2. Outline
 Dual
User
Study
 Background
 Purpose
 Methods
 Results
 Conclusions
 Expert
Panel

3. Acknowledgement
 West
Virginia
Bureau
for
Public
Health,
Division
of
Tobacco
Prevention

4. Background
–
West
Virginia
 90%
of
WV
adults
know
that
SHS
is
a
health
hazard
 72%
of
WV
adults
ban
smoking
in
their
home
 24%
of
WV
adults
–
current
smokers

8%
of
WV
adults
–
current
ST
users
 WV
Dual
Tobacco
Use
 11.4%
of
smokers
use
ST
 34.8%
of
ST
users
smoke
WV
2012
Adult
Tobacco
Survey

6. Background
-­‐
Industry
 Aggressive
industry
promotion
of
snus
and
other
tobacco
products
(OTPs)
as
a
“solution”
for
smokers
 Convenience
Stores
 OTPs:
10%
of
tobacco
sales
 OTPs:
31%
gross
profit
margin
 Cigarettes:
14%
gross
profit
margin
 25%
of
OTP
customers
also
buy
cigarettes
Convenience
Store
News:
http://www.csnews.com/top-­‐story-­‐tobacco-­‐
otp_becoming_increasingly_important_for_c_stores-­‐62283.html

8. Background
-­‐
Industry
 Swedish
Match
 "Taking
care
of
your
OTP
shopper
can
go
a
long
way
to
taking
care
of
your
cigarette
shopper.”
Joe
Teller,
Director,
Category
Management

9. Background
-­‐
Industry
 Reynolds
American
 Camel
Snus
sales
8-­‐10%/year
 Cigarette
sales

3%/year
 $14
billion
“profit
pool”—85%
from
combustibles
 Vuse—a
“digital
cigarette”
http://www.bizjournals.com/triad/news/2012/11/12/reynolds-­‐american-­‐touts-­‐
efforts-­‐to.html

10. Background
-­‐
Industry
 Vuse—a
“digital
cigarette”—"We're
not
looking
to
make
a
little
splash
in
the
category,
we're
looking
to
make
a
big
splash
in
the
category.”
Daan
[sic]
Delen,
President
and
CEO,
Reynolds
American

11. Non-­‐combustible
Tobacco
 Snuff
 Chew
 Snus
 Dissolvable
tobacco
 Sticks,
Strips,
Orbs
(Camel)
 Java
–
Stonewall
 Ariva
(Star
Scientific)

12. But
Wait,
There’s
More!

13. Non-­‐combustible
Tobacco
 Tobacco-­‐derived
Discs
 Verve
(Altria)
 Flex
(RJR)
 Velo
(RJR)

14. “No
matter
how
cynical
you
get,
it’s
impossible
to
keep
up.”
Lily
Tomlin

15. 22 West Virginia Hancock
Counties With Brooke
All Workplace Ohio
Protection Marshall
Wetzel Monongalia
Morgan
Tyler Marion Berkeley
Pleasants Preston
Mineral Jeff-
Taylor erson
Dodd- Harrison Hampshire
Wood Ritchie ridge
Barbour Tucker Grant
Wirt Hardy
Lewis
Cal- Gilmer Upshur
houn
Mason Jackson
Randolph
Roane
Braxton Pendleton
Putnam Webster
Cabell Kanawha Clay
Nicholas Pocahontas
Lincoln
Wayne
Boone Fayette
Greenbrier
BLUE : Smoking banned in all public and private places
Mingo
Logan and places of employment, including restaurants, bars,
Raleigh gambling, and vehicles when used as place of employment.
Sum-
Wyoming mers Monroe
McDowell Mercer

16. Purpose
 Explore
with
current
adult
dual
tobacco
users
 Usage
patterns
 Opinions
 Nicotine
 Health
risks
 Rules
at
home
&
work
 Experience
with
snus
 Tobacco
cessation
history

17. Methods
 Recruitment
with
Wellness
Council
of
WV
 Interviews,
10-­‐20
minutes
 Gift
cards
to
participants
 Approved
by
WVU
IRB
as
exempt
research
 Interviews
transcribed,
imported
into
NVivo
9
software
 Coded
by
both
investigators
 Congruence
between
the
investigators

