1980 to 1985. The prevalence 10 TABLE 4.—Prevalence of the Use of Snuff and Chewing Tobacco Among Males by Age, 1970 NHIS and 1985 CPS Surveys* 1970 HIS 1985 CPS Percentage Percentage Product Age of Users Age of Users Snuff 17-19 0.3 16-19 2.9 20-29 0.6 20-29 2.7 30-39 0.7 30-39 1.8 40-49 1.2 40-49 1.5 50+ 2.7 50+ 1.4 Total 1.4 Total 19 Chewing 17-19 1.2 16-19 3.0 Tobacco 20-29 1.9 20-29 4.2 30-39 28 30-39 3.7 40-49 3.0 40-49 3.3 50+ 6.5 50+ 4.2 Total 3.8 Total 3.9 * Use" not further defined with respect to frequency. Sources: National Center for Health Statistics, National Health Interview Survey, 1970 (unpublished). Office on Smoking and Health, Current Population Survey, 1985 (unpublished). TABLE 5.—National Prevalence of Current Use of Snuff by Gender, Age, and Race for 1980 Through 1985* Percentage of Users Sample 1980 1981 1982 1983 1984 1985 Total 1.6 2.2 2.6 2.3 19 19 Gender Males 2.4 3.7 4.2 3.8 3.0 3.2 Females 0.8 0.8 1.1 0.9 1.0 0.7 Age 18-24 14 2.6 4.3 3.5 3.2 2.8 25-34 2.5 2.8 3.1 3.0 2.0 2.1 35-44 1.0T 1.3 1.6 1.8 1.5 1.0 45-54 13T 1.3 1.4T 1.0f 11t 1.5 55-64 1.27 1.7 1.7 2.3 l1ft 1.3 2 65 L6t 2.8 2.6 1.4 2.5 2.4 Race Black 2.3f 1.6t 3.0 2.9 2.9 2.4 White 1.5 2.2 2.6 2.3 1.9 1.9 Other 19F 1L4T lit NA 0.4t 1.2 * Adults defined as individuals over 18 years of age. Use not further defined with respect to frequency. + Number of cases too small for reliable estimates. Source: Simmons Market Research Bureau, Inc., Study of Media and Markets, 1980-1985. 11 TABLE 6.—Prevalence of Snuff Use Among College Students 18 Years of Age or Older by Gender and Year* Percentage of Users Sample 1983 1985 Total 2.7 3.5 Gender Males 5.4 6.7 Females 0.1 0.2F Race Black 15t 14t White 5.1 3.6 Other 4.9F 4.3 * Current use; frequency of use not specified. + Projection relatively unstable because of small sample. Source: Simmons Market Research Bureau, Inc., Simmons National College Study, 1983 and 1985. rate for “current use”’ of snuff was 2.4 percent for males in 1980 and 0.8 percent for females. Rates for males peaked at 4.2 percent in 1982 and were 3.2 percent in 1985. Since 1982, the highest rates of use have con- sistently been observed in the age group 18 to 24 years old. Compara- tively higher rates of use were also observed in the age groups 25 to 34 years old and over age 65 (22). The Simmons National College Study reports data froma probability sample of full-time students 18 years or older who were attending baccalaureate-granting colleges and universities in the coterminous United States. In 1983, 2,011 students were sampled, and 2,373 students were sampled in 1985. Five to 7 percent of males indicated use of snuff compared to 0.2 percent of females (table 6). The prevalence rate among male students exceeded that of the general adult male popula- tion (tables 5 and 6). In 1985, prevalence among college males was twice that of other adult males, while the rate for college women was less than one-third that among the general adult female population. The com- bined prevalence for male and female college students (3.5 percent) was very similar to that for 18- to 24-year-olds in the general population (2.8 percent) (tables 5 and 6) (23). Current Population Survey In the fali of 1985, the Census Bureau collected health information on approximately 120,000 persons in 58,000 households in its Current Population Survey (CPS) (24). OSH sponsored a supplement to this survey, which included a question on current use of snuff and chewing tobacco. One respondent per household provided information on all members age 16 and older. Provisional estimates of smokeless tobacco use indicate that 1.9 percent of males used snuff and 3.9 percent used chewing tobacco (table 4). 12 TABLE 7.