Unlike the declining market

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1 Association of smokeless tobacco use and smoking in adolescents in the United States An analysis of data from the Youth Risk Behavior Surveillance System survey, 2011 R. Constance Wiener, MA, DMD, PhD Unlike the declining market trends for cigarettes, the sale of smokeless tobacco has been increasing over the last decade in the United States. 1,2 Investigators have described this upward trend as a reaction to smoking bans. 3,4 They have found that smokeless tobacco is being marketed as a way to use tobacco in smoke-free environments such as on airplanes, in restaurants and in workplaces. Smokeless tobacco use is a risk factor for cancer of the oral tissues and pharynx, oral soft-tissue lesions (for example, leukoplakia), periodontal disease, gingivitis, caries, halitosis, tooth loss, tooth stains and nicotine addiction. 5 Using smokeless tobacco also has been associated with low-birth-weight infants 5 and pancreatic cancer. 3 Smokeless tobacco comes in many forms. Fine-cut dipping tobacco, also known as moist snuff, is placed and held between the lower lip and gingiva. It causes excess salivation, which is expectorated. In contrast, chewing tobacco, which is chewed rather than being held in place, is produced in long strands, twists, bits or plugs. The excess saliva also is expectorated. The tobacco used ABSTRACT Background. Using smokeless tobacco and smoking are behaviors that increase the risk of developing oral cancer, soft-tissue lesions, caries, periodontal disease and other oral conditions. The author conducted a study to examine use of smokeless tobacco and smoking by adolescents. Methods. The study was a cross-sectional analysis of participants with complete data regarding smoking, smokeless tobacco use and other variables of interest from the 2011 national Youth Risk Behavior Surveillance System survey (n = 9,655). The author performed descriptive analysis and multivariable logistic regression analyses. Results. The unadjusted odds ratio for smokeless tobacco use and smoking was 9.68 (95 percent confidence interval [CI], ; P ), and the adjusted odds ratio was 3.92 (95 percent CI, ; P ). Adolescents who used smokeless tobacco were more likely to be male, to smoke and to have engaged in binge drinking. Conclusion. Adolescents who were using smokeless tobacco were more likely to be engaging in concomitant smoking and to be participating in other risk-taking behaviors. Practical Implications. Dentists are involved in helping patients with tobacco-use cessation. The association of smoking with using smokeless tobacco needs to be considered in the design of tobacco-use cessation programs for adolescents. Key Words. Tobacco; smoking; smokeless tobacco; adolescence; Youth Risk Behavior Surveillance System survey; cessation, tobacco use. JADA 2013;144(8): C O N T J I N U A I N G D A I O N ARTIC LE 4 E D U C A T Dr. Wiener is an assistant professor, Department of Dental Practice and Rural Health, School of Dentistry, and an assistant professor, Department of Epidemiology, School of Public Health, West Virginia University, 104A Health Sciences Center Addition, P.O. Box 9448, Morgantown, W.Va , rwiener2@hsc.wvu.edu. Address reprint requests to Dr. Wiener. 930 JADA 144(8) August 2013

2 in manufacturing dipping tobacco and chewing tobacco is dried, allowed to ferment and often is treated with additives such as sugar (for example, sucrose, fructose, sorbitol, molasses, dried fruit), water, sodium chloride, ammonium chloride, licorice, menthol and other flavorings, paraffin oil and glycerol. 5 Swedish snus is a pasteurized, unfermented form of moist (often refrigerated) smokeless tobacco that does not contain sugar and does not require spitting. It often is sold in discrete tea bag like or small mesh packets that are placed under the upper lip and are easy to remove and to dispose after use. Snus is regulated as a food product in Sweden, and its contents are labeled on the container. Marketing by tobacco companies and the introduction of new packaging and sales strategies in the United States began in In 2007, the U.S. Food and Drug Administration required a written order to permit the marketing of new tobacco products. 