Nicotine & Tobacco Research, Volume 16, Number 9 (September 2014) 1167–1173

Original Investigation

Prevalence and Correlates of Smokeless Tobacco Use Among Grade 8–11 School Students in South Africa: A Nationwide Study Priscilla S. Reddy PhD1, Shamagonam James PhD2, Ken Resnicow PhD3, Ronel Sewpaul MSc1, Pardon Masuka MPH4, Bart van den Borne PhD5

Corresponding Author: Ronel Sewpaul, MSc, Population Health, Health Systems and Innovation, Human Sciences Research Council, Private Bag X9182, 12th Floor, Plein Park Building, 69-83 Plein Street, Cape Town 8001, South Africa. Telephone: 27-21-466-7912; Fax: 27-21-461-1255; E-mail: [email protected] Received March 8, 2013; accepted February 27, 2014

Abstract Introduction: Smokeless tobacco in South Africa is commonly used in the form of snuff or chewing tobacco. This paper reports its use among secondary school students and provides evidence of its association with demographic characteristics, tobacco smoking, and socioeconomic status. Methods: Data were derived from a nationally representative study conducted in 2008 among 10,270 grade 8–11 students from 192 schools in South Africa. Data were collected with self-administered questionnaires. Multiple logistic regression analyses were used to examine correlates of past-month smokeless tobacco use. Results: Nationally, 12.4% of students used smokeless tobacco such as chewing tobacco or snuff in the month preceding the survey, with significantly higher rates among males (13.6%) than females (10.6%). Smokeless tobacco use differed between racial groups, with African (12.8%) and colored (11.7%) students having the highest rates of past-month use. Grade 8 students (15.3%) reported significantly higher rates of use than grade 11 students (9.1%). Current cigarette smokers (21.3%) reported a higher prevalence of smokeless tobacco use than noncurrent smokers (10.1%). Logistic regression of past-month smokeless tobacco use showed significant associations with race, grade, school socioeconomic level, urbanicity, current cigarette smoking, and having first smoked a cigarette before the age of 10 years. Conclusions: These findings provide evidence for policy makers and program developers to develop targeted and tailored interventions for young people regarding smokeless tobacco use.

Introduction Tobacco use in general is a growing global health problem. While there is a downward trend in developed countries, the same cannot be said for developing countries. The morbidity and mortality associated with tobacco use is preventable and the projected estimates of health care costs are striking (World Health Organization, 2011). Most recently, the emergence of harm reduction strategies has moved the debate on tobacco use from cigarettes to include other tobacco products such as smokeless tobacco. Smokeless tobacco is defined as tobacco that is consumed in an unburnt form, either orally or nasally, and its prevalence and gender distribution rates vary markedly between

countries. In countries such as India, the current use of smokeless tobacco among adult males is as high as 32.9% for males and 18.4% for females (Ministry of Health and Family Welfare, Government of India, 2010). For females, high rates have been found in Bangladesh (27.9%), actually exceeding that of males (26.9%), as well as in Mauritania (28.3% for females and 5.7% for males) (International Agency for Research on Cancer, 2012). In many of these countries, women continue to consume smokeless tobacco such as gutkha, paan masala, and tobacco toothpaste during pregnancy (Conference of the Parties to the WHO FCTC, 2010). In developing countries, tobacco is mostly chewed with other ingredients such as areca nut (betel), betel leaf, and lime (Critchley & Unal, 2003).

doi:10.1093/ntr/ntu044 Advance Access publication April 1, 2014 © The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].

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1Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa; 2Health Promotion Research and Development Unit, Medical Research Council of South Africa, Cape Town, South Africa; 3Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI; 4ARCH Actuarial Consulting, Cape Town, South Africa; 5Department of Health Education and Health Promotion, Maastricht University, Maastricht, the Netherlands

Prevalence and correlates of smokeless tobacco use

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adolescents in South Africa, so as to provide evidence to impact on policy and initiatives directed at smokeless tobacco prevention and cessation.