—National Prevalence of Smokeless Tobacco Use by Adult Status and Sex, NIDA Sample, 1985* Percentage of Users Males Females Use Category < 20 Years 2 21 Years < 20 Years 221 Years Used in Past Year 16 11 2 2 Used Formerly 4 7 2 2 Never Used 79 82 96 96 * Preliminary estimates not adjusted for oversampling of blacks and Hispanics. Source: National Institute on Drug Abuse, 1985 National Household Survey on Drug Abuse. Preliminary results presented at the NIH Consensus Development Conference on the Health Implications of Smokeless Tobacco Use. January 1986. TABLE 8.—Recency of Smokeless Tobacco Use by Sex and Age Group* Percentage of Users by Age Groups 12-17 18-25 26-39 40+ Use Category Males Females Males Females Males Females Males Females Used in Past Year 16 1 16 1 10 1 8 3 Used Formerly 4 2 7 1 5 1 8 2 Never Used 80 97 V7 98 85 98 84 95 * Preliminary estimates not adjusted for oversampling of blacks and Hispanics. Source: National Institute on Drug Abuse, 1985 National Household Survey on Drug Abuse. Preliminary results presented sea NIH Consensus Development Conference on the Health Implications of Smokeless Tobacco Use, anuary 1986. National Institute on Drug Abuse Household Survey The recently completed 1985 National Household Survey on Drug Use provides the national probability data on current use and correlates of use of smokeless tobacco by youth. It is the eighth in a series of na- tional probability surveys conducted among household residents in the coterminous United States by the National Institute on Drug Abuse (NIDA). Data are collected on the use and adverse consequences that are associated with 11 drugs or drug classes. The 1985 survey over- sampled for blacks and Hispanics and younger age groups. The total sample consists of approximately 8,000 face-to-face interviews. The data presented here are based on a preliminary analysis of 4,564 inter- views. Provisional estimates are presented in tables 7 through 9. Sixteen percent of males under the age of 21 reported using chewing tobacco or snuff within the last year, in contrast to 11 percent of older males (table 7). The decline in older age groups is seen more clearly when narrower age categories are used (table 8). An estimate of the preva- lence of weekly use may be obtained by combining the use frequency 13 TABLE 9.—Frequency of Smokeless Tobacco Use in Past Year* Percentage of Users Age Groups for Males Males and Females Past Year Use of Smokeless Tobacco 12-17 1825 2639 40+ Age 12 and Above Most Days/Week 3 7 5 4 2 1 or 2 Days/Week 2 1 1 1 1 1 or More Days/Week 5 8 6 5 3 3-51 Days/Year 5 5 3 3 2 1-2 Days/Year 6 3 2 1 2 Not in Past Year 4 7 5 8 3 Have Tried 20 23 15 16 10 Never 80 77 85 84 90 * Preliminary estimates not adjusted for oversampling of blacks and Hispanics. Source: National Institute on Drug Abuse, 1985 National Household Survey on Drug Abuse. Preliminary results presented at the NIH Consensus Development Conference on the Health Implications of Smokeless Tobacco Use, January 1986. categories of ‘most days a week”’ and “‘1 or 2 days a week”’ (table 9). Use at least once a week peaks in the 18- to 25-year-old age groups at 8 per- cent. As in previous surveys, the use among females was consistently much lower than among males. Responses suggest slightly higher rates of use among women 40 years of age and older than among younger women (table 8) (25). Discussion of National Survey Data Despite varying methodologies among the national surveys (table 2), sufficient commonalities permit meaningful comparisons. The 1970 and 1975 OSH surveys and the 1980 to 1985 Simmons Study of Media and Markets indicate that the use of snuff by adult males remained con- stant within a range of 3 to 