Background:
Alternative tobacco products including smokeless tobacco have been marketed as harm reduction products particularly after 2010 when Phillip Morris International (PMI) bought Smokeless tobacco (SLT) business from Swedish Match. However, little information is available on tobacco use pattern. This study therefore sought to report the pattern of cigarette smoking and smokeless tobacco (SLT) use in South Africa.

Methods:
This study involved a nationally representative sample of South African adults aged ≥16 years who participated in the South African Social Attitude Surveys (SASAS). The SASAS used a face-to-face interviewer-administered questionnaire to obtain information on participants' sociodemographic characteristics and tobacco use behaviour. Data obtained from the 2007 (n=2907), 2011 (n=3004) and 2016 (n=3063) surveys were merged and the resultant dataset was used in the analysis. All statistical test took account of the complex sample design used in the SASAS.

Results:
Exclusive smoking was estimated at 20.3% (95%CI=18.1-22.5) in 2007, 18.8% (95%CI=16.8-21.0) in 2011, increased to 19.3% (95%CI=17.1-21.6) in 2016. Similarly, exclusive snuff use reduced from 4.5% (95%CI=3.4-6.0) in 2007, 1.7% (95%CI=1.2-2.3) in 2011, but then increased significantly to 3.2% (95%CI=2.4-4.2) in 2016. Dual use during 2007, 2011 and 2016 were 0.5%, 0.5% and 0.8% respectively. Unlike smoking, Snuff use was highest among females (6%), black Africans (4.5%), rural residents (5.1%) and those with < Grade 12 education (5.6%). Among smokers, current snuff use was not associated with significantly greater odds of a quit attempt in the past 12 months (OR=2.58; 95%CI = 0.94-7.10).

Conclusions:
The promotion of snuff as harm reduction alternative products in South Africa does not appear to have been associated with significant reduction in smoking, but might have resulted in significant increase in snuff use in recent times.