Snuff just as addictive as cigarettes
Those who use both are even more dependent on nicotine, study shows
Reuters via MSNBC.com
updated 4:35 p.m. ET, Fri., Feb. 26, 2010People who use smokeless tobacco, or "snuff," are just as hooked on nicotine as cigarette smokers, if not more so, new research from Sweden shows.
And those who smoke and use snuff may be especially nicotine-dependent, Dr. Ann Post of the Karolinska Institute in Stockholm and her colleagues found.
The researchers looked at more than 800 teen boys and girls who used tobacco, including 466 who only smoked cigarettes, 209 who only used snus (the traditional Swedish type of snuff), and 144 who used both. Eighty-seven percent of the entire group reported having symptoms of nicotine dependence. The average age of the study participants was around 18.
Post and her team looked at nine different symptoms of nicotine dependence, including using tobacco within a half-hour of waking up in the morning; using tobacco despite being sick; and trying to quit and failing. They also asked the study participants whether they'd experienced any of 12 different withdrawal symptoms when they stopped using tobacco, such as craving, restlessness, and difficulty concentrating.
All but two of the nicotine dependence symptoms were more frequent among exclusive snus users than among smokers, the researchers found, while every symptom was more common among the dual users than the exclusive smokers. For example, around 70 percent of the exclusive smokers said they felt addicted to tobacco, compared to nearly 80 percent of the snus-only users and about 90 percent of the dual users.
The risk of withdrawal symptoms for exclusive snus users and exclusive smokers was fairly similar, but the snus plus tobacco users were two to five times as likely to experience these symptoms as exclusive smokers.
Eighty percent of both snus users and dual users said they had used tobacco on the day of the survey, the researchers note, compared to 56 percent of the smokers, "probably indicating a more advanced stage of progression toward regular use."
They also found that the snus-only users reported fewer quit attempts than the smokers.
"The findings in this study," the researchers say, "support the conclusion that smokeless tobacco in adolescence has a potential to induce nicotine dependence which is at least as high as for cigarette smoking."
Copyright 2010 Reuters
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Symptoms of nicotine dependence in a cohort of
Swedish youths: a comparison between smokers,
smokeless tobacco users and dual tobacco users
Swedish youths: a comparison between smokers,
smokeless tobacco users and dual tobacco users
Journal: Addiction, February 9, 2010 [Epub ahead of print]
Authors: Post A, Gilljam H, Rosendahl I, Bremberg S, Rosaria Galanti M.
Study Abstract (Summary)Aims: To determine whether symptoms of nicotine dependence, addiction and withdrawal symptoms differ between exclusive smokers, exclusive snus (moist snuff) users and dual users.
Design: A cross-sectional survey of a cohort subsample.
Setting: County of Stockholm, Sweden.
Participants: Current exclusive smokers (n = 466), exclusive snus users (n = 209) and dual users (n = 144), mean age 17.6 years.
Measurements: Self-reported life-time experience of nicotine dependence and withdrawal symptoms in periods of discontinued tobacco use. Selected items from the modified Fagerstöm Tolerance Questionnaire (mFTQ), the Hooked on Nicotine Checklist (HONC) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
Findings: The odds ratio of endorsing each of four mFTQ items as well as the HONC item investigating the risk of feeling addicted to tobacco was two to five-fold higher for exclusive snus users and for dual users compared to exclusive smokers. One DSM-IV item (difficult to refrain from use) was elevated among dual users compared to smokers. Dual users reported the highest prevalence of any withdrawal symptom in contrast to exclusive snus users, who reported a lower risk of withdrawal symptoms compared to exclusive smokers.
Conclusions: Smokeless tobacco users show symptoms of nicotine dependence at least as frequently as cigarette smokers. Symptoms of nicotine dependence and of withdrawal during quit attempts are particularly frequent in the subgroup of users who combine smokeless tobacco with smoking.
Source: http://www.ncbi.nlm.nih.gov/pubmed/20148785I put the following table together using data from the above study. It reflects symptoms of nicotine dependency reported in the study among students who used tobacco within the past 30 days. When reading the below table keep in mind that only 46% of smoking students responding were daily smokers, while 74% of oral tobacco users of daily users. Dependency symptoms reported among daily users would obviously have been higher than the figures shown below, with include students who used within the past 30 days but are not yet daily users.
|Use within 30 minutes of waking-up||22%||45%||49%|
|1st daily use is the hardest to give up||33%||42%||49%|
|Difficult to refrain when forbidden||36%||39%||53%|
|Use even when ill||27%||53%||65%|
|Strong need/difficult to think of anything else||59%||52%||73%|
|Used although you decided not to||75%||54%||75%|
|Use caused neglect of important activities||21%||14%||24%|
|Have previously tried to quit and failed||79%||66%||75%|
|Feel as though addicted to tobacco||69%||78%||90%|
Below are researcher discussion comments included at the end of the full-text of the above new study:
In this study of adolescents a significantly higher proportion of dual users and of exclusive snus users reported life-time symptoms of ND [Nicotine Dependence] compared to exclusive cigarette smokers. Also, withdrawal symptoms in periods of reduced or discontinued use were reported more frequently by dual users than by either exclusive smokers or exclusive snus users. Finally, more than 80% of the snus users and dual users reported use on the very same day of the survey compared to 56% of smokers, probably indicating a more advanced stage of progression towards regular use.
