Research Papers

Smokeless Tobacco Use Among Rural High School Students in Arkansas

Tom Williams, Rick Guyton, Phillip J. Marty, Robert J. McDermott, Michael E. Young

ABSTRACT: This study determined the prevalence of smokeless tobacco use among high school students in selected rural communities in Arkansas, and identified factors associated with initiation and maintenance of use. A questionnaire was distributed to 1,237 students in 13 rural high schools in different educational service regions of Arkansas during spring 1985. Results indicated 34.5% of males and 2.5% of females reported regular use of smokeless tobacco. The factor contributing most to initiation of this practice was the influence of a parent who used smokeless tobacco products. Comparisons to other recent studies and implications for health educators are discussed. (J Sch Health 1986;56(7):282-285)

rior to cigarette smoking’s increase in popularity, P smokeless tobacco was the most prevalent form of tobacco use in the United States.’ However, because smokeless tobacco use required spitting, it became regarded as a public health hazard, as the incidence of infectious diseases increased in prominence during the early 20th century. The social acceptability of “dipping and chewing” declined for many years, and inversely paralleled the increase in cigarette smoking as the primary mode of tobacco consumption. With the cur- rent general agreement among scientists concerning the negative health effects from smoking, and the impact of infectious diseases lessened, smokeless tobacco use has reemerged, particularly in youth populations (Me11 D: Youths cut alcohol, drug use. Wisconsin State Journal, Aug 7, 1985, p l).2-9

The American Cancer Society’’ estimates the number of smokeless tobacco users in the U.S. at about 7 million, while other estimates show the number to be as large as 22 million (Harper S: In tobacco, where there’s smokeless fire. Advertising Age, June 23, 1980, p 85). Assumed to be contributing to the reemergence of smokeless tobacco’s popularity have been advertising campaigns targeted at youth,” the “macho” or cowboy image attributed to users of these products, (Heth J: Kids think it’s macho to chew. Des Moines Register. June 6 , 1982)1J2 the widely accepted view that smokeless tobacco is “safer” and less of a “social evil” than

Tom Williams, EdD, Fayetteville Senior High School, Fayetteville, AR 72701; Rick Guyton, PhD, Professor; Phillip J . Marty, PhD, Associate Professor and Coordinator; and Michael E. Young, PhD, Associate Professor, Health Education Program, University of Arkansas, Fayetteville, A R 72701; and Robert J . McDermott, PhD, Associate Professor, University of South Florida, Tampa, FL 33612. This manuscript was submitted November 18, 1985, and revised and accepted for publication April 7, 1986.

smoking (Heth J: Kids think it’s macho to chew. Des Moines Register. June 6 , 1982).”

A National Institutes of Health Consensus Develop- ment Conference on the Health Implications of Smoke- less Tobacco Use held in January 1986 concluded epidemiologic evidence linking use to cancer of the oral cavity was strong. l 4 Data examined by the consensus panel associated other pathologies with smokeless tobacco use, including gingival recession and oral leukoplakia.

This study determined the prevalence of smokeless tobacco use among high school students in selected rural communities in Arkansas. A secondary purpose included identification of some factors that may promote initia- tion and maintenance of dipping/chewing behavior.

METHOD A closed-ended inventory developed and field tested

by the authors was distributed to 1,237 students in grades ten-12 attending 13 rural high schools in Arkansas during spring 1985. The inventory included prevalence/frequency of smokeless tobacco use, initia- tion and reinforcement factors regarding smokeless tobacco use, concurrent cigarette smoking and alcohol drinking by smokeless tobacco users, and selected demographic variables. Test-retest reliability of the instrument was assessed in a separate field test school, and produced item agreements in the 90% to 100% range for the variables under study. This level of reli- ability was consistent with other studies that used similar instrumentation and samples.6-*

The sample was derived by dividing the state into eight geographical regions according to the system designed by the Arkansas Activity Association. One Class A high school (enrollment between 100-185 stu-

282 Journal of School Health September 1986, Vol. 56, No. 7

dents) and one Class B high school (less than 100 students) were selected at random from each of the eight regions. In one of the eight districts, all selected schools refused participation. In one additional district, there was no Class B school, resulting in the eventual sample of 13 schools.

