INTRODUCTION
The rates of cigarette smoking in the United States have declined over the past few decades due to increasing knowledge of health consequences, higher regulations and prices, and changing norms1. However, the recent emergence and rising popularity of diverse non-cigarette alternative tobacco products (ATPs) represent new challenges for tobacco control efforts. Commonly used non-cigarette tobacco products include little cigars/cigarillos (LCCs), smokeless tobacco, e-cigarettes, and hookahs. ATPs are becoming more popular in the United States1-3. Recent research conducted in 2010 found that 13.6% of adults and 25.1% of daily smokers in the United States had tried one or more of non-cigarette tobacco products4. In addition, a study found that 6.6% of adults in the United States are using these products exclusively and 10.6% are using dual cigarette and non-cigarette products5.
The use of ATPs among young adults is particularly concerning, given that this group is more aware of ATPs and more likely to try ATPs. Compared to other age groups, young adults between the ages of 18 and 24 years are more likely to have heard of ATPs6; a study in 2010 found that 18% of young adult respondents reported having tried at least one such product4. Evidence also shows that tobacco companies are targeting youth audience for the market of ATPs7-10, and that young adults are exposed to a fair amount of advertising for tobacco products on a weekly basis11.
The transition to college is a critical period for young adults, when many engage in compromising health behaviors including tobacco use2. A body of research has emerged in recent years on young adult college students’ use of ATPs. Studies have examined predictors of use, trends of dual or poly-tobacco use, as well as perceptions of harms of different products in this population2,12-19. For example, certain sociodemographic (i.e. being male13,14,16) and psychosocial factors (i.e. having favorable attitudes towards smoking14, or perceiving peer use of tobacco products15) have been linked to use of ATPs. Research also shows that poly-tobacco use is more prevalent than single-product use among college students16. In addition, while young adult college students have little understanding of possible health risks associated with ATPs (e.g. cancer risks associated with chewing tobacco)7,15, they also have indicated higher acceptance of these products compared to traditional cigarettes18.
Despite these findings, more research is needed regarding the reasons why young adults initiate and continue the use of a range of these tobacco products. Moreover, we must examine the reasons why they may be motivated to quit and strategies or approaches for cessation, as these topics have yet to receive much attention. Information on reasons for the initiation, continuation, and cessation of tobacco products is needed given the changing landscape of tobacco-use patterns, the diversification of ATPs, and the range of use patterns across products20. Research should explore not only the reasons for use and discontinuation of ATPs as a whole, but also whether these reasons might hold or differ across the range of diverse tobacco products, since preliminary evidence has indicated that motives for use may differ across products for single tobacco product users21. For example, while peer or social influence has been found to positively influence the use of hookahs and e-cigarettes by college students22-24, a study has also shown that social motives were negatively associated with consumption of smokeless tobacco in this population21. In addition, studies have found mixed evidence on whether young adults are using e-cigarettes more for enjoyment or for harm reductions (i.e. as a potentially less harmful alternative to cigarettes or as a cessation aid)23,25. An investigation of motives for use, continuation, and cessation of each product will be crucial to the development of appropriate behavioral interventions aiming at prevention or cessation, as well as policies to regulate these products.
This study used qualitative methods to assess young adults’ experiences with cigarettes and ATPs, specifically LCCs, smokeless tobacco, e-cigarettes and hookahs. For each product, we examined: 1) reasons for initiating use, 2) reasons for continued use, and 3) potential motivations for cessation and experiences with quitting. The theoretical framework guiding our study is the Social Cognitive Theory26,27, which emphasizes that a person acquires and maintains a behavior (e.g. tobacco use) through the dynamic influence of personal factors, behavioral, and environmental factors. Based on the theory, we hypothesize that factors such as outcome expectancies, coping responses, self-efficacy and environmental factors (e.g. interpersonal influences or ability to access and use different products) will play a role in influencing reasons for tobacco uptake and continued use, as well as potential motivations for cessation.
