West Virginia. Population: 1,900,000. WV Median Household Income: $42,801. US Median Household Income: Mean State Cigarette Tax:

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3 West Virginia Population: 1,900,000 Size: 62,258 sq KM Rural: 30.5 people/sq KM WV Median Household Income: $42,801 US Median Household Income: $50,443 WV Cigarette Tax: $0.55 Mean State Cigarette Tax: $1.46

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13 Outline Tobacco Use in the United States Secondhand Smoke Concerns Dual Tobacco Use Research in West Virginia Tobacco Industry Response Advice to Europe

14 High School Student Cigarette Use , Youth Risk Behavior Survey 80,0% 70,0% 60,0% 50,0% Ever Smoked 40,0% 1+ Days 20+ Days 30,0% 20,0% 10,0% 0,0%

15 Purpose Explore with current adult dual tobacco users Usage patterns Opinions Rules at home & work Experience with snus Tobacco cessation history

16 Methods 17 adults interviewed, ages Interviews transcribed, imported into NVivo 9 software Coded by both investigators Co investigator, Lisa Houston, MPH Break Free Alliance:

17 Patterns of Use Initial use Smokeless tobacco: snuff (loose tobacco) or snus Principal reasons for dual use Rules at work (safety; secondhand smoke) Secondhand smoke concerns at home Social situations

18 Why a Dual User? For the simple reason where I have a daughter I don t want to smoke around her, but still when I m [at work] here I just don t want to give them up. Oh God, I smoke when I wake up and the whole time from traveling from work to the mine I smoke and then as soon as I get on the mine site, I work 12 hours a day on the mine site, and as soon as I get up there I start [snuff again], and then when I m off the property I start smoking again. Well if I m in a building I ll use the snus because you don t have to spit with it, but you still get the nicotine. Now if I m working in the basement on the boiler... I ll put [use some snuff].

19 Health Risks More than half believe risks are equal Others believe smoking is riskier

20 Weighing the Risks If you [use snuff] you re not going to have to worry about lung cancer, and if you smoke you re going to have to worry about throat cancer and lung cancer, but if you [use snuff] you just got to worry about your mouth cancer... I think [snuff] is a safer way but I d rather keep my face, that s why I smoke more than I [use snuff].

21 Nicotine Cigarettes vs. smokeless tobacco cigarettes are stronger Several found smokeless tobacco to be stronger

22 Nicotine Cigarettes are a lot more potent as far as the nicotine. Snuff is more of a relaxed, it doesn t hit you right off the bat... If you [use] snuff... you get the nicotine, and it kind of curbs you away from smoking. Yea the snuff just kills the craving more than the cigarette does because if I smoke one cigarette I want another one, and [with snuff] you can [use it longer] so it gives you the nicotine longer.

23 Rules Work tobacco use banned by most employers Most were compliant Home most do not smoke at home, nor permit others to smoke

24 Rules You can t smoke unless you re in a designated smoking area. You re not supposed to [use snuff] unless it s a designated area too. They don t pay too much attention to the [the snuff] though. When [at work]... I ve got my access to cigarettes. I don t have to worry about my daughter, and I d rather smoke than [use snuff] because I m worried about my mouth, but at the same time it s nicotine. So I mean it s keeping me calm at home.

25 Snus 10 tried snus 8 did not like snus 2 are regular users

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33 Trinkets and Trash Artifacts of the Tobacco Epidemic

34 Snus I didn t like it. Snus you can swallow the spit. With [snuff] you can t. I don t think the snus is as strong as what [snuff] is. You can spit or you can swallow it, so it doesn t really matter... I do spit when I smoke more, but it s more or less... the sensation of the menthol and the tingling. [My girlfriend and I] both smoke the same cigarettes and we both use the same Camel Snus, and we get coupons... you buy a Camel product, you get snus for free. If it s free why not use it?

35 Tobacco Cessation All tried to quit 3 cold turkey 3 with medicines 15/17 want to quit Most expect to quit both simultaneously Several expect to quit smoking first

36 Thinking About Quitting? Yes. It s getting too expensive. I mean when you ve got to buy diapers and formula and liners and you work at Wal mart and your wife only works three days a week and goes to school full time, yea. I don t want to be under the stereotype of people saying oh you re a smoker and you smell bad, and I don t want to put that negativity around my clients and patients, you know what I mean? I just don t want that bad persona.

37 Profiles 5 Distinct Types of Dual Tobacco Users Smokers When I have to When I want to When I need to ST Users Social smokers Hard Core Users Use both types daily and love them

38 Conclusions The Law of Unintended Consequences Smoking bans at work Recognition of secondhand smoke dangers Result the initiation of smokeless tobacco use by some smokers INSTEAD OF QUITTING!

39 Advice to Europe The European Union currently prohibits snus The EU should continue that policy Any attempts by the tobacco industry to rescind that ban should be resisted If the industry suggests that smokers will quit cigarettes and take up snus don t believe them!

40 Thank You! Robert H Anderson Prevention Research Center West Virginia University PO Box 9190 Morgantown, WV USA randerson@hsc.wvu.edu