The Association of Newly Emerging Smokeless Tobacco Products with Quit Attempts and Intention-to-quit Smoking by Income

Special Article – Tobacco and Smoking Cessation

J Fam Med. 2016; 3(11): 1100.

The Association of Newly Emerging Smokeless Tobacco Products with Quit Attempts and Intention-to-quit Smoking by Income

Keeler C*, Kageyama M and Ullman J

Department of Population Health Sciences, School of Nursing, University of San Francisco, San Francisco, USA

*Corresponding author: Courtney Keeler, Department of Population Health Sciences, School of Nursing, University of San Francisco, 2130 Fulton Street, San Francisco, CA 94117, USA

Received: November 28, 2016; Accepted: December 19, 2016; Published: December 21, 2016


Introduction: The literature highlighted several gray areas relating to the association between smokeless tobacco (ST) use, especially newer ST products, and cessation across income groups. The existing research further emphasized the potential role of dental providers in mediating this relationship. Focusing on current smokers from the 2010-2011 Tobacco Use Supplement to the Current Population Survey, this paper investigated the association between use of new ST products with quit attempts, intention-to-quit, and intention-toquit conditional on a previous quit attempt across income groups. Analyses controlled for dental advice to quit.

Methods: Three outcomes were explored: any annual quit attempts, intention-to-quit, and intention-to-quit conditional on any quit attempts. Multiple logistic regressions were run for the full study sample and stratified by income, controlling for any use of newly emerging ST products, dental advice to quit, smoking behaviors, and sociodemographic characteristics.

Results: Use of ST products was not significantly associated with quit attempts but positively associated with intention-to-quit smoking for the full sample and across stratified income groups. This association disappeared once conditioning intention-to-quit on previous quit attempts. Advised cessation by a dentist was largely significant and positively associated with cessation behaviors across all outcomes explored.

Conclusions: Relative to smokers who do not use ST products, dual users were more likely to intend to quit although no difference was observed in actualized quit attempts. The relationship was particularly strong for the higher income group. The results further emphasized the role of dental providers in mediating this relationship.

Keywords: Smoking cessation; Smokeless tobacco; Income; Dentist

Policy Implications

The results from the current work highlighted a nuanced relationship between ST use with quit attempts and intention-toquit across income groups. The findings indicate that one-size-fitsall cessation strategies will not work. Cessation strategies reflecting one’s risk factors and sociodemographic characteristics may be more effective than a more homogenous approach. Dentists are wellplaced to engage in behavioral and education interventions. Among both clinicians and patients, the relative safety of newly emerging ST products, such as electronic cigarettes, remains ambiguous; dentists can use this opportunity to educate and discuss the relative risk of ST products with their patients.


Between 2005 and 2014, the overall prevalence of cigarette smoking among U.S. adults declined from 20.9% to 16.8% [1]. In response to stricter smoking policies and diminishing cigarette use, tobacco companies have expanded smokeless tobacco (ST) product lines, promoting ST products as alternatives to traditional cigarettes [2]. From 2000-2011, ST sales increased by nearly $1 billion; companies also increased associated advertising/promotional spending, boosting expenditure by $227 million [3]. While ST use, including consumption of traditional products like chewing tobacco and snuff, declined throughout 1980-1999, usage of these products has increased since 2000 [1,4]. The 2014 National Survey on Drug Use and Health indicated that 3.3% of all U.S. individuals aged 12 and older identified as a current ST user [4].

In 2009, the US Food and Drug Administration (FDA) received petitions from major tobacco companies like Philip Morris and RJ Reynolds to endorse ST as a harm reduction product [5,6]. Among those who have ever used ST products, 50% of respondents from a nationally representative telephone survey cited harm reduction or use as a cessation aid as a reason for trying ST products; 30% of respondents believed that the products were less harmful than traditional cigarettes.7 Data from a nationally representative consumer-based survey found that 7.5%, 2.1%, and 45.2% of dual users, cigarette-only users, and ST-only users, respectively, believed ST products to be less harmful than cigarettes [7].

Perceptions of ST products as a safer alternative to traditional combustible tobacco products and the benefits of ST products as an effective cessation tool have given rise to the dual use of ST products and cigarettes, especially among younger, non-Hispanic white males [6,8-9]. Evidence of ST products as an effective smoking cessation tool has yet to be established; however, recent nationally representative studies have yielded mixed results. While some research suggested a positive association between ST use and quit attempts, dual users also have lower rates of successful cessation [10-12] and higher rates of relapse compared to exclusive smokers [9]. Some literature has shown that ST use may be a stepping-stone to combustible cigarette use. For instance, a longitudinal study found that, while exclusive smokers rarely switched solely to ST products, ST users were more likely to switch to cigarettes or dual use [13].

