Use of Smokeless Tobacco Among Adults -- United States, 1991

Consumption of moist snuff and other smokeless tobacco products in the United States almost tripled from 1972 through 1991 (1). Long-term use of smokeless tobacco is associated with nicotine addiction and increased risk of oral cancer (2) -- the incidence of which could increase if young persons who currently use smokeless tobacco continue to use these products frequently (1). To monitor trends in the prevalence of use of smokeless tobacco products, CDC's 1991 National Health Interview Survey-Health Promotion and Disease Prevention supplement (NHIS-HPDP) collected information on snuff and chewing tobacco use and smoking from a representative sample of the U.S. civilian, noninstitutionalized population aged greater than or equal to 18 years. This report summarizes findings from this survey.

The 1991 NHIS-HPDP supplement asked "Have you used snuff at least 20 times in your entire life?" and "Do you use snuff now?" Similar questions were asked about chewing tobacco use and cigarette smoking. Current users of smokeless tobacco were defined as those who reported snuff or chewing tobacco use at least 20 times and who reported using snuff or chewing tobacco at the time of the interview; former users were defined as those who reported having used snuff or chewing tobacco at least 20 times and not using either at the time of the interview. Ever users of smokeless tobacco included current and former users. Current smokers were defined as those who reported smoking at least 100 cigarettes and who were currently smoking and former smokers as those who reported having smoked at least 100 cigarettes and who were not smoking now. Ever smokers included current and former smokers. Data on smokeless tobacco use were available for 43,732 persons aged greater than or equal to 18 years and were adjusted for nonresponse and weighted to provide national estimates. Confidence intervals (CIs) were calculated by using standard errors generated by the Software for Survey Data Analysis (SUDAAN) (3).

In 1991, an estimated 5.3 million (2.9%) U.S. adults were current users of smokeless tobacco, including 4.8 million (5.6%) men and 533,000 (0.6%) women. For all categories of comparison, the prevalence of smokeless tobacco use was substantially higher among men. For men, the prevalence of use was highest among those aged 18-24 years (Table 1); for women, the prevalence was highest among those aged greater than or equal to 75 years. The prevalence of smokeless tobacco use among men was highest among American Indians/Alaskan Natives and whites; the prevalence among women was highest among American Indians/Alaskan Natives and blacks. Among both men and women, prevalence of smokeless tobacco use declined with increasing education. Prevalence was substantially higher among residents of the southern United States and in rural areas. Although the prevalence of smokeless tobacco use was higher among men and women below the poverty level,* this difference was significant only for women (p less than 0.05) (Table 1).

Among men, the prevalence of current use of snuff was highest among those aged 18-44 years but varied considerably by age; the prevalence of use of chewing tobacco was more evenly distributed by age group (Table 2). Although women rarely used smokeless tobacco, the prevalence of snuff use was highest among those aged greater than or equal to 75 years.

An estimated 7.9 million (4.4% {95% CI=4.1-4.6}) adults reported being former smokeless tobacco users. Among ever users, the proportion who were former smokeless tobacco users was 59.9% (95% CI=57.7-62.1). Among persons aged 18-24 years, the proportion of former users was lower among snuff users (56.2% {95% CI=49.4-63.0}) than among chewing tobacco users (70.4% {95% CI=64.2-76.6}). Among persons aged 45-64 years, the proportion of former users was similar for snuff (68.9% {95% CI=63.1-74.7}) and chewing tobacco (73.5% {95% CI=68.9-78.1}).

Among current users of smokeless tobacco, 22.9% (95% CI=19.9-26.0) currently smoked, 33.3% (95% CI=30.0-36.5) formerly smoked, and 43.8% (95% CI=39.9-47.7) never smoked. In comparison, among current smokers, 2.6% (95% CI=2.3-3.0) were current users of smokeless tobacco.

Daily use of smokeless tobacco was more common among snuff users (67.3% {95% CI=63.2-71.4}) than among chewing tobacco users (45.1% {95% CI=40.6-49.6}). Reported by: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Health Interview Statistics, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that the use of smokeless tobacco was highest among young males. Adolescent and young adult males, in particular, are the target of marketing strategies by tobacco companies that link smokeless tobacco with athletic performance and virility. Use of oral snuff has risen markedly among professional baseball players, encouraging this behavior among adolescent and young adult males and increasing their risk for nicotine addiction, oral cancer, and other mouth disorders (4).

Differences in the prevalence of smokeless tobacco use among racial/ethnic groups may be influenced by differences in educational levels and socioeconomic status as well as social and cultural phenomena that require further explanation. For example, targeted marketing practices may play a role in maintaining or increasing prevalence among some groups, and affecting the differential initiation of smokeless tobacco use by young persons (5,6).

In this report, one concern is that nearly one fourth of current smokeless tobacco users also smoke cigarettes. In the 1991 NHIS-HPDP, the prevalence of cigarette smoking was higher among former smokeless tobacco users than among current and never smokeless tobacco users. In a previous study among college students, 18% of current smokeless tobacco users smoked occasionally (7). In addition, approximately 7% of adults who formerly smoked reported substituting other tobacco products for cigarettes in an effort to stop smoking (8). Health-care providers should recognize the potential health implications of concurrent smokeless tobacco and cigarette use.

The national health objectives for the year 2000 have established special population target groups for the reduction of the prevalence of smokeless tobacco use, including males aged 12-24 years (to no more than 4% by the year 2000 {objective 3.9}) and American Indian/Alaskan Native youth (to no more than 10% by the year 2000 {objective 3.9a}) (9). Strategies to lower the prevalence of smokeless tobacco use include continued monitoring of smokeless tobacco use, integrating smoking and smokeless tobacco-control efforts, enforcing laws that restrict minors' access to tobacco, making excise taxes commensurate with those on cigarettes, encouraging health-care providers to routinely provide cessation advice and follow-up, providing school-based prevention and cessation interventions, and adopting policies that prohibit tobacco use on school property and at school-sponsored events (5).

References

1. Office of Evaluations and Inspections. Spit tobacco and youth. Washington, DC: US Department of Health and Human Services, Office of the Inspector General, 1992; DHHS publication no. (OEI-06)92-00500.

2. National Institutes of Health. The health consequences of using smokeless tobacco: a report of the Advisory Committee to the Surgeon General. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (NIH)86-2874.

3. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30 {Software Documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1989.

4. Connolly GN, Orleans CT, Blum A. Snuffing tobacco out of sport. Am J Public Health 1992;82:351-3.

5. National Cancer Institute. Smokeless tobacco or health: an international perspective. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1992; DHHS publication no. (NIH)92-3461.

6. Foreyt JP, Jackson AS, Squires WG, Hartung GH, Murray TD, Gotto AM. Psychological profile of college students who use smokeless tobacco. Addict Behav 1993;18:107-16.

7. Glover ED, Laflin M, Edwards SW. Age of initiation and switching patterns between smokeless tobacco and cigarettes among college students in the United States. Am J Public Health 1989;79:207-8.

8. CDC. Tobacco use in 1986: methods and tabulations from Adult Use of Tobacco Survey. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1990; DHHS publication no. (OM)90-2004.

9. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives.Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50213.

• Poverty statistics are based on definitions developed by the Social Security Administration that include a set of income thresholds that vary by family size and composition.

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