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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Smokeless Tobacco Use Among Rural Women in NE Alabama a
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Brenda Talley RN, PhD, NEA-BC , Alison Rushing RN, PhD & Rose Mary Gee RN, PhD
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a
College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama b
Georgia Southern University, School of Nursing, Statesboro, Georgia Published online: 30 Oct 2014.
Click for updates To cite this article: Brenda Talley RN, PhD, NEA-BC, Alison Rushing RN, PhD & Rose Mary Gee RN, PhD (2014) Smokeless Tobacco Use Among Rural Women in NE Alabama, Journal of Community Health Nursing, 31:4, 212-224, DOI: 10.1080/07370016.2014.958404 To link to this article: http://dx.doi.org/10.1080/07370016.2014.958404
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Journal of Community Health Nursing, 31: 212–224, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.958404
Smokeless Tobacco Use Among Rural Women in NE Alabama Brenda Talley, RN, PhD, NEA-BC
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College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama
Alison Rushing, RN, PhD and Rose Mary Gee, RN, PhD Georgia Southern University, School of Nursing, Statesboro, Georgia
Smokeless tobacco use among women living in rural areas is poorly understood and largely ignored. This qualitative study explored the use of smokeless tobacco with 10 participants living in rural areas in Alabama, with the women telling their own stories of use. Themes emerging from interviews included the initiation of use, secrecy, health-risk beliefs, daily-use patterns, and thoughts about quitting. The study results could assist community health nurses in awareness of risks, case finding, and development of community-based prevention strategies. Additional research would help better understanding of the epidemiology of the problem, cultural implications, and practice interventions.
Smokeless tobacco use among women, especially women living in rural areas, is poorly understood and largely ignored. Smokeless tobacco is any form of tobacco that is not smoked, but sniffed through the nose, held in the mouth, or chewed. It is available in moist and dry snuffs and various forms of chewing tobacco that may be enhanced by sweetening or flavoring agents. Worldwide studies have confirmed relationships between smokeless tobacco use and serious health problems such as metabolic syndrome (Norberg, Stenlund, Lindahl, Boman, & Weinehall, 2006), stroke, and other cardiovascular diseases (Hergens, Lambe, Pershagen, Terent, & Ye, 2008). Smokeless tobacco contains multiple carcinogens (American Chemical Society, 2012) and use increases the risk for cancers of the mouth, throat, esophagus, pancreas, and stomach, as well as oral problems such as leukoplakia, gingival disease, tooth abrasions, and dental caries leading to tooth loss (American Cancer Society, 2013; Centers for Disease Control and Prevention [CDC], 2010; Chao, et al., 2002; Jayalekshmi et al. 2009). Despite the available data, the significance of smokeless tobacco use may not be fully appreciated even by health care providers. Primary care providers often fail to assess smokeless tobacco use. In a survey of providers, 24% showed no item related to tobacco use at all on their health history form. Others included questions related to smoking, but only 7% of those surveyed asked for information on any type of smokeless tobacco use (Talley et al., 2011). Although the prevalence of cigarette smoking between 2005 and 2012 decreased from 20.9% to 18.1%, (CDC, 2014), no Address correspondence to Brenda Talley, RN, PhD, NEA-BC, Associate Professor, 302 Nursing Building, College of Nursing, University of Alabama in Huntsville, Huntsville, AL 35899. E-mail: [email protected]
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decrease was reported for the use of smokeless tobacco products in the latest available Behavioral Risk Factor Surveillance System findings administered by the Centers for Disease Prevention and Promotion (CDC, 2010). The objective of reducing the prevalence of smokeless tobacco use, as stated in Healthy People 2010, made little progress (National Center for Health Statistics, 2012). The use of smokeless products has actually increased, especially among women, young people, specific ethnic and cultural groups, and in the southern states (Arabi, 2007; Lee, 2009; Pechacek, 2014). The highest prevalence in women were in the largely rural states of Montana, with 2.5% of women reported using smokeless tobacco and in Alaska where 7.8% of women both smoked and used smokeless tobacco (CDC, 2010). In response to antismoking campaigns and legislation designed to curb use and advertising, tobacco companies took a hardline approach in their sales and distribution efforts and expended an estimated one million dollars between 2005 and 2006 in research, market testing, and advertising for moist snuff alone (New Jersey Department of Health and Human Service et al., 2009; Pechacek, 2014). The products being tested included merchandise the use of which was less conspicuous than traditional spit tobacco, had appealing flavors such as berry or mint, were produced in forms that looked like candies or gum, and did not require spitting. Although these products may be perceived as harmless by some, they do deliver significant nicotine dosing of between 0.6 and 3.1 milligrams (Beirne, 2008: Easton, 2009). Some marketing strategies, such as new flavors and product premiums, are specifically targeted toward young users and women (Walker & Ridner, 2007). These products may be perceived as being safer than other products (US Food and Drug Administration Fact Sheet, 2011). Another form of smokeless tobacco being targeted in advertising blitzes in the United States is snus. It is distributed as a form of ground tobacco packaged in a tiny teabag-like pouch or sachet that is held between the upper lip and gum (Pechacek, 2014). This form, long used in the Scandinavian countries, has a much lower percent of nicotine and other harmful carcinogens than smoked or other inhaled products. This does not, however, negate its use as a health risk (Pechacek, 2014). Some forms of smokeless tobacco are being promoted as a means to reduce smoking, citing overall reduction of health risks, especially for cancer. This idea has been promoted by American Council on Science and Health (2013) and others as an acceptable alternative (Ericson, 2013; Foulds, n.d.; University of Louisville, 2012). Counter to this position is the reminder that smokeless tobacco is not without significant risks, and that other effective means of smoking cessation are available (American Cancer Society, 2009, 2013.; Barrett, Mallory, Campbell, & Good, 2011; Niergarten, 2007; Pechacek, 2014). Even proponents of substitution recognize the continued risks for cancer and cardiovascular disease, as well risks as to unborn children (Foulds, n.d.), and warn that US-produced smokeless tobacco differs significantly from Scandinavian products (Foulds & Forberg, 2008). The risks associated with use of any form of tobacco was underscored by the passage of the Family Smoking Prevention and Tobacco Control Act by the 111th United States Congress in 2009 (US Congress, 2009) which assigned regulation of tobacco products to the US Food and Drug Administration. All tobacco products must now be labeled according to ingredients and nicotine content. Tobacco products introduced after March 2011 must have FDA approval prior to marketing (US Food and Drug Administration, 2014). Flavored cigarettes, excepting menthol, are banned under these regulations, although other types of flavored tobacco products remain
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available for purchase. However, some states have banned flavored smokeless tobacco products, as well (Tobacco Control Legal Consortium, 2011). The purpose of this research was to understand the underlying factors contributing to the use of smokeless tobacco in women residing in rural northeastern Alabama. The objectives that drove this investigation were to: (a) describe the patterns of use of smokeless tobacco among women in rural southern united states, (b) identify perspectives on use and health concerns of women who use smokeless tobacco, and (c) uncover areas for future research.
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RESEARCH DESIGN This study employed a qualitative descriptive design. Guided interviews were conducted and a health history and demographic survey obtained.