METHODS
Participants and procedures
The parent study, Project DECOY (Documenting Experiences with Cigarettes and Other Tobacco in Young Adults) is a two-year, six-wave longitudinal cohort study that involves 3418 racially/ethnically diverse students (18-25 years) from seven colleges and universities in Georgia. Schools are located in both rural and urban settings, and include two public universities/colleges, two private universities, two community/technical colleges, and one historically black university. Project DECOY was approved by the Emory University and ICF Institutional Review Boards, as well as those of the participating colleges and universities. Data collection began in Fall 2014 and consisted of self-report assessments via an online survey every four months for two years (during Fall, Spring, and Summer).
Detailed information on sampling and recruitment are described elsewhere28 and briefly summarized here. The registrar’s office from each campus provided e-mail addresses for English-speaking students 18-25 years. We randomly selected 3000 email addresses from each of the three largest campuses and emailed a census of students at the four smaller campuses with fewer than 3000 students. Response rates at the campuses ranged from 12.0% to 59.4%. The overall response rate of 22.9% (N=3574/15607), albeit low, was obtained over a short time frame (24 hours at the private schools, seven days at the technical colleges) and met the sampling quota targets28. Our intent was to enroll participants who were engaged in email and were potentially more likely to be retained in the subsequent waves of the larger, multi-wave longitudinal project. The sociodemographic characteristics of the baseline sample were largely reflective of the student bodies of the college campuses included in this study; however, the sample was disproportionately female28.
We recruited via email the users of each tobacco product (cigarettes, little cigar/cigarillos [LCCs], smokeless tobacco, electronic cigarettes [e-cigarettes], and hookahs) identified at Wave 2 of Project DECOY to participate in semi-structured interviews during Summer 2015. Eligibility criteria for this part of the study were: 1) used cigarettes, LCCs, smokeless tobacco, or e-cigarettes ≥15 days out of the past 30 days; or 2) used hookah ≥10 days out of the past 30 days (due to the lower frequency of use in this product category). Of the 99 participants recruited, 80 (80.8%) consented, and 60 (60.6%) actually participated in this part of the study.
Measures
Telephone-based interviews that lasted approximately 30 minutes were audio-recorded and transcribed verbatim. Participants provided verbal consent at the start of the interviews and were compensated with a $40 Amazon gift card. The interviews were conducted by female MPH (Masters in Public Health) students trained in qualitative data collection. Sociodemographic data, derived from their baseline assessment of the longitudinal survey, and current substance use were assessed via a sort questionnaire prior to the interview. The interview guide focused on assessing reasons for initiating use of cigarettes and the respective ATPs, reasons for continued use, potential reasons for cessation, and experiences with quitting.
Data analysis
Qualitative data were analyzed using MAXQDA 12 (Berlin, Germany, http://www.maxqda.com/). Two members of the authorship team (trained MPH-level study personnel) independently reviewed all transcripts and generated preliminary codes using deductive and inductive coding methods. A preliminary codebook for analysis was developed. Primary (major topics) and secondary (recurrent themes within primary topics) codes were established. Then, each transcript was fully and independently analyzed by two additional MPH students, and coded using the preliminary codebook. New codes that arose during this step were added to the codebook and applied to all transcripts. Codes were compared and consensus for coding was reached (kappa=93.3%). Relevant and representative quotes were extracted for each theme. Descriptive statistics were conducted to characterize the interview sample using SPSS 23.0.
RESULTS
Participant characteristics
Participants were on average 21.01(SD=2.07) years, 56.7% (n=34) female, and 65% (n=39) Black (Table 1). In terms of tobacco product use, 56.7% (n=34) reported current (past-30-day) cigarette use, 43.3% (n=26) LCC use, 26.7% (n=16) smokeless tobacco use, 45.0% (n=27) e-cigarette use, and 41.7% (n=25) hookah use. Regarding other substance use, almost all participants (95.0%, n=57) reported current alcohol use, and half (43.3%, n=26) reported current marijuana use. Table 2 includes sample quotes for major themes that emerged from our data across the range of tobacco products.
