Our study is the first to report prevalence and risk factors by type of alternative tobacco product use among Latin American youth. Nearly one third of our sample had used tobacco products other than manufactured cigarettes, and almost half of those who were current smokers had used any alternative product. GYTS data (1999–2001) showed that the world mean of current use of other tobacco products was 8.8%, and the mean for the Americas was 11.3%. Boys were more likely than girls to use other tobacco products in the Americas, Europe, and South East Asia. No significant overall differences were reported by sex in other world regions. In addition, no sex differences were reported in 98 of the 147 sites [19
]. A recent GYTS report analyzing changes between 1999 and 2008 shows that other tobacco use had increased in 34 world sites, and there was a significant increase between 2003 and 2007 for girls in Argentina [20
]. However, GYTS does not provide data on lifetime use or on type of product used. In our sample, the overall use of other tobacco products was more likely to occur among boys. However, after controlling for social, demographic, and psychosocial factors, no significant differences were found between boys and girls for using tobacco leaf, or for smoking hand-rolled cigarettes or cigars. Similarly, although the overall proportion of younger youth who used other tobacco products was lower, age was not a significant risk factor after adjustment for other variables, except for smoking cigars.
Tobacco leafs for chewing was the only smokeless product examined in this study. The use of tobacco leafs, easily available in this tobacco growing region, could constitute and appealing practice among a population of largely low-income individuals with precarious working conditions. Nevertheless, only 2.3% of our sample reported using this product. This may be due to the common use of coca leaf as a chewing product. This practice is legal in Jujuy; and has strong and ancient cultural roots. The implementation of smoke free policies for indoor public places is incipient or nonexistent in Jujuy, thus it is unlikely that tobacco leafs for chewing are used as a substitute for cigarettes, where smoking is not allowed.
In previous reports, youth in this sample who self identified as being indigenous had higher rates of manufactured cigarette smoking, compared with youth of European descent. They were also more likely to smoke cigarettes after controlling for other factors [14
]. In the present report, no significant association was found for the alternative tobacco products examined and self-reported indigenous ethnicity, but indigenous language spoken in the family was associated with the use hand-rolled cigarettes and pipe. This is an indication that indigenous youth living in less acculturated households where use of an indigenous language is maintained are at increased risk. Furthermore, the ceremonial use of pipes among Indigenous Peoples in the region in the past has been documented by archeological findings. However there are no published reports of contemporary ceremonial pipe use, only key informant reports that merit further exploration. Future studies should ascertain whether adolescents use pipes exclusively for recreational purposes or if there is any association to ritual practices.
Hand-rolled cigarettes constitute a cheaper alternative to commercial cigarettes and were more frequently used by working youth, and especially those in tobacco sales. Use of rolled cigarettes and cigars is almost exclusively seen among youth who have tried manufactured cigarettes. Preference for cigar smoking may be a trait of youth of higher social class and of European descent, since it was associated with attendance to a private school. This finding also merits further elucidation. Other factors associated with current smoking of manufactured cigarettes were also associated with cigar smoking such as having friends who smoke, alcohol drinking, a thrill seeking orientation, and having depressive symptoms [14
Results indicate that the consumption of alternative tobacco products in this region may not only be due to popular trends [21
] but also that socioeconomic and cultural factors play a significant role. Moreover, social and demographic characteristics define groups of at-risk youth, in particular girls, younger youth, and working and less acculturated Indigenous youth. Different types of tobacco products appear to be readily available. Additionally, the potential role of alternative tobacco use in facilitating the transition from experimenting to current smoking is a salient cause for concern that deserves further study. Our results show the importance of addressing socioeconomic and cultural aspects of behavior in tobacco control prevention in the region, the need to restrict accessibility of all types of tobacco products by youth, and to monitor the promotion of these products by the tobacco industry. These findings also highlight the importance of public health surveillance of alternative tobacco products use among youth and the significance of expanding the reach of studies that address the ethnic diversity and vast socioeconomic gaps in Latin America.