4 percent. Use by adult females also re- mained constant at about 1 percent. During this same 15-year period, the population over the age of 18 increased 32 percent from 133.5 million to 175.8 million (26). The production of all forms of smokeless tobacco increased 42 percent from 95.2 to 135.6 million pounds, and the production of fine-cut/moist snuff tripled. This may indicate the emergence of a new population of users. The 1970 NHIS and the 1985 CPS both relied on the use of proxy re- spondents. Estimates of smokeless tobacco use are likely to be lower than the actual population prevalence because respondents may not always be aware of smokeless tobacco use by other members of the household. In fact, in 1970, the NHIS estimated that 1.4 percent of males used snuff and 3.8 percent used chewing tobacco. In the same year, the OSH Adult Survey, which did not use proxy respondents, pro- vided corresponding estimates of 3 and 6 percent. Similarly, the CPS estimates that 1.9 percent of males used snuff in 1985, while the Sim- mons Study of Media and Markets estimates 3.2 percent. 14 However, comparisons between the 1970 NHIS and the 1985 CPS for the purpose of examining trends are appropriate. They suggest little change in the overall rate of adult male use of smokeless tobacco but indicate a marked change in the age distribution of users (table 4). In 1970, the use of smokeless tobacco was most common among older men; in 1985, the prevalence in the younger age groups had greatly increased. Both the Simmons Study of Media and Markets and the NIDA survey show the highest rates of use among young adults ages 18 to 24. The Simmons National College Study indicates that male college students are as likely to use snuff as are other 18- to 24-year-olds. The Simmons data also show a slight elevation in prevalence among persons over the age of 65, which reflects the age distribution of traditional users of smokeless tobacco. If the NIDA prevalence estimates are applied to current population figures (26), there are at present over 12 million persons in the United States ages 12 and older who have used some form of smokeless tobacco in the past year. Three million are under the age of 21, and 1.7 million of these are males 12 to 17 years old. An estimated 6 million persons use smokeless tobacco at least weekly. Of these, 0.5 million are males ages 12 to 17; 1.3 million are males ages 18 to 25; and approximately 780,000 are females. The 1980 to 1985 Simmons Study of Media and Markets estimated that 2 to 4 million persons over the age of 18 were users of snuff. Of these, 0.6 to 1.2 million were between the ages of 18 and 24. Table 10 summarizes data on the prevalence of smokeless tobacco use by region from three national surveys conducted in 1985. Among these adult samples, use was highest in the South and lowest in the North- east, with the West and North Central/Midwest falling in between. These surveys provide self-report data only; no direct validation at- tempts were made. Because no strong social sanctions regarding smokeless tobacco use exist for adults, systematic misrepresentation by them is unlikely. However, under the conditions of a personal inter- view, as used in the NIDA study, adolescents would be more likely to underreport than overreport their use of smokeless tobacco. In addi- tion, the preliminary estimates from the NIDA survey have not been adjusted for oversampling of blacks and Hispanics. In this sample, blacks and Hispanics reported less smokeless tobacco use than whites, and their overrepresentation would result in underestimates of national prevalence. State and Local Survey Data State and local surveys provide much of the information after 1980 on the use of smokeless tobacco. Since most of these surveys were con- ducted in schools, often motivated by apparent increases in students’ 15 TABLE 10.