The inventory was distributed in homeroom settings by a teacher in each school who had been briefed about performing this task. Respondents were limited to stu- dents in attendance on the days of questionnaire administration. No follow-up was done on absent stu- dents. Of 1,237 questionnaires distributed, 36 were dis- carded from analysis because too few items had been completed to allow meaningful assessment. Data were transferred to coding forms and entered into a file on a university main frame computer. Data analysis was per- formed with the Statistical Package for the Social Sciences’ and included frequencies and percentages to describe the population of users and nonusers.

RESULTS Respondents ranged from 14-19 years of age with a

mean age of 16. In this study, 595 (49.5%) were male and 606 (50.5’?’0) were female. Of 595 males sampled, 205 (34.5%) presently used smokeless tobacco. Only 15 females (2.5%) reported current use of smokeless tobacco. The periods of time during which persons indi- cated they had used smokeless tobacco varied and are reported in Table 1. About 43.3% of dippers/chewers reported use for less than two years. However, slightly more than one-third had engaged in the activity for more than three years.

Table 1 Number of Years of Reported Use of Smokeless Tobacco Products

(N=219)

Ouration of Use Number of Users Percentage of Users Less than one year 50 22.8 One to two years 45 20.5 Two to three years 46 21 .o Three to four years 76 34.7 Over four years 2 1 .o Total: 219 100.0

___ -

Table 2 Most Significant Influence for Initiation of Smokeless Tobacco Use

(N-217)

Influence Number of Users Percentage of Users Parent 124 57 1 Coach 71 32 7 Teacher 20 9 2 Friend 1 0 5 Advertisement 1 0 5 Total 217 100 0

~ ___

Table 3 Most Frequently Reported Occasions For Using Smokeless

Tobacco (N = 220)

Occasion Number 01 Users Percentage of Users When bored or alone 140 63 6 When participating in athletics 74 33 6 When working 5 2 3 When with friends 1 0 5

Total 220 100 0 __ __

Survey participants were asked, “On the average, how many dipdchews of smokeless tobacco per day do you use?” The modal response was “at least one diplchew nearly every day” (84.0%). Another 13.4% stated they used “two-three dipdchews nearly every day.” In this sample, smokeless tobacco use was more than an occasional pasttime. In a follow-up question, participants were asked, “When you use smokeless tobacco, approximately how long do you leave each dip/chew in your mouth?” Though duration of use varied, the modal response was “one to 30 minutes.” Of 220 users, 66 (30.0%) reported each dip or chew was kept in the mouth in excess of 30 minutes.

Users were asked, “Who/what was the single most significant influence in your decision to begin using smokeless tobacco?” Responses are in Table 2. A strong parental influence was evident in the reason most frequently cited for deciding to use smokeless tobacco. Among 217 respondents, 124 (57.1%) pointed to “a parent” as the most significant influence. A “coach” was identified by 71 (32.7%) respondents, and 20 (9.2%) reported a “teacher” as being most influential.

Subjects were asked, “Which situation best repre- sents when you most like to dip/chew?” Responses are reported in Table 3. The most frequently cited situation by 140 (63.6%) of 220 respondents was “when bored or alone.” However, 74 (33.6%) cited “when participating in athletics” as the circumstances during which they most liked to dip/chew.

Users of smokeless tobacco products were queried about their concurrent use of cigarettes and related smoking products, as well as about their use of beverage alcohol. Sixty-six (30.5%) smokeless tobacco users responded they occasionally smoked cigarettes, and 115 (53.2%) indicated periodic use of alcohol. When asked if parents or guardians approved of their dipping or chewing habit, 120 of 220 users (54.5%) indicated parent or guardian disapproval. The final question was, “If you could, would you like to stop using smokeless tobacco?” Of 220 users, only 25 (11.4%) reported an interest in discontinuing the activity.

