Bukola Olutola - The Economics of Tobacco Control Project

Report
Socio-economic correlates of snuff
use in South Africa during 2003 –
2011
Olutola Bukola G, Ayo-Yusuf OA
University of Pretoria & Office of the Director, School of
Oral Health Sciences, University of Limpopo, Medunsa
Campus, Pretoria
1
Introduction
•
While the prevalence of cigarette smoking is reducing in the developed world,
the use of SLT is on the increase.
•
It has been suggested that this is as a result of smokers switching to the
perceived less dangerous SLT, while others have raised concerns that SLT
may serve as an entry point to tobacco smoking.
•
South African cultural practices are such that it is predominantly black
women who use SLT, as it is considered a culturally acceptable
behaviour and a more socially discreet behaviour than smoking, which is
considered a taboo for women.
•
SLT use is socially acceptable among the indigenous black people mainly for
ceremonial and medicinal purposes. (Ayo-Yusuf et al, 2006)
2
Smokeless tobacco as a smoking initiator
• Evidence suggests that ST use is a gateway into smoking
• The use of smokeless tobacco has been shown to be a potential
predictor of smoking initiation and has been associated with a
significantly increased risk of adult-onset smoking initiation.
• SLT users may switch to cigarette as their degree of tolerance to
nicotine develops and the nicotine dependence process progresses.
3
Smokeless as a form of harm reduction
•
There is a growing interest in using smokeless tobacco (ST) products for
tobacco harm reduction (USA and Sweden).
•
Studies have shown that the use of ST by young people may reduce smoking
initiation. (Bates et al, 2003; Kozlowski et al, 2003).
•
Evidence from Sweden which has a sizeable market for snus (moist
smokeless tobacco) shows that snus plays a protective role.
•
The commercial brands of ST in South Africa deliver more nicotine than other
brands from Sweden and other developed countries and such brands may
have a higher addiction potential. (Ayo-Yusuf et al, 2004).
4
Types of snuff used in South Africa
• Two types of snuff are available in South Africa.
 Industrially-made SLT- “Ntsu”, “Taxi-Red”, “SingletonMenthol” and “Tobacco-rette original”
 Traditional, home-made SLT as ‘snuff’ prepared with local
additives, such as ash obtained from burning the mukango
vegetable plant.
5
Smokeless tobacco use in South Africa
More commercialized products, including
snus test-marketed in 2005-2007
7
SmokelessTobacco outlook by major market: Value (US$) 2008-2013
(Euromonitor, 2008)
US
2008
5,176.7
2013
8,274.5
% growth*
59.8
India
5,602.6
6,550.3
16.9
Sweden
1,204.8
1,468.7
21.9
Norway
Algeria
Canada
Denmark
366.1
347.6
175.5
10.6
709.9
338.2
198.4
39.7
93.9
-2.7
13.1
276.1
Germany
38.2
39.0
2.1
South Africa
2.7
3.3
24.5
Mexico
Tunisia
Venezuela
2.0
1.9
0.2
2.1
1.8
0.3
5.4
-4.5
8.1
Slovenia
0.2
0.2
5.9
SLT -Nicotine
•
Nicotine is the addicting agent in tobacco that prevents cessation and sustains
long term use.
•
The pH of SLT strongly influences nicotine absorption through the nose and
mouth, especially the free base (unionised) nicotine, which is the form most
readily absorbed.
•
Nicotine dose obtained from a unit (‘‘dip’’ or‘‘sniff’’) of SLT is primarily determined
by characteristics of the product itself and to a lesser extent by the amount of
snuff used, and behavioural and physiological factors unique to each user.16
•
South African commercial brands of SLT have been found to deliver more
nicotine than other brands from developed countries, and such brands may
therefore have a higher addiction potential. (Ayo-Yusuf et al, 2004).
11
Health effects of SLT
•
The levels of carcinogenic tobacco specific nitrosamines in traditional South
African SLT products are up to 19 times higher than those in Swedish-style
snus. (Ayo-Yusuf & Burns, 2012).