—Prevalence of Smokeless Tobacco Use by Census Region, 1985 Percentage Reporting Use Prevalence Category Northeast North Central South West CPS Chewing Tobacco 1.6 3.7 7.0 3.9 Snuff 1.2 2.3 3.1 1.6 Simmons Snuff 15 1.3 2.9 1.3 NIDA* (Snuff and/or chewing tobacco) Weekly Use or More Often 1.0 2.0 5.0 4.0 Any Use in Past Year 4.0 6.0 8.0 9.0 * Preliminary estimates not adjusted for age and race. Sources: Office on Smoking and Health, Current Population Survey, 1985 (unpublished). Simmons Market Research Bureau, Inc., Study of Media and Markets, 1980-1985. National Institute on Drug Abuse, 1985 House- hold Survey on Drug Abuse. Preliminary results presented at the NIH Consensus Development Conference on the Health Implications of Smokeless Tobacco Use, January 1986. use of smokeless tobacco products, there may be a selection bias. However, the large and growing number of reports and the wide geographic coverage support the conclusion that smokeless tobacco use is not a localized phenomenon. Indeed, the consistency of such data sug- gests that smokeless tobacco has become a product that is used by large numbers of teenage and young adult males. Adult Use Several reports provide a tentative profile of local usage patterns of smokeless tobacco among adults. In 1979, tobacco use information was collected from 4,282 men between the ages of 21 and 84 in 10 geographic areas as part of the National Bladder Cancer Study, a population-based case control study (27). The overall prevalence for having “ever used snuff for 6 months or more’ among the control subjects (randomly selected from the general population) was 5 percent; for chewing to- bacco, the corresponding figure was 12 percent. A breakdown by age indicated much more use of smokeless products by older men than younger men (table 11). Glover and his colleagues conducted a random sample telephone survey of 280 persons in Pitt County, North Carolina (28). A user was defined as a person who answered “yes” to the question, “‘Do you dip or chew tobacco?” Forty percent of males and 9 percent of females answered positively. High rates of use are probably not a new phenome- non since there is a tradition of smokeless tobacco use among both sexes in this area, and tobacco is a major agricultural product. 16 TABLE 11.—Prevalence of Snuff and Chewing Tobacco Use by Adult Males in 10 Geographic Areas Percentage Reporting Ever Used Sample n Snuff Chewing Tobacco All Men 4,282 5 12 Age 21-44 240 0 2 45-64 1,653 3 6 65-84 2,389 7 16 Area of Residence Atlanta 186 8 23 Connecticut 654 4 12 Detroit 355 8 20 lowa 552 12 14 New Jersey 1,288 2 10 New Mexico 129 7 20 New Orleans 115 1 6 San Francisco 542 2 8 Seattle 255 10 6 Utah 206 5 7 Race White 3,892 5 11 Nonwhite 390 5 18 Source: National Bladder Cancer Study. Hartge, P., Hoover, R., and Kantor, A. Bladder cancer risk and pipes, cigars, and smokeless tobacco. Cancer, 55: 901-906, 1985. Research supported by the National Cancer Institute, the Food and Drug Administration, and the Environmental Protection Agency. Gritz, Ksir, and McCarthy surveyed a sample of 214 students at the University of Wyoming (29). In their sample, 27.1 percent of males and 4.1 percent of females reported “current use,” with the criterion for “current use” unspecified. The vast majority of users (84 percent) used moist snuff. Glover and his colleagues reported a survey of 5,894 students in physical education classes at 72 colleges and universities from 8 States (Oregon, Arizona, Colorado, Oklahoma, Minnesota, Ohio, South Caro- lina, and Connecticut) (30). Twenty-two