Assessing Tobacco Use Among Working Adults in the United States: the Need to Consider Poly-tobacco Use

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To the Editor:
Syamlal et al1 have published an excellent study that highlights significant differences in tobacco use patterns among US workers. Their analysis of National Health Interview Survey data found high levels of combustible and smokeless tobacco use among some workers, especially those in construction and extraction industries, and demonstrates that “any tobacco use” is an important factor to be considered in public health surveillance.2–4 Notably, these results support our previous work, published in this journal, which described any (combustible or smokeless) tobacco use among U.S. workers and found elevated prevalence among workers in extraction, construction, and mining industries.4
An important variable that we described but that was not included by Syamlal et al1 is poly-tobacco use. Poly-tobacco use is the use of cigarettes in combination with other tobacco products. It is important, as it reflects the complexity of tobacco use in the US population as a whole and among today's workers, as well as the increased of multi-product, rather than single product, use. Poly-tobacco use also has implications for both health and tobacco control, as these users may incur increased nicotine exposure, dependence, and risk of tobacco-attributable morbidity and mortality compared with single tobacco product users. As such, poly-tobacco use should be considered when assessing the contribution of tobacco exposure in analyses of the health consequences of various workplace exposures. As Syamlal et al1 point out, the adverse effects of cigarette smoking may synergistically worsen the combined effect of other hazardous occupational exposures on respiratory and other health outcomes.5,6 In the increasingly complex world of tobacco use, we must move beyond assessing smoking or other single tobacco product use, alone in our assessment of disease risk. Detailed information should be collected on the use of all tobacco products in medical and public health surveillance programs, as well as in epidemiologic studies.
We agree with Syamlal et al1 that this body of work supports the need for ongoing tobacco-use surveillance of US working populations and has important implications for workplace cessation programs. A current gap between surveillance and implementation programs also needs to be addressed, how tobacco use patterns are integrated into the workplace including the influence of the workplace and community culture.7 Better characterization of tobacco use behaviors in blue-collar workers is particularly needed, especially those who are at risk of occupational dust exposure.
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