18. Participants
 16
men;
1
woman
 Ages:
20-­‐58
 16
Caucasian;
1
African
American

19. Patterns
of
Use
 Initial
use
 ST:
snuff
or
snus;
no
chew
 Principal
reasons
for
dual
use
 Rules
at
work
(safety;
secondhand
smoke)
 Secondhand
smoke
concerns
at
home
 Social
situations

20. Why
a
Dual
User?
For
the
simple
reason
where
I
have
a
daughter
I
don’t
want
to
smoke
around
her,
but
still
when
I’m
[at
work]
here
I
just…don’t
want
to
give
them
up.
Oh
God,
I
smoke
when
I
wake
up
and
the
whole
time
from
traveling
from
work
to
the
mine
I
smoke
and
then
as
soon
as
I
get
on
the
mine
site,
I
work
12
hours
a
day
on
the
mine
site,
and
as
soon
as
I
get
up
there
I
start
chewing,
and
then
when
I’m
off
the
property
I
start
smoking
again.
Well
if
I’m
in
a
building
I’ll
use
the
snus
because
you
don’t
have
to
spit
with
it,
but
you
still
get
the
nicotine.
Now
if
I’m
working
in
the
basement
on
the
boiler
.
.
.
I’ll
put
a
rub
in.

21. Health
Risks
 More
than
half
believe
risks
are
equal
 Others
believe
smoking
is
riskier
 None
believe
that
ST
is
riskier

22. Weighing
the
Risks
If
you
chew
you’re
not
going
to
have
to
worry
about
lung
cancer,
and
if
you
smoke
you’re
going
to
have
to
worry
about
throat
cancer
and
lung
cancer,
but
if
you
chew
you
just
got
to
worry
about
your
mouth
cancer
.
.
.
I
think
chewing’s
a
safer
way
but
I’d
rather
keep
my
face,
that’s
why
I
smoke
more
than
I
chew.

23. Nicotine
 Cigarettes
vs.
ST—cigarettes
are
stronger
 Several
found
ST
to
be
stronger

24. Nicotine
Cigarettes
are
a
lot
more
potent
as
far
as
the
nicotine.
Snuff
is
more
of
a
relaxed,
it
doesn’t
hit
you
right
off
the
bat
.
.
.
If
you
dip
snuff
.
.
.
you
get
the
nicotine,
and
it
kind
of
curbs
you
away
from
smoking.
Yea
the
snuff
just
kills
the
craving
more
than
the
cigarette
does
because
if
I
smoke
one
cigarette
I
want
another
one,
and
then
when
I
dip
I
can
dip
and
you
can
keep
that
dip
in
longer
and
it
gives
you
the
nicotine
longer.

25. Rules
 Work—tobacco
use
banned
by
most
employers
 Most
were
compliant
 Home—most
do
not
smoke
at
home,
nor
permit
others
to
smoke

26. Rules
You
can’t
smoke
unless
you’re
in
a
designated
smoking
area.
You’re
not
supposed
to
chew
unless
it’s
a
designated
area
too.
They
don’t
pay
too
much
attention
to
the
chewing
though.
No
when
[at
work]
I
don’t
chew.
I
mean
it’s
because
I’ve
got
my
access
to
cigarettes.
I
don’t
have
to
worry
about
my
daughter,
and
I’d
rather
smoke
than
chew
because
I’m
worried
about
my
mouth,
but
at
the
same
time
it’s
nicotine.
So
I
mean
it’s
keeping
me
calm
at
home.

27. Snus
 10
tried
snus
 8
not
impressed
 2
are
regular
users

28. Snus
I
didn’t
like
it.
Snus
you
can
swallow
the
spit.
With
chewing
tobacco
you
can’t.
I
don’t
think
the
snus
is
as
strong
as
what
chewing
tobacco
is.
You
can
spit
or
you
can
swallow
it,
so
it
doesn’t
really
matter
.
.
.
I
do
spit
when
I
smoke
more,
but
it’s
more
or
less
.
.
.
the
sensation
of
the
menthol
and
the
tingling.
[My
partner
and
I]
both
smoke
the
same
cigarettes
and
we
both
use
the
same
Camel
Snus,
and
we
get
coupons
.
.
.
you
buy
a
Camel
product,
you
get
snus
for
free.
If
it’s
free
why
not
use
it?

