Smokeless Tobacco Use Among American Indian Women -- Southeastern North Carolina, 1991

Rates of smokeless tobacco use among U.S. adults are highest for young males, American Indians/Alaskan Natives, persons residing in the South or rural areas of the country, and those of low socioeconomic status (1). In addition, the prevalence of smokeless tobacco use has been reported to be high in tobacco-producing regions, including rural North Carolina and Kentucky (2,3). In southeastern North Carolina, reports from physicians and dentists suggested a high prevalence of smokeless tobacco use in the local American Indian population, the Lumbee -- particularly among women and children. In response to these reports, the Department of Family and Community Medicine at the Bowman Gray School of Medicine of Wake Forest University analyzed data from a National Cancer Institute-sponsored cervical cancer prevention program to estimate the prevalence of smokeless tobacco use during 1991 among Lumbee women aged greater than or equal to 18 years residing in Robeson County, North Carolina (1990 population: 105,179).

This analysis was based on responses to a survey conducted as part of the cancer-prevention program; these data are the most complete on tobacco use for this population. The survey included questions about cervical cancer knowledge, attitudes, and practices; demographic characteristics; social support; and health behavior, including use of tobacco and alcohol. A random sample of 479 women was selected from the official Lumbee tribal enrollment database using a computer-generated list of phone numbers; the database lists approximately 43,000 persons (86% of the estimated 1990 population of the Lumbee tribe). A telephone number was listed for 99% of the Lumbee tribal members in the database. The survey was conducted in respondents' homes during August-October 1991 by nine Lumbee women who had been trained as research assistants.

Smokeless tobacco use was classified as ever or never use based on the question, "Have you ever used chewing tobacco or snuff?" Ever use was further subdivided into current use (those who reported using smokeless tobacco at the time of the survey) and former use (those who reported not using smokeless tobacco at the time of the survey). Early initiation (defined as beginning use at age less than 6 years) was based on the question, "How old were you when you began using chewing tobacco or snuff regularly?" The survey also assessed smoking status (never, former {smoked at least 100 cigarettes during their lifetime but did not smoke at the time of the survey}, and current {smoked at least 100 cigarettes during their lifetime and smoked at the time of the survey}), self-reported health status (excellent, good, fair, or poor), social or church group participation, number of close friends, and reported use of medical services. Chi-square analysis was used to assess differences in smokeless tobacco use by demographic, social support, and health behavior categories and to assess the frequency of early initiation of smokeless tobacco use in relation to age group.

Of the 479 women surveyed, 307 (64%) reported never using smokeless tobacco, 64 (13%) reported former use, and 108 (23%) reported current use. The prevalence of current smokeless tobacco use was greatest among women aged greater than or equal to 65 years (51%) and lowest among those aged 25-34 years (6%) and 18-24 years (11%) Table_1. Current use also was high among women who had less than 12 years of education (42%), whose annual income was less than $11,000 (31%), who were widowed (42%), who had never smoked cigarettes (30%), and who perceived their health as poor or fair (39%). Current smokeless tobacco use was not associated with alcohol use, use of medical services, church or social group participation, or number of close friends.

Age at initiation of smokeless tobacco use was unknown for 18 (10%) of the 172 ever users; although demographic characteristics of these women were similar to those for whom complete initiation data were available, these respondents were excluded from analyses of age at initiation of use. The median age at initiation of smokeless tobacco use was 10 years; of the ever users for whom data were available, 90% initiated smokeless tobacco use before age 18 years. Median duration of smokeless tobacco use among all current users was 37 years.