Within this context, it is important to identify factors that mediate the relationship between ST and cessation. Specifically, research has indicated that socioeconomic status is associated with both cigarette smoking and ST use [14]. Drawing on the nationally representative 2008 Consumer Styles survey data, McClave-Regan and Berkowitz found that dual users were almost five times more likely to report an annual income of less than $15,000 compared to users of only ST products (25.9% vs. 5.2%); dual users were more likely to fall into the < $15,000 income category compared to cigarette only smokers (25.9% vs. 19.0%) [6]. The literature has also suggested that, among ST users, income and cessation were negatively associated. For instance, using data 2008-2012 collected from exclusive ST users registered with the Oklahoma Tobacco Helpline, Mushtaq and colleagues found higher income smokers (annual income >$20,000) were 1.74 times more likely to abstain from tobacco for at least 30 days [15].

In this context, the role of health and dental care providers is also worth considering. In particular, dental providers have a unique ability to offer cessation assistance to patients. In 2008, an estimated 23.1% U.S. adults who did not receive outpatient care visited a dentist, amounting to approximately 19.5 million patients who had visited dentist but not a physician [16]. Furthermore, given its association with oral cancer and oropharyngeal cancer, dentists have the opportunity to serve as an authority on ST products [17]. Between 2010-2011, data from a large nationally representative US survey suggested that adult tobacco users were significantly less likely to be advised to quit during a dental visit (31.2%) than an outpatient physician visit (64.8%) [18]. The data further indicated that only 24% of dental patients who are tobacco users report receiving at least one form of assistance beyond advice to quit [18]. Not surprisingly, dentists report higher rates of inquiry. By some estimates, 90% of dental providers report inquiring about tobacco use, although the same study found that only 76% counseled patients and 45% routinely offer cessation advice [19]. Advice to quit appears to be a function of patient sociodemographic characteristics [20]. Regardless, if cessation advice in dental settings were maximized, the benefits could be enormous. A systematic review revealed that interventions by dental professionals potentially increased abstinence rates among cigarette smokers and ST users alike [21]. Moreover, given that patterns in cessation advice and smoking participation vary across sociodemographic groups, stratified analyses targeting specific subgroups could help inform more effective cessation interventions among dental patients.

The literature highlighted several gray areas relating to the relationship between ST use, especially newer ST products, and cessation across income groups. The existing research further emphasizes the potential role of dental providers in mediating this relationship. Focusing on current smokers from the 2010-2011 Tobacco Use Supplement to the Current Population Survey (TUSCPS), this paper explored the relationship between new ST products and dental visits with any quit attempts in the past year, intentionto- quit smoking, and intention-to-quit smoking months conditional on a previous quit attempt. Analyses were run for the population as whole and stratified by median U.S. family income during this period (< $50,000 and > $50,000).


Data source

This work drew on the most recent TUS-CPS data (2010/2011). The data include information relating to sociodemographic characteristics and smoking behaviors, including smoking patterns, cessation efforts, and tobacco-related norms and policies [22]. Most interviews were completed by telephone. Only self-respondents (approximately 80%) were eligible to answer the full set of TUS questions. The sample comprised current smokers aged >18. Given that all individuals included in the sample identified as current smokers, those who reported use of ST products were necessarily dual users.

Dependent variables

Any annual quit attempt: Among all current smokers, including occasional and everyday smokers, an individual was categorized as making a quit attempt if they reported having quit smoking one day or longer in the last 12 months with the intention-to-quit smoking [23-24].

Intention-to-quit smoking: Among all current smokers, an individual was categorized as intending to quit smoking if they indicated that they were “seriously considering quitting smoking within the next 6 months [23-24].”

Intention-to-quit smoking conditional on a previous quit attempt: The literature suggests that ST products are used both as a cessation aid as well as a means of smoking in otherwise restricted, smoke-free areas [6]. To help capture the association between ST use and desired cessation, intention-to-quit analyses were run for the full sample and among those who made a quit attempt in the last 12 months.