6 In 2009, the agency s role was expanded to regulate the manufacturing, marketing and distribution of tobacco products by means of the Family Smoking Prevention and Tobacco Control Act. 6 American snus often is refrigerated before sale, as is Swedish snus. Generally, American snus is not sold in as moist a condition as Swedish snus is, and it often has flavorings and sugar added (although the exact ingredients are not listed). Other forms of smokeless tobacco consisting of dissolvable, fine-milled tobacco, combined with food-grade binders and candy flavorings, have been processed as pellets shaped like candy or mints, processed into toothpick-shaped products or processed as films. The pellets and sticks are held between the gingiva and lips, similar to snus; the films are placed on the tongue, where they dissolve. 7 There is no associated expectorating with use of the pellets, sticks or films. 7 Cigarette smoking by adolescents has decreased since 2002, but there has not been a decrease in their use of other tobacco products. 8 Using data from the National Youth Tobacco Survey, Saunders and Geletko 9 estimated that the number of nonsmoking adolescents aged 14 through 17 years who used other tobacco products increased 5.9 percent per year from 2004 through Investigators evaluated dual use of cigarettes and smokeless tobacco in male adolescents by using data from the Monitoring the Future Survey from 2005 and 2006 and the National Youth Tobacco Survey. 10 The investigators stated that the results may be considered as a baseline measure of the extent of dual use before the major cigarette companies began to encourage smokeless tobacco use by expanding their product lines. Eighth-grade boys who were daily users of smokeless tobacco had a 10 percent higher prevalence of smoking one-half pack of cigarettes than did eighth-grade boys who did not use smokeless tobacco, and 27.7 percent of male middle-school students who smoked daily during the preceding 30 days also used smokeless tobacco compared with 1.6 percent of male middle-school students who had not smoked during the preceding 30 days. 10 As indicated by the increasing sales of smokeless tobacco and the promotion of smokeless tobacco as a substitute for cigarettes in situations in which smoking is disallowed, the dual-use pattern of tobacco use by adolescents may be changing. The results of research conducted in rural Ohio indicated that adolescents thought that dissolvable tobacco would be convenient to use during school. 11 A study of snus sales in Minnesota indicated that underaged buyers (younger than 18 years) were successful in 12.9 percent of their purchase attempts, suggesting that the percentage of successful purchases of snus appears to be higher and easier than that of the successful purchase of cigarettes. 12 The results of a study regarding videos of smokeless tobacco use on YouTube (San Bruno, Calif.) indicated that there were no restrictions on youth creating or viewing the videos, that only 9.8 percent of the videos had public health messages and that only 12.2 percent of the videos presented the effects of nicotine use. 13 In addition, adolescents have reported being curious about new smokeless tobacco products, packaging and flavorings, as well as being willing to experiment with the products. 14 Although advertisements for tobacco products are required by law to include warnings in boldfaced type stating that all forms of tobacco can cause oral cancer, the message is diluted by means of glamorous advertisements, price discounts, flavorings, convenient packaging and promotional allowances have been effective in generating large sales. The results of a study of magazine advertisements indicated that the number of advertisements for tobacco products per issue increased from 0.24 in 1998 and 1999 to 0.49 in 2005 and The advertisements appealed to both traditional smokeless tobacco users and all readers of general adult magazines. 15 Since 2006, marketing campaigns, particularly promotions for flavored and discounted varieties of smokeless tobacco products, may ABBREVIATION KEY. BMI: Body mass index. YRBSS: Youth Risk Behavior Surveillance System. JADA 144(8) August

3 have been directed toward youth. 1,16 In addition, the models in advertisements are representative of young, sophisticated, upscale, urban consumers, 3 as well as of the traditional outdoorsmen and people in the individualistic marketing target group. A 1983 memo from Philip Morris (Pittsburgh) reported that 60 percent of smokeless tobacco sales were made to consumers younger than 24 years and that a growing number of smokeless tobacco users were women. 17 In a 1998 study, investigators estimated that the prevalence of smokeless tobacco use was 0.6 percent among women 18 years or older. 