Adolescent dual-product users: Acquisition and situational use of cigarettes and cigars

Highlights

• Youth reported acquiring cigarettes and cigars in similar ways.

• Cigarettes were more likely to be used in solitary situations compared to cigars.

• Differences in acquisition and situational use exist among user subgroups.

Abstract

Background

Little is known about how adolescents who smoke both cigarettes and cigar products obtain and use these products. This study sought to explore cigarette and cigar acquisition and situational use among high school smokers.

Methods

Data are drawn from the 2011 Cuyahoga County Youth Risk Behavior Survey. Analysis was limited to youth who smoke cigarettes as well as cigars, cigarillos, and little cigars (CCLC) in the past month (N = 649). Consumption of both products was calculated and used to create four subtypes of users based on high or low use of each product (Dual High, Dual Low, High CCLC/Low Cigarette, and Low CCLC/High Cigarette users). Current users were asked to identify situations in which they use cigarettes and CCLCs and ways in which they obtain these products. Data were analyzed overall and by user subtype.

Results

Youth reported acquiring cigarettes and CCLC in similar ways, although youth were more likely to take cigarettes from family members than CCLC (11.1% vs. 4.8%). Several differences were observed between cigarettes and CCLC for situational use. While both products are frequently used in social situations (e.g., with friends), cigarettes were more likely to be used in solitary situations (e.g., before bed). Further, significant differences were observed among the four user subtypes.

Conclusions

Study results highlight important, nuanced differences regarding how young multi-tobacco users obtain and the situational use of such products. Importantly, these findings vary by user subtype, informing future interventions to prevent and reduce smoking among the most vulnerable subgroups of youth.

Introduction

Rates of cigarette and cigar, cigarillo, and little cigar (CCLC) use have been declining over the last two decades among adolescents, and rates of current use of both products among high school students are similar, with 10.8% reporting cigarette use and 10.3% for CCLC (Kann et al., 2016). Further, 43.0% of adolescents (12–17 years old) who currently use tobacco report using more than one tobacco product. Cigarette and cigarillo use is the second most common combination of tobacco products for 10.1% of adolescent users of multiple types of tobacco; among multiple tobacco product users, 14% of youth and 22% of adults report using cigarettes with another cigar product (Kasza et al., 2017). Among adults, dual cigarette and CCLC users are more likely to be male, young adults (18–29), non-Hispanic Black, and have lower education levels (Cohn et al., 2015; Richardson et al., 2012). Adult dual cigarette and CCLC users report more symptoms of nicotine dependence than cigarette-only users (Rostron et al., 2016), prompting concern for increased risk of dependence among adolescents reporting dual cigarette and CCLC use. Notably, a significant number of adolescent smokers are using multiple products during adolescence, and earlier age of tobacco initiation is associated with an increased likelihood of being a multiple product user (Soneji et al., 2014). Additional research is needed to inform tobacco control strategies inclusive of CCLC use (Symm et al., 2005) to prevent and reduce smoking among youth, particularly with the extension of the US Food and Drug Administration’s regulatory authority to all tobacco products, including CCLC (Food and Drug Administration, 2016).

In a previous study, we found that the acquisition and use of CCLCs is similar to that of cigarettes as described in other research (Acosta et al., 2008; Castrucci et al., 2002; Hahn et al., 1990; Kaestle, 2009; Proctor et al., 2012; Seo and Huang, 2012; Sussman et al., 1993; Trapl et al., 2016b) with most adolescents, regardless of gender, race, and ethnicity purchasing their own CCLC and using them in social situations (Trapl et al., 2016b). Differences among subgroups were found in sharing and solitary use of CCLCs; females were more likely to share and youth identifying as black or Hispanic were more likely to smoke in solitary situations (Trapl et al., 2016b).

Many youths use more than one tobacco product. Adolescent users of more than one tobacco product are more likely than single product users to think that their close friends use cigarettes, hookah, and cigars as well as to report they would date someone who used these products (Cooper et al., 2016). Additionally, there are differences in the acquisition and use patterns of single product CCLC users and those who use both CCLC and cigarettes; dual users of CCLC and cigarettes are more likely to use in solitary situations as well as buy and take CCLC compared to CCLC-only users (Trapl et al., 2016b). However, we do not know if dual users are smoking CCLCs and cigarettes in different situations or acquiring each product in different ways, information that could provide additional evidence to inform prevention strategies.

The empirical literature has demonstrated that amount of tobacco consumption is related to smoking patterns, motivations, quitting behaviors, and dependence. While the definition of a light smoker has varied across studies, there are differences demonstrated in the literature between intermittent/light and daily cigarette smokers (Coggins et al., 2009; Tindle and Shiffman, 2011). In their review of studies on intermittent/light smokers, Coggins and colleagues found that smoking behavior of intermittent/light smokers is motivated by positive reinforcement and related to relaxation and socialization (Coggins et al., 2009). Intermittent cigarette smokers are more likely to try quitting than daily smokers, but most are not successful in their quit attempt (Tindle and Shiffman, 2011); in addition, they also tend to demonstrate lower nicotine dependence (Coggins et al., 2009). While research has focused on categorization of an intermittent/light smoker in terms of cigarette use, multiple product users may also be at risk for nicotine dependence even with low cigarette use (Husten, 2009). Moreover, the varying definitions of dual use and different use frequencies further complicate associated risk profiles (Klesges et al., 2011).

A growing body of research has highlighted the trend of dual use of cigarettes and cigars among adolescents, and there is limited understanding of acquisition and situational smoking patterns among this group. Further, given the variation noted above in consumption patterns and correlates, it is unclear how levels of cigarette and CCLC consumption may be associated with unique patterns of acquisition and situational use. Understanding acquisition and situational use among dual product users while taking into account consumption how it varies by demographic characteristics, will inform strategies to reduce adolescent tobacco use, initiation, and potentially address cessation.

Given the rise of dual use of tobacco products and opportunities presented by the FDA’s recent regulatory authority of CCLC (Food and Drug Administration, 2016), understanding the situational use and access patterns of dual users could inform strategies to prevent and reduce adolescent CCLC use. Thus, this study focuses on a sample of high school youth who identified as current users of both cigarettes and cigar products and compared their acquisition and situational use of each product. The sample was segmented into four user categories (i.e., Dual High, Dual Low, High CCLC/Low Cigarette, and Low CCLC/High Cigarette users) to understand if smoking patterns are associated with acquisition and situational use.