DESIGN OF THE STUDY Protection of Participants Prior to the study, all required materials were submitted to the Institutional Review Board at the University of Alabama in Huntsville, and the study was approved in keeping with established guidelines and standards. Each participant was fully informed of the nature and purposes of the research and each signed a consent to participate. Participants were assigned a code number and each individual’s name, with personal information and the assigned codes, were stored in the primary investigator’s personal file under lock and key. All data was filed by participant code only. Electronic access was password protected. Recruitment of Participants Due to the hidden nature of smokeless tobacco use, nonprobability sampling was used. Recruitment of participants involved a variety of means. Twenty-seven flyers and posters describing the study and providing contact information were placed in a variety of locations: at points of sale for smokeless tobacco products, in health care providers’ offices, and in community centers, although there were many refusals to allowing posters to be placed. All manufacturing facilities refused poster placements outright. None of the posters yielded any participants. Only personal connections in the community and the snowball technique proved productive in recruiting participants. Three of the participants were known to the primary investigator and the remaining participants were referred by other participants or community residents. In all, 12 women were contacted and 10 elected to participate in the study. However, even a refusal of a retail outlet to allow posters to be placed yielded useful information. “They won’t talk to you,” he warned. The tobacco companies run big promotions for free stuff and the women who use snuff won’t even sign up. Not even for free things will they put their names down. Some make their husbands sign up, but rarely does a woman. Lots of them come in to buy though.
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Sample and Setting The sample included a group of 10 women who self-identified as meeting the inclusion criteria: (a) a history of smokeless tobacco use; (b) woman over the age of 19; (c) English-speaking; (d) able to read, understand, and provide consent to participate in the study; (e) able to participate in the interview discussions; (f) live in a rural area; and (g) willing to have their interviews recorded. The women ranged in age from 32 to 87, with age at first use ranging from 8 years of age to 42. Number of years of use varied from 2 to 77 years. Two of the participants identified themselves as being Native American. These two were members of the Cherokee tribe recognized by the state of Alabama. The other participants defined themselves as Caucasian. Nine of the 10 were lifelong residents of the northeast Alabama area. The one participant born elsewhere had lived for a number of years in this area and was strongly influenced by her husband, who was a native of the area. (Please refer to Table 1 for additional data.) The setting for the study was a multicounty rural area in northeastern Alabama lying at the southern end of the Appalachian Mountains. Rural was defined as “any incorporated place or CDP (census designated place) with fewer than 2,500 inhabitants that is located outside of a UA (urban area)” (Census Bureau, 2010). According to the Census Bureau, a place is either entirely urban or entirely rural (US Census Bureau, 2010). Data Collection Participants who agreed to be interviewed were contacted and an appointment was set up for an initial meeting at a date and time mutually agreeable for both the participant and the researcher. In addition to the interviews, demographic data was obtained and a health history completed. A guided interview form was developed and used to facilitate consistency in data collection and to focus the interview toward the desired information. The interview guide items were selected by members of the research group as a means to facilitate the storytelling of the women. Influences on the inclusion of items were clinical practice and personal contact with women who used smokeless tobacco. This guide included a single question that, hopefully, engaged the participant in a dialogical exchange but did not restrict information the participant was willing to share. Other items on the guided interview form included discussion points such as age of first use, duration of use, amount and type of use, and thoughts about health risks and quitting. These items were introduced as opened-ended questions and used only if the information did not arise during the conversation with the participant. This approach served to ensure that specific basic information was included. The guided interview format allowed the interviewer flexibility to ask needed questions, add personal commentary, and clarify information provided by the participant. A decision was made, due to the suggested sensitivity of the topic, for the primary investigator to conduct all of the interviews, as she was known in the community and a sense of trust and rapport was more easily established. Each participant’s data was collected by the primary investigator in two to five dialogue sessions of approximately 30 min for each session. The number of interviews varied from two to five, as did the duration of the interviews, and were dependent on the intensity of the information given, the fatigue level of the participant, the desire and ability of the participant to reflect on the research questions, and the complexity of the history. Field notes containing reflections about the interview were completed by the primary investigator after each interview session was completed. The stories were shared with the additional researchers who provided critical insight and an additional degree of objectivity to the data analysis.
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55 52 38 52 72
87 60 70 83
32
1 2 3 4 5
6 7 8 9
10
High school
Grammar school High school Grammar school High school
2 years college Technical college High school High school Grammar school
Education None Paramedical Retail sales Garment manufacturing Retired garment manufacturing None None None Retired garment manufacturing Clerk, formerly manufacturing
Employment
Note. CA = Cancer. SVT = Supraventricular Tachycardia.
Age
Participant
Snuff
Snuff Snuff Snuff Snuff
Snuff Cut, moist Snuff Snuff Snuff
Type of Tobacco
30
10 17 12 13
10 42 34 12 8
Age at First Use
2
77 43 58 30
48 10 4 40 64
Years of Use
TABLE 1 Smokeless Tobacco Use Among Rural Women in Alabama Selected Demographic Data
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CA
CA
SVT
Diagnosis
Yes
No No No Yes
Yes No No No No
Have Quit?
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RESULTS Data Analysis Variables included demographic data, quantifiable use history, and health events. These data are presented as descriptive statistical information in Table 1. Means were not calculated at this time due to the number of participants in the study and to the heterogeneity of the data. Ten individuals fully participated in the study.
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Descriptive Data Data from the interviews were analyzed and coded on a continuing basis to help with identification of the themes. The themes were not developed prior to the study, but were derived from the interview data and the field notes. As themes emerged and were identified, the supporting data were related in the form of thick descriptions; that is, case studies that collapsed the data providing insights into what was learned. After the data were analyzed and integrated into this format for communication, the results were shared with each participant for validation, which provided and strengthened the authenticity of the analysis. Themes Six major themes emerged from the data, and each of these themes had polarizing points that helped define or describe each. These themes were validated with each of the participants. The six themes are presented in the following section along with the supporting dialogue for each. The identified themes corroborate and illustrate the first research objective to describe the patterns of use of smokeless tobacco among women in rural southern United States, while the remaining themes provide insight into the second study objective: Identify perspectives on use and health concerns of women who use smokeless tobacco. The first theme, beginning use of smokeless tobacco, had two distinct poles: childhood initiation-culturally embedded versus adult initiation-substitution behavior. Seven of the participants reported beginning use of snuff as children; all had multiple family members who used snuff. One explained, “My mother left us when I was little and my grandmother and aunt raised me. They started me on snuff when I was 12 or 13.” Another reported that she has used snuff since about the age of 10. She was introduced to snuff by her mother. “I have used it almost all my life.” Three of her five sisters use snuff and she reports that she keeps a bolus of tobacco in the space between her cheek and gum almost all the time. One participant related to the interviewer: I didn’t marry until I was in my 50s. I raised all my brothers and sisters—10 of them—and I’m the oldest, making 11 of us. I started using snuff when I was about eight; my mother would give it to me if I did the chores, like washing the dishes. My mother didn’t really like to work; she just liked having babies, so I grew up doing all the cleaning and the cooking when I got old enough to reach the old wood stove. The others worked in the fields, like picking cotton. I’d go out and pick between chores, but I had to have the meals ready and keep the clothes washed up. We didn’t have much and the only luxury we had was tobacco. The boys rolled cigarettes and the girls used snuff.
