Cigarette smokers’ concurrent use of smokeless tobacco: dual use patterns and nicotine exposure

Abstract

BackgroundThe concurrent use of cigarettes with other tobacco products, such as smokeless tobacco (SLT), is increasingly common. Extant work with cigarette smokers who also use SLT is based heavily on retrospective reports and between-group comparisons. The purpose of this study was to assess prospectively the patterns of dual users’ product use and nicotine exposure on days when cigarettes were smoked exclusively (single use) versus concurrently with SLT (dual use).DesignForty-six dual cigarette-SLT users recorded their product use in real time via ecological momentary assessment for a 2-week longitudinal design. They responded to questions about situational factors (eg, location, mood) using this same diary, and collected saliva samples each night for later cotinine measurement. At the end of this 2-week period, users reported on their reasons for and beliefs about SLT use.ResultsCotinine levels were significantly higher on dual versus single use days (mean±SEM=374.48±41.08 ng/mL vs 300.17±28.13 ng/mL, respectively; p<0.01), and the number of cigarettes logged was higher on dual versus single use days (11.13±0.98 vs 9.13±1.11, respectively; p<0.01). Product use was distinguished by situational factors, with the strongest predictor being location of use. Moreover, the most common reason for initiating (56.52%) and continuing (67.39%) SLT use was to circumvent indoor smoking restrictions.ConclusionsResults support the idea of product supplementation rather than replacement among this convenience sample of dual users. For smokers whose primary motivation for SLT use involves situations where they would otherwise be tobacco free, the potential benefits of clean indoor air laws may be diminished.

Nicotine pharmacokinetics and subjective responses after using nicotine pouches with different nicotine levels compared to combustible cigarettes and moist smokeless tobacco in adult tobacco users

“…While we have no direct evidence, the product use behavior may be different among exclusive smokers or exclusive MST users vs. dual users of cigarettes and MST products. There is some evidence of differential product use behavior; for example, Felicione et al ( 2020 ) observed significantly lower cotinine levels among dual users on days when they only smoked cigarettes as opposed to when they dual used both cigarettes and MST. Additional factors likely contributing to the lower-than-expected nicotine delivery could be due to differences in own brand products or inherent inter-subject variability, including variations in use behavior, such as the size of the MST quid used in the ad libitum vs. controlled use periods.…”

Measurement of cigarette smoking: Comparisons of global self-report, returned cigarette filters, and ecological momentary assessment.

“…Although cotinine concentrations in urine are correlated with those in saliva, concentrations are consistently higher in the former fluid (Shaik et al, 2019). Another difference is that the cigarette smokers included herein used SLT regularly; dual cigarette-SLT users’ salivary cotinine concentrations are higher on days when both products are used relative to when only cigarettes are smoked (Felicione et al, 2020). Participants’ SLT use was controlled for in regression analyses, though additional work should examine whether either measure is consistent with exposure to cotinine in a sample of cigarette smokers who do not use other tobacco products.…”

“…On one hand, spent filter collection is inexpensive and likely requires less effort from participants than using an electronic diary (Saddleson et al, 2017). On the other hand, electronic diaries can collect a wealth of information about the context of cigarette smoking, such as location of use, concurrent engagement in other behaviors, and mood (Felicione et al, 2020; Ferguson et al, 2015). For researchers who do not need to evaluate contextual-level factors, returned filters may offer a cost-effective and convenient tool for reliable measurement of smoking behavior.…”

“…Participants collected a single saliva sample before bed each night. Details regarding collection and quantification of salivary cotinine are provided in Felicione et al (2020).…”

Snus and snus-like nicotine products moving across Nordic borders: Can laws protect young people?

“…A systematic review found few primary studies investigating the possible association between snus and changes in smoking behaviour ( SBU 2020 ). However, it is noteworthy that (1) snus may serve as a gateway for smoking, at least among Finnish adolescents ( Araneda et al, 2020 ; SBU, 2020 ), (2) many school children end up as dual users ( European Commission, 2012 ; FCTC, 2012 ; Felicione et al, 2020 ; Lund & Scheffels, 2016 ; Ollila & Ruokolainen, 2016 ), (3) nicotine is also harmful in itself, especially for the developing body, including the brain ( Drug and Therapeutics Bulletin, 2014 ; USDHHS 2014 ; Viarisio, 2015 ), and (4) that snus carries considerable health risks ( European Commission, 2012 ; Folkehelseinstituttet, 2019 ; IARC, 2018 ; SCENIHR et al, 2008 ).…”