Smokeless Tobacco Use Among Men in the U.S., 2000 and 2005

Epidemiologist Philip Cole and I recently completed a study of smokeless tobacco (ST) users in the United States in 2000 and 2005, based on data from National Health Interview Surveys (NHIS), which are also used by the Centers for Disease Control and Prevention to estimate how many Americans smoke. Our manuscript was published in the Journal of Oral Pathology and Medicine.

Overall, we found that the percentage of American men who use ST is a low but stable 4%. Almost all ST users are white, about half are 25-44 years old, and the majority have up to a high school education. Eight out of ten ST users live in the South or the Midwest. Over 50% of ST users lived in small metropolitan and rural areas, while only 2% lived in metro areas with populations of 5+ million.

There was some good news: of the 4.1 million ST users in 2000, 1.1 million were former smokers. Only 120,000 of them had quit smoking by switching to ST; the other 980,000 had used other methods. However, at some point, these former smokers apparently made the decision that they wanted to remain smoke-free without abstaining entirely from nicotine and tobacco, so they became ST users. By 2005, the number of ST users who were former smokers had grown to 1.4 million. 

Although over a million ST users are former smokers, we also found that there were about three million smokers who were former ST users. This is the bad news, because these men have gone from very low risk ST to high risk cigarettes. This reflects the fact that most American smokers are not aware of the large difference in risk between ST use and smoking. For example, a 2003 survey found that while 80% of American smokers were aware of ST products, only 11% correctly believe that they are less hazardous than cigarettes. Another survey found that 82% of American smokers incorrectly believe that chewing tobacco is just as likely to cause cancer as is smoking cigarettes. A 2007 study of adult smokers in Australia, Canada, the UK and the U.S. found that only 13% correctly believed that ST is less hazardous than cigarettes.

In 2005, there were 1.4 million American men who were dual users of both cigarettes and ST products. These men consumed nicotine both from cigarettes and from ST, and the latter clearly resulted in lower consumption of the former. In both 2000 and 2005, every-day smokers who also used ST every day consumed significantly fewer cigarettes on average than exclusive smokers (13 cigarettes per day vs. 20 cigarettes). If these dual users knew that ST products were only 1% as hazardous as cigarettes, it is possible that many would have chosen to use only ST.

Many media reports have noted the sharp increases in sales of moist snuff over recent years. Our study revealed that increased snuff use among men between 2000 and 2005 is due in large part to a decline in the use of chewing tobacco, a long-term trend that has been apparent since the mid 1980s. These changes for chewing tobacco and snuff are in line with a report from the U.S. Department of Agriculture Economic Research Service showing that consumption of chewing tobacco in the U.S. decreased 20% from 49.4 million pounds in 2000, to 39.2 million pounds in 2005. In contrast, moist snuff consumption increased 28% over the same period, from 65.9 million to 84.5 million pounds.

Our study provides important information about American ST users, and it reveals that a large proportion of ST users are concurrent or former smokers. These findings should inform the growing discussion among health and policy experts about how ST can serve as a less hazardous cigarette substitute for inveterate smokers.