18 Using 2010 Behavioral Risk Factor Surveillance Survey data, Mushtaq and colleagues 19 found that the prevalence of smokeless tobacco use among women 18 through 24 years of age was 0.63 percent and that the concurrent use of smokeless tobacco and cigarettes was 0.56 percent. Smokeless tobacco products often had been provided as free samples at tractor pulls, spitting contests and fishing events; however, since 2006, snus products have been introduced at concerts, urban bars and nightclubs. 3 Snus products are advertised as smoke-free, spit-free, not-dip, novel and sophisticated. 3 Some smokeless tobacco products are sold from a refrigerator case as a novel feature indicating the products sophistication. For discretion, some products also are sold in tins similar to tins of mints or in packages the size and shape of cell phones. The use of smokeless tobacco as a harmreduction strategy or as an alternative to smoking is controversial. 5 The harm-reduction strategy has been studied in Sweden, where there is a high prevalence of snus use. 5 Tobacco users were encouraged to replace combustible tobacco totally with smokeless tobacco. This effort resulted in Sweden s having the lowest prevalence of smoking (17 percent) in Europe. However, a single use of smokeless tobacco raises many concerns: d smokeless tobacco products may be gateway products that may lead to smoking and the use of other combustible tobacco products (for example, electronic nicotine delivery systems, hookahs, bidis and cigars); d people who attempt to quit smoking by using these products may develop a habit of dual use of tobacco (smokeless tobacco use and smoking); d people may equate less harmful with safe ; d the message of tobacco-use cessation will be diluted; d there is an ethical dilemma regarding the potential marketing of smokeless tobacco as a harm-reduction agent for recalcitrant smokers when there are known health risks associated with smokeless tobacco use, as well as with smoking. 5,20 Adding to the dilemma are the results of a study in which investigators found no increased risk of developing cancer or heart disease from snus use, although the study had limited and sometimes weak evidence. 21 Harm reduction by means of substitution is a radical, controversial approach to decrease tobacco use. 22 (European Union countries have banned the sale of snus in all of its member countries, except for Sweden, which insisted on its exception. 21 ) Risk-taking behaviors often are established early in life, particularly during adolescence. 23 It is not known whether curiosity about and engagement in smokeless tobacco use is associated with smoking in adolescents. It is important to determine whether adolescent smokeless tobacco users are also smoking so that tobacco-use cessation programs could be tailored to address an emerging problem. I conducted a study to examine whether adolescents who are smokers are more likely to also use smokeless tobacco than are adolescents who are not smokers. Methods The West Virginia University Institutional Review Board approved the study. The study investigators use data from the 2011 Youth Risk Behavior Surveillance System (YRBSS) survey. The methodology of the 2011 YRBSS survey is presented in detail elsewhere. 24 The YRBSS survey had a sampling frame of U.S. school students in grades 9 through 12 from each state and Washington that had students in at least one of the grades. Investigators oversampled non-hispanic black and Hispanic students to allow for separate subgroup analyses regarding race and ethnicity. The survey was anonymous and voluntary. Investigators sought parental permission for students to take the survey. The Centers for Disease Control and Prevention s Institutional Review Board C approved the protocol. The investigators did not impute missing data. The response rate was 81 percent for schools, 87 percent for students and 71 percent overall. There were 15,425 participants. In my study, I used data from participants who provided responses to the survey variables regarding tobacco use. The sample was 9,655 participants of the 15,425 participants in the YRBSS. Outcome variable. The outcome variable was the YRBSS s derived and dichotomized variable for the use of smokeless tobacco during the 932 JADA 144(8) August 2013

