Scott L. Tomar

Is use of smokeless tobacco a risk factor for cigarette smoking? The U.S. experience

Some researchers are promoting the use of smokeless tobacco as safer than cigarette smoking and as a possible method for quitting smoking, but smokeless tobacco might be a gateway drug that leads to smoking, and the availability and marketing of smokeless tobacco may keep smokers from quitting. This study assessed 4-year initiation rates of smokeless tobacco use and cigarette smoking in relation to each other and examined switching between the products. Data were from the 1989 Teenage Attitudes and Practices Survey and its 1993 follow-up study, comprising a nationally representative U.S. cohort of 7,960 people aged 11-19 years at baseline. Analyses were limited to males with complete data on smoking and smokeless tobacco use at both interviews (n=3,996). Young males who were not smokers in 1989 but regularly used smokeless tobacco were more than three times as likely as never users to be current smokers 4 years later (23.9% vs. 7.6%), adjusted OR=3.45 (95% CI=1.84-6.47). In contrast, 2.4% of current smokers and 1.5% of never smokers at baseline became current regular smokeless tobacco users by follow-up. More than 80% of baseline current smokers were still smokers 4 years later, and more than 40% of baseline current regular smokeless tobacco users became smokers either in addition to or in place of smokeless tobacco use. It appears that smokeless tobacco may be a starter product for subsequent smoking among young U.S. males but may have little effect on quitting smoking.

Trends in Smokeless Tobacco Use Among Adults and Adolescents in the United States

OBJECTIVES Smokeless tobacco has many adverse health effects. We analyzed long-term national trends in smokeless tobacco use. METHODS We used 1987 to 2000 National Health Interview Survey data for adults aged 18 years and older, 1986 to 2003 data from Monitoring the Future surveys of adolescents, and 1991 to 2003 data from the Youth Risk Behavior Survey for 9th- to 12th-grade students to examine overall and demographic-specific trends. RESULTS Smokeless tobacco use among adult and adolescent females was low and showed little change. Smokeless tobacco use among men declined slowly (relative decline=26%), with the largest declines among those aged 18 to 24 years or 65 years and older, Blacks, residents of the South, and persons in more rural areas. Overall and demographic-specific data for adolescent boys indicate that smokeless tobacco use increased for 12th-grade students from 1986 until the early 1990s, but has subsequently declined rapidly in all grades since then (range of relative overall declines=43% to 48%). CONCLUSIONS Smokeless tobacco use has declined sharply, especially among adolescent boys. Ongoing prevention and cessation efforts are needed to continue this trend.

Evidence of emerging hookah use among university students: a cross-sectional comparison between hookah and cigarette use

BackgroundThe emergence of hookah is being noted on college campuses and in large U.S. cities and evidence points to an increasing trend for college students. The purpose of this study was to assess hookah use and identify associations with cigarette smoking and demographic factors.MethodsAn intercept sampling method was used at various locations on a large university campus in the southeastern United States, yielding a high participation rate (52%). A total of 1,203 participants completed a computer-aided survey that assessed the use of tobacco products. The sample characteristics were then weighted to match the University population of students enrolled during the same semester. Bivariate (chi-square and t-test) and multivariate (logistic regression) tests of association were conducted to assess differences between cigarette and hookah users.ResultsHookah smoking exceeded cigarette smoking for both ever use (46.4% vs 42.1%) and past year use (28.4% vs 19.6%). Females and males used hookah at similar rates. Hispanic respondents had the highest prevalence of current use of hookah (18.9%) and cigarettes (16.4%).ConclusionsAs hookah surpasses cigarette use, efforts need to be made to slow the increase in new tobacco products that are attractive to young adults and that pose many of the same health risks as those related to traditional tobacco products. Prevalence of all emerging tobacco products, including hookah, and the relationship with cigarette use needs to be monitored on an ongoing basis.

