We explored whether dual use of smokeless and cigarettes among adolescents predicts continued smoking. Data came from Waves I (1994-95) and II (1996) of the National Longitudinal Study of Adolescent Health, using information from 3,284 Wave I current smokers. Multivariate models were used to assess whether use of smokeless tobacco at Wave I was associated with continuation of cigarette smoking at Wave II, controlling for possible confounders. The prevalence of current cigarette smoking at Wave 1 was 27.9%; among this group of adolescents and young adults, 14.5% also used smokeless tobacco. At Wave II, 73.6% of dual product users and 78.4% of cigarette-only users in Wave I reported continued smoking (
In the United States, smokeless tobacco use is more common among young white males, American Indians/Alaskan Natives, and people living in southern and Midwestern states than in other groups or parts of the country [
Tomar and colleagues [
One issue that was not addressed in the Tomar et al. [
The purpose of the current study was to examine whether current use of ST in addition to current use of cigarettes is related to continuing smoking or to cessation one year later. We used data from the National Longitudinal Study of Adolescent Health (Add Health) Survey to examine this relationship.
Add Health is a school-based longitudinal study of a nationally representative sample of US adolescents who were in grades 7–12 during the 1994-95 school year (Wave I of data collection). Wave II was conducted in 1996, Wave III in 2001-2002, and Wave IV in 2007-2008. Because the survey objectives did not remain constant over time, not all questions and data collection components were the same for every Wave. Unfortunately, while a substantial proportion of participants in Wave I were reinterviewed in Wave III approximately 7 years later, the interview did not include some necessary questions on tobacco use and cessation we needed for our study. Therefore, only Wave I and II data from the in-home interviews are included in the present analyses. Complete descriptions of the Add Health sampling, questionnaires, and interview procedures can be found at the University of North Carolina website
A brief summary of the data that were used in the current set of analyses is included here. A cluster school-based sample was used in Wave I; systematic sampling and stratification were used to ensure representation of high schools (could include grades 7 through 12) that differed with regard to county, urbanicity, size, type, and ethnicity. Students were asked to complete a self-administered in-school questionnaire; approximately 90,000 out of 100,000 who were contacted to participate completed the questionnaire [
Given the exploratory nature of the analyses and the focus on description rather than hypothesis testing, only select variables that have been associated with smoking among adolescents and young adults from Wave I were included in the analyses [
Future educational plans, (respondents were asked at Wave I, “on a scale of 1 to 5, where 1 is low and 5 is high, how likely is it that you will go to college?”) depression, and delinquency have been repeatedly demonstrated to be related to tobacco use in both longitudinal and cross-sectional analyses and were also included in the analysis [
We used SUDAAN 10.0 (RTI International, RTP, NC) to take into consideration the complex survey design and adjust for nonresponse. The sampling weight from Wave II was applied to both Waves in the current analyses. Descriptive comparisons were produced using the CROSSTAB procedure, and modeling was carried out using the RLOGIST procedure. Backwards stepwise logistic regression modeling (starting with a full model which contained all variables that were statistically significantly [
The smoking prevalence overall at Wave I was 27.9% and among current cigarette smokers at Wave I, 14.5% were also smokeless tobacco users. Overall, 7.36% of the total Wave I sample used smokeless tobacco either in combination with cigarettes or by itself. In unadjusted analysis comparing Wave I current cigarette smokers who also used smokeless tobacco to cigarette smokers who did not use smokeless tobacco (cigarette-only users), we observed differences between these two groups in distributions of gender, race/ethnicity, number of cigarettes smoked per day, binge drinking, and depression. Users of both products were more likely to be male (81.8%) than cigarette only users (44.1%) as shown in Table
Demographic and other characteristics of current cigarette smokersa by current smokeless tobacco useb: Add Health Wave I.
