Outline Dual User Study Background Purpose Methods Results Conclusions Expert Panel
Acknowledgement West Virginia Bureau for Public Health, Division of Tobacco Prevention
Background – West Virginia 90% of WV adults know that SHS is a health hazard 72% of WV adults ban smoking in their home 24% of WV adults – current smokers 8% of WV adults – current ST users WV Dual Tobacco Use 11.4% of smokers use ST 34.8% of ST users smoke WV 2012 Adult Tobacco Survey
Background -‐ Industry Aggressive industry promotion of snus and other tobacco products (OTPs) as a “solution” for smokers Convenience Stores OTPs: 10% of tobacco sales OTPs: 31% gross proﬁt margin Cigarettes: 14% gross proﬁt margin 25% of OTP customers also buy cigarettes Convenience Store News: http://www.csnews.com/top-‐story-‐tobacco-‐otp_becoming_increasingly_important_for_c_stores-‐62283.html
Background -‐ Industry Swedish Match "Taking care of your OTP shopper can go a long way to taking care of your cigarette shopper.” Joe Teller, Director, Category Management
Background -‐ Industry Reynolds American Camel Snus sales 8-‐10%/year Cigarette sales 3%/year $14 billion “proﬁt pool”—85% from combustibles Vuse—a “digital cigarette” http://www.bizjournals.com/triad/news/2012/11/12/reynolds-‐american-‐touts-‐ eﬀorts-‐to.html
Background -‐ Industry Vuse—a “digital cigarette”—"Were not looking to make a little splash in the category, were looking to make a big splash in the category.” Daan [sic] Delen, President and CEO, Reynolds American
“No matter how cynical you get, it’s impossible to keep up.” Lily Tomlin
22 West Virginia HancockCounties With BrookeAll Workplace OhioProtection Marshall Wetzel Monongalia Morgan Tyler Marion Berkeley Pleasants Preston Mineral Jeff- Taylor erson Dodd- Harrison Hampshire Wood Ritchie ridge Barbour Tucker Grant Wirt Hardy Lewis Cal- Gilmer Upshur houn Mason Jackson Randolph Roane Braxton Pendleton Putnam Webster Cabell Kanawha Clay Nicholas Pocahontas Lincoln Wayne Boone Fayette Greenbrier BLUE : Smoking banned in all public and private places Mingo Logan and places of employment, including restaurants, bars, Raleigh gambling, and vehicles when used as place of employment. Sum- Wyoming mers Monroe McDowell Mercer
Purpose Explore with current adult dual tobacco users Usage patterns Opinions Nicotine Health risks Rules at home & work Experience with snus Tobacco cessation history
Methods Recruitment with Wellness Council of WV Interviews, 10-‐20 minutes Gift cards to participants Approved by WVU IRB as exempt research Interviews transcribed, imported into NVivo 9 software Coded by both investigators Congruence between the investigators
Patterns of Use Initial use ST: snuﬀ or snus; no chew Principal reasons for dual use Rules at work (safety; secondhand smoke) Secondhand smoke concerns at home Social situations
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 chewing, 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 a rub in.
Health Risks More than half believe risks are equal Others believe smoking is riskier None believe that ST is riskier
Weighing the Risks If you chew 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 chew you just got to worry about your mouth cancer . . . I think chewing’s a safer way but I’d rather keep my face, that’s why I smoke more than I chew.
Nicotine Cigarettes vs. ST—cigarettes are stronger Several found ST to be stronger
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 dip 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 then when I dip I can dip and you can keep that dip in longer and it gives you the nicotine longer.
Rules Work—tobacco use banned by most employers Most were compliant Home—most do not smoke at home, nor permit others to smoke
Rules You can’t smoke unless you’re in a designated smoking area. You’re not supposed to chew unless it’s a designated area too. They don’t pay too much attention to the chewing though. No when [at work] I don’t chew. I mean it’s because I’ve got my access to cigarettes. I don’t have to worry about my daughter, and I’d rather smoke than chew 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.
Snus 10 tried snus 8 not impressed 2 are regular users
Snus I didn’t like it. Snus you can swallow the spit. With chewing tobacco you can’t. I don’t think the snus is as strong as what chewing tobacco 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 partner 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?
Cost Little brand loyalty Some buy whatever cigarette brand is cheapest One used RYO tobacco Some vary ST brand, always going with whatever was cheapest One estimate for Monthly cost of tobacco for the participant and his girlfriend: $400.
Tobacco Cessation All tried to quit 3 cold turkey 3 with meds 15/17 want to quit Most expect to quit both simultaneously Several expect to quit smoking ﬁrst
Tobacco Cessation Well if I tried to quit smoking I’d probably dip a whole lot more, and then I’d want to dip all the time, and after the dip wasn’t doing nothing for me I’d have to buy me cigarettes. So I’d have to try doing both at the same time because there’s no way I could just quit. I’d probably hold on to the snuﬀ to transition out of the cigarettes, because I can put the snuﬀ down. I know I can quit that anytime.
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.
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
Conclusions Variability When products are used Where products are used Why products are used Messages need to be tailored
Conclusions The Law of Unintended Consequences Smoking bans at work Recognition of secondhand smoke dangers Result -‐ the initiation of ST use
Conclusions User version of “tobacco harm reduction”—smoke less, dip more Strong recognition of SHS smoke hazards
Addressing Dual Tobacco Use in West Virginia Recommendations of the Expert Panel
Goals Explore the prevalence of dual tobacco use in WV. Identify successes and challenges. Identify cessation practices and models. Develop targeted recommendations for addressing dual tobacco use for dissemination to . . . Policy Makers Local Health Depts Clinicians Health Care Providers Researchers NGOs
Process Break Free Alliance – lead agency Experts (in state and out of state) planned Participants recruited Panel met: December 13, 2011
Recommendations Increase support to $28,000,000 Maintain the Quitline, able to counsel dual users Maintain/expand partnerships to address dual use Develop a statewide research group on dual use Maintain/expand regional tobacco networks Continue/expand provider education eﬀorts on dual use
Recommendations Maintain and add clean indoor (and outdoor) smoking regulations; advocate for a statewide comprehensive, non-‐preemptive law Increase taxes $2/pack tax on cigarettes Parity tax on smokeless tobacco