Table 1
Participant characteristics, n=60
Table 2
Themes and sample responses regarding reasons for use initiation, continued use, and potential cessation among young adult tobacco users
Reasons for initiation of use
Several participants reported interpersonal influences from friends and family members as reasons for initiation of use. The majority of participants discussed initiating tobacco use because they felt pressured by their friends or wanted to feel like they ‘fit in’ with their social groups. Additionally, seeing or growing up with parents and siblings using tobacco (familial influence) was also mentioned as a reason for initiation of use of cigarettes and LCCs for some participants. For example, a cigarette smoker said: ‘If my sister hadn’t smoked whenever I was younger and she wasn’t around, I probably never would have picked up the habit’. Another said: ‘I learned about [little cigars and cigarillos] because my father used to… Well, he still does smoke them. I don’t want to say parental influence, but I mean, I’ve been around it since I was a kid, so you copy what you see…’.
Apart from interpersonal influences, many participants stated reasons related to their perceptions of product characteristics. LCCs, smokeless tobacco, e-cigarettes and hookahs appealed to participants because of either the variety of flavors or the fact that these products did not taste or leave behind smells as ‘strong’ or ‘bad’ as cigarettes. For example, a participant who used cigarettes, smokeless tobacco, and hookahs said that, in regard to smokeless tobacco use, ‘the flavoring is probably the most crucial part of it, because if there wasn’t a flavor that I liked then I wouldn’t want to use it… So the flavor is definitely essential to use and selection of smokeless tobacco’. A user of cigarettes, smokeless tobacco, and hookah stated in regard to hookahs that ‘The smell and the flavor were both nice, real fruity, didn’t really smell necessarily bad afterwards. The room smelled kind of good’.
Several participants also perceived e-cigarettes and hookahs as ‘safer’ alternatives to cigarettes. E-cigarettes, in particular, were also used as a cessation aid, and participants mentioned initiating use of e-cigarettes to ‘transition away’ from cigarettes and gradually reduce the amount of nicotine intake. A user of e-cigarettes said: ‘I had tried to quit [cigarettes] without anything, just cold turkey, and it was near impossible for me, but it was really, really easy to just switch out buying cigarettes with using the electronic cigarette, and like I said, going down on the nicotine has really helped me as well’.
In addition to reasons for initiation of use related to interpersonal influences, perception of product characteristics, and lower perceived health risks, reasons related to ease of product access and low levels of regulations were also mentioned by a few participants. Smokeless tobacco was reported to be more easily located and purchased compared to other substances, such as marijuana or alcohol among college students. Some users of e-cigarettes stated that they could use e-cigarettes in places where cigarettes were not allowed, such as inside schools. For LCCs, low costs were also a reason for product uptake.
Influences on continued use
Several themes already acknowledged as reasons for initiation of use were also identified by participants as influences on their continuation of product use. The majority of participants mentioned peer influence (cigarettes, LCCs and hookahs) and flavors and tastes (e-cigarettes and hookahs). In addition, many discussed reasons such as potentially less harmful alternative to cigarettes (e-cigarettes), cessation aid (e-cigarettes), and ease of access (smokeless tobacco and e-cigarettes).
Moreover, stress management was mentioned by the majority of participants as a reason why they continued to use cigarettes, LCCs, smokeless tobacco, and e-cigarettes. Several participants reported that using tobacco products helped with stress related to schoolwork, stress related to job and family responsibilities, and anxiety issues. A few users of smokeless tobacco also brought up the aspect of addictiveness. A participant who used smokeless tobacco stated that ‘After a while I became addicted to the nicotine, so then it was more of like I had cravings for it all the time’.
Use with other substances, such as alcohol or marijuana, was also identified as an influence on continuation of use for some participants, especially for cigarettes, LCCs, and hookahs. For instance, a cigarette user said: ‘Cigarettes they tend to be smoked more while you’re drinking, so when we’re at a bar with friends, or at a house party we tend to smoke cigarettes there’. A user of cigarettes and LCCs described: ‘About 15 times [a month], like I use [LCCs] to roll the marijuana with, just take the tobacco out and then put the marijuana in it and just roll it back up’.
