Our findings related to the high prevalence of ST use among rural high school males in California who smoke and/or who participate in rodeos, FFA, and the sports of wrestling, football, and baseball are of great concern. These activities are very popular and encouraged among young males in rural areas. The high ST use prevalence in these male subgroups highlights the need for caution in using state-level overall prevalence of ST use among high school students as a benchmark for policy-makers’ assessment of preventive programs needed. Using such an overall benchmark masks higher ST use among at-risk subgroups of rural high school males, erroneously suggesting that ST use is not a problem among California high school youths. Indeed, in California, and perhaps elsewhere, there is still much to be done to prevent oral disease and promote oral health among rural high school males at risk for ST use. Dental public health practitioners need to assess rural community subgroups to determine risk of ST use and associated oral health effects and to raise policy-makers’ awareness of the need to develop and implement targeted preventive programs to influence social norms related to ST use. For example, ST use assessment could be incorporated into community-based health screening programs as ST-associated oral health problems are visually detectable. One study found 79 percent of ST users had observable oral leukoplakia, a precancerous lesion (18
), compared with 6 percent among non-ST users. In addition, among ST users, 85 percent of lesions were in the area where ST was placed (18
). These oral lesions, when pointed out to users in their own mouths, appear to motivate many ST users to make a quit attempt (19
). They also may serve to reinforce the benefits of cessation as the lesions often heal quickly if the user refrains from ST use for at least 2 weeks (21
To date, five randomized controlled trials of ST cessation treatment report (22
) that an oral cancer screening with feedback about ST-related oral problems, cessation advice, self-help materials, and brief counseling by a dental hygienist significantly promoted ST cessation. Thus, dental screenings provide public health practitioners with a “teachable moment” to discuss oral health effects of ST, relate adverse oral changes to ST use, deliver a brief ST cessation intervention, and refer the client to an external ST cessation program for additional assistance with quitting. In health-related clinical settings, tobacco cessation rates have been reported to double when three to four intervention formats are used in addition to face-to-face counseling (27
). Thus, adding a self-help quit guide, referral to a telephone quit line, and/or to a tobacco cessation Web site or community-based cessation program could maximize quitting success. Estimated abstinence rates for self-help and telephone counseling range from 12 to 23 percent depending on the format used (28
The public health service guidelines for brief clinical interventions (30
) recommend all individuals seeking health care to be: asked if they use tobacco, advised to quit, assessed for willingness to quit, assisted appropriately based on willingness to quit, and scheduled for follow-up. Public health practitioners could not only deter experimental tobacco use among adolescents by discussing the addiction’s dangers but also could provide referral for treatment for highly dependent users.
To maximize ST use assessment among high-risk male adolescent subgroups and provide services on an ongoing basis, dental public health practitioners need to build broad-based coalitions that are community-based, cross-disciplinary, and culturally sensitive to develop integrated comprehensive programs that include oral health. Such coalitions could increase the number and types of settings where oral health assessment and services, including tobacco use prevention and cessation intervention, are provided.
As our study took place for over 4 years and schools that participated each year had different distributions by year in school, we weighted the study by the overall distribution of year in school to allow comparisons across the years of the study. Also, students from the same school were likely to be more correlated than those from different schools. Thus, all analyses used a survey sampling approach to account for the clusters and weights. Unweighted, unclustered analyses produced very similar findings with smaller variances (e.g., narrower CIs) indicating that weighting did not change the relationship between ST use and other factors.
Our overall estimate of 9.8 percent for prevalence of current ST use among rural California high school males is similar to the 11 percent reported in the 2002 NYTS and in the 2003 YRBSS for current ST use prevalence among high school males nationally. Similar to our study, the latter two national studies used school-based, self-administered questionnaires. However, the overall ST use prevalence we found is lower than the 2005 NYTS-reported ST use prevalence among high school males (13.6 percent) nationally (14
). In contrast, our 9.8 percent estimate of current ST use among high school males in rural California is much higher than the 0.5 percent current ST use among all California adolescents reported in the 2003 CTS using a random-digit-dial telephone survey. This latter inconsistency may be because of the fact that our findings relate to males in rural areas of California and are based on a written, self-completed questionnaire procedure rather than on a random-digit-dial telephone survey. Evidence suggests that ST use estimates can vary widely depending on mode of data collection (31
). A limitation of our study is that the student participation rate was only 56 percent and the total (school × student) participation rate was 28 percent, potentially resulting in bias from respondent schools and students differing from nonrespondents. However, respondents were similar to overall county- and school demographics.
Surprisingly, we found that ST use among African-American high school males living in rural areas of California overall was higher than that of their White male counterparts (18.1 percent versus 10.7 percent), significantly so among smokers. This high prevalence of ST use among African-American youth compared with White youth is inconsistent with overall national data (pooled across urban/rural location), which may reflect level of nicotine addiction or the influence of culture in rural areas (10
). This potential rural influence on African-American students needs to be further explored. Perhaps community-based protective factors such as cultural norms, racial/ethnic peer support, and church-related factors that may protect African-American male adolescents in urban areas may be less potent in rural areas. As a result, African-American male adolescents in rural areas, compared with those in urban areas, may be more vulnerable to ST use, a behavior traditionally associated with rural White culture (7
). Such an explanation is consistent with our previously reported findings regarding ST use among high school baseball athletes in rural areas of California (8
). In that study, the prevalence of current ST use by non-White athletes at rural high schools tended to be much higher than that of non-White athletes at urban high schools (22 percent versus 6 percent, respectively). Tobacco control programs targeting high school males in rural areas need to incorporate non-White as well as White positive role models/spokespersons.
Moreover, in our study sample, ST use increased significantly with year in school suggesting the need to intervene early in the high school years. In addition, student participation in organized sports or FFA increased risk of ST use. Davis and colleagues similarly report that high school male athletes are more likely to use ST than nonathletes, but athletes participating in sports characterized by a high level of dynamic exercise (e.g., soccer and basketball) had lower rates of ST use than other athletes (32
). Our finding that smokers were 2.5-30 times more likely to use ST compared with non-smokers is consistent with our findings from an earlier study that being a current smoker is the strongest predictor of ST use among male high school baseball athletes in rural areas (8
Use of ST as a smoking cessation method or as a means to reduce cigarette use among addicted smokers is advocated by some (33
). The impact of ST use as such, however, is relatively unknown (34
). Promoting ST use as an alternate to smoking might actually increase the uptake of ST use among adolescents who misinterpret the message to mean “smokeless is harmless.” Potential harm at the population level of recommending ST use in smoking cessation/reduction needs to be studied. This need for further study appears to be supported by reports that ST use leads to increased smoking among high school males (35
) and among young adult males (37
We found that high school males who perceived little, or no risk of, harm from ST use were significantly more likely to be ST users than high school males who perceived moderate or great risk of harm associated with use (3.6-13.3 more times, depending on race/ethnicity). A number of authors have suggested that perception of harm from smoking may be a consequence from, and not necessarily a cause of, smoking (i.e., smokers frequently deny the potential harm as a way to rationalize smoking) (38
). In addition, adolescent smokers also have been reported to have unrealistic optimism about their own ability to stop smoking compared with their more pessimistic views about other smokers (40
). This evidence of unrealistic optimism about smoking risk suggests that ST-using adolescents also may not have adequate knowledge to understand potential ST risks (42
Dental public health practitioners need to assess ST use among high school males in rural communities, and, if indicated, educate policy-makers that ST use continues to be a problem among male youths in rural areas. Community-based partnerships need to be built to develop and implement ST use prevention programs targeting young males in rural elementary and junior high schools.