Because women in older age groups had a greater chance of beginning smokeless tobacco use at age greater than or equal to 18 years, women who initiated smokeless tobacco use at age greater than or equal to 18 years (n=16) were eliminated from the analysis of women who initiated smokeless tobacco use at an early age to ensure comparability between the youngest and older age groups; the women who were excluded did not differ from the others by income or education. The prevalence of early initiation of smokeless tobacco use was highest among those aged 18-24 years (77%) Table_2. The prevalence of early initiation in other age groups ranged from 18% to 30%. Based on analysis of aggregated data, 35% of women aged less than or equal to 44 years began smokeless tobacco use before age 6 years, compared with 22% of women aged greater than or equal to 45 years. Reported by: JG Spangler, MD, MB Dignan, PhD, R Michielutte, PhD, Dept of Family and Community Medicine, Bowman Gray School of Medicine of Wake Forest Univ, Winston-Salem, North Carolina. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Based on the findings of this survey, the prevalence of smokeless tobacco use among Lumbee women in North Carolina in 1991 was nine times the national mean prevalence for American Indian women (2.5%) and 38 times that for women in the total U.S. population (0.6%) (1). Robeson County, where most of the Lumbee reside, is the third largest tobacco-producing county in North Carolina (E. Davis, Robeson County {North Carolina} Agricultural Extension Service, personal communication, 1994), and the high prevalence of smokeless tobacco use among the Lumbee women may reflect, in part, the tobacco-based local economy. High prevalences of smokeless tobacco use also have been documented in other tobacco-producing regions of the United States (2,3). However, the prevalence of smokeless tobacco use among these women was more than twice that of women in Pitt County, North Carolina (3), the leading tobacco-producing county in the United States, and approximates the prevalence among some male adolescent populations (4).

Cultural factors specific to American Indians and the economic impact of tobacco on residents of this region may be associated with this unusually high prevalence of smokeless tobacco use. For example, use of tobacco has been a part of American Indian culture, including medicinal uses such as treatment of gastrointestinal symptoms (5), since before the arrival of Europeans (6,7). Such uses of tobacco, combined with the availability of tobacco leaf among tobacco-farming families, may be associated with initiation of nicotine addiction in young children.

The findings in this study are subject to at least two limitations. First, respondents were asked to recall their use of smokeless tobacco as children; because early age at initiation among younger women was more recent and, therefore, more likely to be remembered, the high prevalence of early onset of use among younger women may partly reflect this bias. Second, family use of tobacco and family or personal involvement in tobacco production were not analyzed. Employment in tobacco production may play a role in attitudes toward smokeless tobacco use (3) because personal involvement in growing tobacco has been associated with a high prevalence of smokeless tobacco use among adolescents (2).

The high prevalence of smokeless tobacco use among Lumbee women increases the risk for health hazards, including gingival recession, tooth loss, leukoplakia, and oral cancer. Nicotine use may also increase the risk for cardiovascular disease (8) and reproductive risks such as low birthweight, premature delivery, and spontaneous abortion (9). Further assessment of parents' attitudes toward childhood smokeless tobacco use, the anthropologic characteristics of smokeless tobacco use among the Lumbee, and the influence of a tobacco-based economy on early initiation and high prevalence of smokeless tobacco use should assist in the development of culturally and economically acceptable interventions.

References

1. CDC. Use of smokeless tobacco among adults -- United States, 1991. MMWR 1993;42:263-6.

2. Noland MP, Kryscio RJ, Riggs RS, Linville LH, Perritt LJ, Tucker TC. Use of snuff, chewing tobacco, and cigarettes among adolescents in a tobacco-producing area. Addict Behav 1990; 15:517-30.

3. Glover ED, O'Brien K, Holbert D. Prevalence of smokeless tobacco use in Pitt County, North Carolina. Int J Addict 1987;22:557-65.

4. Kann L, Warren W, Collins JL, Ross J, Collins B, Kolbe LJ. Results from the national school-based 1991 Youth Risk Behavior Survey and progress toward achieving related health objectives for the nation. Public Health Rep 1993;108(suppl 1):47-55.

5. Vogel V. American Indian medicine. Norman, Oklahoma: University of Oklahoma Press, 1994.

6. Christen AG, Swanson BZ, Glover ED, Henderson AH. Smokeless tobacco: folklore and social history of snuffing, sneezing, dipping, and chewing. J Am Dent Assoc 1982;105:821-9.

7. CDC. Smoking and health in the Americas: a 1992 report of the Surgeon General, in collaboration with the Pan American Health Organization. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992; DHHS publication no. (CDC)92-8419.

8. Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health 1994;84: 399-404.

9. National Institutes of Health. Smokeless tobacco or health: an international perspective. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1992; NIH publication no. 93-3461.