Approximately nine of 10 adolescents had experienced any of the ND items, including withdrawal symptoms, in their life-time. Dual users and exclusive snus users reported more frequent ND symptoms from the modified mFTQ compared to exclusive smokers. They also reported feeling addicted to tobacco more often than smokers, with dual users reporting a fivefold higher prevalence OR [odds ratio] compared to exclusive smokers. However, the life-time prevalence of three criteria for ND in the DSM-IV did not differ between the groups.
A slightly different picture emerged concerning withdrawal symptoms. While dual users reported the highest frequency of almost all symptoms, exclusive snus users generally reported similar frequency to exclusive smokers. It should also be noted that snus users reported a lower frequency of quit attempts. The typology of withdrawal symptoms (whether reflecting prevalently psychological distress or physical distress) was not different between the three groups of users.
Some differences in response to the items assessing dependence and withdrawal symptoms can probably be explained by the topography of smokeless tobacco use. A dip of snus is held in place between the lip and the gum without chewing or spitting. This makes it relatively easy to conceal and therefore possible to use where tobacco use is forbidden (e.g. in schools). Also, the risk of adverse health effects, both short- and long-term, is lower with snus than with cigarettes . Therefore, the low perceived health risk may be a possible explanation for the low frequency of quit attempts among exclusive snus users compared to smokers.
A previous analysis of this cohort of youths showed that dual users had a high-risk profile of consumption compared to exclusive users of either snus or cigarettes . Also, recent data from a cross-sectional study indicated a higher grade of ND among young adult smokers using more than one tobacco product . The order of initiation of products in this longitudinal study indicated that the risk to proceed to current use was lowest among exclusive snus users and highest among experimenters of both product . In this sample socio-demographic characteristics were similar, but dual users reported earlier initiation of any tobacco and also higher frequency of alcohol consumption compared to the exclusive users. This profile of substance use has been reported previously among Swedish adolescents and suggests the presence of a subgroup of adolescents that is particularly vulnerable to substance use progression .
To our knowledge, this is the first study comparing profiles of ND among adolescent smokeless tobacco users with those of adolescent cigarette smokers. Previous studies suggest that smokeless tobacco users are exposed to high nicotine doses [20,21]. Indeed, these levels can be sustained for a much longer time than among smokers. The slower decline in nicotine plasma levels may be due to a nicotine depot effect in themucous membrane of the mouth, as this tissue can release nicotine for a longer time after the product is removed . This may explain why the severity of withdrawal symptoms is somewhat lower among adult smokeless tobacco users . If habitual adolescent users of smokeless tobacco are exposed to similar doses as adults it can explain the higher prevalence of dependence despite the lower frequencies of withdrawal symptoms compared to exclusive smokers in our study.
A major limitation of this study is that we did not employ a complete instrument for the assessment of nicotine dependence. Comparisons are therefore limited
to single items or group of items belonging to different scales. However, the evaluation of full scales using multiple items to measure withdrawal symptoms did not yield more reliable or accurate measurements than the reduced scales [25,26]. It should also be noted that the development of instruments to assess ND among smokeless tobacco users is still under way [7,8]. Snus users in this study reported lowfrequency of quit attempts or urge to use tobacco when not allowed. This indicates that, in pursuing more efficient instruments to assess ND among smokeless tobacco users, efforts are needed to disentangle the effect of topography of product use from that of the addictive properties of the product as such.
Another major limitation is that symptoms of ND were investigated based on life-time experience. This choice was motivated by the young age of this study population, with few addicted users and probably few past quit attempts. As all participants in the study were current users of tobacco, it is likely that their reports reflect relatively recent experiences. In fact, adolescents' recall of events occurring more than 1 year ago is inconsistent, although older adolescents show better recall than younger adolescents [27,28]. On the other hand, the concurrent assessment of withdrawal symptoms or other symptoms of ND would require much more sophisticated media, not suitable to be employed in large-scale epidemiological studies. The strengths of the study include the sample size, high participation rate and detailed history of both cigarette smoking and snus use.
The findings in this study support the conclusion that smokeless tobacco in adolescence has a potential to induce nicotine dependence which is at least as high as for cigarette smoking. It also reveals a high frequency of symptoms of nicotine dependence and of withdrawal during quit attempts among the subgroup of young users who combine smokeless tobacco with smoking. In order to unravel whether this finding indicates subgroup vulnerability or differential addictive properties of combined tobacco use, further longitudinal studies are warranted, with refined assessment of personality traits and psychopathological symptoms preceding tobacco use.
Copyright 2010 Addiction