4 preceding 30 days. The question was During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman [Pinkerton Tobacco, Owensboro, Ky.], Levi Garrett [American Snuff, Memphis, Tenn.], Beechnut [Swedish Match, Stockholm], Skoal [U.S. Smokeless Tobacco, Richmond, Va.], Skoal Bandits [U.S. Smokeless Tobacco] or Copenhagen [U.S. Smokeless Tobacco]? 25 Variable of interest. Smoking was a YRBSS-derived variable with a yes-or-no response to the question During the past 30 days, on how many days did you smoke cigarettes? 25 Investigators categorized a response of 0 as a no response, and they categorized all other responses as a yes response. Other variables. Demographic variables included sex, race and ethnicity, and education. Investigators determined sex on the basis of a response of female or male to the question What is your sex? 25 They identified race and ethnicity as non-hispanic white, non-hispanic black, other non-hispanic and Hispanic on the basis of answers to the questions Are you Hispanic or Latino? 25 (yes/no) and What is your race? 25 (American Indian or Alaska Native, Asian, black or African American, Native Hawaiian or other Pacific Islander or white). They determined year in school on the basis of answers to the question In what grade are you? 25 The possible responses were 9th grade, 10th grade, 11th grade, 12th grade and ungraded or other grade. Lifestyle variables included playing on a sports team, body mass index (BMI) and soda use. I included playing on a sports team because the results of previous research indicated that smokeless tobacco use was associated with participation in organized sports. 26 I included soda (with the presence of caffeine) owing to the potential of its being a confounding factor, as investigators have reported that use of one drug is correlated with the use of another, although dependence on nicotine and caffeine were not correlated. 27 I included BMI because it was a relevant variable in a previous study on smoking 28 and because it had the potential to be a confounding factor in my study. I dichotomized the responses to the survey question During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups.) 25 into a yes-or-no variable. I also dichotomized the responses to the question During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke [Coca-Cola, Midtown Atlanta, Ga.], Pepsi [PepsiCo, Dallas], or Sprite [Coca-Cola]? (Do not count diet soda or diet pop.) 25 into a yesor-no variable. YRBSS investigators calculated and presented the BMI data set regarding being overweight and obesity on the basis of self-reported height and weight compared with sex- and age-specific Centers for Disease Control and Prevention growth chart reference data from Being overweight involved having a BMI at or above the 85th percentile and below the 95th percentile for the student s age and sex, and being obese involved having a BMI at or above the 95th percentile. Risk-taking behaviors were binge drinking, riding in a vehicle with a driver who had been drinking, using marijuana and having sexual intercourse. The YRBSS investigators dichotomized responses to the question During the past 30 days, on how may days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours? 25 into a yes-or-no variable. They dichotomized the responses to the question During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol? 25 into a yes-or-no variable. Investigators categorized a 0 response as a no response, and they categorized all other responses as a yes response. They also dichotomized the responses to the question During your life, how many times have you used marijuana? 25 into a yes-or-no variable. Sexual intercourse was a variable with a yes-orno response to the question Have you ever had sexual intercourse? 25 Statistical analysis. The YRBSS has a complex survey design in which oversampling is used to represent population subgroups adequately. The survey results provided weights for the data so they could be used to provide a more accurate representation than if the survey weights were not used. Therefore, I conducted analyses by using weighted data. I performed descriptive data, c 2 analyses, multivariable analyses, as well as sex and race and ethnicity subgroup analyses by using statistical software (SAS 9.3, SAS Institute, Cary, N.C.). I set statistical significance at a P value of less than.05. Results Descriptive statistics are presented in Table 1. The sample was 51.4 percent female, primarily non-hispanic white (62.2 percent), and relatively equally distributed from ninth grade through 12th grade. Most participants did not play on a sports team (61.1 percent), and most (82.7 percent) had a normal BMI for their ages and sexes. Smokeless tobacco use was reported at 6.2 JADA 144(8) August