TABLE 1. Percentage of Lumbee women reporting current smokeless tobacco
use, by demographic, health, and social support categories
-- North Carolina, 1991
========================================================================
                           Sample              Current use
Category                    size        No.    (%)     (95% CI *)
------------------------------------------------------------------------
Demographics
  Age group (yrs)
    18-24                    80           9   (11.2)   ( 4.3-18.1) +
    25-34                   106           6   ( 5.7)   ( 1.3-10.1)
    35-44                   104          24   (23.1)   (15.0-31.2)
    45-54                    66          19   (28.9)   (18.0-39.8)
    55-64                    56          16   (28.6)   (16.8-40.4)
     >=65                    67          34   (50.7)   (38.7-62.7)

  Education (yrs)
    <12                     175          74   (42.3)   (35.0-49.6) +
     12                     169          22   (13.0)   ( 7.9-18.1)
    >12                     135          12   ( 8.9)   ( 4.1-13.7)

  Annual household income
          <=$10,999         132          41   (31.0)   (23.1-38.9) +
    $11,000-$19,999         120          26   (21.7)   (14.3-29.1)
          >=$20,000         227          41   (18.1)   (13.1-23.1)

Health
  Self assessment of health
    Poor or fair            148          57   (38.5)   (30.7-46.3) +
    Good or excellent       331          51   (15.4)   (11.5-19.3)

  Smoking status
    Never smoker            278          83   (29.8)   (24.4-35.2) +
    Former smoker &          71          11   (15.5)   ( 7.1-23.9)
    Current smoker @        130          14   (10.8)   ( 5.6-16.1)

  Alcohol use
    Monthly, weekly,
     or daily                46          11   (23.9)   (11.6-36.2) +
    Never or infrequent     433          97   (22.4)   (14.2-30.6)

  Annual physical exam
    Yes                     301          61   (20.3)   (15.8-24.8)
    No                      178          47   (26.4)   (19.6-33.2)

Social Support
  Marital status
    Married                 275          53   (19.2)   (14.5-23.9) +
    Separated/Divorced       60          18   (30.0)   (18.4-41.6)
    Widowed                  55          23   (41.8)   (28.8-54.8)
    Never married            89          14   (15.7)   ( 8.1-23.3)

  Church group
   participation
    Yes                     241          59   (24.5)   (19.1-29.9)
    No                      238          49   (20.6)   (15.5-25.7)

  Social group
   participation
    Yes                      42           6   (14.3)   ( 3.7-24.8)
    No                      437         102   (23.3)   (19.3-27.7)

  Number of close friends
       0                     26           6   (23.1)   ( 6.9-39.3)
     1-5                    361          78   (21.6)   (17.4-25.8)
      >5                     92          24   (26.1)   (17.1-35.1)

Total population            479         108   (22.5)   (14.6-30.4)
------------------------------------------------------------------------
* Confidence interval.
+ p<0.05.
& Smoked at least 100 cigarettes during their lifetime and did not smoke
  at the time of the survey.
@ Smoked at least 100 cigarettes during their lifetime and smoked at the
  time of the survey.
========================================================================

TABLE 2. Frequency of initiation of smokeless tobacco use among
Lumbee women at age <6 years among ever users *, by age group
-- North Carolina, 1991
===============================================================
Age group      Total        Initiation of use at age <6 yrs
  (yrs)       ever users        No.  (%)    (95% CI +)

  18-24         13             10   (77)  (54.1%-99.9%) &
  25-34         17              4   (23)  ( 5.4%-42.1%)
  35-44         36              9   (25)  (10.9%-39.1%)
  45-54         20              6   (30)  ( 9.9%-50.1%)
  55-64         18              4   (22)  ( 3.0%-41.3%)
   >=65         34              6   (17)  ( 5.2%-30.8%)

  Total        138             39   (28)  (20.5%-35.5%)
---------------------------------------------------------------
* n=172. Age was unknown for 18 (10%). To make older groups
  comparable to the youngest age group (18-24 years), ever
  users were limited to those initiating use by age <18 years;
  this eliminated 16 (10%) ever users from the analysis.
+ Confidence interval.
& p<0.005.
===============================================================

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