Initiation, continuation of use and cessation of alternative tobacco products among young adults: A qualitative study
More details
Hide details
Department of Behavioral Sciences and Health Education, Emory University, Atlanta, United States
College of Global Public Health, New York University, New York City, United States
Carla J. Berg   

Emory University, 1518 Clifton Rd NE, 30322 Atlanta, United States
Publication date: 2018-02-28
Submission date: 2017-10-01
Final revision date: 2017-11-19
Acceptance date: 2018-01-28
Tob. Prev. Cessation 2018;4(February):8
Diverse non-cigarette alternative tobacco products are increasingly popular in the United States. This study investigates the reasons why young adults initiate and continue the use of these products, as well as potential motivations and approaches for quitting. Products assessed include cigarettes, little cigars/cigarillos (LCCs), smokeless tobacco, e-cigarettes, and hookahs.

We conducted 60 telephone interviews, of 30-minute duration, with tobacco users enrolled in colleges in Georgia. Qualitative analysis was used to identify themes emerging from the data.

Reasons for initiation, continued use, and (potential) cessation showed similarities and differences across products. Most commonly cited reasons for initiation included: peer influence (all products), flavors/tastes (all products except cigarettes), and easy environmental access and/or low costs (LCCs, smokeless tobacco, and e-cigarettes). Participants discussed several influences on continued use, such as peer influence (cigarettes, LCCs, and hookahs), stress management (all products except hookahs), and use with other substances (cigarettes, LCCs, and hookahs). Primary motivations for cessation mentioned by participants were family responsibilities (cigarettes, e-cigarettes, and hookahs) and health concerns (all products except e-cigarettes). Frequently used cessation strategies included avoidance of other tobacco users (cigarettes, LCCs, and hookahs) and a reduction of nicotine intake (cigarettes and e-cigarettes).

Our findings suggest that researchers should consider the differences in reasons for use and discontinued use of tobacco products in order to develop targeted messaging strategies, particularly noting the differential impact of interpersonal influences and health concerns. We also point to a need for regulatory action that limits diversification and accessibility of different products.

Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am J Public Health. 2013;103(5):923-30. doi:10.2105/ajph.2012.301070
Berg CJ, Stratton E, Schauer GL, Lewis M, Wang Y, Windle M, et al. Perceived harm, addictiveness, and social acceptability of tobacco products and marijuana among young adults: marijuana, hookah, and electronic cigarettes win. Subst Use Misuse. 2015;50(1):79-89. doi: 10.3109/10826084.2014.958857
Kozlowski LT, Dollar KM, Giovino GA. Cigar/cigarillo surveillance: limitations of the U.S. Department of Agriculture system. Am J Prev Med. 2008;34(5):424-6. doi:10.1016/j.amepre.2007.12.025
McMillen R, Maduka J, Winickoff J. Use of emerging tobacco products in the United States. J Environ Public Health. 2012;2012:989474. doi:10.1155/2012/989474
Lee YO, Hebert CJ, Nonnemaker JM, Kim AE. Multiple tobacco product use among adults in the United States: cigarettes, cigars, electronic cigarettes, hookah, smokeless tobacco, and snus. Prev Med. 2014;62:14-9. doi:10.1016/j.ypmed.2014.01.014
Regan AK, Dube SR, Arrazola R. Smokeless and flavored tobacco products in the U.S.: 2009 Styles survey results. Am J Prev Med. 2012;42(1):29-36. doi:10.1016/j.amepre.2011.08.019
Wray RJ, Jupka K, Berman S, Zellin S, Vijaykumar S. Young adults' perceptions about established and emerging tobacco products: results from eight focus groups. Nicotine Tob Res. 2012;14(2):184-90. doi:10.1093/ntr/ntr168
Duke JC, Lee YO, Kim AE, Watson KA, Arnold KY, Nonnemaker JM, et al. Exposure to electronic cigarette television advertisements among youth and young adults. Pediatrics. 2014;134(1):e29-36. doi:10.1542/peds.2014-0269
Richardson A, Williams V, Rath J, Villanti AC, Vallone D. The next generation of users: prevalence and longitudinal patterns of tobacco use among US young adults. Am J Public Health. 2014;104(8):1429-36. doi:10.2105/ajph.2013.301802
L M Dutra; R A Grana; L Lempert JJKCSAGBLH-FPMLLPMW, . FDA Should Restrict E-cigarette Marketing to Protect Youth as Part of the Currently Proposed Regulation. 2014 2014. Contract No.: Docket No. FDA-2014-N-0189.
Roberts ME, Lu B, Browning CR, Ferketich AK. Tracking Young Adults' Attitudes Toward Tobacco Marketing Using Ecological Momentary Assessment (EMA). Subst Use Misuse. 2017;52(9):1219-24. doi:10.1080/10826084.2017.1302958
Berg CJ, Romero DR, Pulvers K. Perceived harm of tobacco products and individual schemas of a smoker in relation to change in tobacco product use over one year among young adults. Subst Use Misuse. 2015;50(1):90-8. doi:10.3109/10826084.2014.958858
Evans-Polce R, Lanza S, Maggs J. Heterogeneity of alcohol, tobacco, and other substance use behaviors in U.S. college students: A latent class analysis. Addict Behav. 2016;53:80-5. doi:10.1016/j.addbeh.2015.10.010
Enofe N, Berg CJ, Nehl EJ. Alternative tobacco use among college students: who is at highest risk? Am J Health Behav. 2014;38(2):180-9. doi: 10.5993/ajhb.38.2.3
Noland M, Ickes MJ, Rayens MK, Butler K, Wiggins AT, Hahn EJ. Social influences on use of cigarettes, e-cigarettes, and hookah by college students. J Am Coll Health. 2016;64(4):319-28. doi:10.1080/07448481.2016.1138478
Loukas A, Chow S, Pasch KE, Li X, Hinds Iii JT, Marti CN, et al. College Students' Polytobacco Use, Cigarette Cessation, and Dependence. Am J Health Behav. 2016;40(4):514-22. doi:10.5993/ajhb.40.4.13
Cooper M, Loukas A, Harrell MB, Perry CL. College students' perceptions of risk and addictiveness of e-cigarettes and cigarettes. J Am Coll Health. 2016:1-9. doi:10.1080/07448481.2016.1254638
VanDevanter N, Zhou S, Katigbak C, Naegle M, Sherman S, Weitzman M. Knowledge, Beliefs, Behaviors, and Social Norms Related to Use of Alternative Tobacco Products Among Undergraduate and Graduate Nursing Students in an Urban U.S. University Setting. J Nurs Scholarsh. 2016;48(2):147-53. doi: 10.1111/jnu.12192
Latimer LA, Batanova M, Loukas A. Prevalence and harm perceptions of various tobacco products among college students. Nicotine Tob Res. 2014;16(5):519-26. doi: 10.1093/ntr/ntt174
Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the missing link between youth prevention and adult cessation. J Environ Public Health. 2012:1-9. doi:10.1155/2012/679134
Wong EC, Haardorfer R, Windle M, Berg CJ. Distinct Motives for Use among Polytobacco Versus Cigarette Only Users and among Single Tobacco Product Users. Nicotine Tob Res. 2016. doi:10.1093/ntr/ntw284
Braun RE, Glassman T, Wohlwend J, Whewell A, Reindl DM. Hookah use among college students from a Midwest University. J Community Health. 2012;37(2):294-8. doi:10.1007/s10900-011-9444-9
Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults. Nicotine Tob Res. 2015;17(7):847-54. doi:10.1093/ntr/ntu257
Castaneda G, Barnett TE, Soule EK, Young ME. Hookah smoking behavior initiation in the context of Millennials. Public Health. 2016;137:124-30. doi:10.1016/j.puhe.2016.02.013
Saddleson ML, Kozlowski LT, Giovino GA, Goniewicz ML, Mahoney MC, Homish GG, et al. Enjoyment and other reasons for electronic cigarette use: Results from college students in New York. Addict Behav. 2016;54:33-9. doi:10.1016/j.addbeh.2015.11.012
Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall; 1986.
Bandura A. Health promotion from the perspective of social cognitive theory. Psychology and Health. 1998;13:623-49. doi:10.1080/08870449808407422
Berg CJ, Haardörfer R, Lewis M, Fakhouri T, Getachew B, Lloyd S, et al. DECOY: Documenting Experiences with Cigarettes and Other Tobacco in Young Adults. American Journal of Health Behavior. 2016;40(3):310-21. doi:10.5993/ajhb.40.3.3
Gilman SE, Rende R, Boergers J, Abrams DB, Buka SL, Clark MA, et al. Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. Pediatrics. 2009;123(2):e274-81. doi:10.1542/peds.2008-2251
Hu MC, Davies M, Kandel DB. Epidemiology and correlates of daily smoking and nicotine dependence among young adults in the United States. Am J Public Health. 2006;96(2):299-308. doi:10.2105/ajph.2004.057232
Maxwell KA. Friends: The Role of Peer Influence Across Adolescent Risk Behaviors. Journal of Youth and Adolescence. 2002;31(4):267-77.
Morrell HE, Cohen LM, Bacchi D, West J. Predictors of smoking and smokeless tobacco use in college students: a preliminary study using web-based survey methodology. J Am Coll Health. 2005;54(2):108-15. doi:10.3200/jach.54.2.108-115
Cavazos-Rehg PAK, Melissa J.; Sowles, Shaina J.; Spitznagel, Edward L.; Grucza, Richard; Chaloupka, Frank J.; Bierut, Laura J. Multiple Levels of Influence That Impact Youth Tobacco Use. Tobacco Regulatory Science. 2016;2(2):106-22. doi:10.18001/trs.2.2.2
Krishnan-Sarin S, Morean ME, Camenga DR, Cavallo DA, Kong G. E-cigarette Use Among High School and Middle School Adolescents in Connecticut. Nicotine Tob Res. 2015;17(7):810-8. doi:10.1093/ntr/ntu243
Kobus K. Peers and adolescent smoking. Addiction. 2003;98(S1):37-55. doi: 10.1046/j.1360-0443.98.s1.4.x
Paula M Lantza PDJ, Kenneth E Warnera, Jeffrey Wassermanb, Harold A Pollacka, Julie Bersona, Alexis Ahlstroma. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tobacco Control. 2000;9(1):47-63. doi:10.1136/tc.9.1.47
Abroms LC, Ahuja M, Kodl Y, Thaweethai L, Sims J, Winickoff JP, et al. Text2Quit: results from a pilot test of a personalized, interactive mobile health smoking cessation program. J Health Commun. 2012;17 Suppl 1:44-53. doi:10.1080/10810730.2011.649159
McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE. Motivation to quit using cigarettes: a review. Addict Behav. 2006;31(1):42-56. doi:10.1016/j.addbeh.2005.04.004
Heinz AJ, Giedgowd GE, Crane NA, Veilleux JC, Conrad M, Braun AR, et al. A comprehensive examination of hookah smoking in college students: use patterns and contexts, social norms and attitudes, harm perception, psychological correlates and co-occurring substance use. Addict Behav. 2013;38(11):2751-60. doi: 10.1016/j.addbeh.2013.07.009
Ramo DE, Liu H, Prochaska JJ. Tobacco and marijuana use among adolescents and young adults: a systematic review of their co-use. Clin Psychol Rev. 2012;32(2):105-21. doi: 10.1016/j.cpr.2011.12.002
Weitzman ER, Chen YY. The co-occurrence of smoking and drinking among young adults in college: national survey results from the United States. Drug Alcohol Depend. 2005;80(3):377-86. doi:10.1016/j.drugalcdep.2005.05.008
Fix BV, O'Connor RJ, Vogl L, Smith D, Bansal-Travers M, Conway KP, et al. Patterns and correlates of polytobacco use in the United States over a decade: NSDUH 2002-2011. Addict Behav. 2014;39(4):768-81. doi:10.1016/j.addbeh.2013.12.015
Butler KM, Ickes MJ, Rayens MK, Wiggins AT, Hahn EJ. Polytobacco Use Among College Students. Nicotine Tob Res. 2016;18(2):163-9. doi:10.1093/ntr/ntv056
Bonnie RJ, Stratton K, Kwan LY, Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products, Institute of Medicine (U.S.). Board on Population Health and Public Health Practice. Public health implications of raising the minimum age of legal access to tobacco products. Washington, D.C.: The National Academies Press; 2015. xix, 378 pages p.
Morain SR, Winickoff JP, Mello MM. Have Tobacco 21 Laws Come of Age? N Engl J Med. 2016;374(17):1601-4. doi:10.1056/nejmp1603294
Winickoff JP, Gottlieb M, Mello MM. Tobacco 21--an idea whose time has come. N Engl J Med. 2014;370(4):295-7. doi:10.1056/nejmp1314626
Administration USFaD. Tobacco Control Act 2016. 11/07/2016. (accessed 1 October 2017).
Villanti AC, Richardson A, Vallone DM, Rath JM. Flavored tobacco product use among U.S. young adults. Am J Prev Med. 2013;44(4):388-91. doi:10.1016/j.amepre.2012.11.031
Gartner CE, Hall WD, Chapman S, Freeman B. Should the health community promote smokeless tobacco (snus) as a harm reduction measure? PLoS Med. 2007;4(7):e185. doi:10.1371/journal.pmed.0040185
Hennink MM, Hutter I, Bailey A. Qualitative research methods. London: Sage; 2011.
Cost, prevalence and correlates of cigarillo use in 28 European countries in 2017
Filippos Filippidis, Enkeleint Mechili, Charis Girvalaki, Constantine Vardavas
Central European Journal of Public Health