The roughly one in 20 middle and high schoolers who use "chaw," snuff, or other smokeless tobacco have typically added it on to their cigarette habit, a study showed, countering the idea of a less harmful replacement for smoking.
Classroom surveys indicated 5.6% of 6th to 12th graders currently used any smokeless tobacco product, of whom 72% also smoked, Israel T. Agaku, DMD, MPH, of the Harvard School of Public Health's Center for Global Tobacco Control in Boston, and colleagues found.
Peer pressure came in as the biggest influence, with nearly 10-fold higher likelihood of using smokeless tobacco use if a close friend did, the researchers reported in the September issue of Pediatrics.
"These findings are generally at odds with the recent positions in favor of novel smokeless tobacco products as a means of harm reduction," they wrote.
Newer forms of smokeless tobacco, like snus (moist snuff) and dissolvable tobacco, contain lower levels of carcinogenic tobacco-specific nitrosamines than cigarettes or conventional chewing tobacco, snuff, or dip and thus have been increasingly promoted to youth as an alternative to smoking, the group explained.
Switching might reduce an individual's risk, but the evidence suggested adolescents and teens don't quit one form of tobacco when they start another, which doesn't reduce their risk and might increase it, Agaku's group pointed out.
While cigarette use has been declining over the past decade, smokeless tobacco use has continued to remain steady at about 5%, noted coauthor Constantine I. Vardavas, MD, MPH, PhD, also of the Center for Global Tobacco Control.
"Clinicians when they are engaging an adolescent patient shouldn't only ask 'Do you smoke cigarettes?,' but also 'Do you use any form of tobacco, including smokeless?'," he told MedPage Today. "It's important that a clinician convey the message that all tobacco products are harmful."
The group analyzed questionnaire responses from 18,866 U.S. students in sixth to 12th grade classrooms at 178 schools in the 2011 National Youth Tobacco Survey.
In the prior 30 days, 5% of all students reported using chewing tobacco, snuff, or dip; 1.9% using snus; and 0.3% using dissolvable tobacco products.
Factors associated with smokeless tobacco use were:
Older age, with a prevalence of 2.2% at ages 9 to 11 that rose to 10.8% at ages 18 and above
Male gender, with a prevalence of 9% versus 2% among girls
Non-Hispanic white or Native American ethnicity, with prevalence of 6.7% and 7.4%, respectively, compared with 2.2% among non-Hispanic blacks
In an adjusted analysis, one or more close friends who used smokeless tobacco predicted 9.56-fold higher likelihood that a student would use it himself (95% CI 7.14–12.80).
The next strongest predictors were current use of smoking tobacco or unspecified "new tobacco products," followed by smokeless tobacco use by a member of their household at home (adjusted odds ratio 3.32, 95% CI 2.23–4.95).
Cigarette smoking by peers or in the home didn't appear to impact smokeless tobacco use among the middle and high school students.
The only significant protective factor was endorsing that all tobacco products are harmful (adjusted OR 0.55, 95% CI 0.38-0.79).
Among survey participants who said they remembered seeing warning labels on packages, there was actually an association with a higher likelihood of use, which "suggests the need for more effective warning labels on smokeless tobacco products," Agaku's group wrote.
Nearly all the smokeless tobacco users said it would be easy to obtain the products if they wanted. Their most common route in obtaining smokeless tobacco was getting it from someone else (53.9%) or buying it (32.2%), typically from a retail store.
Many of the adolescents and teens said they intended to quit all tobacco use, but that proportion was lower among those who used both conventional and novel smokeless tobacco products compared with only the novel forms (34.2% versus 57.7%).
The researchers cautioned that recall bias may have led to underreporting of tobacco use and that the cross-sectional study design meant no cause-and-effect links could be drawn.
The study was supported by National Cancer Institute grants and funded by the NIH.
The researchers reported no conflicts of interest.
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