Variable | No ST use mean/% (s.e.) | Sample size ( | Current ST user | Sample size ( | |
---|---|---|---|---|---|
Age (mean years) | 15.5 (0.1) | 2847 | 15.7 (0.2) | 480 | .0961 |
Gender | |||||
Male | 44.1% (1.6) | 1249 | 81.8% (2.9) | 401 | <.0001 |
Female | 55.9%(1.6) | 1598 | 18.2% (2.9) | 79 | <.0001 |
Race/Ethnicity | |||||
NH-White | 75.0% (2.6) | 1834 | 79.5% (3.1) | 362 | .0862 |
NH-Black | 8.5% (1.4) | 287 | 4.4% (1.1) | 26 | .0002 |
Hispanic | 10.2% (1.5) | 436 | 9.6% (2.5) | 54 | .7682 |
NH-Other | 6.4% (0.9) | 281 | 6.6% (1.2) | 37 | .8848 |
Number of days smoked in past 30 days (mean) | 16.3 (0.5) | 2847 | 15.8 (0.7) | 480 | .5518 |
Number of Cigarettes/day: | |||||
<1 cig/day | 4.1% (0.4) | 112 | 2.8% (1.0) | 12 | .2274 |
1 cig/day | 24.8% (1.4) | 738 | 18.6% (2.3) | 100 | .0263 |
2–5 cigs/day | 36.7% (1.3) | 1076 | 40.0% (3.2) | 190 | .3119 |
6–10 cigs/day | 13.3% (0.9) | 403 | 15.2% (2.2) | 72 | .4226 |
11–20cigs/day | 17.5% (1.3) | 425 | 19.0% (2.2) | 81 | .5815 |
>20 cigs/day | 3.7% (0.5) | 87 | 4.4% (1.2) | 21 | .5041 |
Binge drinkingc | |||||
Binge drinker | 55.1% (1.5) | 1558 | 67.2% (2.9) | 326 | <.0001 |
Non-binge drinker | 25.0% (1.2) | 707 | 11.5% (1.7) | 61 | <.0001 |
Non-drinker | 20.0% (1.1) | 564 | 21.3% (2.5) | 90 | .5836 |
Future education Scale (mean)d | 3.8 (0.1) | 2843 | 3.8 (0.1) | 480 | .3020 |
Depression scale (mean)e | 32.8 (0.2) | 2847 | 31.3 (0.5) | 480 | .0077 |
Delinquency scale (mean)f | 21.9 (0.2) | 2842 | 23.0 (0.5) | 474 | .0559 |
aCurrent smokers were those who said they had smoked on at least 1 of the past 30 days. bCurrent ST users were those who used chewing tobacco or snuff on at least 1 of the past 30 days. cA binge drinker is one who drank five or more drinks in a row, at least once in the past year. A nonbinge drinker is one who drank at least once during the past year but did not drink five or more drinks in a row during the past year. dRespondents were asked “On a scale of 1 to 5, where 1 is low and 5 is high, how likely is it that you will go to college?” This is the average of the responses. eThe sum of the responses to 19 questions of the feelings scale. All questions had response values from 1 to 4 and respondents had to answer at least 15 of the questions. fThe sum of the responses to 15 questions of the delinquency scale. All questions had response values from 1 to 4 and respondents had to answer at least 12 of the questions.
When we examined cigarette smoking status at Wave II among both groups from Wave I, we found that the proportion who reported continued cigarette smoking at Wave II was similar (statistically nonsignificant;
Cigarette smoking and smokeless tobacco use at Wave II by cigarette smoking and smokeless tobacco use at Wave I: Adolescent Health Study. Wave I current cigarette smoking defined as those who said they smoked on at least 1 of the past 30 days. Current smokeless tobacco use was defined as those who used chewing tobacco during the previous 30 days.
Variables that were included in the initial model were (from Wave I) ST use, age, sex, race/ethnicity, number of cigarettes smoked per day, number of days smoked in the past 30 days, binge drinking, feelings scale, depression scale, and future educational plans.
Using multivariate analysis, we assessed whether dual use of cigarettes and smokeless tobacco at Wave I was associated with continuation of cigarette smoking at Wave II, while controlling for demographic characteristics and other variables that were shown to have bivariate relationships with continued smoking (variables included were ST use, race/ethnicity, binge drinking, number of cigarettes smoked per day, number of days smoked, and future educational plans). All variables were included initially in the model. Using stepwise backward regression, we retained the demographic variables in the model and those that were not statistically significant at 0.05 were eliminated (see Table
Odds ratios of continued use and 95% confidence intervals associated with continued smoking at Wave IIa among current smokersb at Wave I: Adolescent Health Study.