Snuff use and smoking in U.S. men: Implications for harm reduction

BACKGROUND Encouraging smokers to switch to snuff may have unintended public health implications. This study examined the associations between snuff use and smoking in a representative sample of U.S. men. METHODS Subjects were males aged >or=18 years in the National Health Interview Survey (N=13,865). The data analysis was conducted between August 2001 and April 2002. Multiple logistic regression modeling was used to examine the association between using snuff and quitting smoking. RESULTS In 1998, 26.4% of U.S. men smoked, 3.6% used snuff, and 1.1% used both products. Adjusting for age and race/ethnicity, current smoking was most prevalent among males who used snuff on some days (38.9%) and lowest among those who used snuff every day (19.2%). Daily snuff users were significantly more likely than never-users to have quit smoking in the preceding 12 months (odds ratio [OR]=4.23; 95% confidence interval [CI]=2.16-8.28). However, U.S. men were more likely to be former snuff users who currently smoked (2.5%) than to be former smokers who currently used snuff (1.0%). Occasional snuff users (some day users) were more likely than never users to have tried to quit smoking in the preceding year (OR=1.69; 95% CI=1.04-2.76) but tended to be less likely to succeed (OR=0.50; 95% CI=0.19-1.33). CONCLUSIONS Some men may use snuff to quit smoking, but U.S. men more commonly switch from snuff use to smoking. Some smokers may use snuff to supplement their nicotine intake, and smokers who also use snuff are more likely than nonusers to try to quit smoking but tend to have less success.

Carbon Monoxide Levels Among Patrons of Hookah Cafes

BACKGROUND Individuals who use a hookah (water pipe) as a method of tobacco smoking are exposed to high levels of carbon monoxide (CO). Assessing hookah use in one of the venues of its use (hookah bars) will aid the understanding of the toxins and exposure for the user. In Florida, smoking is prohibited in public places under the Florida Clean Indoor Act but permitted in establishments that have less than 10% gross revenue from food. PURPOSE To assess the CO level of hookah cafe patrons, using traditional bar patrons as a comparison. METHODS After IRB approval, a nighttime field study of patrons (aged >18 years) exiting hookah cafes and traditional bars in 2009 was conducted, using sidewalk locations immediately outside these establishments in a campus community. As hookah cafes and bars are typically entered and exited in groups, every other group of people exiting the establishment was approached. For comparison purposes, the sample collected was similar in number, 173 hookah cafe and 198 traditional bar participants. RESULTS Results from analysis conducted in 2010 indicate that patrons of hookah cafes had significantly higher CO levels (mean=30.8 parts per million [ppm]) compared to patrons of traditional bars (mean=8.9 ppm). Respondents who indicate no cigarette use in the past month but had visited a hookah cafe still demonstrated significantly higher CO values (mean=28.5 ppm) compared to those exiting traditional bars (mean=8.0 ppm). Current cigarette smokers also produced significantly more CO if exiting a hookah cafe (mean=34.7 ppm) compared to a traditional bar (mean=13.3 ppm). CONCLUSIONS CO levels are higher for patrons of hookah cafes, for both current and non-cigarette smokers. Although users report that they perceive hookah to be less harmful than cigarettes, the greater CO exposure for hookah users that was observed in this study is not consistent with that perception.

Trends and Patterns of Tobacco Use in the United States

&NA; This review summarizes recent trends and current patterns of tobacco use in the United States. Although adult smoking dropped between 1965 and 1990, from 50% to 28% of men and from 35% to 23% of women, the past decade has seen little further progress. In 2000, 25.7% of US men and 21.0% of women were smokers. Adolescent smoking has been declining since the late 1990s, but nearly 30% of high school seniors still smoke. In 2000, 4.4% of US men and 0.3% of women used snuff or chewing tobacco. Although adolescent smokeless tobacco use has declined in recent years, 14.8% of male high school students were current users in 2001. In 2001, 22.1% of male high school students and 8.5% of women students were current cigar smokers. Bidis and kreteks may be gaining popularity among young people, and more than 15% of adolescent smokers use these tobacco products. Despite recent progress, tobacco use remains prevalent in the United States. State and local governments need to invest adequate resources in the full range of tobacco control activities.