percent of the males who were surveyed reported using smokeless tobacco compared to 2 percent of the females. Combined rates of use for both sexes ranged from 15 per- cent in Oklahoma to 8 percent in Connecticut. The majority of the users reported using less than one can or pouch per week. Adolescent Use Studies of school-age youth conducted since 1980 are summarized in table 12 (31-45). Five different criteria for classifying use have been selected for data display: daily use, weekly use, monthly use, current use (no frequency specified), and ever used. Recent regional data on the use of smokeless tobacco have been col- lected by a number of National Cancer Institute grantees in the course 17 TABLE 12.—Prevalence of Use of Smokeless Tobacco Among Youth by Gender and Grade: Regional and State-Level Surveys Reported Since 1980* Location (reference) Grade(s) Males Females Total n Daily Use Arkansas (31) 10-12 26.0 _ - 179 Arkansas (32) 10-12 - _ 15.0 901 Nebraska (33) 7-12 2.5 0.0 _ 2,612 Ohio (34) 4-12 Chewing Tobacco 11.4 0.2 — 1,004 Snuff 19.7 0.4 - 1,004 Oregon (35) 7 8.8 0.7 _ 443 9 18.5 0.0 _ 249 10 23.1 2.4 _ 130 Oregon (36) 7 4.6 _ _ 710 8 5.8 - - 139 9 9.7 - — 432 10 10.6 — _ 255 Wisconsin (37) 7 3.0 0.0 _ _ 8 6.0 0.0 = = 9 3.0 0.0 _ = 10 8.0 0.0 — _ ll 11.0 0.0 - _ 12 15.0 0.0 - - Total = — -_ = Weekly Use (Or more often) Nebraska (33) 7-12 48 0.0 — 2,616 Wisconsin (37) 7 12.0 - —~ _ 8 18.0 _ - - 9 15.0 - - — 10 24.0 ~ — _— 11 25.0 — _ ~_ 12 37.0 = _ = Total _- 1.0 - 25,000 Monthly Use (Or more often) Arizona (38) 8-12 18.4 _ — 1,080 Midwestern States (39) 10-12 33.0 0.0 _ 323 Nebraska (33) 7-12 Tl 0.0 _- 2,616 Current Use (Frequency not specified) Arkansas (31) 10-12 31.8 2.2 - 179 Arkansas (32) 10 _ 7 13.8 326 11 i — 20.6 330 12 = _ 23.7 245 Total 36.7 2.2 — 901 18 TABLE 12.—Continued Location (reference) Grade(s) Males Females Total n Current Use (Cont.) Colorado (40) 10-12 21.6 0.6 _ 1,119 Colorado (41) 10-12 26.0 0.0 _ 445 Louisiana (42) 1976-1977 Chewing Tobacco 8-9 11.0 _ _ _ 10-11 17.0 _ — - 12-13 25.0 — — - 14-15 24.0 _ _ _ 16-17 15.0 _ _ - Snuff 8-9 4.0 — - - 10-11 7.0 — _— _ 12-13 5.0 — - _ 14-15 11.0 _ _ _ 16-17 5.0 - _ - Total — — - 2,880 1981-1982 Chewing Tobacco 8-9 24.0 —_ — _ 10-11 32.0 — _ a 12-13 39.0 _- _ _ 14-15 43.0 _ ~_ _ 16-17 15.0 — — - Total - — — 1,981 Snuff 8-9 21.0 _ _ _ 10-11 26.0 - - _ 12-13 32.0 _ - - 14-15 30.0 _ - —- 16-17 14.0 _ — - Total — — — 1,981 Pennsylvania (43) 7-12 30.0 0.0 — §38 Texas (44) 7-12 19.0 0.0 — 5,392 Wyoming (29) 7-9 24.5 1.2 - 2,408 Ever Used Arkansas (45) K _ — 21.4 112 Ohio (34) Chewing Tobacco 4-12 58.0 12.0 _ _ Total - _ — 1,007 Snuff 4-12 64.0 24.0 - _ Total _ - - 1,007 Oregon (35) 7 63.4 19.9 - 445 9 72.7 16.4 — 249 10 76.7 23.8 _ 133 Wisconsin (37) 7 32.0 -— = _ 8 45.0 — —_ — 9 47.0 _ — _ 10 50.0 — _ = 11 47.0 = _ _ 12 48.0 _ _ _ Total _ _ 11.0 25,000 * Uniess otherwise indicated, figures represent the usage of chewing tobacco and/or snuff. Multiple entries have been made for studies that provide for more than one classification criterion. t Age listed rather than grade. 19 of their ongoing research on tobacco use by youth (46). Through col- laboration, these investigators have achieved more standardization in data collection than in previous studies, which makes comparisons among the different locales more meaningful. Although there were some differences in methodology, all of the studies addressed one or both of the following research questions: 1. What percentages of males and females have ever used smokeless tobacco? 