Final model | |||
Variable | Odds Ratio | 95% CI | |
Smokeless tobacco usec | |||
No ST use | 1.00 | .0352 | |
Current ST user | 0.71 | (0.52–0.98) | |
Age (years) | 1.04 | (0.95–1.14) | .4258 |
Gender | |||
Male | 1.00 | (1.00–1.00) | |
Female | 1.29 | (1.00–1.67) | .0510 |
Race/Ethnicity | |||
NH-White | 1.00 | (1.00–1.00) | |
NH-Black | 0.53 | (0.36–0.78) | .0016 |
Hispanic | 0.65 | (0.47–0.89) | .0071 |
NH-Other | 0.99 | (0.61–1.61) | .9783 |
Number of days smoked in past 30 days | 1.05 | (1.03–1.06) | <.0001 |
Number of cigarettes/day | |||
<1 cig/day | 1.00 | (1.00–1.00) | |
1 cig/day | 1.11 | (0.67–1.85) | .6800 |
2–5 cigs/day | 1.73 | (1.03–2.91) | .0393 |
6–1 cigs/day | 1.92 | (0.92–3.98) | .0799 |
11–20 cigs/day | 2.22 | (1.07–4.59) | .0325 |
>20 cigs/day | 1.49 | (0.63–3.54) | .4258 |
Binge drinkingd | |||
Binge drinker | 1.00 | (1.00–1.00) | |
Non-binge drinker | 0.78 | (0.56–1.07) | .1249 |
Non-drinker | 0.59 | (0.43–0.80) | .0009 |
Future education scalee | 0.90 | (0.83–0.99) | .0233 |
aContinued smoking is one who smoked at Waves I and II. A current smoker at Wave II is one who smoked on at least 1 of the past 30 days. bAt Wave I, a current smoker was one who said they had smoked on at least 1 of the past 30 days. cCurrent ST users were those who used chewing tobacco or snuff on at least one of the past 30 days at Wave I. d A binge drinker is one who drank five or more drinks in a row, at least once in the past year, at Wave I. A nonbinge drinker is one who drank at least once during the past year, but did not drink five or more drinks in a row during the past year, at Wave I. eRespondents were asked at Wave I, “On a scale of 1 to 5, where 1 is low and 5 is high, how likely is it that you will go to college?” This is the average of the responses.
In the current set of analyses, approximately 4% of the total sample reported dual use of cigarettes and ST (14.5% of 27.9% = approximately 4%). This figure is very close to the prevalence of 3.8% found in the most current 2009 National Youth Tobacco Survey (NYTS) for dual use of cigarettes and ST in a similar age group. The applicability of the findings from this set of analyses need to be considered in light of the changes in the environment of tobacco control in the two time periods. Many efforts aimed at reducing the burden of tobacco use began in the mid 1990s and continue today. The Master Settlement Agreement (MSA) was enacted in 1998. The American Legacy’s Truth Campaign was begun under the terms of the MSA and has used state of the art advertising to promote prevention and cessation among youth. In 2009, the Food and Drug Administration was granted the authority to regulate tobacco products. In spite of the sanctions, there is a proliferation of new smokeless tobacco products being developed by the tobacco industry including snus and dissolvables. Therefore, it is important to examine dual product use and the implications for future tobacco use behavior. Examination of whether dual users are less likely to quit tobacco use completely needs to be addressed in light of the current environment. Are dual users more or less likely to quit tobacco use and are they more or less likely to relapse than single product users?
The use of both ST and cigarettes found in the current analysis is lower than that found in analyses of earlier years of the NYTS. However, the NYTS analyses were not limited to dual use of smokeless tobacco but included all other types of tobacco products [
Few studies have examined the influence of multiple tobacco product use on future tobacco use behavior among adolescents. The results from the unadjusted analyses in this study suggest that adolescent cigarette smokers who also use smokeless tobacco may not be at greater risk of continued tobacco use than cigarette-only smokers over a one-year followup period. Given that the follow-up time period was relatively short and that adolescence is a period of experimentation, it is important that the relationships between types of tobacco use and continued smoking be assessed over longer periods. Future studies should attempt to incorporate questions on new and emerging tobacco products such as new snuff, snus products, orbs, and other dissolvable tobacco products.
The findings in this study are subject to a few limitations. First, the data used in this analysis are between fifteen and seventeen years old. However, we selected the Add Health data set because it is a longitudinal study, and we were able to assess students’ tobacco and alcohol use as well as psychological aspects at two different time periods. We were not able to locate any more current data sets that provide the same longitudinal information. As noted above, the prevalence of dual use in this study is very similar to that reported in the 2009 NYTS.
Second, we were not able to address why cigarette smokers were using smokeless tobacco (i.e., for cessation, for use when they could not smoke, products were available), so we could not include reasons for use in the analyses. These questions could be addressed in future qualitative studies. Third, several measures to assess binge drinking have been used in the published literature [
Understanding adolescent use of smokeless tobacco, cigarettes, and both products provides information that may be useful in tobacco cessation and prevention programs for adolescents. The 2008 Update to the Public Health Services guidelines for Treating Tobacco Use and Dependence concluded that clinicians should ask their pediatric and adolescent patients about tobacco use and provide strong messages that stress the importance of abstaining from tobacco use [
Michelle O’Hegarty has no financial disclosures. Linda Pederson has no financial disclosures. Katherine Asman has no financial disclosures. Ann Malarcher has no financial disclosures. Sara Mirza has no financial disclosures.
The finds and conclusions in this paper are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.
This paper uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by GRANT P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgment is due to Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website (