Methods The data for the present study were derived from the second South African National Youth Risk Behaviour Survey (YRBS). It was collected in 2008 through a cross-sectional survey among a nationally representative sample of grades 8–11 secondary school students in South Africa. Sampling A provincially stratified two-stage cluster sampling design was used. The most recent list of all 26,278 schools in the country, provided by the South African National Department of Education, was used as the sampling frame, to ensure nationally representative data. The sampling frame was first stratified by province. Schools were the primary sampling units and were selected with a probability proportional to schools’ learner enrolment in grades 8–11, that is, schools with larger grade 8–11 enrolments had a higher probability of being selected. At the second stage of sampling, classes were randomly selected within each participating school. It was determined that 1,200 students in each province were to be selected, and it was assumed that each class would have approximately 40 students. A participation rate of 80% was expected, based on recent experience of youth surveys (Swart, Reddy, Pitt, & Panday, 2001). A  sample of 13,379 enrolled students from grades 8–11 in the participating schools was yielded. All students in the selected classes were eligible to participate. Students completed a self-administered questionnaire, comprising close-ended or multiple-choice questions on a range of sociodemographic characteristics and risk behaviors. The YRBS questionnaire was adapted from the U.S. Youth Risk Behavior Survey, a health survey conducted biennially among high school students in the United States (Troped et al., 2007). Further details regarding the South African YRBS survey and methodology can be found elsewhere (Reddy et al., 2010). Measures Current use of smokeless tobacco was measured by a positive response to the question “During the past month (30  days), have you ever used any form of smokeless tobacco products (e.g., chewing tobacco, snuff)?” Race was reported using the South African Department of Labour designated categories: African, colored (mixed Black and White descent), of Indian descent, White, or Other. The measures used in the study were calculated as follows. School Socioeconomic Status Level Using the information provided by the South African National Department of Education, schools were categorized into five socioeconomic status (SES) quintiles, which served as a proxy for SES. Quintiles were derived from several factors computed from census data, including income, unemployment, and illiteracy level within the school catchment area. Quintile 1 depicted the poorest schools and quintile 5 the least poor schools. We collapsed the five quintiles into three groups (with

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In South Africa, smokeless tobacco is commonly inhaled as “snuff” by African women and children (Ayo-Yusuf, Swart, & Pickworth, 2004; Peltzer, Phaswana, & Malaka, 2001). Smokeless tobacco is usually made at home particularly when used for ritual practices. The homemade variety was preferred over commercial forms because it is believed to be less costly, not to have chemicals, not to contain menthol, and is not too strong (Peltzer et al., 2001). The homemade variety has much higher levels of tobacco-specific nitrosamines content than the popular commercial brands, which have higher nicotine delivery capacity (Stanfill et al., 2011). The commercial manufacturers in South Africa are not mandated to disclose the nicotine content of their products (South African Government, 1999). Smokeless tobacco products in South Africa are only subject to value added tax with no excise taxes in place (South African Government, 1999). The latter poses a dilemma in terms of control, monitoring, and assessing the impact of smokeless tobacco on individual health and disease sequel (Ayo-Yusuf et  al., 2004). The use of smokeless tobacco in younger individuals is of concern for several reasons namely the reported gateway effects, dual use, and the impact on smoking control measures. Smokeless tobacco may be used as a substitute for smoking in smoke-free environments (Rantao & Ayo-Yusuf, 2012). Although less harmful than cigarettes, use of smokeless tobacco does cause oral cancer, nicotine addiction, and is associated with other oral conditions (Tomar & Giovino, 1998). Furthermore, users of smokeless tobacco have a higher risk of cardiovascular disease than nonusers (Gupta, Gurm, & Bartholomew, 2004). Thus, there is a need to understand the correlates associated with smokeless tobacco use in order to develop effective intervention strategies. The Global Youth Tobacco Surveys report that there is substantial use of smokeless tobacco in the vulnerable age group 13–15 years. The proportion of boys using smokeless tobacco, by WHO region, is highest (42%) in the Western Pacific Region followed by the African Region (17%). Among girls, the highest proportion is found in the Western Pacific Region (32%) and the Eastern Mediterranean Region (12%) (World Health Organization, 2010). The U.S. Youth Risk Behaviour Survey found that in 2009, 8.9% [7.3–10.8] of high school youth used smokeless tobacco in the month preceding the survey (Muscari, 2010). In South Africa, 7.6% of secondary school students in 2008 reported current snuff use and 8.1% currently used chewing tobacco (Reddy, James, Sewpaul, & Koopman, 2010). Regarding correlates of smokeless tobacco, a study in Ghana showed that tobacco use (including smoking and smokeless tobacco) among adolescents was found to be more prevalent in lower socioeconomic groups. It was reported that higher socioeconomic groups were more likely to be exposed to available health education, educated parents, and other sociocultural factors that favored less tobacco use (Doku, Koivusilta, Raisamo, & Rimpelä, 2010). In the United States, past-month smokeless tobacco use was higher for boys (15.0% [12.1–18.5]) than girls (2.2% [1.8–2.7]) (Muscari, 2010). For South Africa, the association with factors like binge drinking, depression, and cannabis use among students that were dual users of cigarettes and smokeless tobacco (Rantao & Ayo-Yusuf, 2012) creates the impetus to further investigate the associations of smokeless tobacco, using a nationally representative sample of schoolgoing adolescents. The purpose of this paper, therefore, is to examine the factors associated with smokeless tobacco use among school-going

Nicotine & Tobacco Research quintiles 1–2 representing lower SES schools, 3–4 middle SES schools, and 5 high SES schools), to increase average sample size per cell and to simplify the presentation of results. Rural/Urban The schools database from the South African National Department of Education categorized schools as rural or urban. Current Cigarette Smoking Students were categorized as being current cigarette smokers if they reported smoking cigarettes on at least 1 day in the month preceding the survey.

