Smokeless Tobacco Usage Among Teens

A Public Health Perspective presented by Erika Lindwall

(Through with Chew, 2014)

Introduction: What is the problem? Due to higher awareness of the harmful effects of tobacco,

cigarette smoking has decreased among teens over the last decade (Agaku et al., 2013).

However, the rate of smokeless tobacco product (STP) usage among teens in the United States has been unchanged. Over 9 million teenagers in the U.S. report using STPs

Why do so many teens use STPs? Perceived lower risk (no second hand exposure, no combustion) More discreet/socially acceptable Perceived safer substitute to cigarettes

Introduction: What are STPs?

Define: “A form of the leaf of the plant meant to be chewed or otherwise ingested orally, rather than smoked.”

Variants: Chewing Tobacco/Snuff: placed between gum and cheek Dip: moist chewing tobacco Snus: small pouch of moist snuff

Introduction: How does this relate to public health?To understand the issue from a public health perspective,

certain key subjects will be analyzed. Epidemiology: risk factors and distribution of the condition

Biostatistics: stats on health risks, vulnerable demographics

Biomedical basis: analysis of chemical content

Social and Behavioral factors: factors by which teens are influenced to start using smokeless tobacco products.

EpidemiologyHealth Risks:

Though there is a perceived lower risk in using smokeless tobacco, there are actually many negative health related correlations with its usage (American Cancer Society, 2013).

Cancer: esophageal, mouth, stomach, pancreatic Tobacco contains carcinogens, which are cancer-causing agents.

Heart Disease & Stroke Chemicals in tobacco can cause blood to thicken, leading to blood

clots.

Prevalence: In the teen population, rates of usage of STPs varies greatly by gender, race/ethnicity, and socioeconomic status (Timberlake & Huh, 2009) National prevalence by gender:

Male teens: 14% Female teens: 2.1%

Biostatistics: Oral CancerOne of the major health risks of using STPs is oral cancer

(tongue, gums, cheeks). According to the Oral Cancer Foundation (2014), 43,250

Americans are diagnosed with oral cancer every year, causing approximately 8,000 deaths yearly.

STP users have an 80 percent higher risk of oral cancer and a 60 percent higher risk of pancreatic and esophageal cancer.

There are 28 carcinogens found in smokeless tobacco products, all of which can contribute to a higher risk of cancer (WHO, 2007).

Biostatistics: DemographicsStudies have shown that race/ethnicity is a factor in the

likelihood of a teen using STPs. The highest concentration of STP users are of white, Native American, Hispanic decent (Boyd, 1987).

A Study by Eaton et al. (2006) found that 13.6% of high school students use STPs. Here is the break down of that percentage by ethnicity:

Percentage of Male Populations that use STPs

White Hispanic Black

10.2% 5.1% 1.7%

Biomedical BasisSmokeless tobacco products contain more than just the

tobacco leaves from which they are made. Contained in these STPs are harmful chemicals inherent to

the leaves themselves and acquired through the manufacturing process (Lawler et al., 2013).

There are more than 4,000 chemicals in tobacco products, 28 of which are carcinogenic (Dugdale, 2010; Stepanov et al., 2010). The most notable are: nicotine, polycyclic aromatic hydrocarbons,

radioactive polonium, and tobacco-specific nitrosamines (TSNAs) (Richter & Spierto, 2003).

Biomedical Basis: Nicotine Nicotine is a highly addictive chemical inherent to

tobacco. However, the levels vary depending on the manufacturer (Richter & Spierto, 2003).

Nicotine exists in two forms, but only readily absorbs in one of them. The form depends on the pH (acidity/alkalinity) Protonated (stable molecule that contains an extra

hydrogen (SEE TOP RIGHT) Unprotonated (aka “freebase” which is more unstable and

absorbs readily through the membranes in the oral cavity) (SEE BOTTOM RIGHT)

Freebase nicotine only occurs in high pH environment. To increase the rate of absorption, manufactures

increase the pH of the tobacco itself. By increasing nicotine absorption, the consumer is put at higher risk of addiction (Tomar & Henningfield, 1997)

Biomedical Basis: Nicotine (cont.)

Interestingly, the most popular brands of smokeless tobacco also happen to have the highest pH (Tomar & Henningfield, 1997)

This means that these brands contain the most freebase (readily absorbable) nicotine.

Therefore, the most popular brands are not necessarily the best tasting or highest quality, but are the most addictive.

Biomedical Basis: Health Risks of Nicotine The way that nicotine functions in addiction is through both psychological

and biological processes (Dugdale, 2012). A person addicted to nicotine may experience:

elevated mood stimulated memory better concentration

Nicotine also has negative health effects increased heart rate and blood pressure vomiting gastrointestinal irritation (hemorrhaging and/or diarrhea)

Nicotine addiction is further maintained by the withdrawal symptoms. depression, anxiety, insomnia, intense craving for nicotine, trouble

concentrating, and headaches.