29. Cost
 Little
brand
loyalty
 Some
buy
whatever
cigarette
brand
is
cheapest
 One
used
RYO
tobacco
 Some
vary
ST
brand,
always
going
with
whatever
was
cheapest
 One
estimate
for
Monthly
cost
of
tobacco
for
the
participant
and
his
girlfriend:
$400.

30. Tobacco
Cessation
 All
tried
to
quit
 3
cold
turkey
 3
with
meds
 15/17
want
to
quit
 Most
expect
to
quit
both
simultaneously
 Several
expect
to
quit
smoking
first

31. Tobacco
Cessation
Well
if
I
tried
to
quit
smoking
I’d
probably
dip
a
whole
lot
more,
and
then
I’d
want
to
dip
all
the
time,
and
after
the
dip
wasn’t
doing
nothing
for
me
I’d
have
to
buy
me
cigarettes.
So
I’d
have
to
try
doing
both
at
the
same
time
because
there’s
no
way
I
could
just
quit.
I’d
probably
hold
on
to
the
snuff
to
transition
out
of
the
cigarettes,
because
I
can
put
the
snuff
down.
I
know
I
can
quit
that
anytime.

32. Thinking
About
Quitting?
Yes.
It’s
getting
too
expensive.
I
mean
when
you’ve
got
to
buy
diapers
and
formula
and
liners
and
you
work
at
Wal-­‐mart
and
your
wife
only
works
three
days
a
week
and
goes
to
school
full
time,
yea.
I
don’t
want
to
be
under
the
stereotype
of
people
saying
oh
you’re
a
smoker
and
you
smell
bad,
and
I
don’t
want
to
put
that
negativity
around
my
clients
and
patients,
you
know
what
I
mean?
I
just
don’t
want
that
bad
persona.

33. Profiles
 5
Distinct
Types
of
Dual
Tobacco
Users
 Smokers
 “When
I
have
to”
 “When
I
want
to”
 “When
I
need
to”
 ST
Users
 “Social
smokers”
 Hard
Core
Users
 Use
both
types
daily
and
love
them

34. Limitations
 17
interviews
 Convenience
sample
 Not
generalizable

35. Conclusions
 Variability
 When
products
are
used
 Where
products
are
used
 Why
products
are
used
 Messages
need
to
be
tailored

36. Conclusions
 The
Law
of
Unintended
Consequences
 Smoking
bans
at
work
 Recognition
of
secondhand
smoke
dangers
 Result
-­‐
the
initiation
of
ST
use

37. Conclusions
 User
version
of
“tobacco
harm
reduction”—smoke
less,
dip
more
 Strong
recognition
of
SHS
smoke
hazards

38. Addressing
Dual
Tobacco
Use
in
West
Virginia
Recommendations
of
the
Expert
Panel

39. Goals
 Explore
the
prevalence
of
dual
tobacco
use
in
WV.
 Identify
successes
and
challenges.
 Identify
cessation
practices
and
models.
 Develop
targeted
recommendations
for
addressing
dual
tobacco
use
for
dissemination
to
.
.
.
Policy
Makers
Local
Health
Depts
Clinicians
Health
Care
Providers
Researchers
NGOs

40. Process
 Break
Free
Alliance
–
lead
agency
 Experts
(in
state
and
out
of
state)
planned
 Participants
recruited
 Panel
met:
December
13,
2011

41. Recommendations
 Increase
support
to
$28,000,000
 Maintain
the
Quitline,
able
to
counsel
dual
users
 Maintain/expand
partnerships
to
address
dual
use
 Develop
a
statewide
research
group
on
dual
use
 Maintain/expand
regional
tobacco
networks
 Continue/expand
provider
education
efforts
on
dual
use

42. Recommendations
 Maintain
and
add
clean
indoor
(and
outdoor)
smoking
regulations;
advocate
for
a
statewide
comprehensive,
non-­‐preemptive
law
 Increase
taxes
 $2/pack
tax
on
cigarettes
 Parity
tax
on
smokeless
tobacco