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Those who started use later in life also shared their stories. One participant told the interviewer that she began using cut tobacco at the age of 42 because it “smelled good.” (Her boyfriend used cut tobacco). Another of the women related that she started using snuff at age 32 after her marriage. Her husband could not tolerate her smoking cigarettes and suggested that she use snuff as an acceptable substitute. Her new husband’s mother uses snuff. The participant, herself, had no prior connection to snuff use. The third participant who began as an adult was using snuff to quit smoking. She worked in a garment factory where smoking was not allowed, due to the danger of lint explosion. She related that many of the women used snuff while they were working. The second theme emerged as secrecy: insider versus outsider. The insiders were people that the women were comfortable knowing that they used smokeless tobacco products; usually family members and/or close friends who may or may not also use. Individuals not in the women’s circle of intimates were deemed outsiders. Information was not imparted voluntarily to those considered outsiders, even to health care personnel, and the women were not forthcoming unless the question was directly and specifically asked. “I don’t smoke,” one woman explained. “I would say I used snuff if they asked me.” Use was restricted to certain situations if others were around who did not know of their using. This was especially true in public situations. One of the participants related that she did not care if others knew about the use of cut tobacco, but stated that she did not want her teenage son and his friends to know, because she did not want him to use tobacco. Use in public was covert, if it was even used. Almost all of the snuff users felt that the use of snuff would be “looked down upon” by those outside their circle, so they were careful about who knew and who did not know about their use. The one exception was a participant who had had extensive surgery for cancer related to the use of snuff. “I’d go on television if I could. I want everyone to know what it can do.” The third theme involved awareness about health risks: knowledge about risks versus lack of awareness. Health risks became apparent to the participants who had had significant health problems and had been told that these problems were related to their smokeless tobacco use. They stated they were not aware of health risks prior to diagnosis. Two of the women had a history of oral cancer and were presently aware of the correlation between their diagnosis and the use of snuff. A third participant reported that she had recurrent supraventricular tachycardia (SVT; which can be precipitated by nicotine), although she did not make the connection between her arrhythmias and her use of smokeless tobacco. When asked what the cardiologist thought about her use of smokeless tobacco products, she shared, “Well, I don’t think he thinks anything—I haven’t told him. He asked me if I smoked, but he didn’t ask about snuff and I didn’t tell him. I’ve never had anyone ask me.” The remaining participants had never had the health risks of using smokeless tobacco products discussed with them by health care providers and most stated that they had limited or no knowledge about the risks associated with its use. None of the participants had reported the use of smokeless tobacco products to health care providers (except the two who were asked due to findings of oral cancer) but stated that they would have done so if asked, and none had ever had the health risks of using smokeless tobacco discussed with them (except on diagnosis of a related illness). Most told the investigator that they had limited or no knowledge about the risks associated with its use. One of the participants stated, “I never really thought about any danger in using snuff.” Another knew the risks, but said she didn’t think she used it enough to be harmful.
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The fourth theme revolved around significant health issues: related health events versus none reported. As pointed out, three of the 10 participants had been diagnosed with serious health problems. Also as noted, participants had never had the health risks of using smokeless tobacco products discussed with them by health care providers or anyone else, and most had limited or no knowledge about the risks associated with use. Because they (or any of their family members) had not developed any significant changes in health that could be attributed to their use of smokeless tobacco, they had no reason to question its use. The woman who had recurrent SVT had already required two ablation procedures and was faced with a third. She told us that her cardiologist said that if the third ablation treatment doesn’t help, she will have no other options available to her. One participant who had undergone numerous surgeries and radiation treatments shared, In the 1970s, I started having sores in my mouth. They wouldn’t heal, so I went to a doctor. He said it was leukoplakia and I had to take antibiotics for a long time and he cauterized some of them. He said probably I would get cancer in my mouth. It took 20 years, but I did. I had my first surgery in July of 1996. I’ve had four surgeries. I had surgery again that November. Then, in 1998, I had radiation treatments and then surgeries again in 1999 and in 2001. I’ve had part of my left jawbone removed and the roof of my mouth, some of my gum, and all of my teeth are gone. I use a plate in there that helps my speech some, but you can see that I’m hard to understand. Some people won’t talk to me.
She no longer uses snuff. Another participant said, The doctor told me I have to quit now; I have cancer in my mouth and I already had surgery 2 months ago. I haven’t stopped using it yet, but I know I need to. He said I could have more cancer. I have breast cancer, too.
When asked by the interviewer if she had been given any information on quitting, she replied, “No, he just said to quit using it.” She also related that she had never been asked about the use of snuff by any health care providers, and hadn’t thought much about risk of using to health. The remaining participants had never personally experienced any health events attributed to their use of smokeless tobacco and, because most of these women had been unaware of the connection between the use of smokeless tobacco products and health issues, they had seen no reason to discontinue its use. The fifth theme revolved around quitting: I don’t intend to quit versus I might, but I don’t know how. Most had no thoughts about quitting and found the use pleasurable. The interviewer heard comments such as: “I’ve never tried to quit. The subject never comes up.” “I don’t intend to quit. I enjoy it. It relieves stress.” “I enjoy using tobacco and don’t have a problem with it.” One participant was ambivalent: “I don’t think I can quit until my mother passes. She is 97 and she still uses snuff in the nursing home. I’ll quit then. It is my connection to her. I know it sounds crazy, but that’s how I feel.” Another participant told the interviewer, “My mother tends to be self-centered and possessive. Snuff was the only thing she ever shared with me freely. I think I may quit after she is gone. I don’t think I can until then.” Participants who have thought about quitting were fewer, but there were several who were possibly considering quitting. “I hadn’t thought about it before. But I have thought about it since we have begun talking. I’m going to quit. I think I can do it.”
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The last theme identified was: how much and why: use all the time versus recreational use only. Seven participants used regularly and/or almost continuously. They recognized that they were probably addicted, like smokers are to cigarettes. However, three told the investigator that their use was restricted to only certain times or in certain situations; not as a habit of continual use. “sing snuff was just something you did. I’ve never really thought much about it. I do know I get nervous if I can’t use my snuff, so I guess it is a habit like smoking. Sometimes I get where I really don’t want to use it, and then I can’t wait to get where I can; I guess like someone wanting a cigarette. I try to ration myself. You know, it is expensive! I use about a large can (about an 8 oz. tumbler size) each week. I can’t afford any more than that. I try not to use it all the time, but that’s just what I end up doing. My husband didn’t want me to smoke and he thought snuff would take care of the smoking. His mother used snuff. I work in a clothes factory making shirts. It is dangerous to smoke anywhere around there and a lot of the women use snuff. I used to smoke, but I started using snuff then. I still use it but I don’t smoke. You can’t go by how often someone takes snuff. You can take a lot and it will last for hours. You keep it between your cheek and gum and it lasts a while. Some snuff is very strong. Mine (Beechnut) is not so strong but my sister uses the stuff in the red can and it is too strong for me. I pretty much use it all the time, except during meals. I can’t imagine not using snuff. I have used it almost all my life. It relaxes me. I use Copenhagen and it is strong; it really gives a “kick.” I don’t use it all the time; mostly on weekends and when I get off work. I take it in the evenings like some women might take a glass of wine. Why? It’s an “in your face” kind of thing. That’s my personality. I like to do the unexpected. My boyfriend, who became my husband and then not, thought it was cool. I think my current husband kind of likes it, too. Hey, it’s better than smoking!
