Key points

Introduction

Dual tobacco use, the concurrent use of smoked and smokeless tobacco, is a growing US phenomenon. Approximately 15% of US adult tobacco users concurrently use some form of smoked and smokeless tobacco. Dual tobacco users represent a unique high-risk population. Compared with those who use cigarettes only, dual users tend to be from low socioeconomic status environments, more heavily addicted to nicotine, have extensive difficulties quitting tobacco and sustaining cessation, and may experience compounding risks of chronic diseases and certain cancers.

With an expanding number of tobacco products now available and heavily marketed, dual tobacco use is on the increase among youth. This phenomenon may signal a new pathway to nicotine addiction among youth. A recent National Youth Tobacco Survey found that 12.6% of youth ages 14 to 19 currently use 2 or more types of tobacco. The addictive power of cigarettes is generally well accepted in the United States. Youth, however, even when they acknowledge the dangers of cigarette smoking, perceive that other tobacco products are less harmful. Currently, the field lacks literature that illuminates the short- and long-term effects of dual use on youth, but prevention is critical. Recent evidence shows how industry marketing is one of the most significant influences of dual tobacco uptake. Misperceptions are conveyed through advertisements that encourage cigarette smokers to switch to smokeless tobacco products rather than quitting, to use them in environments in which smoking is prohibited, or to use them as social alternatives. Tobacco companies spend billions of dollars annually to portray tobacco use as attractive, accepted, and culturally engrained.

While we await the studies of immediate and long-term consequences on youth, experts recommend that widespread public education and aggressive product regulations are needed to prevent escalation of dual tobacco use among youth.

More specifically, a recent report by The Community Preventive Services Task Force recommends mass-reach health communication interventions as evidence-based approaches to reducing tobacco use among youth. Unfortunately, we have limited knowledge of prevention efforts focused on dual tobacco use, particularly through mass health communication approaches as a part of comprehensive tobacco control initiatives. According to the Centers for Disease Control and Prevention mass-reach health communication refers to the numerous channels by which targeted public health information reaches large numbers of people. Although there are many systematic reviews of mass health communication interventions for distinct tobacco products, especially cigarette smoking, there are no such published systematic literature reviews focusing on dual tobacco use. This type of review is needed to inform the understanding, design, and implementation of dual tobacco use prevention for youth.

To address this gap, this systematic review focused on the synthesis of empirical results in the context of dual tobacco use rather than particular theories or frameworks. We did not conduct a meta-analysis of extant data, rather the primary goal was to determine what portion of the existing literature had the prevention of dual use as the sole object of study. As a secondary goal, we assessed, within that body of knowledge, the extent to which studies informed population level approaches using any type of mass health communication strategy. The expected outcomes of these systematic reviews were: (1) a compilation of literature on mass health communication approaches addressing dual use tobacco prevention, (2) a methodology for identifying and categorizing such literature, and (3) recommendations for dual tobacco use prevention as gleaned from the literature review, including future development of a research agenda to build the evidence base for dual use prevention among youth.