Dual Use of Smokeless Tobacco and Cigarettes: A Public Health Warning Sign

1. Dual Use of Smokeless Tobacco and Cigarettes: A Public Health Warning Sign Centers for Disease Control and Prevention Office on Smoking and Health Terry F. Pechacek, PhD Associate Director for Science 68th Annual Kansas Public Health Association Conference Wichita, Kansas September 22, 2011 The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The responsibility for all of the presented material rests exclusively with the author. TM

2. Presentation Overview The problem: stalled in a steady state Trends in smoking Overview of smokeless tobacco Trends in use of tobacco products Trends in smokeless tobacco use Trends in dual use Conclusions & implications

3. A Steady State Too Few Smokers Quitting Too Many Youth Starting to Smoke

4. The Problem Slowing of decline in youth smoking rate Slowing of decline in adult smoking rate decline Increasing smoking initiation rates Increasing rates of smokeless tobacco use among high school boys and young adult men

5. Emerging Changes in Tobacco Use Use of other tobacco products besides cigarettes Pattern of using two or more tobacco products Dual use of cigarettes and smokeless tobacco is special concern

6. The Bottom Line Progress in reducing tobacco use among both youth and adults has slowed in recent years Smokeless use and dual use are part of the problem

7. When will we take the handle off the tobacco pump? 1854 - Dr. John Snow removed the pump handle from Broad Street water pump to stop a Cholera Epidemic in London

8. Product, Price, Promotion, Placement* *Source: Cummings KM, Morley CP, Horan JK, Steger C, Leavell N-R. Marketing to America’s Youth: evidence from corporate documents. Tobacco Control 2002;11(Suppl 1):i5-i17. PRODUCT – Certain features of tobacco products appeal to youth & young adults PRICE– Youth and young adults are especially price sensitive PROMOTION– Youth are more sensitive to advertising and promotional campaigns PLACEMENT– Strategic placement of youth-oriented images and brands in media, advertising, and retail environments

9. Overview Cigarette Use Smokeless Tobacco Use Dual Tobacco Use

10. Cigarette Use

11. Current Cigarette Smoking* Among Adults By Sex, U.S.—1955-2010 54.2 Males Percent 21.5 Females 24.5 17.3 *Estimates since 1992 include some-day smoking. Sources: 1955 Current Population Survey; 1965-2006 National Health Interview Survey 2010

12. Average Annual Rates of ChangeNHIS 1974-2010 *adj (definition change in 1992 – adjusted estimates used in analysis of rates of change) 1974 adj. (37.8%) – 2010 (19.4%) = -0.51% 1974 (37.1%) – 1990 (25.5%) = -0.73% 1990 adj. (26.2%) – 1997 (24.7%) = -0.21% 1997 (24.7%) – 2004 (20.9%) = -0.54% 2004 (20.9%) – 2010 (19.4%) = -0.25% 1990 adj. (26.2%) – 2010 (19.4%) = -0.34%

13. Prevalence (%) of daily and less than daily smoking among U.S. adults (ages 18+ years old) -- 2002-2009 NHIS, BRFSS, and NSDUH * LESS THAN DAILY SMOKING *

14. Percentage of daily smokers* aged ≥18 years, by number of cigarettes smoked per day (CPD) and year, NHIS, United States, 2005--2010 Persons who reported smoking at least 100 cigarettes during their lifetime and who, at the time of the survey, reported smoking cigarettes every day. Source: CDC. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—US, 2005-2010. MMWR 60 (Early Release); 1-6

15. Current High School Cigarette Smoking And Projected Rates If Decline Had Continued, U.S. 1991-2009 3 million fewer youth and young Adults would be smokers *High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey, 1991-2009. **Projected High School students who smoked 1 or more days of past 30 days if 1997-2003 decline had been maintained.

16. Past Year Initiation of Cigarette Use Among Youth and Young Adults: 2004 to 2009 Percent Year Source: SAMHSA and NSDUH, 2004, 2005, 2006, 2007, 2008, 2009 * Initiation is defined as smoking cigarettes for the first time in the past year.