Explanatory variables

Any use of new ST products: The 2010-11 TUS-CPS probed, “Tobacco companies are developing new smokeless tobacco products, in various shapes, such as a pellet, a toothpick size stick, and a film strip, made from finely ground flavored tobacco that dissolves. Some common brands are Camel Orbs, Strips and Sticks. Have you tried any new smokeless tobacco products?” Respondents who answered “yes” to this question were categorized as having ever used new ST products.

Advised to quit smoking by dental provider: The TUS-CPS inquired, “In the past 12 months, have you seen a dentist?” Among those who visited a dentist, the TUS-CPS then asked, “During the past 12 months, did any dentist advise you to stop smoking?” Based on responses to these questions, a variable was constructed indicating whether an individual visited a dentist in the past 12 months and was advised to quit (yes/no).

Usual cigarette type: Following previous work [24], a categorical variable was created indicating whether an individual usually smoked menthol cigarettes, non-menthol cigarettes or had no usual type.

Cigarettes per day (CPD): Among everyday smokers, the TUSCPS probed, “On the average, about how many cigarettes do you now smoke each day?” Among occasional smokers, CPD was constructed from two TUS-CPS questions, which asked (1) “On how many of the past 30 days did you smoke cigarettes?” and (2) “On the average, on those days, how many cigarettes did you usually smoke each day?” Based on these questions CPD was calculated as follows: [number of days smoked x number of cigarettes smoked on those days]/30. Finally, a categorical measure was constructed by creating three CPD groupings: <10, 10-14, and >15.

Nicotine dependence: The literature suggests that nicotine dependence can be proxied by how soon an individual smokes their first cigarette after waking [25]. Mirroring previous work, a categorical variable was constructed indicating whether a respondent reported typically smoking their first cigarettes within 30 minutes of waking (yes/no/no usual pattern) [24].

Smoking status: A categorical variable was created reflecting whether an individual was an occasional or everyday smoker.

Sociodemographic variables: We controlled for a variety of sociodemographic characteristics including gender, age [18 to 34, 35 to 49, 50 to 64, 65+], race/ethnicity [non-Hispanic white, non-Hispanic Black, non-Hispanic Asian, non-Hispanic Other, or Hispanic], highest level of educational attainment [high school graduate or less, some college, college graduate or more], family income [< $25,000, $25,000-$49,999, $50,000-$74,999, $75,000+], marital status [never married, married, widowed, divorced/separated], and geographic region [Northeast, South, Midwest, West].

Study sample

We began with all current smokers ages 18 and older (n = 25,209). The study sample excluded observations with missing information for the dependent variable (dropping 1,123 observations) and explanatory variables (losing an additional 3,177 observations). The final study sample included 20,909 observations, comprising 3,667 occasional and 17,242 everyday smokers. According to the US Department of Commerce, in 2010 and 2011, the median family income in the United States was $51,144 and $50,502, respectively [26]. Of the total population, 14,079 individuals have a total family income < $50,000 and 6,830 have a family income above this threshold.

Statistical analysis

Analyses were conducted in Stata 14.0 [27] and accounted for survey design of the data by incorporating replicate weights with Fay’s balanced repeated replication [28-29]. A series of chi-squared tests assessed differences in each outcome and explanatory variable across income groups (< $50,000 vs. >$50,000). For each of the three dependent variables, multiple logistic regressions were run both for the full sample and stratified by income. Following previous work exploring smoking cessation outcomes using TUS-CPS data [24], Bonferroni-adjusted significance levels were used to account for multiple comparisons.


Sociodemographic characteristics and smoking behaviors

The full sample was predominately male (54.3%), between the ages of 18-34 (34.5%), non-Hispanic White (74.3%), had a high school education or less (57.6%), had a family income of less than $25,000 (37.2%), was married (39.8%), and lived in the Southern portion of the US (33.9%) (Table 1). Half of smokers reported typically smoking their first cigarette within 30 minutes of waking (50.5%). Individuals usually smoked non-menthol cigarettes (69.3%), smoking fewer than 10 cigarettes on days when they did smoke (51.3%). Bivariate analyses revealed significant differences in the distribution of smoking behaviors across income groups. Those with above median income were less likely to smoke within 30 minutes of waking (45.4% vs. 53.0%), more likely to smoke non-menthol cigarettes (72.7% vs. 67.6%), and more likely to smoke a middling number of CPD (10- 14) (12.0% vs. 10.1%). Individuals with above median income were also more likely to report being only an occasional smoker (20.8% vs. 18.1%). The overall prevalence of use of new ST products was quite low, with only 1.8% of the full sample reporting any experience with these products. No significant differences were observed across income groups.