Association of smokeless tobacco use with the use of other illicit drugs in the United States

Document Type



School of Nursing and Midwifery, Pakistan


Background: There has been an increase in the use of smokeless tobacco in recent times. Whether smokeless tobacco use may predispose individuals to use other addictive substances is unknown. The use of multiple addictive substances may compound their adverse health effects.
Methods: In a cross-sectional analysis, we used the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) survey database to identify all individuals who reported the use of smokeless tobacco and extracted data regarding baseline and demographic patterns, as well as information regarding the use of other addictive substances. Weighted multivariable logistic regression models adjusting for age, gender, race/ethnicity, poverty level, education, employment status, and marital status were used to determine the odds ratios(ORs) for use of alcohol, cigarettes, e-cigarettes and marijuana amongst smokeless tobacco users.
Results: We identified 30,395 (3.38%) individuals in our study population who reported smokeless tobacco use. Compared to non-users, smokeless tobacco users were more likely to be unmarried, male, Caucasian, belonging to the lower socio-economic strata, and have not received a formal college education (p<0.01). In multivariable analyses, smokeless tobacco use was associated with a higher likelihood of cigarettes use [OR: 1.76 (95% CI:1.66-1.86, p<0.01)], e-cigarette use [OR:1.61(95% CI: 1.52-1.71,p<0.01)], heavy alcohol consumption[OR:2.36 (95% CI:2.17-2.56, p<0.01)], but not marijuana use [OR:1.11 (95% CI:0.90-1.38,p=0.33)].
Conclusion: In a large, nationally representative sample, smokeless tobacco use was associated with the increased use of cigarettes, e-cigarettes, and alcohol. Simultaneous use of these substances may compound the adverse health effects of smokeless tobacco use. Public health interventions addressing this concerning trend are warranted.


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American Journal of Medicine