17. Past Year Cigarette Initiates among Persons Aged 12 or Older, by Age at First Use: 2002-2010 Numbers in Millions 2.5 2.4 2.4 2.4 2.2 2.3 2.1+ 2.0+ Initiated at Age 18 or Older 1.9+ Initiated Prior to Age 18 + Difference between this estimate and the 2010 estimate is statistically significant at the .05 level. Note: Due to rounding, the stacked bar totals may not add to the overall total. 17

18. Overview of Smokeless Tobacco

19. Types of Smokeless Tobacco • Chewing tobacco • Dry snuff • Moist snuff • Dissolvables • Lozenges, orbs, sticks, strips • Substance Abuse and Mental Health Services Agency, Office of Applied Studies. The NSDUH Report: Smokeless tobacco use, initiation, and relationship to cigarette smoking: 2002 to 2007. Rockville, Maryland: SAMHSA, March 5, 2009.

20. New Smokeless Products Have Broader Appeal Spitless Discreet Flavored Packaged in novel, attractive ways Blur the line between tobacco & non-tobacco products Cigarette brand extensions Heavily promoted

21. Smokeless Tobacco: Health Effects International Agency for Research on Cancer. Smokeless tobacco and some tobacco-specific N-nitrosamines. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 89. Lyon, France: IARC, 2007. European Commission Health & Consumer Protection Directorate-General, Scientific Committee on Emerging and Newly Identified Health Risks. Health effects of smokeless tobacco products. Brussels, Belgium: European Commission, 2008. National Toxicology Program. NTP report on carcinogens background document for smokeless tobacco. National Toxicology Program, 1997. Contains at least 28 carcinogens Oral cancer Esophageal cancer Pancreatic cancer Fatal heart attacks Premature birth & low birthweight

22. Smokeless Tobacco: Addiction Contains nicotine Highly addictive Increasing intensity of use “Graduation” to brands with higher nicotine levels

23. Major Cigarette Manufacturers Now Dominate Smokeless Market • Reynolds American acquired the Conwood Company in 2006 • Grizzly, Kodiak, Hawken • Altria acquired the U.S. Smokeless Tobacco Company in 2008 • Copenhagen, Skoal, Red Seal, Husky • Reynolds and Altria have also introduced their own brands. • Implications • Increased resources for promotion • Ability to draw on existing retail programs • Smokeless extensions of cigarette brands

24. Advertising Expenditures In 2006, U.S. smokeless manufacturers spent $354 million on advertising and promotion Up from $251 million in 2005 Preceded acquisitions of main smokeless manufacturers by Reynolds and Altria Compares to $10.5 billion spent on cigarette and smokeless products advertising in 2008 Federal Trade Commission. Smokeless Tobacco Report for the Year 2006; Cigarette Report for 2006.

25. Potential Promotion Messages Use smokeless to sustain nicotine addiction in smoke-free places Complement cigarette use with use of smokeless extension of same brand Use smokeless as aid in cessation Switch to smokeless as safer alternative (harm reduction) Switch to smokeless as more socially acceptable alternative Common denominator: many of these messages appear to target smokers

26. Snus ads “Boldly go everywhere” “Bar-friendly” “Encore-friendly” “Fancy hotel-friendly” “Enjoy taxicabs, subways, and bar hopping”

27. Snus Ads Advertisements picturing smokefree places like airplanes and concert venues “Pleasure for wherever”

29. Potential Trajectories of Smokeless & Cigarette Use Smokers switch to smokeless, then quit all tobacco use Smokers switch to smokeless, subsequently become exclusive long-term smokeless users Smokers initiate smokeless use while continuing to use cigarettes (dual use)

30. Potential Adverse Population Effects • Increased initiation of smokeless tobacco use • Some users could later switch to cigarettes • Increased relapse of former smokers to tobacco use • Could take up smokeless use, then relapse back to cigarettes • Continued smoking by smokers who would otherwise have quit • Instead of using no tobacco products, end up smoking and using other tobacco products

31. Health Implications of Dual Use Prolonging smoking substantially increases risk Duration is a stronger determinant of risk than intensity Use of smokeless in addition to cigarette adds further layer of risk Combined effects are unknown, worrisome

