This study is the first to examine the characteristics of career fire service personnel who were classified as SLT users only or dual users of SLT and cigarettes, and factors associated with their use of these tobacco products. In our cohort of firefighters, the prevalence of exclusive SLT use was almost two times that found in national surveys of men, 13.4% versus 7.0% [2
], and was higher than rates from states represented in this study (i.e., current rates range from 7.2% in Colorado to 11.9% in South Dakota). In addition, the prevalence of dual use in our sample was 2.6%, which is 3-4 times higher than that found nationally, 0.6–0.8% [19
Health behaviors associated with SLT or dual tobacco included alcohol intake and meat/snack consumption. Both SLT and dual users were almost 4 and 5 times more likely to binge drink than nontobacco users. Interestingly, dual users reported consuming meat and/or high-fat foods eight times more than nontobacco users. Dual users also were more involved in a number of health risk behaviors including reporting driving while intoxicated in the past 30 days, being less likely to eat fruit and vegetables, more likely to eat meat and high-fat foods, and less likely to use SCBAs during a fire. Although these risk behaviors of dual users were not found significant due to the low sample size, they were relatively distinct from those of both nontobacco and SLT users, indicating a unique group of tobacco users.
Several study limitations should be noted. First, the sample consisted of career firefighters in one IAFC geographic region in the USA. Data may not be generalizable to other populations or regions. Second, tobacco use (except for cigarette smoking) was based on self-reports and not validated by biochemical markers, which could underestimate actual tobacco use. However, self-reports have been found to be valid for assessing all forms of tobacco use in several epidemiological studies [31
], and self-reports of smoking were very accurate when compared to biochemically verification in this cohort [13
]. Next, only 11 participants were dual users in this sample, which could influence and reduce the precision of the study outcomes. Finally, the study was cross-sectional, so drawing causal and directional inferences between the various forms of tobacco use and their correlates is not possible.
Our findings have several public health implications. First, the trend toward clustering of tobacco use and other health-risk behaviors emphasizes the need to address these behaviors by using intervention strategies that consider multiple risk factors and treatment contexts, such as providing treatment in dental or medical offices [32
]. Second, future research is needed to examine social and industrial factors that support tobacco use and evaluate occupationally tailored interventions to help firefighters to successfully quit. This is particularly important given the high proportion of dual users found in this sample. Third, fire service organizations should address and focus more on SLT cessation programs in order to reduce the risks of SLT-related illnesses given that SLT use is associated with some cancers and other oral diseases [8
]. Finally, because of the exceptionally high levels of SLT and dual use in the fire service, and its unique job characteristics (e.g., spending extended periods of time living together during extended shifts, frequently working in outside weather conditions, and having high level of interdependence among crews), intervention programs should be specifically developed and tailored for this occupational group.
The current findings support earlier studies reporting that SLT products were more likely to be used by White adults than among minority respondents [9
]. For example, Rodu and Cole [1
] found that nearly all SLT users were Caucasian. In addition, previous studies generally show SLT and other tobacco use cluster with other health risks, particularly substance use [17
]. For instance, Lando et al., [17
] found that SLT users reported more total alcohol use and binge drinking compared to never users. Alcohol use also has been associated with increased tobacco consumption including SLT [9
]. Although both SLT users and dual users in this sample were more likely to drink alcohol and binge drink, they were not more likely to engage in occupational risk-taking such as not wearing their SCBA during a fire.
In contrast, there have been extensive data indicating that cigarette smokers demonstrate higher occupational risk behaviors, such as being less likely to use seat belts and more likely to use drugs and be involved in physical altercations when compared to nontobacco users [33
]. Thus, SLT users and dual users are probably more health focused or have higher health consciousness than smokers. As we stated previously, detailed information on SLT and dual users' health risk behaviors can be useful for developing an SLT cessation intervention strategies that consider multiple risk factors and delivery contexts in the program design. In addition, knowing associated risk behaviors of SLT and dual can be useful for health care providers in assisting SLT and dual users quitting.
The use of both cigarette and SLT, or dual use, was observed to be very high in this cohort. Although there were no statistically significant differences in age SLT initiation and mean numbers of SLT use between SLT users and dual users, we found that dual users started using SLT later than when they started smoking and that they used less SLT than exclusive SLT users. In addition, almost half of dual users in this sample reported using SLT after joining the fire service, indicating that fire service restrictions on smoking cigarettes might play the crucial role [11
Several studies have shown that smokers who use other forms of tobacco have higher health risks compared to other tobacco users [17
]. It has been suggested that dual users are trying to quit or reduce smoking by using SLT as a replacement for nicotine delivery. Also, it has been reported that dual use is associated with high levels of nicotine addiction [19
], which could lead them to use SLT in addition to cigarettes. Our findings support this notion, as dual users in this sample initiated cigarette use at an earlier age than SLT use, and smoked cigarettes as much as that found in the exclusive smokers (10.00 ± 9.03; [13
]). As mentioned earlier, smokers may become dual users due to smoking restrictions, health concerns, and advertising and marketing factors [11
]. Therefore firefighters who use other forms of tobacco in addition to cigarettes are in particular need of research on best methods to encourage cessation and deliver treatment.