2. What percentages of males and females have used smokeless tobacco in the last 7 days? Adolescent males may be subject to pressures that simultaneously discourage and encourage smokeless tobacco use. Underreporting of use may result from the presence of teachers and the setting in which the survey is administered. Overreporting may result from peer pressure to be seen as a smokeless tobacco user. Accurate reporting may be facilitated by collecting breath or saliva samples when surveys are completed. Respondents who believe that their self-reports can be objectively verified via biochemical testing tend to provide more accu- rate responses (47-49). Biochemical validation was used in 14 of the 17 subsamples reported in table 13. Most studies do not distinguish between snuff and chewing tobacco. In reports where the two have been separated, both substances were found to be in use (34,42,43). Rates of smokeless tobacco use were consistently higher among males than females. This difference is especially marked when more precise classifications for regular use are employed. While substantial numbers of adolescent females report having tried smokeless tobacco at least once, very few use it on a regular basis (33-35,37,39,46). The use of smokeless tobacco by youth was generally higher in rural than urban areas, in small communities, and in areas where there is a tradition of smokeless tobacco use (34,37,46). However, high rates of use have also been reported in large metropolitan areas as well (37,40,46). Table 14 summarizes data on smokeless tobacco use by ethnic groups collected by investigators using standardized questions (46). To date, lit- tle information has been available on smokeless tobacco use by non- whites, and some early research suggested that minority youth were not taking up the practice (42). In these studies, however, Hispanic youth showed rates of smokeless tobacco use comparable to whites, and Native American rates were consistently higher. In most locales, use was less common among Asians and blacks. Nationally, black college stu- dents are less likely to use snuff than are white college students ‘table 6). Prevalence estimates for smokeless tobacco use by black adults, however, have equaled or exceeded those of whites (tables 5 and 11). The likelihood of using smokeless tobacco appears to increase with age as well as over time (3235,37,42, 46). Only one study has collected 20 TABLE 13.—Prevalence of Use of Smokeless Tobacco Among Youth by Gender and Grade: Local Surveys Using Standardized Questions Males Females Sample Grade Percentage n Percentage n Used in Last 7 Days California Suburban/Rural 6 4.7 (469) 0.7 (407) 7 14.8 (574) 1.4 (557) 8 9.2 (487) 1.6 (499) Minnesota Suburban/Urban 9 18.1 (2,015) 2.4 (2,146) Montana Urban 4 9.4 (477) 2.0 (403) 5 11.9 (429) 1.5 (392) 6 13.9 (446) 3.2 {402) New York Urban 4 3.9 (306) 0.3 (298) 5 2.9 (272) 0.4 (275) 6 10.7 (252) 0.4 (243) New York New York City 6 11 (1,488) 0.9 (1,494) New York Suburban 7 3.0 (2,016) 0.0 (1,811) Oregon Suburban/Rural 6 6.0 (602) 0.9 (542) 7 9.1 (627) 0.8 (618) 8 13.6 (663) 1.0 (608) 9 17.3 (572) 0.5 (567) 10 22.2 (514) 2.3 (471) 11 22.7 (440) 0.5 (431) Oregon Suburban/Urban 6 1.9 (571) 0.4 (525) 7 4.6 (570) 14 (575) 8 6.8 (514) 0.8 (533) 9 14.8 (588) 1.2 (575) Southeastern United States 6 9.8 (305) 1.3 (228) 10 SMSA’s 7 12.1 (346) 0.6 (325) 8 10.4 (279) 1.6 (313) Vermont Rural 5 9.3 (288) 0.3 (317) 6 14.9 (328) 1.0 (289) Vermont Urban 4 2.8 (216) 0.0 (199) 5 48 (207) 1.0 (201) 6 5.4 (204) 0.0 (193) Washington Rural 4 4.4 (45) 0.0 (47) 5 6.4 (141) 1.3 (156) 6 8.8 (968) 2.1 (964) 7 13.1 (521) 4.1 (514) 8 14.8 (316) 5.2 (325) Washington Rural 10 23.7 (215) 0.4 (233) 21 TABLE 13.