5 TABLE 1 Smokeless tobacco use, demographics, lifestyle and behavioral factors, and risk-taking behaviors, according to responses from the Youth Risk Behavior Surveillance System survey, 2011 (n = 9,655).* Sample Characteristic Smokeless tobacco use No smokeless tobacco use P value No. of Participants (Weighted %) No. of Participants (Weighted %) Demographic Sex Female , Male , Race and ethnicity Non-Hispanic white , Non-Hispanic black , Hispanic , Other Education Ninth grade , th grade , th grade , th grade , Lifestyle and Behavioral Factor Playing on a sports team More than one team 0 0 NA NA One team , No teams , Body mass index Normal , Overweight , Obese 0 0 NA NA Soda consumption None , One to three per week , Risk-Taking Behavior Binge drinking within the past 30 days Yes , No , Riding in a vehicle with a driver who had been drinking within the past 30 days Yes , No , Smoking Yes , No , Marijuana use Yes , No , Sexual intercourse Yes , No , * Of the 9,655 participants, 518 used smokeless tobacco (weighted percentage, 6.2), and 9,137 participants did not use smokeless tobacco (weighted percentage, 93.8). Weighted percentages were obtained to control for complex sample design; therefore, division of individual cell sizes by the total sample does not reflect weighted percentages. All group differences were tested by means of c 2 statistics (Rao-Scott c 2 ). NA: Not applicable. percent. Approximately one in five participants reported smoking (16.8 percent), binge drinking (21.2 percent) or riding in a vehicle with a driver who had been drinking (22.7 percent). In addition, 38.7 percent reported ever using marijuana, and 45.9 percent reported ever engaging in sexual intercourse. Nearly three-fourths of the participants (73.5 percent) reported drinking one to three sodas per week. All of the variables had significant c 2 differences between those who used smokeless tobacco and those who did not. Table 2 presents the overall unadjusted and 934 JADA 144(8) August 2013

6 TABLE 2 Association between smokeless tobacco use and smoking, according to responses from the 2011 Youth Risk Behavior Surveillance System survey subgroup analysis for sex. Variable Overall OR* (95% CI ) (n = 9,655) P Value Female OR (95% CI) (n = 5,146) P Value Male OR (95% CI) (n = 4,509) P Value Smoking Unadjusted association 9.68 ( ) NA NA NA NA Adjusted model 3.92 ( ) 5.45 ( ) ( ) Other Variables Male versus female 7.28 ( ) NA NA NA NA Race and ethnicity Non-Hispanic white 2.55 ( ) 1.74 ( ) ( ) Non-Hispanic black 0.45 ( ) 0.65 ( ) ( ) Other 1.94 ( ) ( ) ( ).0198 Education 10th grade 1.08 ( ) ( ) ( ) th grade 1.09 ( ) ( ) ( ) th grade 0.82 ( ) ( ) ( ).0384 Playing on a sports team 0.57 ( ) 0.77 ( ) ( ) Being overweight 1.46 ( ) ( ) ( ).0650 Consuming one to three 0.72 ( ) ( ) ( ).0271 sodas per week Marijuana use 1.31 ( ) ( ) ( ).0624 Sexual intercourse 2.10 ( ) 1.94 ( ) ( ).0081 Binge drinking within 2.50 ( ) 2.73 ( ) ( ) the past 30 days Riding in a vehicle with 1.60 ( ) ( ) ( ).0029 a driver who had been drinking within the past 30 days * OR: Odds ratio. CI: Confidence interval. NA: Not applicable. The adjusted model included smoking within the past 30 days (yes versus no), race and ethnicity (non-hispanic whites and non-hispanic blacks and others, non-hispanic versus Hispanic), education (10th, 11th and 12th grades versus ninth grade), playing on a sports team (yes versus no), body mass index (overweight versus normal weight), drinking one to three sodas during the last week (yes versus no), using marijuana (yes versus no), having sexual intercourse (yes versus no), binge drinking within the past 30 days (yes versus no) and riding in a vehicle with a driver who had been drinking within the past 30 days (yes versus no). multivariable adjusted analyses of smokeless tobacco use and risk behaviors with subgroup analysis for sex. The unadjusted odds ratio (OR) for using smokeless tobacco and smoking was 9.68 (95 percent confidence interval [CI], ; P ). In multivariable analysis, the adjusted OR remained significant, but it decreased to 3.92 (95 percent CI, ; P ). Smokeless tobacco users also were more likely to be non-hispanic white, to be male, to be overweight, to ride with a driver who has been drinking alcohol and to have engaged in binge drinking and sexual intercourse. They were less likely to drink one to three sodas per week and were less likely to play on a sports team. Female smokeless tobacco users had an adjusted OR of 5.45 (95 percent CI, ; P =.0003) for smoking. In addition, they were more likely to be non-hispanic white and to have engaged in binge drinking. Male smokeless tobacco users had an adjusted OR of 3.73 (95 percent CI, ; P ) for smoking and were more likely to be non-hispanic white, to ride with a driver who had been drinking alcohol and to have engaged in binge drinking and sexual intercourse. Table 3 shows the results of the race and ethnicity subgroup analysis. Across all races and ethnicities, participants who were male and smokers were more likely to use smokeless tobacco. Compared with ninth grade, there was no difference in grade level for using smokeless tobacco. Non-Hispanic white smokeless tobacco users had significant ORs for riding in a vehicle with a driver who had been drinking alcohol, for being overweight and for engaging in sexual intercourse and binge drinking. Hispanic smoke- JADA 144(8) August