Biomedical Basis: PAHs and TSNAsSmokeless tobacco products also contain carcinogens. Two of the

most potent groups are polycyclic aromatic hydrocarbons (PAHs) and tobacco-specific nitrosamines (TSNAs).

PAHs: found everywhere in nature, and are a byproduct of the combustion of carbon-based materials (Stepanov et al., 2010).

Linked to esophageal, oral, pancreatic cancer A single portion of smokeless tobacco contains 5 times the amount

of PAHs than the smoke of one cigarette.

TSNAs: formed from nicotine and other alkaloids found in tobacco during the curing process (Hecht & Hoffman, 1988).

Linked to lung and abdominal cancers (Ashley et. al. 2010). function in DNA binding, which can cause mutation resulting in

uncontrolled cell growth.

Biomedical Basis: Reducing Harmful ChemicalsThe harmfulness of STPs could be reduced if these

carcinogens were removed. As it turns out, these chemicals are actually present at unnecessary levels (Tomar & Henningfield, 1997).

Freebase nicotine is most abundant in STPs with a high pH. If the pH of the tobacco product were to be lowered, the amount of nicotine available for absorption would be reduced significantly.

PAH and TSNA levels could be reduced by adjusting the manufacturing processes (Ashley et. al. 2010; Stepanov et al., 2010).

The only way to eliminate the threats posed by STPs, however, is to stop usage all together.

Social and Behavioral FactorsThere are many factors by which teens are influenced to start

using smokeless tobacco products. These factors are present at varying levels of their social environment.

The social and behavioral factors related to smokeless tobacco usage among teens will be considered through the ecological model and the health belief model.

By looking at how teens’ environments affect their behavior, it is possible to formulate a solution for how to encourage healthy behaviors instead of unhealthy ones.

Social and Behavioral Factors: Ecological Model The level with one of the highest influences for teens is the interpersonal

level: family, friends, and peers (Schneider, 2014; Chassin, 1988). Teens are more likely to use STPs if a parent is a user (CDC, 2012; CDC, 2013). Teens are liked to use STPs for the perceived social benefit, or if it is seen as

acceptable among peers (Chassin, 1988).

A teen is at high risk of using STPs if he or she is exposed to any of the following influencing factors (NCCDPHP, 2012): low socioeconomic status ready accessibility to STPs general acceptance of STP usage in the community low academic achievement and involvement lack of skills needed to resist media influences to use STPs low self-efficacy and self-esteem belief that tobacco is functional or serves a purpose.

Social and Behavioral Factors: Health Belief ModelThere are four key factors in this model: perceived

susceptibility to a threat, perceived severity of the threat, perceived benefits of taking action, and perceived barriers to taking action (Schneider, 2014; Champion & Skinner, 2008).

Health Behavior Model for Smokeless Tobacco FACTOR DEFINITION

Perceived VulnerabilityUser’s perceived chance of developing the health issues related to STP use (i.e. oral

cancer, nicotine addiction)

Perceived Severity User’s perception of seriousness of tobacco- related illness and chance of recovery

Perceived BenefitsUser’s belief in the validity of the cautions

against using STPs to avoid associated health issues

Perceived Barriers User’s outlook on the psychological and physical expenses of cessation of usage

ConclusionThe epidemiology and biostatistics tell us that smokeless

tobacco usage among teens occurs in a significantly sized part of the population: approximately 9 million This makes STP usage among teens a valid public health concern

The biomedical basis tells us that these smokeless tobacco products are harmful to those that use them. This 9 million has a notably higher risk of esophageal, pancreatic,

and oral cancer

The social and behavioral factors that occur at the various levels of influence provide insights into how to best go about creating programs that will be effective in educating the populations at risk so their health may be improved.

Conclusion: Government InterventionsCurrently, there exist many anti-smokeless tobacco

campaigns, but few target teens on a national scale The National Cancer Institute funds a project called “My Last Dip”

that focuses on finding ways to help people quit using STPs (Oregon Research Institute, 2014) not specifically directed at teens

“Don’t be a Dip” program funded by Texas A&M (Texas A&M AgriLife Extension Service, 2013) Not conducted at a national level

Conclusion: National EffortsNational Spit Education Program (NSTEP): “Our mission is to

prevent people, especially young people, from starting to use smokeless tobacco products, and help all users quit,” (Oral Health America, 2014)

“Through with Chew Week”: event that takes place all over the country as a way to educate teens about the risks of using STPs and promote healthier lifestyles (Through with Chew, 2014).

Conclusion: Next Steps Though there are public health interventions working toward

improving the status of STP usage among teens in the U.S., there is still more work to be done if this issue is to be resolved on a national scale.

For example, it may be beneficial to pass new regulations about STP sales to make access more unavailable for minors.

It may also be prudent to work on changing the social and behavioral conditions surround this issue that influence teens to use STPs. Low socioeconomic status, academic under-achievement, and poor family

life all contribute to influence teens to start using STPs (NCCDPHP, 2012). Therefore, by helping teens improve their lives in a holistic manner, the

correlation would be a decrease in STP usage in this population.

References:

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