Is Smokeless Tobacco Use an Appropriate Public Health Strategy for Reducing Societal Harm from Cigarette Smoking

Four arguments have been used to support smokeless tobacco (ST) for harm reduction: (1) Switching from cigarettes to ST would reduce health risks; (2) ST is effective for smoking cessation; (3) ST is an effective nicotine maintenance product; and (4) ST is not a “gateway” for cigarette smoking. There is little evidence to support the first three arguments and most evidence suggests that ST is a gateway for cigarette smoking. There are ethical challenges to promoting ST use. Based on the precautionary principle, the burden of proof is on proponents to provide evidence to support their position; such evidence is lacking.

Declining smoking in Sweden: is Swedish Match getting the credit for Swedish tobacco control’s efforts?

It is imperative that public policy be based on the most thorough, balanced, and critical appraisal of the available evidence. Regrettably, the two papers1,2 on which we were invited to comment fall short of those criteria. Bates et al 2 concluded snus played a “positive public health role” but did not weigh all available evidence nor critically appraise the methodologies, funding sources, or interpretations of the studies they included. Their “Evidence from Sweden” section included only an unpublished survey with unknown methodology,3 a newspaper article,4 and a study from northern Sweden.5 Foulds et al 1 concluded that snus had “...a direct effect on the changes in male smoking and health” with little additional evidence. However, both papers ignored published studies and selectively reported findings. A consideration of all the available evidence suggests snus played, at best, a minor role in reducing smoking in Sweden. A one year Swedish cohort study of persons aged 45–69 years at baseline in 1992–94 examined predictors of smoking cessation or change to non-daily smoking among baseline daily smokers (n  =  3550).6 At baseline, 7.0% of men and 0.4% of women used snuff. At follow up, 7.2% of daily smokers had quit and 6.5% were non-daily smokers. The study found: snus use was not associated with smoking cessation; snuff use by non-daily smokers neither predicted cessation nor prevented transition to daily smoking7; and even if snuff helped some smokers to quit, it accounted for a small fraction of cessation. In another prospective study, 5104 persons aged 16–84 years were interviewed in 1980–81 and followed up in 1988–89.8 These included 1546 daily smokers, 418 men who used snuff daily, and 129 men who used both snuff and cigarettes. By follow up, 26% of female and 28% of male …

A review of malocclusion among individuals with mental and physical disabilities

Oral health disparities between individuals with disabilities and the general population are widely reported in the literature, and malocclusion is no exception. As the number of people living with disabilities grows, so does the need to explore their oral health status. This review examines the reported prevalence of malocclusion in individuals with Down syndrome (DS), cerebral palsy (CP), cleft disorders, mental disabilities, and physical disabilities from 1976 to 2004. Malocclusion was assessed according to Angles classifications, the Dental Aesthetic Index (DAI), and selected occlusion characteristics. The prevalence of malocclusion was higher in individuals with disabilities than in controls without disabilities. Malocclusion was more frequent when the handicap was mental rather than physical in origin. Class II and Class III malocclusions were common in individuals with CP and DS, respectively. Crowding, anterior diastema, and >1/2 cusp antero-posterior molar relations were frequent among people with disabilities. Findings varied according to disability, but were attributed to musculoskeletal abnormalities, altered cranial-base relationships, premature tooth eruption, corrective surgery, and lip incompetence. Only a deep bite was more frequent in controls compared to the individuals with disabilities.

Smokeless Tobacco: an Addicting Drug

In 1986, the Surgeon General concluded that smokeless tobacco is an addictive drug sharing many qualities with other drugs of abuse such as morphine and cocaine. Smokeless tobacco can be used to deliver psycho-active and dependence-producing levels of nicotine. Tolerance develops with repeated use, causing the user to increase nicotine dosing through increased use and/or switching to products with higher nicotine yields. Clinical signs of nicotine withdrawal develop upon cessation of use. Recent data show that smokeless tobacco products vary widely in their nicotine dosing capabilities. Low-dose products tend to be those commonly marketed toward, and used by, young people without previous smokeless tobacco experience. Many of these people develop dependence and switch to high-dose products. The present article discusses each of these qualities of smokeless tobacco in greater detail. The article also discusses qualities of smokeless tobacco that make it an effective nicotine delivery device that leads to addiction.