Current Alcohol Use Students were categorized as being current alcohol users if they responded positively to having drunk alcohol (e.g., a beer, a glass of wine, or a “tot” of brandy) at least once in the month preceding the survey. Analyses Data were weighted to approximate province level distributions of gender and grade and to account for nonresponse and province size. The primary outcome measure used was current smokeless tobacco use. The predictor variables used were categorized into demographic profile (gender, race, and grade); SES (school SES level and urbanicity); and substance use (cigarette and alcohol use). Multiple logistic regression was used to examine the association of the demographic, socioeconomic, and tobacco and alcohol use variables with current smokeless tobacco use. IBM SPSS 20 Complex Samples were used to run the weighted logistic regression analyses, as it accounts for the sample design, stratification, and clustering. In the sampling procedure, schools and classes were treated as clusters and students within each school and within each class may be likely to respond similarly. Hence, the regression procedure used needed to incorporate the multistage sample design employed in the study.

Ethical approval for the study was obtained from the South African Medical Association Research Ethics Committee. Active informed consent for participation in the study was obtained from the National Department of Education, school principals, the students, and their parents. Parent and learner consent forms were distributed to the students in the selected classes, and the completed consent forms were collected on the day of the study. Assent was also obtained from students on the day of the study.

Results A total of 10,270 students from 192 participating schools submitted completed questionnaires. The national weighted overall response rate was 71.1%. The provincial sampling and response rate breakdown are presented in Table 1. Demographic, Socioeconomic, and Substance Use Profile of the Sample The sample comprised 49.1% male students (Table 2). More than three quarters of the students classified themselves as African (78.1%), while 14.2% reported being colored. The students were equally distributed over each grade. The mean age was 16.2 years. More than four fifths of the students were from low and middle SES schools, with just over a third reporting having used alcohol and over a fifth having smoked cigarettes in the month preceding the survey. Prevalence of Current Smokeless Tobacco Use by Demographic, Socioeconomic, and Substance Use Variables Nationally 12.4% of students used smokeless tobacco in the month preceding the survey, with higher rates among male than female respondents, as shown in Table 3. Grade 8 and 9 students reported significantly higher rates of current smokeless tobacco use than grade 11 students. Current smokeless tobacco use was significantly higher among African and colored students than their White and Indian counterparts. The prevalence of smokeless tobacco use was significantly higher among students from rural environments. Significantly higher rates of smokeless tobacco use were found among students from low and middle SES schools than those from upper SES schools.

Table 1.  Unweighted and Weighted Response Rates Number of schools National Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape North West Western Cape

Number of students

Sampled

Participated

Sampled

Participated

206 23 23 22 23 23 23 23 23 23

193 21 22 19 20 22 23 22 21 23

13,482 1,349 1,617 1,522 1,237 1,492 1,593 1,549 1,646 1,477

10,270 1,007 1,252 973 969 1,169 1,289 1,147 1,268 1,196

Weighted response rates School (%) 93.1 89.3 94.0 87.1 82.4 98.0 100.0 97.8 94.2 95.6

Students (%) 76.2 74.6 77.4 63.9 78.3 78.4 80.9 74.0 77.0 81.0

Overall (%) 71.1 66.7 72.8 55.7 64.5 76.8 80.9 72.4 72.6 77.4

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First Used Cigarettes Before Age 10 A binary variable was derived to indicate those who initiated cigarette smoking before age 10, based on students’ responses to the age at which they first tried a cigarette.

Ethical Approval and Consent Procedures

Prevalence and correlates of smokeless tobacco use Table 2.  Weighted Demographic, Socioeconomic, and Substance Use Characteristics of the Samplea

Table 3.  Smokeless Tobacco Use by Demographic, Socioeconomic, and Substance Use Variables

Characteristic

Characteristic

4,976 (49.1) 5,164 (50.9) 2,389 (23.4) 2,440 (23.9) 3,001 (29.8) 2,440 (22.9) 7,999 (78.1) 1,452 (14.2) 125 (1.1) 545 (5.7) 92 (0.9)

1,330 (14.1) 5,017 (51.3) 3,537 (34.7) 4,421 (43.0) 5,849 (57.0)

3,773 (34.9) 6,335 (65.1) 2,249 (22.1) 7,932 (77.9) 720 (6.8) 9,460 (93.2)

Note. SES = socioeconomic status. aWeighted percentages and unweighted counts presented.

National Demographic  Gender   Male   Female  Grade   Grade 8   Grade 9   Grade 10   Grade 11  Race   African   Colored    Of Indian descent   White   Other Socioeconomic  Rural/urban   Rural   Urban   School SES level   Upper   Middle   Low Substance use   Current alcohol use   Yes   No   Current cigarette smoking   Yes   No First smoked cigarettes before age 10   Yes   No

% (95% CI)

p value

12.4 (11.1, 13.8)

13.6 (12.0, 15.2) 10.6 (9.3, 12.0)

Prevalence and correlates of smokeless tobacco use among grade 8-11 school students in South Africa: a nationwide study.

Smokeless tobacco in South Africa is commonly used in the form of snuff or chewing tobacco. This paper reports its use among secondary school students...
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