DISCUSSION Initial appraisal of the data identified divergence patterns around initiation of first use. Those who had been using smokeless tobacco longest tended to use dry snuff, began use as children, and were strongly influenced by relatives. By contrast, users who began use as adults or later in life began for different reasons. Use could be either continuous or occasional; however, almost all tended to be guarded about disclosure of use. Those who began use as adults chose types of product similar to women who began earlier in life and their initiation of use was to appease a significant other, as a substitute for cigarettes, or just for fun. The use of smokeless tobacco in women is not a rarity. Although we make no effort to make projections about wider use based on this study; it is highly probable that the prevalence is higher than might be expected, especially in some geographical areas. It is possible there is a significant population of women who currently use smokeless tobacco and have since an early age. This needs additional research for substantiation and verification. Implications for Community Health Nurses Public education in the health risks of tobacco should include the risks of smokeless tobacco use. Information currently found in the literature suggests the use of smokeless tobacco products can assist smoking cessation and use of these products are less harmful than smoked tobacco
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products (American Council on Science and Health, 2013; Ericson, 2013). This notion should be countered in the professional literature and in community education programs by those who have knowledge of the risks of smokeless tobacco. Other safer and more effective means of smoking cessation should be made known to the public. Existing marketing strategies promote products that are appealing to women and young users (Curry, Pederson & Stryker, 2011; Southwell et al., 2012). Due to the limited understanding of the patterns of smokeless tobacco use among specific population groups, this surge in marketing is not being countered by public education or individual professional counseling relating the risks to health of new, seemingly less harmful tobacco products. Strategies for smokeless tobacco cessation should consider cultural norms with attention to accessibility in rural communities. Cessation strategies should consider the whys of smokeless tobacco use, as well as the cultural underpinnings important to those who use it. Primary and secondary prevention strategies should be tailored to take into account whether the individual initiated smokeless tobacco use at an early age as a cultural norm, or later in life as a substitution for smoking or other reasons. Interventions to support change may be very different in approach, considering the motivation for and cultural propensity to use and the barriers for quitting. Community health nurses should have heightened awareness of the significant health consequences; this fact is vividly illustrated by the study data, illustrated by the fact that three of the 10 participants of this small research sample had already experienced significant, disfiguring, and/or life-threatening health consequences. This information, alone, underscores the need for improved accuracy of health histories which include all tobacco use, not just a smoking history. Health care providers are not adequately assessing risky health behaviors related to smokeless tobacco use by women, nor counseling those at risk. While oral cancer is one of the most obvious of risks, research studies have found links to other cancers as well other health conditions (American Cancer Society, 2009; CDC, 2010; Chao et al., 2002; Hergens et al., 2008; Jayaleskshmi et al., 2009; Norberg et al., 2006) and, except for after the diagnoses of the two women found to have oral cancer, the participants in this study had neither been queried by health care providers about use nor been informed of the health risks of using smokeless tobacco products. Community health nurses are situated in a strategic position to take advantage of this information to obtain more comprehensive assessment data, identify at-risk clients, and personalize interventions aimed at prevention and education of those who they treat. It should be noted that community health nurses, especially in rural communities, are likely to be able to gain the trust and confidence of women who use smokeless tobacco. In small communities, these women would be neighbors, friends, and relatives. The community health nurse’s role in the community is of vital importance.
Potential Directions for Future Research Certainly, this study should be expanded. The difficulty in recruitment of potential participants is a barrier. Additional connections must be made in the communities to facilitate recruitment. Convincing the local industries to participate would add dimension and access to potential participants. Other avenues would be through the public school system and health care facilities. Dentists, especially, may prove valuable allies.
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Tobacco companies currently continue to pour substantial resources into marketing new products that appeal to younger and younger consumers, many of whom are women (Beirne, 2008: Easton, 2009; New Jersey Department of Health and Human Service et al., 2009; Pechacek, 2014). How might these marketing strategies influence beginning or continued use of smokeless products? How should public health or regulatory bodies respond? What factors might influence first use? None of the women in this study had received information relating to quitting the use of smokeless tobacco. What are the most effective means of communicating information to those at risk? What motivations or approaches would be most likely to influence successful cessation? Due to the hidden nature of the phenomena evidenced in this study, it is imperative to expand the current research focusing on patterns of use in rural populations in other sections of the country to identify or validate the scope of the problem. Risks to well-being are increased when an individual lacks information regarding the dangers of a behavioral choice. What other factors might increase an individuals’ vulnerability to choosing this behavior? It was clear from the data that most of the participants functioned in a social group where the use was acceptable. Are there other cultural or ethnic groups that have influence on an individual’s choices? It should be recalled that two of the participants identified as Native American. What is the cultural significance, if any, in specific groups? Is there an actual difference between types of geographical settings? Some participants began, or increased, use when employed in work where smoking was not permitted. However, they stated that they could use smokeless tobacco all the time they were working. What is the prevalence in specific industries, such as the garment making industry where some of the women were employed? In summary, suggestions for future research include: • Investigate use in other at-risk groups • Use of smokeless tobacco in the manufacturing industry, • Use of smokeless tobacco in young women, • Use of smokeless tobacco in urban or suburban ethnic groups, • What influences the use of smokeless tobacco in females, and • Differences in use patterns based on a variety of demographic variables. • Develop and implement multisite interventional studies that can: • Provide needed strength to make recommendations for changes in practice guidelines, especially as they impact the overlying cultural aspects of users consistent with the patterns identified in this study and others; • Suggest primary and secondary prevention programs to aid in better mitigating the health consequences of smokeless tobacco use in at-risk populations; and • Provide guidance for policy change.
FUNDING This work is supported by a grant from the University of Alabama in Huntsville, Office of Sponsored Programs, Distinguished Faculty Award, Huntsville, Alabama.