32. Trends in Use of Any & Multiple Tobacco Products

33. Percentage of High School Students Who Reported Current Cigarette and Tobacco Use,* 1991-2009 Percent Year Source: National Youth Risk Behavior Survey, 1991 – 2009 * Smoked cigarettes on > 1 of the 30 days preceding the survey † Current cigarette use, current smokeless tobacco use, or current cigar use

34. Small cigars weigh less than or equal to 1.36 grams Features common to cigarettes, such as shape, length (70 to 100 mm), and use of filter tips Cigarillo Considered a “large” cigar for taxation purpose Large Cigar weigh > 1.36 grams Wide variety of cigar products Source: Cristine Delnevo, UMDNJ School of Public Health

35. Per Capita Consumption of Cigars (Number of Sticks) – 2000-2010 Source: US Department of Treasury; Alcohol and Tobacco Tax and Trade Bureau

37. Trends in Smokeless Tobacco Use

38. Who Uses Smokeless Tobacco? • Substance Abuse and Mental Health Services Agency, Office of Applied Studies. The NSDUH Report: Smokeless tobacco use, initiation, and relationship to cigarette smoking: 2002 to 2007. Rockville, Maryland: SAMHSA, March 5, 2009. Males Teens and young adults Rural residents Residents of the South and Midwest American Indians

39. Percentage of High School Students, by Sex, Who Reported Current Smokeless Tobacco Use,* 1995-2009 Percent Year Source: National Youth Risk Behavior Surveillance Surveys, 1995 – 2009 * Used chewing tobacco, snuff, or dip on  1 of the 30 days preceding the survey

40. Percentage of Male High School Students Who Reported Current Smokeless Tobacco Use* by Ethnicity, 1995-2009 Source: National Youth Risk Behavior Surveillance Survey, 1995 – 2009 *Used chewing tobacco, snuff, or dip on  1 of the 30 days preceding the survey **Non-Hispanic

41. Percentage of Smokeless Tobacco Use in the Past Month among Persons 18-25 years of age, by sex: 2004-2009 Source: SAMHSA, 2004-2009, NSDUH

42. Percentage of Youth 12-17 and 18-25 Initiating Smokeless Tobacco Use, Among Those Eligible for Initiation, 2004-2009 Percent Year Source: SAMHSA, 2004 to 2009, NSDUH

43. Trends in Prevalence of Smokeless Tobacco Use: Grades 8, 10 and 12 Source: Monitoring the Future survey, 2000-2010 Question text: “Have you ever used smokeless tobacco?”; “How frequently have you used smokeless tobacco during the past 30 days?”

44. Trends in 30 day Prevalence of smokeless tobacco use by sex: Grade 12 Source: Monitoring the Future survey, 2000-2010 Question text: “How much do you think people risk harming themselves (physically or in other ways) if they use smokeless tobacco regularly?”

45. Trends in 30 day Prevalence of smokeless tobacco use by Race/Ethnicity: Grade 12 Source: Monitoring the Future survey, 2000-2010 Question text: “How much do you think people risk harming themselves (physically or in other ways) if they use smokeless tobacco regularly?”

46. Trends in Attitudes about Regular Smokeless Tobacco Use: grades 8 and 10 Disapproval Source: Monitoring the Future survey, 2000-2010 Question text: “Do you disapprove of people using smokeless tobacco regularly?”

47. Trends in Dual Use

48. Percentage of High School Students Who Were Current SLT Users Who Were Also Current Smokers: 1995-2009 Source: National Youth Risk Behavior Survey 1995-2009

49. Percentage of High School Students Who Reported Current Any Tobacco Use* and Current Poly Tobacco Use† by Race/Ethnicity and Sex: 2009 Source: National Youth Risk Behavior Survey, 2009 *Any Tobacco Use: Current use of one or more tobacco products (cigarettes, cigar, SLT). † Poly Tobacco Use: Current use of 2 or more tobacco products (cigarettes, cigar, SLT).

50. Sequence of Initiation of Smokeless Tobacco and Cigarette Use among Persons Who Had Ever Used Both Smokeless Tobacco and Cigarettes: 2004 to 2007 Source: SAMHSA, 2004 to 2007 NSDUHs