—Continued Males Females Sample Grade Percentage n Percentage n Ever Used California Suburban/Rural 6 32.6 (473) 7.8 (411) 7 56.2 (578) 19.6 (567) 8 56.7 (492) 20.0 (504) California Los Angeles 7 24.9 (273) 6.7 (310) SHARP California Los Angeles 7 25.3 (479) V7 (480) SMART 8 31.9 (429) 8.1 (418) California Los Angeles 8 32.0 (1,240) 6.9 (1,474) TVSP Minnesota Suburban/Urban 9 62.1 (2,001) 22.9 (2,133) Montana Urban 4 41.0 (480) 17.5 (401) 5 56.9 (431) 19.3 (394) 6 68.2 (443) 24.6 (402) New York Urban 4 23.1 (307) 3.4 (298) 5 33.5 (272) 5.1 (275) 6 47.8 (255) 7.0 (243) New York New York City 6 6.7 (1,488) 3.0 (1,494) New York Suburban 7 25.3 (2,016) 4.1 (1,811) Oregon Suburban/Rural 6 48.3 (607) 16.2 (551) 7 57.9 (639) 19.8 (630) 8 64.5 (677) 23.8 (617) 9 70.4 (577) 26.7 (576) 10 74.7 (522) 31.1 (485) 11 77.5 (445) 34.2 (436) Oregon Suburban/Urban 6 32.4 (568) 8.7 (528) 7 44.9 (568) 16.8 (572) 8 54.1 (512) 17.2 (535) 9 61.3 (589) 24.7 (575) Southeastern United States 6 47.6 (309) 11.4 (229) 10 SMSA's 7 49.0 (353) 13.5 (325) 8 51.4 (280) 15.6 (314) Vermont Rural 5 38.8 (289) 8.2 (317) 6 54.8 (332) 7.2 (290) Vermont Urban 4 17.4 (213) 3.0 (200) 5 26.2 (207) 5.5 (201) 6 39.8 (206) 3.1 (193) Washington Rural 4 15.6 (45) 0.0 (47) 5 27.0 (141) 7.7 (156) 6 49.0 (968) 13.0 (964) 7 52.0 (521) 16.0 (514) 8 58.9 (316) 20.1 (325) Washington Rural 10 73.5 (215) 30.9 (233) Waterloo, Canada Suburban/Rural 11 26.0 (281) 5.5 (444) 22 TABLE 14.—Mean Frequency of Smokeless Tobacco Use During Last 7 Days by Ethnicity of Male Respondents Prevalence Sample Ethnicity n %o California Asian 192 3.7 Suburban/Rural Black 118 6.1 Grades 6-8 Hispanic 188 11.2 White 1,046 11.4 Minnesota Asian 36 13.9 Suburban/Urban Black 201 4.0 Murray Hispanic 24 45.8 Native American 38 18.4 White 1,602 19.6 New York Asian 119 2.5 New York City Black 205 0.5 Grade 6 Hispanic 510 1.0 White 501 1.2 New York Asian 23 4.3 Suburban Black 47 2.1 Grade 7 Hispanic 39 2.6 Native American 26 3.8 White 1,796 3.3 Oregon Asian 38 5.3 Suburban/Rural Black 33 15.2 Grades 6-11 Hispanic 61 16.4 Native American 120 23.3 White 3,162 14.2 Oregon Asian 71 2.8 Suburban Black 231 3.9 Grades 6-9 Hispanic 26 0.0 Native American 48 12.5 White 1,847 7.6 Southeastern Black 258 3.9 United States White 652 14.0 10 SMSA's Washington Asian 148 6.1 Rural Black 119 1.7 Grades 4-8 Hispanic 111 9.0 Native American 179 30.7 White 1,434 9.4 23 both cross-sectional and longitudinal data. Hunter and her colleagues assessed tobacco use by children in Bogalusa, Louisiana, in 1976-77 and again in 1981-82 (42). The use of both snuff and chewing tobacco in- creased over time within age categories, within age cohorts, and across age categories (table 12). A decrease in use was observed in the oldest age category, 16-17 years old, but has not been seen in other locales (tables 12 and 13). The decrease may reflect age-related changes in nor- mative behavior particular to that area or a cohort effect. Peer and family members are found consistently to be important in- fluences on smokeless tobacco use by children and adolescents. Young users of smokeless tobacco have more friends who also use smokeless tobacco (34,36,39,45) and may themselves identify friends’ encourage- ment as a reason for use (35,44), Users of smokeless tobacco are also more likely to have family members who themselves use smokeless tobacco (34,36,45) and encounter less parental disapproval of the prac- tice (31,34) In a special National Program Inspection study prepared by the Of- fice of the Inspector General of the Department of Health and Human Services, young current and former users of smokeless tobacco were interviewed in depth (50). Two hundred and ninety students in junior and senior high schools from 16 States volunteered to participate. All had used smokeless tobacco ona weekly or daily basis. While this study was not designed to provide prevalence