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Norberg, M., Stenlund, H., Lindahl, B., Boman, K., & Weinehall, L. (2006). Contribution of Swedish moist snuff to the metabolic syndrome: A wolf in sheep’s clothing? Scandinavian Journal of Public Health, 34, 576–583. Pechacek, T. F. (2014, April 14). CDC Congressional Testimony: Smokeless tobacco: Impact on the health of our nation’s youth and use in major league baseball. Washington, DC: Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/washington/testimony/2010/t20100414.htm Southwell, B., Kim, A., Tessman, G., MacMoneagle, A., Choiniere, C., Evans, S., & Johnson, R. (2012). The marketing of dissolvable tobacco: Social science and public policy research needs. American Journal of Health Promotion; 26, 331–332. Talley, B., Gee, R. M., Allen, D., Marshall, E., Encinas, K., & Lim, S. (2011). Assessment of smokeless tobacco use in the history and physical examination by primary health care providers. Journal of the American Academy of Nurse Practitioners, 3, 445–447. Tobacco Control Legal Consortium. (2011). Regulating flavored tobacco products. Public Health Law Center. Retrieved from http://publichealthlawcenter.org/sites/default/files/resources/tclc-guide-regflavoredtobaccoprods-2011.pdf US Census Bureau, (2010). Urban and rural classifications: Rural places and territory. Retrieved from http://www. census.gov/geo/reference/pdfs/GARM/Ch12GARM.pdf US Congress, 111th Session. (2009). H. R. 1256, Family Smoking Prevention and Tobacco Control Act. Washington, DC: United States Government Printing Office. Retrieved form http://www.gpo.gov/fdsys/pkg/BILLS-111hr1256enr/pdf/ BILLS-111hr1256enr.pdf US Food and Drug Administration. (2011). USDA flavored tobacco fact sheet. Washington, DC: US Food and Drug Administration, US Department of Health and Human Services. Retrieved from http://www.fda.gov/TobaccoProducts/ ProtectingKidsfromTobacco/FlavoredTobacco/ucm183198.htm US Food and Drug Administration. (2014). Protecting and promoting your health. Washington, DC: US Food and Drug Administration, US Department of Health and Human Services. Retrieved from http://www.fda.gov/TobaccoProducts/ ResourcesforYou/ForManufacturers/default.htm University of Louisville. (2012, February 19). Substituting with smokeless tobacco saves lives, research suggests. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2012/02/120219135553.htm Walker, K. L., & Ridner, L. (2007). Exploratory study of young adults’ perceptions of tobacco use and tobacco marketing. Intercultural Communication Studies, 16, 26–33.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Smokeless Tobacco Use Among Rural Women in NE Alabama a
b
Brenda Talley RN, PhD, NEA-BC , Alison Rushing RN, PhD & Rose Mary Gee RN, PhD
b
a
College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama b
Georgia Southern University, School of Nursing, Statesboro, Georgia Published online: 30 Oct 2014.
Click for updates To cite this article: Brenda Talley RN, PhD, NEA-BC, Alison Rushing RN, PhD & Rose Mary Gee RN, PhD (2014) Smokeless Tobacco Use Among Rural Women in NE Alabama, Journal of Community Health Nursing, 31:4, 212-224, DOI: 10.1080/07370016.2014.958404 To link to this article: http://dx.doi.org/10.1080/07370016.2014.958404
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Journal of Community Health Nursing, 31: 212–224, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.958404
Smokeless Tobacco Use Among Rural Women in NE Alabama Brenda Talley, RN, PhD, NEA-BC
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College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama
Alison Rushing, RN, PhD and Rose Mary Gee, RN, PhD Georgia Southern University, School of Nursing, Statesboro, Georgia
Smokeless tobacco use among women living in rural areas is poorly understood and largely ignored. This qualitative study explored the use of smokeless tobacco with 10 participants living in rural areas in Alabama, with the women telling their own stories of use. Themes emerging from interviews included the initiation of use, secrecy, health-risk beliefs, daily-use patterns, and thoughts about quitting. The study results could assist community health nurses in awareness of risks, case finding, and development of community-based prevention strategies. Additional research would help better understanding of the epidemiology of the problem, cultural implications, and practice interventions.
Smokeless tobacco use among women, especially women living in rural areas, is poorly understood and largely ignored. Smokeless tobacco is any form of tobacco that is not smoked, but sniffed through the nose, held in the mouth, or chewed. It is available in moist and dry snuffs and various forms of chewing tobacco that may be enhanced by sweetening or flavoring agents. Worldwide studies have confirmed relationships between smokeless tobacco use and serious health problems such as metabolic syndrome (Norberg, Stenlund, Lindahl, Boman, & Weinehall, 2006), stroke, and other cardiovascular diseases (Hergens, Lambe, Pershagen, Terent, & Ye, 2008). Smokeless tobacco contains multiple carcinogens (American Chemical Society, 2012) and use increases the risk for cancers of the mouth, throat, esophagus, pancreas, and stomach, as well as oral problems such as leukoplakia, gingival disease, tooth abrasions, and dental caries leading to tooth loss (American Cancer Society, 2013; Centers for Disease Control and Prevention [CDC], 2010; Chao, et al., 2002; Jayalekshmi et al. 2009). Despite the available data, the significance of smokeless tobacco use may not be fully appreciated even by health care providers. Primary care providers often fail to assess smokeless tobacco use. In a survey of providers, 24% showed no item related to tobacco use at all on their health history form. Others included questions related to smoking, but only 7% of those surveyed asked for information on any type of smokeless tobacco use (Talley et al., 2011). Although the prevalence of cigarette smoking between 2005 and 2012 decreased from 20.9% to 18.1%, (CDC, 2014), no Address correspondence to Brenda Talley, RN, PhD, NEA-BC, Associate Professor, 302 Nursing Building, College of Nursing, University of Alabama in Huntsville, Huntsville, AL 35899. E-mail: [email protected]
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decrease was reported for the use of smokeless tobacco products in the latest available Behavioral Risk Factor Surveillance System findings administered by the Centers for Disease Prevention and Promotion (CDC, 2010). The objective of reducing the prevalence of smokeless tobacco use, as stated in Healthy People 2010, made little progress (National Center for Health Statistics, 2012). The use of smokeless products has actually increased, especially among women, young people, specific ethnic and cultural groups, and in the southern states (Arabi, 2007; Lee, 2009; Pechacek, 2014). The highest prevalence in women were in the largely rural states of Montana, with 2.5% of women reported using smokeless tobacco and in Alaska where 7.8% of women both smoked and used smokeless tobacco (CDC, 2010). In response to antismoking campaigns and legislation designed to curb use and advertising, tobacco companies took a hardline approach in their sales and distribution efforts and expended an estimated one million dollars between 2005 and 2006 in research, market testing, and advertising for moist snuff alone (New Jersey Department of Health and Human Service et al., 2009; Pechacek, 2014). The products being tested included merchandise the use of which was less conspicuous than traditional spit tobacco, had appealing flavors such as berry or mint, were produced in forms that looked like candies or gum, and did not require spitting. Although these products may be perceived as harmless by some, they do deliver significant nicotine dosing of between 0.6 and 3.1 milligrams (Beirne, 2008: Easton, 2009). Some marketing strategies, such as new flavors and product premiums, are specifically targeted toward young users and women (Walker & Ridner, 2007). These products may be perceived as being safer than other products (US Food and Drug Administration Fact Sheet, 2011). Another form of smokeless tobacco being targeted in advertising blitzes in the United States is snus. It is distributed as a form of ground tobacco packaged in a tiny teabag-like pouch or sachet that is held between the upper lip and gum (Pechacek, 2014). This form, long used in the Scandinavian countries, has a much lower percent of nicotine and other harmful carcinogens than smoked or other inhaled products. This does not, however, negate its use as a health risk (Pechacek, 2014). Some forms of smokeless tobacco are being promoted as a means to reduce smoking, citing overall reduction of health risks, especially for cancer. This idea has been promoted by American Council on Science and Health (2013) and others as an acceptable alternative (Ericson, 2013; Foulds, n.d.; University of Louisville, 2012). Counter to this position is the reminder that smokeless tobacco is not without significant risks, and that other effective means of smoking cessation are available (American Cancer Society, 2009, 2013.; Barrett, Mallory, Campbell, & Good, 2011; Niergarten, 2007; Pechacek, 2014). Even proponents of substitution recognize the continued risks for cancer and cardiovascular disease, as well risks as to unborn children (Foulds, n.d.), and warn that US-produced smokeless tobacco differs significantly from Scandinavian products (Foulds & Forberg, 2008). The risks associated with use of any form of tobacco was underscored by the passage of the Family Smoking Prevention and Tobacco Control Act by the 111th United States Congress in 2009 (US Congress, 2009) which assigned regulation of tobacco products to the US Food and Drug Administration. All tobacco products must now be labeled according to ingredients and nicotine content. Tobacco products introduced after March 2011 must have FDA approval prior to marketing (US Food and Drug Administration, 2014). Flavored cigarettes, excepting menthol, are banned under these regulations, although other types of flavored tobacco products remain
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available for purchase. However, some states have banned flavored smokeless tobacco products, as well (Tobacco Control Legal Consortium, 2011). The purpose of this research was to understand the underlying factors contributing to the use of smokeless tobacco in women residing in rural northeastern Alabama. The objectives that drove this investigation were to: (a) describe the patterns of use of smokeless tobacco among women in rural southern united states, (b) identify perspectives on use and health concerns of women who use smokeless tobacco, and (c) uncover areas for future research.