7 TABLE 3 Association between smokeless tobacco use and smoking, according to responses from the 2011 Youth Risk Behavior Surveillance System survey subgroup analyses for race and ethnicity.* variable Non-Hispanic White, OR (95% CI ) (n = 4,518) P value Non-Hispanic Black, OR (95% CI) (n = 1,451) P value Hispanic, OR (95% CI) (n = 2,698) P value Smoking 3.74 ( ) ( ) ( ).0001 Male Versus Female 7.67 ( ) 4.32 ( ) ( ) Education 10th grade 1.04 ( ) ( ) ( ) th grade 1.17 ( ) ( ) ( ) th grade 0.83 ( ) ( ) ( ).3276 Playing on a Sports 0.57 ( ) ( ) ( ).2583 Team Being Overweight 1.87 ( ) ( ) ( ).0914 Consuming One to Three 0.70 ( ) ( ) ( ).6148 Sodas per Week Marijuana Use 1.38 ( ) ( ) ( ).9728 Sexual Intercourse 2.05 ( ) 0.29 ( ) ( ).0817 Binge Drinking Within 2.48 ( ) 1.99 ( ) ( ) the Past 30 Days Riding in a Vehicle With a Driver Who Had Been Drinking Within the Past 30 Days 1.60 ( ) ( ) ( ).1504 * The models included smoking within the past 30 days (yes versus no), sex (male versus female), education (10th, 11th and 12th grades versus ninth grade), playing on a sports team (yes versus no), body mass index (overweight versus normal weight), drinking one to three sodas during the last week (yes versus no), using marijuana (yes versus no), having sexual intercourse (yes versus no), binge drinking within the past 30 days (yes versus no) and riding in a vehicle with a driver who had been drinking within the past 30 days (yes versus no). OR: Odds ratio. CI: Confidence interval. less tobacco users were more likely to engage in binge drinking (adjusted OR, 3.28 [95 percent CI, ; P ]). Non-Hispanic white smokeless tobacco users were less likely to drink one to three sodas per week. Non-Hispanic white and non-hispanic black smokeless tobacco users were less likely to participate in sports. Discussion The findings of this study indicate a strong association between smoking and smokeless tobacco use in a nationally representative sample of adolescents. Although the results of multivariable analyses showed that the association of smoking and smokeless tobacco use attenuated with the addition of other variables, the association remained significant. The results of the sex and race and ethnicity subgroup analyses also remained significant. Most students were nonsmokers and did not use smokeless tobacco. The prevalence of smoking in this study was 16.8 percent, whereas the prevalence of dual use was 3.92 percent. The results of an analysis of all participants in the 2011 YRBSS indicated that 18.1 percent smoked cigarettes on at least one day during the 30 days before the survey. 23 Results from my study of dual use were lower than the results of a study of the National Youth Tobacco Surveys, which showed a smoking prevalence of 16 percent and the use of multiple forms of tobacco (polytobacco use) of 6.9 percent. 29 My study s findings indicated that participants who were male were more likely to use smokeless tobacco than were those who were female, a result that is similar to those of other studies. 2,8,29 The results of multivariable analyses showed that other risk behaviors emerged as being associated with smokeless tobacco use, including binge drinking, engaging in sexual intercourse and riding in a vehicle with a driver who has been drinking alcohol. The results of a study of youth tobacco use in West Virginia indicated that smoking and smokeless tobacco use were related to problematic behaviors. 30 The results of my study support those results. One finding was that smokeless tobacco use was associated with not playing on a sports team; that is, smokeless tobacco users were less likely to participate in organized sports. A strength of my study was that I used data from a large, recent and representative sample 936 JADA 144(8) August 2013