estimates, it provides useful in- formation about the attitudes and practices of some adolescent smoke- less tobacco users. Over 90 percent of these respondents used snuff exclusively, and over 55 percent indicated that they would have strong cravings if they tried to quit. On the average, this group reported first trying snuff at age 10 and beginning regular use by age 12. Fifty percent cited pressure from friends as their primary reason for initiating use, but continued use was most often attributed to enjoyment of taste (64 percent) and habit strength (“being hooked,” 37 percent). Over 85 percent thought that dipping and chewing can be harmful to health, but less than 55 percent considered regular use to present a moderate or severe risk, CONCLUSIONS 1. Recent national data indicate that over 12 million persons used some form of smokeless tobacco (chewing tobacco and snuff) in 1985 and that approximately 6 million used smokeless tobacco weekly or more often. Use is increasing, particularly among young males. 2. The highest rates of use are seen among teenage and young adult males. A recent national survey indicates that 16 percent of males between 12 and 25 years of age have used some form of 24 smokeless tobacco within the past year and that from one-third to one-half of these used smokeless tobacco at least once a week. Use by females of all ages is consistently less than that of males; about 2 percent have used smokeless tobacco in the last year. 3. State and local studies corroborate the national survey findings. The prevalence of smokeless tobacco use by youth and young adults varies widely by region, but use is not limited to a single region. In several parts of the country, as many as 25 to 35 per- cent of adolescent males have indicated current use of smokeless tobacco. RESEARCH NEEDS More systematic and detailed national and local surveys on smoke- less tobacco should be conducted.* National probability sample surveys need to be supplemented with surveys of suspected ‘hot spots” to detect the extent of high-risk areas in the country and the prevalence of use in these areas. Standardized methods are essential to facilitate appropriate compari- sons among data. The current state of assessment is similar to the early days of research on cigarette smoking before standardized formats for assessment of prevalence and quantification of dosage became available. Accurate and reproducible dosage measurement for smokeless tobacco products is needed. Standardization may prove more difficult than for cigarette smoking because of the multiplicity of product forms. Specific items that require standardization include the following: * Collection of data separately for snuff and chewing tobacco. ° Definition of user classified according to the frequency of use. To date, little attention has been given to finer distinctions of use, in- cluding quantity used, the appropriate unit of measurement, and time that the product is allowed to remain in the mouth. ¢ Description of use. Data need to be gathered on patterns of use as well as the relationship of use to cigarette smoking. ¢ Reporting of age of initiation and duration of use. * Definition of quit attempts and a quitter. ¢ Natural history of smokeless tobacco use and its relationship to other substance use, including other forms of tobacco, particularly cigarettes. ¢ Surveys of adequate sizes to permit stratification of the samples by relevant variables such as gender, age, ethnicity, socioeconomic status, cigarette smoking status, and various behavioral factors such as attitudes and knowledge, peer pressure, and academic status. * The 1986 OSH Adult Use of Tobacco Survey will address many of the items listed below. 25