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RESEARCH DESIGN This study employed a qualitative descriptive design. Guided interviews were conducted and a health history and demographic survey obtained.
DESIGN OF THE STUDY Protection of Participants Prior to the study, all required materials were submitted to the Institutional Review Board at the University of Alabama in Huntsville, and the study was approved in keeping with established guidelines and standards. Each participant was fully informed of the nature and purposes of the research and each signed a consent to participate. Participants were assigned a code number and each individual’s name, with personal information and the assigned codes, were stored in the primary investigator’s personal file under lock and key. All data was filed by participant code only. Electronic access was password protected. Recruitment of Participants Due to the hidden nature of smokeless tobacco use, nonprobability sampling was used. Recruitment of participants involved a variety of means. Twenty-seven flyers and posters describing the study and providing contact information were placed in a variety of locations: at points of sale for smokeless tobacco products, in health care providers’ offices, and in community centers, although there were many refusals to allowing posters to be placed. All manufacturing facilities refused poster placements outright. None of the posters yielded any participants. Only personal connections in the community and the snowball technique proved productive in recruiting participants. Three of the participants were known to the primary investigator and the remaining participants were referred by other participants or community residents. In all, 12 women were contacted and 10 elected to participate in the study. However, even a refusal of a retail outlet to allow posters to be placed yielded useful information. “They won’t talk to you,” he warned. The tobacco companies run big promotions for free stuff and the women who use snuff won’t even sign up. Not even for free things will they put their names down. Some make their husbands sign up, but rarely does a woman. Lots of them come in to buy though.
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Sample and Setting The sample included a group of 10 women who self-identified as meeting the inclusion criteria: (a) a history of smokeless tobacco use; (b) woman over the age of 19; (c) English-speaking; (d) able to read, understand, and provide consent to participate in the study; (e) able to participate in the interview discussions; (f) live in a rural area; and (g) willing to have their interviews recorded. The women ranged in age from 32 to 87, with age at first use ranging from 8 years of age to 42. Number of years of use varied from 2 to 77 years. Two of the participants identified themselves as being Native American. These two were members of the Cherokee tribe recognized by the state of Alabama. The other participants defined themselves as Caucasian. Nine of the 10 were lifelong residents of the northeast Alabama area. The one participant born elsewhere had lived for a number of years in this area and was strongly influenced by her husband, who was a native of the area. (Please refer to Table 1 for additional data.) The setting for the study was a multicounty rural area in northeastern Alabama lying at the southern end of the Appalachian Mountains. Rural was defined as “any incorporated place or CDP (census designated place) with fewer than 2,500 inhabitants that is located outside of a UA (urban area)” (Census Bureau, 2010). According to the Census Bureau, a place is either entirely urban or entirely rural (US Census Bureau, 2010). Data Collection Participants who agreed to be interviewed were contacted and an appointment was set up for an initial meeting at a date and time mutually agreeable for both the participant and the researcher. In addition to the interviews, demographic data was obtained and a health history completed. A guided interview form was developed and used to facilitate consistency in data collection and to focus the interview toward the desired information. The interview guide items were selected by members of the research group as a means to facilitate the storytelling of the women. Influences on the inclusion of items were clinical practice and personal contact with women who used smokeless tobacco. This guide included a single question that, hopefully, engaged the participant in a dialogical exchange but did not restrict information the participant was willing to share. Other items on the guided interview form included discussion points such as age of first use, duration of use, amount and type of use, and thoughts about health risks and quitting. These items were introduced as opened-ended questions and used only if the information did not arise during the conversation with the participant. This approach served to ensure that specific basic information was included. The guided interview format allowed the interviewer flexibility to ask needed questions, add personal commentary, and clarify information provided by the participant. A decision was made, due to the suggested sensitivity of the topic, for the primary investigator to conduct all of the interviews, as she was known in the community and a sense of trust and rapport was more easily established. Each participant’s data was collected by the primary investigator in two to five dialogue sessions of approximately 30 min for each session. The number of interviews varied from two to five, as did the duration of the interviews, and were dependent on the intensity of the information given, the fatigue level of the participant, the desire and ability of the participant to reflect on the research questions, and the complexity of the history. Field notes containing reflections about the interview were completed by the primary investigator after each interview session was completed. The stories were shared with the additional researchers who provided critical insight and an additional degree of objectivity to the data analysis.
216
55 52 38 52 72
87 60 70 83
32
1 2 3 4 5
6 7 8 9
10
High school
Grammar school High school Grammar school High school
2 years college Technical college High school High school Grammar school
Education None Paramedical Retail sales Garment manufacturing Retired garment manufacturing None None None Retired garment manufacturing Clerk, formerly manufacturing
Employment
Note. CA = Cancer. SVT = Supraventricular Tachycardia.
Age
Participant
Snuff
Snuff Snuff Snuff Snuff
Snuff Cut, moist Snuff Snuff Snuff
Type of Tobacco
30
10 17 12 13
10 42 34 12 8
Age at First Use
2
77 43 58 30
48 10 4 40 64
Years of Use
TABLE 1 Smokeless Tobacco Use Among Rural Women in Alabama Selected Demographic Data
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CA
CA
SVT
Diagnosis
Yes
No No No Yes
Yes No No No No
Have Quit?
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RESULTS Data Analysis Variables included demographic data, quantifiable use history, and health events. These data are presented as descriptive statistical information in Table 1. Means were not calculated at this time due to the number of participants in the study and to the heterogeneity of the data. Ten individuals fully participated in the study.
