Research article
Snuff use and smoking in U.S. men: Implications for harm reduction1

https://doi.org/10.1016/S0749-3797(02)00491-9Get rights and content

Abstract

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 ≥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.

Introduction

Oral use of snuff is capable of delivering rapid, high dosages of nicotine1, 2 and can result in levels of nicotine dependence comparable to those seen in smokers.3 There is substantial evidence that manufacturers of snuff can and do manipulate the nicotine-dosing characteristics of their products to create low nicotine dosage “starter” products, which are targeted toward novice users, and a range of medium- and high-dosage products, which are targeted toward more experienced users as they progress in their levels of nicotine tolerance and dependence.4, 5, 6, 7, 8

Several expert panels have concluded that oral use of snuff can cause cancer in humans.9, 10, 11 This conclusion recently has been questioned, at least concerning Swedish brands of moist snuff, or “snus.”12 Other researchers acknowledge that snuff is a risk factor for cancers of the oral cavity and pharynx, but claim that switching from smoking to use of snuff would save thousands of lives because of a reduction in risk for other smoking-associated diseases.13, 14 On that basis, the use of snuff has been advocated as a method for quitting smoking in both professional and lay publications,13, 15 although the only evidence supporting the efficacy of snuff use as a method for quitting smoking comes from one uncontrolled pilot study16 whose methodology and approach have been criticized.17, 18, 19, 20 Some researchers have attributed the decline in cigarette smoking among Swedish men from 36% in 1980 to17% in 1998 to a switch to use of snus,21, 22 and there have been recent calls for a lifting of the ban on sales of oral snuff products in European Union (EU) countries (Sweden was exempt when it joined EU in 1995).12 However, there is little evidence supporting the role of snus in reducing smoking among men in Sweden: the prevalence of smoking among Swedish women also has been declining in recent years without any appreciable use of snus by women, snus use by men increased by less than two percentage points between 1980 and 1998, and Sweden has experienced a broad range of tobacco-control efforts during that time period.23, 24 U.S. Smokeless Tobacco Company (USST), the nation’s leading manufacturer of smokeless tobacco products, clearly has been marketing some of its products as supplements to smoking, particularly in response to smoke-free policies. USST recently petitioned the U.S. Federal Trade Commission for permission to make explicit claims that its products are less hazardous than cigarettes. Despite the theoretical benefits of getting smokers who are unable to quit to switch to less harmful forms of tobacco use, the feasibility of such a “harm-reduction” approach to tobacco control is unknown.25

The widespread availability of moist snuff products, the increased prevalence of clean indoor air policies in the United States,26 marketing of snuff products to smokers, and advocacy by some health professionals of switching to the use of snuff raises two opposing questions of public health relevance:

  • Can snuff help smokers to quit smoking?

  • Does partial substitution of smoking with snuff reduce smokers’ success in quitting?

The purpose of this study was to examine the patterns of snuff use in relation to current smoking, former smoking, and quit attempts in a representative sample of U.S. men.

Section snippets

Subjects

Data for this study were drawn from the 1998 National Health Interview Survey (NHIS), a multipurpose health survey conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). The NHIS is representative of the civilian, noninstitutionalized, household population of the United States, and has been conducted continuously since 1957. Data were collected through personal household interviews. Adult participants in the 1998 NHIS were asked about

Prevalence of tobacco use

In 1998, 26.4% of U.S. males aged ≥18 years were current smokers and 3.6% were current snuff users (Table 1). Snuff use was more prevalent among males aged 18 to 44 years than among those in older age groups and was more prevalent among non-Hispanic white males than among Hispanics or non-Hispanic blacks. Smoking was more prevalent among males with a high school education (33.2%) or less (35.4%) than among those with more than a high school education (19.5%). In contrast, snuff use did not

Discussion

Daily snuff users were significantly more likely than men who never used snuff to have quit smoking. This pattern suggests that snuff may serve as an alternative form of nicotine dosing for smokers who will not or cannot overcome their nicotine dependence, and perhaps can help smokers to quit. However, 2.5 times as many men in the United States followed the opposite pattern, and were former snuff users who were current smokers at the time of the interview.

This study provides further evidence

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