DISCUSSION Data in this study substantiate widespread preva-

lence of smokeless tobacco use among male high school students in these rural geographic regions of Arkansas. More than one-third of male respondents in this sample reported current use. Responses showed more than one- half (56.7%) of users already had participated in the activity for more than two years. Thus, the critical period for initiation for this group appears to have been in the waning years of junior high school. It could be speculated that interest in smokeless tobacco products and temptation to try them may occur years earlier.

Perhaps special prevention/intervention programs targeting males in particular should occur no later than junior high school. However, at least one study16 reports smokeless tobacco use in a significant propor- tion of kindergarten children, supporting an argument for initiating comprehensive tobacco education at the start of formal schooling. Among users identified in this study, 97.4% reported participation on nearly a daily basis. Thus, many young people in this setting have sig-

Journal of School Health September 1986, Vol. 56, No. 7 283

nificant exposure to an agent with potentially life- threatening health consequences.

The most often cited initiation factor was the influ- ence of “a parent.” This observation is interesting because more than 50% of users also indicated their parent or guardian disapproved of involvement with smokeless tobacco. The additional influences of “a coach” and “a teacher” strongly favor an “adult role model explanation” as accounting for most early involvement of current adolescent users of smokeless tobacco products. In this study, the role of “a friend” as the “most significant influence” accounted for little of the initial dipping/chewing practice. These findings contrast greatly with those of an earlier investigation in an Arkansas metropolitan high school sample,6 and with those of a collegiate sample in southern Illinois.8

Those earlier studies supported a “peer influence model” for initial smokeless tobacco use. The dis- crepancy in getting consistent results is not really ex- plained by differences in instrumentation, suggesting a real difference may exist between urban youth and their rural counterparts. If such a relationship is true, health education programs for early prevention or intervention might necessarily have to take substantially different approaches, depending on geographic location. Perhaps the adult role model accounts for many first exposures, but the peer influence assumes a larger role over time, and reinforces subsequent experiences with smokeless tobacco products. Further investigation is required to examine these relationships.

The most frequently cited occasion for using smoke- less tobacco was “when bored or alone,” suggesting a substantial number of users dip or chew as a solitary activity, rather than as a group activity. However, about one-third of users reported the usual circumstance for engaging in the activity was during athletic patticipa- tion, giving rise to a belief this form of tobacco use is, at least in part, a social or group activity. If “being alone” or “being bored” accounts for much of the circumstan- tial influence associated with smokeless tobacco use, interventions need to address such factors as coping with being alone, and teaching people to structure time and activity in ways that have less potential for being destructive to health.

Previous studies demonstrated interest in cessation among adolescent smokeless tobacco users ranging from 28.2Yo6 to 41.9%.’These data indicate only 11.4% of rural adolescent users expressed such interest. The reason for this discrepancy is unknown. An apparent social reinforcer or educational deficit in the current group supports desire for continued use. Presently, no reliable data exist regarding effective ways to prevent smokeless tobacco use. While smoking cessation pro- grams have existed for some time, and with varying degrees of reported success, attempts at “smokeless cessation” programs have been made only recently. I’ It is worth noting again that a substantial number of users also reported cigarette smoking activity (30.5%) and periodic alcohol consumption (53.2%). The combina- tion of these activities with smokeless tobacco use leaves open the possibility of some users being exposed to products that have synergistic potential.

Future work may need to identify shifts between use of smoking and smokeless tobacco, as well as combined

use during adolescence. Additional effort also needs to be placed on further delineating the role of coping skills and psychosocial variables such as perceived self-esteem and self-concept in creating a “proneness” toward use of smokeless tobacco.

It is possible that effective health information alone may deter some current users. It is probable that most teachers are provided little formal education about these tobacco products, and therefore, are unprepared in- formationally to respond to questions or provide guid- ance for their students. Effective education resulting in desirable outcomes is likely to occur only if professional preparation efforts are expanded and specially targeted.