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Descriptive Data Data from the interviews were analyzed and coded on a continuing basis to help with identification of the themes. The themes were not developed prior to the study, but were derived from the interview data and the field notes. As themes emerged and were identified, the supporting data were related in the form of thick descriptions; that is, case studies that collapsed the data providing insights into what was learned. After the data were analyzed and integrated into this format for communication, the results were shared with each participant for validation, which provided and strengthened the authenticity of the analysis. Themes Six major themes emerged from the data, and each of these themes had polarizing points that helped define or describe each. These themes were validated with each of the participants. The six themes are presented in the following section along with the supporting dialogue for each. The identified themes corroborate and illustrate the first research objective to describe the patterns of use of smokeless tobacco among women in rural southern United States, while the remaining themes provide insight into the second study objective: Identify perspectives on use and health concerns of women who use smokeless tobacco. The first theme, beginning use of smokeless tobacco, had two distinct poles: childhood initiation-culturally embedded versus adult initiation-substitution behavior. Seven of the participants reported beginning use of snuff as children; all had multiple family members who used snuff. One explained, “My mother left us when I was little and my grandmother and aunt raised me. They started me on snuff when I was 12 or 13.” Another reported that she has used snuff since about the age of 10. She was introduced to snuff by her mother. “I have used it almost all my life.” Three of her five sisters use snuff and she reports that she keeps a bolus of tobacco in the space between her cheek and gum almost all the time. One participant related to the interviewer: I didn’t marry until I was in my 50s. I raised all my brothers and sisters—10 of them—and I’m the oldest, making 11 of us. I started using snuff when I was about eight; my mother would give it to me if I did the chores, like washing the dishes. My mother didn’t really like to work; she just liked having babies, so I grew up doing all the cleaning and the cooking when I got old enough to reach the old wood stove. The others worked in the fields, like picking cotton. I’d go out and pick between chores, but I had to have the meals ready and keep the clothes washed up. We didn’t have much and the only luxury we had was tobacco. The boys rolled cigarettes and the girls used snuff.
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Those who started use later in life also shared their stories. One participant told the interviewer that she began using cut tobacco at the age of 42 because it “smelled good.” (Her boyfriend used cut tobacco). Another of the women related that she started using snuff at age 32 after her marriage. Her husband could not tolerate her smoking cigarettes and suggested that she use snuff as an acceptable substitute. Her new husband’s mother uses snuff. The participant, herself, had no prior connection to snuff use. The third participant who began as an adult was using snuff to quit smoking. She worked in a garment factory where smoking was not allowed, due to the danger of lint explosion. She related that many of the women used snuff while they were working. The second theme emerged as secrecy: insider versus outsider. The insiders were people that the women were comfortable knowing that they used smokeless tobacco products; usually family members and/or close friends who may or may not also use. Individuals not in the women’s circle of intimates were deemed outsiders. Information was not imparted voluntarily to those considered outsiders, even to health care personnel, and the women were not forthcoming unless the question was directly and specifically asked. “I don’t smoke,” one woman explained. “I would say I used snuff if they asked me.” Use was restricted to certain situations if others were around who did not know of their using. This was especially true in public situations. One of the participants related that she did not care if others knew about the use of cut tobacco, but stated that she did not want her teenage son and his friends to know, because she did not want him to use tobacco. Use in public was covert, if it was even used. Almost all of the snuff users felt that the use of snuff would be “looked down upon” by those outside their circle, so they were careful about who knew and who did not know about their use. The one exception was a participant who had had extensive surgery for cancer related to the use of snuff. “I’d go on television if I could. I want everyone to know what it can do.” The third theme involved awareness about health risks: knowledge about risks versus lack of awareness. Health risks became apparent to the participants who had had significant health problems and had been told that these problems were related to their smokeless tobacco use. They stated they were not aware of health risks prior to diagnosis. Two of the women had a history of oral cancer and were presently aware of the correlation between their diagnosis and the use of snuff. A third participant reported that she had recurrent supraventricular tachycardia (SVT; which can be precipitated by nicotine), although she did not make the connection between her arrhythmias and her use of smokeless tobacco. When asked what the cardiologist thought about her use of smokeless tobacco products, she shared, “Well, I don’t think he thinks anything—I haven’t told him. He asked me if I smoked, but he didn’t ask about snuff and I didn’t tell him. I’ve never had anyone ask me.” The remaining participants had never had the health risks of using smokeless tobacco products discussed with them by health care providers and most stated that they had limited or no knowledge about the risks associated with its use. None of the participants had reported the use of smokeless tobacco products to health care providers (except the two who were asked due to findings of oral cancer) but stated that they would have done so if asked, and none had ever had the health risks of using smokeless tobacco discussed with them (except on diagnosis of a related illness). Most told the investigator that they had limited or no knowledge about the risks associated with its use. One of the participants stated, “I never really thought about any danger in using snuff.” Another knew the risks, but said she didn’t think she used it enough to be harmful.
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The fourth theme revolved around significant health issues: related health events versus none reported. As pointed out, three of the 10 participants had been diagnosed with serious health problems. Also as noted, participants had never had the health risks of using smokeless tobacco products discussed with them by health care providers or anyone else, and most had limited or no knowledge about the risks associated with use. Because they (or any of their family members) had not developed any significant changes in health that could be attributed to their use of smokeless tobacco, they had no reason to question its use. The woman who had recurrent SVT had already required two ablation procedures and was faced with a third. She told us that her cardiologist said that if the third ablation treatment doesn’t help, she will have no other options available to her. One participant who had undergone numerous surgeries and radiation treatments shared, In the 1970s, I started having sores in my mouth. They wouldn’t heal, so I went to a doctor. He said it was leukoplakia and I had to take antibiotics for a long time and he cauterized some of them. He said probably I would get cancer in my mouth. It took 20 years, but I did. I had my first surgery in July of 1996. I’ve had four surgeries. I had surgery again that November. Then, in 1998, I had radiation treatments and then surgeries again in 1999 and in 2001. I’ve had part of my left jawbone removed and the roof of my mouth, some of my gum, and all of my teeth are gone. I use a plate in there that helps my speech some, but you can see that I’m hard to understand. Some people won’t talk to me.
She no longer uses snuff. Another participant said, The doctor told me I have to quit now; I have cancer in my mouth and I already had surgery 2 months ago. I haven’t stopped using it yet, but I know I need to. He said I could have more cancer. I have breast cancer, too.
When asked by the interviewer if she had been given any information on quitting, she replied, “No, he just said to quit using it.” She also related that she had never been asked about the use of snuff by any health care providers, and hadn’t thought much about risk of using to health. The remaining participants had never personally experienced any health events attributed to their use of smokeless tobacco and, because most of these women had been unaware of the connection between the use of smokeless tobacco products and health issues, they had seen no reason to discontinue its use. The fifth theme revolved around quitting: I don’t intend to quit versus I might, but I don’t know how. Most had no thoughts about quitting and found the use pleasurable. The interviewer heard comments such as: “I’ve never tried to quit. The subject never comes up.” “I don’t intend to quit. I enjoy it. It relieves stress.” “I enjoy using tobacco and don’t have a problem with it.” One participant was ambivalent: “I don’t think I can quit until my mother passes. She is 97 and she still uses snuff in the nursing home. I’ll quit then. It is my connection to her. I know it sounds crazy, but that’s how I feel.” Another participant told the interviewer, “My mother tends to be self-centered and possessive. Snuff was the only thing she ever shared with me freely. I think I may quit after she is gone. I don’t think I can until then.” Participants who have thought about quitting were fewer, but there were several who were possibly considering quitting. “I hadn’t thought about it before. But I have thought about it since we have begun talking. I’m going to quit. I think I can do it.”
