Smokeless tobacco use among American Indian women - Southeastern North Carolina, 1991

Morbidity and Mortality Weekly Report, Feb 17, 1995

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 <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 ambng those aged 25-34 years (6%) and 18-24 years (11%) (Table 1). Current use also was high among women who had <12 years of education (42%), whose annual income was <$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.

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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.