•
The traditional South African SLTs may also contain a considerable amount of
toxic combustion products from the ash, which comes from burning of
Mukango—used in the mixture. (Fant, 1999; Peltzer et al, 2001).
•
Long term use of oral SLT has been associated with development of
oropharyngeal and upper respiratory tract cancers and is a risk factor for
cardiovascular disease and adverse reproductive outcome.
•
SLT use may also be a risk factor for the development of chronic bronchitis and
may predispose to tuberculosis infections in South Africa.
12
Existing legislation or public campaign
•
The prevalence of smoking has decreased in South Africa over
the last 20 years but, little attention has been given to the use of
snuff.
•
SLT manufacturers in South Africa are required by law (since
1995) to include the phrase ‘‘causes cancer’’ on every can of
SLT. (WHO, 2012).
•
They are not mandated by law to disclose the nicotine content of
their products.
•
Snuff is much less expensive than cigarettes in South Africa.
13
Objective
This study therefore sought to determine trends
and socio-economic correlates of snuff use among
South African adults.
14
Methods
• This secondary data analysis involved three waves of the South African
Social Attitude Survey –Survey years and sample sizes were: 2003
(n=2,855), 2007 (2,907) and 2011 (3,003). (N=8765)
• Using interviewer-administered questionnaire, information obtained
included socio-demographic data and current smoking status.
• Current snuff users were respondents who reported using oral and/or
nasal snuff every day or some days. The datasets from the three surveys
were then merged.
• Data analysis included chi-square statistics and multivariable-adjusted
logistic regression analysis.
15
Characteristics of the study population
16
Mostly nasal use, but oral use slightly
increased
17
Snuff use among those who smoke negligible, but increased
18
Percentage of current snuff use in the study population in relation
to various characteristics
Characteristics
Gender
Race
Age
Location
Current smoking
Marital status
Education
Male
Female
Black
Others
16-24
25-34
35-44
45-54
55-64
65+
Urban
Rural
No
Current snuff use %(n)
0.98 (32)
6.02 (286)
4.60 (302)
0.38 (16)
0.80 (22)
2.78 (61)
2.95 (62)
5.80 (70)
7.28 (40)
10.71 (63)
2.93 (165)
4.97 (153)
4.09 (284)
Yes
Single
Divorce/widow
Married
No education
Grade
>Grade 12
1.83 (34)
2.18 (107)
10.62 (92)
3.84 (114)
13.16 (71)
3.31 (238)
0.53 (6)
p-Value
<0.001
<0.001
<0.001
0.002
0.001
<0.001
<0.001
19
Trends in snuff use between 2003 and 2011
20
Factors associated with current snuff use
Characteristics
Gender
Race
Age
Survey year
Marital status
Education
Male
Female
Others
Black
16-24
25-34
35-44
45-54
55-64
65+
2003
2007
2011
Single
Divorce/widow
Married
No education
Grades 1-12
>Grade 12
Odds ratio(95% Conf Interval)
1.0
5.8 (3.67-9.23)
1.0
20.2 (9.90-41.06)
1.0
3.06 (1.59-5.91)
3.34 (1.61-6.94)
6.46 (3.17-13.15)
6.29 (2.97-13.32)
9.23 (4.22-20.18)
1.0
1.28 (0.83-1.96)
0.56 (0.36-0.87)
1.0
1.71 (1.09-2.68)
1.26 (0.83-1.92)
1.0
0.58 (0.36-0.93)
0.15 (0.06-0.40)
21
Conclusion
•
The use of snuff, which is on the decline, remains predominantly among nonsmoking women, those of low socioeconomic status and among rural residents.
These socioeconomic determinants should be considered when planning snuff
use prevention interventions.
•
Although, not significant, the fact that oral tobacco use and dual use tended to
have increased following the test marketing of oral tobacco – snus, during
2005-2007, suggest need for vigilance in ensuring tobacco control regulation
covers all forms of tobacco.
•
There is nonetheless, need for further studies on the trends in smokeless
tobacco use and its relationship with smoking among adolescents from low
SES in South Africa.
22
THANK YOU
Acknowledgement:
This study was supported by the
American Cancer Society
(Grant A0U146)
.

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