CONCLUSION Though the popularity of and support for snuff

dipping and tobacco chewing among some males no longer are going unchallenged, smokeless tobacco use should remain an important issue for school health educators. While a sales decline in smokeless tobacco products occurred during the fourth quarter of 1985, U.S. Tobacco Co., Greenwich, Conn., expects further growth in the market to produce a 1986 per-share earn- ings increase of 10% after adjusting for inflation (Hall T: U.S. Tobacco sees smokeless products gaining sales despite health concerns. Wall Street Journal, March 1 1 , 1986, p 7). Though advertising of these products by broadcast media is banned as of Aug. 27, 1986, and warning labels on products mandatory as of Feb. 27, 1987, these efforts to curb use may be insufficient. The youth surveyed in this study did not report advertising to be instrumental in the initiation of product use. Moreover, the U.S. Tobacco Co., president cites “word of mouth about the product” as “the basis of [product] sales” (Hall T: U.S. Tobacco sees smokeless products gaining sales despite health concerns. Wall Street Journal, March 1 1 , 1986, p 7). Thus, current and future tobacco education programs that are not comprehen- sive, and are negligent in teaching about the health risks and social pressures related to smokeless tobacco use, may be doing a less than adequate job .0

References 1. Christen AG, Swanson BZ, Glover ED, Henderson AH:

Smokeless tobacco: the folklore and social history of snuffing, sneezing, dipping, and chewing. J A m Dent Assoc 1982;105:821-829.

2 . Bonaguro JA, Smith BJ, Bonaguro EW: Parental approval and smokeless tobacco usage. Health Educ, to be published.

3. Greer RO, Poulson TC: Oral tissue alterations associated with the use of smokeless tobacco by teenagers, 1. Clinical Findings. Oral Surg 1983;56:275-284.

4 . Guggenheimer J , Zullo TG, Kruper DC, Verbin RS: Changing trends of tobacco use in a teenage population in western Pennsyl- vania. A m J Public Health 1986;76:196-197.

5. Hunter SM, Croft JB, Burke GL, Parker FC, et al: Longitudinal patterns of cigarette smoking and smokeless tobacco use in youth: The Bogalusa heart study. A m J Public Health 1986;87:

6. Marty PJ, McDermott RJ, Williams T: Patterns of smokeless tobacco use in a population of high school students. A m J Public Health 1986;76: 190-192.

7. Marty PJ, McDermott RJ, Young M, Guyton R: Prevalence and psychosocial correlates of dipping and chewing behavior in a group of rural high school students. Health Educ 1986;17(2):28-31.

193- 195.

284 Journal of School Health September 1986, Vol. 56, No. 7

8. McDermott RJ, Marty PJ: Dipping and chewing behavior among university students: Prevalance and patterns of use. J Sch Health 1986;56(5): 170- 175.

9. Severson H, Lichtenstein E, Gallison C: A pinch or a pouch instead of a puff? Implications of chewing tobacco for addictive processes. Bull SOC Psycho1 Addict Behav 1985;4(2):85-92.

10. American Cancer Society: Editor’s note. CA: A cancerjournal for clinicians 1984;34:247.

11. Squier CA: Smokeless tobacco and oral cancer: A cause for concern? CA: A cancer journal for c/inicians1984;34:242-247.

12. Frankel HH: Another cowboy selling cancer. West J Med

13. Glover ED, Edwards SW, Christen AG, Finnicum P: Smoke- 1979;130:270-271.

less tobacco research: An interdisciplinary approach. Health Values

14. National Institutes of Health: Consensus development con- ference statement health implications of smokeless tobacco use. Bethesda, Md, National Institutes of Health, 1986.

15. Nie NH, Hull CH, Jenkins JG, Steinbrenner K, et al: Statistical Package for the Social Sciences, 2nd ed. New York, McGraw Hill, 1975. 16. Young M, Williamson D: Correlates of use and expected use of

smokeless tobacco among kindergarten children. Psycho/ Rep

17. Glover ED: Conducting smokeless tobacco cessation clinics.

1984;8(3):21-25.

