Initiation and use of smokeless tobacco in relation to smoking

Questionnaire data obtained from 1,631 tenth grade students in 14 school districts in the State of Washington are used in this investigation of the relationship between the onset processes for smokeless tobacco use and smoking. Emphasized is the use of time-to-event data on the ages of occurrence of six events in these onset processes. Concepts and methods for the statistical analysis of time-to-event data are demonstrated. The occurrence of events in the smoking onset process are strongly related to increases in the subsequent onset rate for smokeless tobacco use. Compared with before initial smoking has occurred, the onset rates for weekly smokeless tobacco use after initial smoking has occurred are 2.03 (P less than .001) and 6.72 (P less than .001) times as large for males and females, respectively. Furthermore, both initial and weekly use of cigarettes contributes to the risk of subsequent weekly smokeless tobacco use. Conversely, the steps in the onset process of smokeless tobacco use are strongly related to increases in the subsequent smoking onset rate. Possible implications for intervention in prevention of smokeless tobacco use and for further research are discussed.