8 of U.S. adolescents. The YRBSS study has a complex study design that includes oversampling to give researchers large enough sample sizes to enable them to conduct subgroup analyses such as for sex and race and ethnicity. The limitations of the study were that the responses were self-reports and not verified by means of clinical biomarkers. In conducting the surveys, however, the Centers for Disease Control and Prevention used test-retest reliability studies of the 1991 and 1999 questionnaires. 31 In addition, other studies were performed to test the validity of self-reported height and weight, the effect of altering the race and ethnicity question wording, the adminstration mode and the setting for administering the survey. Greater detail is available at the YRBSS website. 31 Because the study was cross-sectional, temporal associations and causality cannot be attributed to the study results. The definitions of smoking and smokeless tobacco use were based on a 30-day recall and may have been subject to recall bias, social desirability bias or both. However, the combination of biases most likely would be skewed toward the reporting of less smoking and less smokeless tobacco use. The potential of fewer reports of smoking and smokeless tobacco use would bias the results toward the null hypothesis because the associations would be weakened as the result of fewer reports. Furthermore, it is not known whether the adolescents in the study considered the other smokeless tobacco products, some of which were new to the market, to be smokeless tobacco when they responded to the questions regarding smokeless tobacco use. Pellets, toothpick-shaped products, films and snus were not mentioned specifically as examples in the YRBSS survey, possibly leading to underreporting of smokeless tobacco use. The results of my study add to the literature the strong association between smokeless tobacco use and smoking across both sexes, as well as among non-hispanic white, non-hispanic black and Hispanic adolescents. Adolescents in this study who were using smokeless tobacco also were more likely to be participating in other risk-taking behaviors. The results of this study raise potential research questions about dual smoking and smokeless tobacco use. These questions include the following: d Is smokeless tobacco being used as an aid to smoking cessation, as a means to decrease the number of cigarettes smoked or as a nicotine delivery system alternative to smoking? Or is smokeless tobacco use a gateway to smoking and other alternative and emerging nicotine delivery systems? d Should the controversial harm-reduction strategy be considered? d Will adolescents who concomitantly use smokeless tobacco and cigarettes be more likely to continue dual use into adulthood? d Is there a need for more stringent restrictions on advertising and promotion of smokeless tobacco to youth? 5 Tobacco-use cessation programs need to address and counter the tobacco-use advertising campaigns. Tobacco companies use surveys, market researchers, focus groups, test markets, promotions and sponsorships to attract and maintain new tobacco users. They invest millions of dollars to teach people how to use smokeless tobacco (particularly snus) and have tried to make the products appear popular, glamorous, adventurous and trendy. 3 Adolescents who concurrently smoke and use smokeless tobacco, in particular, need to be targeted for tobacco-use cessation programs. Health care providers need to be aware of and proactive in providing prevention and tobacco-use cessation activities. Dental care providers have an opportunity to educate, intervene and provide tobaccouse cessation programs in the normal course of providing dental care. conclusions The results of this study indicate that there is a strong association between adolescent smoking and smokeless tobacco use. Being knowledgeable about associated behavioral factors in adolescents (for example, not playing on a sports team, binge drinking, riding in a vehicle with someone who has been drinking, using marijuana, engaging in sexual intercourse and drinking soda in moderate amounts) can help target or strengthen messages for adolescent dental patients who are at risk of using smokeless tobacco and smoking. n Disclosure. Dr. Wiener did not report any disclosures. The research reported in this article was supported by grant U54GM from the National Institute of General Medical Sciences, National Institutes of Health, Bethesda, Md. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health. 1. Delnevo CD, Wackowski OA, Giovenco DP, Manderski MT, Hrywna M, Ling PM. Examining market trends in the United States smokeless tobacco use: (published online ahead of print Oct. 31, 2012). Tob Control. doi: /tobaccocontrol Bhattacharyya N. Trends in the use of smokeless tobacco in the United States, Larygoscope 2012;122(10): Mejia AB, Ling PM. Tobacco industry consumer research on smokeless tobacco users and product development. Am J Public Health 2010;100(1): JADA 144(8) August

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