1 985 ;56:63-66.

A m J Public Health 1986;76:207.

Depression and Suicide in Children The Raphell Sims Lakowitz Memorial Conference, “Depression and Suicide in

Children and Adolescents,” Friday, Sept. 26, will alert professionals and provide training for recognition, diagnosis, treatment, and prevention of depression and suicide in children. For registration information, contact: Mary B. Strong, MA, Conference Coordinator, Dept. of Health Education/Community Affairs, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030.

Committee on Aging Education and Death Education James M. Eddy, DEd (1987) College of HPER. White Building Pennsylvania State University University Park, PA 16802

Committee on College Health Education and Professional Preparation Barbara A. Rienzo, PhD (1986) Dept. of Health Education Bldg. 4, Florida Gym University of Florida Gainesville. FL 3261 1

Committee on Consumer Health Carolyn G. Plonsky. EdD, FASHA (1988) 54 South Ave. Staten Island. NY 10303

Committee on Dental Health Susan Seffrin. MS, FASHA (1988) Assistant Director Bureau of Health Education and Audiovisual Services American Dental Association 211 E. Chicago Ave. Chicago, IL 6061 1

Committee on Drug Education Susan R. Levy, PhD (1986) University of Illinois at Chicago Circle Campus P.O. Box 4348 Chicago, IL 60680

Committee on Environmental Health Anita G. Hocker, MA (1987) Sarasota County Schools 2418 Hatton St. Sarasota, FL 33577

American School Health Association Study Committee Chairpersons

Committee on Health Guidance in Sex Education David C. Marini, PhD (1986) Dept. of Physiology 8, Health Science Ball State University Muncie, I N 47306

Committee on International Health Alan N. Rabe. PhD (1987) Liberty Baptist College Box 20,000 Lynchburg, VA 24506

Committee on Mental Health David K . Lohrmann, PhD (1988) Dept. of Health & Safety University of Georgia Stigeman Hall Athens, GA 30602

Committee on Nontraditional Thought in Health and Health Education Rebecca L. Banks, PhD. FASHA (1988) Dept. of Health Sciences Box 50 Mankato State University Mankato. MN 56001

Committee on Nutrition Beatrice P. Largay BS, MA (1988) Health Specialist 771 1 Livingston Road Oxon Hill, MD 20745

Committee on Physical Activities James W. Lochner, EdD (1986) Weber State College P.O. Box 2801 Ogden, UT 84408

Committee on Safety & Emergency Care R. Ken Peden, EdD, FASHA (1987) Professor of Education College of Education Clemson University Clemson, SC 29634-0709

Committee on School Health Education Lorraine H. Jones, RN, MA, MSN (1988) School of Nursing Ball State University Muncie. IN 47306

Committee on School Nurses Alicia A. Snyder, RN. MA, FASHA (1986) 37 Rock Ridge Dr., NE Albuquerque, NM 87122

Committee on School Physicians Vivian K . Harlin, MD, FASHA (1988) P.O. Box 340 Ravensdale, WA 98501

Committee on Special Health Problems of Children Corinne C. Cloppas, RN (1988) School Health Consultant Illinois Dept. of Public Health 245 W. Roosevelt Road, Bldg. 5 West Chicago, IL 60785

Coordinator of Study Committees Larry K. Olsen. DrPH, FASHA (1986) College of HPER. White Bldg. Pennsylvania State University University Park, PA 16802

Executive Director Dana A. Davis ASHA National Office P.O. Box 708 Kent, OH 44240-0708

Study Committees are organized to develop and promote useful studies and related activities in health instruction, school health services, and healthful school environments. Committee appointments are made by the Coordinator of Study Committees. Any questions concerning study committee activities should be directed to the respective chairperson. Membership on these committees is open to all ASHA members in good standing.

Journal of School Health September 1986, Vol. 56, No. 7 285