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The last theme identified was: how much and why: use all the time versus recreational use only. Seven participants used regularly and/or almost continuously. They recognized that they were probably addicted, like smokers are to cigarettes. However, three told the investigator that their use was restricted to only certain times or in certain situations; not as a habit of continual use. “sing snuff was just something you did. I’ve never really thought much about it. I do know I get nervous if I can’t use my snuff, so I guess it is a habit like smoking. Sometimes I get where I really don’t want to use it, and then I can’t wait to get where I can; I guess like someone wanting a cigarette. I try to ration myself. You know, it is expensive! I use about a large can (about an 8 oz. tumbler size) each week. I can’t afford any more than that. I try not to use it all the time, but that’s just what I end up doing. My husband didn’t want me to smoke and he thought snuff would take care of the smoking. His mother used snuff. I work in a clothes factory making shirts. It is dangerous to smoke anywhere around there and a lot of the women use snuff. I used to smoke, but I started using snuff then. I still use it but I don’t smoke. You can’t go by how often someone takes snuff. You can take a lot and it will last for hours. You keep it between your cheek and gum and it lasts a while. Some snuff is very strong. Mine (Beechnut) is not so strong but my sister uses the stuff in the red can and it is too strong for me. I pretty much use it all the time, except during meals. I can’t imagine not using snuff. I have used it almost all my life. It relaxes me. I use Copenhagen and it is strong; it really gives a “kick.” I don’t use it all the time; mostly on weekends and when I get off work. I take it in the evenings like some women might take a glass of wine. Why? It’s an “in your face” kind of thing. That’s my personality. I like to do the unexpected. My boyfriend, who became my husband and then not, thought it was cool. I think my current husband kind of likes it, too. Hey, it’s better than smoking!
DISCUSSION Initial appraisal of the data identified divergence patterns around initiation of first use. Those who had been using smokeless tobacco longest tended to use dry snuff, began use as children, and were strongly influenced by relatives. By contrast, users who began use as adults or later in life began for different reasons. Use could be either continuous or occasional; however, almost all tended to be guarded about disclosure of use. Those who began use as adults chose types of product similar to women who began earlier in life and their initiation of use was to appease a significant other, as a substitute for cigarettes, or just for fun. The use of smokeless tobacco in women is not a rarity. Although we make no effort to make projections about wider use based on this study; it is highly probable that the prevalence is higher than might be expected, especially in some geographical areas. It is possible there is a significant population of women who currently use smokeless tobacco and have since an early age. This needs additional research for substantiation and verification. Implications for Community Health Nurses Public education in the health risks of tobacco should include the risks of smokeless tobacco use. Information currently found in the literature suggests the use of smokeless tobacco products can assist smoking cessation and use of these products are less harmful than smoked tobacco
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products (American Council on Science and Health, 2013; Ericson, 2013). This notion should be countered in the professional literature and in community education programs by those who have knowledge of the risks of smokeless tobacco. Other safer and more effective means of smoking cessation should be made known to the public. Existing marketing strategies promote products that are appealing to women and young users (Curry, Pederson & Stryker, 2011; Southwell et al., 2012). Due to the limited understanding of the patterns of smokeless tobacco use among specific population groups, this surge in marketing is not being countered by public education or individual professional counseling relating the risks to health of new, seemingly less harmful tobacco products. Strategies for smokeless tobacco cessation should consider cultural norms with attention to accessibility in rural communities. Cessation strategies should consider the whys of smokeless tobacco use, as well as the cultural underpinnings important to those who use it. Primary and secondary prevention strategies should be tailored to take into account whether the individual initiated smokeless tobacco use at an early age as a cultural norm, or later in life as a substitution for smoking or other reasons. Interventions to support change may be very different in approach, considering the motivation for and cultural propensity to use and the barriers for quitting. Community health nurses should have heightened awareness of the significant health consequences; this fact is vividly illustrated by the study data, illustrated by the fact that three of the 10 participants of this small research sample had already experienced significant, disfiguring, and/or life-threatening health consequences. This information, alone, underscores the need for improved accuracy of health histories which include all tobacco use, not just a smoking history. Health care providers are not adequately assessing risky health behaviors related to smokeless tobacco use by women, nor counseling those at risk. While oral cancer is one of the most obvious of risks, research studies have found links to other cancers as well other health conditions (American Cancer Society, 2009; CDC, 2010; Chao et al., 2002; Hergens et al., 2008; Jayaleskshmi et al., 2009; Norberg et al., 2006) and, except for after the diagnoses of the two women found to have oral cancer, the participants in this study had neither been queried by health care providers about use nor been informed of the health risks of using smokeless tobacco products. Community health nurses are situated in a strategic position to take advantage of this information to obtain more comprehensive assessment data, identify at-risk clients, and personalize interventions aimed at prevention and education of those who they treat. It should be noted that community health nurses, especially in rural communities, are likely to be able to gain the trust and confidence of women who use smokeless tobacco. In small communities, these women would be neighbors, friends, and relatives. The community health nurse’s role in the community is of vital importance.
Potential Directions for Future Research Certainly, this study should be expanded. The difficulty in recruitment of potential participants is a barrier. Additional connections must be made in the communities to facilitate recruitment. Convincing the local industries to participate would add dimension and access to potential participants. Other avenues would be through the public school system and health care facilities. Dentists, especially, may prove valuable allies.
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Tobacco companies currently continue to pour substantial resources into marketing new products that appeal to younger and younger consumers, many of whom are women (Beirne, 2008: Easton, 2009; New Jersey Department of Health and Human Service et al., 2009; Pechacek, 2014). How might these marketing strategies influence beginning or continued use of smokeless products? How should public health or regulatory bodies respond? What factors might influence first use? None of the women in this study had received information relating to quitting the use of smokeless tobacco. What are the most effective means of communicating information to those at risk? What motivations or approaches would be most likely to influence successful cessation? Due to the hidden nature of the phenomena evidenced in this study, it is imperative to expand the current research focusing on patterns of use in rural populations in other sections of the country to identify or validate the scope of the problem. Risks to well-being are increased when an individual lacks information regarding the dangers of a behavioral choice. What other factors might increase an individuals’ vulnerability to choosing this behavior? It was clear from the data that most of the participants functioned in a social group where the use was acceptable. Are there other cultural or ethnic groups that have influence on an individual’s choices? It should be recalled that two of the participants identified as Native American. What is the cultural significance, if any, in specific groups? Is there an actual difference between types of geographical settings? Some participants began, or increased, use when employed in work where smoking was not permitted. However, they stated that they could use smokeless tobacco all the time they were working. What is the prevalence in specific industries, such as the garment making industry where some of the women were employed? In summary, suggestions for future research include: • Investigate use in other at-risk groups • Use of smokeless tobacco in the manufacturing industry, • Use of smokeless tobacco in young women, • Use of smokeless tobacco in urban or suburban ethnic groups, • What influences the use of smokeless tobacco in females, and • Differences in use patterns based on a variety of demographic variables. • Develop and implement multisite interventional studies that can: • Provide needed strength to make recommendations for changes in practice guidelines, especially as they impact the overlying cultural aspects of users consistent with the patterns identified in this study and others; • Suggest primary and secondary prevention programs to aid in better mitigating the health consequences of smokeless tobacco use in at-risk populations; and • Provide guidance for policy change.
FUNDING This work is supported by a grant from the University of Alabama in Huntsville, Office of Sponsored Programs, Distinguished Faculty Award, Huntsville, Alabama.
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