Experiences with cessation
Participants reported several motivations to quit using tobacco products as well as cessation strategies. In terms of motivations to quit, a theme for most products (all except for LCCs) was interpersonal influences, such as pressure from others around them or family responsibilities. Women, in particular, often cited pregnancy or responsibilities associated with raising children as reasons for cessation. For example, a user of cigarettes said that ‘When I conceive my first child, I would definitely quit [smoking cigarettes] then. That’s it, done’. Another participant who used cigarettes said: ‘I can’t do anything to hurt my body anymore, because I have other priorities to look at. I have a kid to take care of’. Apart from interpersonal influences, several participants also discussed concerns about current and future health associated with using cigarettes, LCCs, smokeless tobacco, and hookahs. A user of e-cigarettes shared that he wanted to quit using cigarettes because ‘[cigarettes] generally made me feel terrible. I kind of felt like I had bronchitis all the time’. Additionally, a user of smokeless tobacco stated: ‘There was no direct reasoning [for quitting] except for I knew that it was not good for me. I knew that using it was detrimental to my health so I stopped using it’.
Moreover, several users of cigarettes cited physical appearance as a motivation for cessation. A user of cigarettes said that ‘I don’t want to stink every time I walk past somebody just because I smell like an ash tray’. For cigarettes and e-cigarettes, costs and perceived high spending on these products were also a reason why several participants attempted to quit.
In terms of past cessation attempts as well as future strategies for cigarettes, LCCs, and hookahs, several participants said that they would avoid other users or social situations that would make them want to use these products. For example, a user of cigarettes, LCC, e-cigarettes, and hookahs described her strategy to stop smoking cigarettes as ‘[to] put myself in fewer situations where people around me will be using them’. Redirecting focus onto other activities was another common cessation strategy for users of LCCs and smokeless tobacco. A user of cigarettes, smokeless tobacco and hookahs stated: ‘Whenever I would get a craving [for smokeless tobacco], I would always substitute that with either reading or exercising’.
Additionally, the majority of users of cigarettes and e-cigarettes discussed cessation strategies that included a gradual reduction of the amount of nicotine intake. Many cigarette smokers described the use of e-cigarettes and nicotine replacement therapy (NRT) for lowering their nicotine dosage. The majority of users of e-cigarettes also talked about how they decreased their nicotine intake. A participant who used e-cigarettes said: ‘I’ve brought my nicotine content down four times, and I’m planning on going down again in the next couple of months and then continuing on until I’m down to zero, and then I’m going to just try to quit the habit then’.
DISCUSSION
Our qualitative study of 60 users of cigarettes, LCCs, smokeless tobacco, e-cigarettes, and hookahs in Georgia yields several important findings with implications for research and practice. Consistent with the Social Cognitive Theory, we found that factors from the three domains of determinants (cognitive, behavioral, and environmental) drive not only use but also attempted cessation of different tobacco products. For example, perceptions regarding safety of products and of one’s own health (knowledge and outcome expectancies) motivated participants to use certain products (e.g. e-cigarettes) and to attempt quitting others (e.g. cigarettes or smokeless tobacco). Interpersonal influences from family and friends (environmental factors) were the reasons for initiation and continued use across cigarettes and all ATPs and also played an important role as a motivation for cessation for most products. Additionally, for all products assessed except for cigarettes, easy access and variety in flavors and tastes (environmental factors) influenced participants’ uptake and continued use of these emerging products. Below we highlight how our results can inform future development of prevention and cessation interventions targeting young adults using cigarettes and ATPs, as well as policy and regulations of these products.
Our results suggest that interpersonal-related factors play an important role in the different stages of tobacco use initiation, continuation, and cessation among young adults. Evidence in the literature supports these findings. Studies have established that parental smoking is associated with a higher risk of smoking uptake in adolescent offspring29, and that parental and peer smoking are associated with daily smoking and lifetime nicotine dependence among young adults in the United States30. Recent research on ATPs has also demonstrated that peer influence is associated with experimentation with, and/or continued use of, smokeless tobacco31-33, e-cigarettes23,34, and hookahs24 among adolescents and young adults. Thus, public health professionals should consider these influences and take into account interpersonal relationship dynamics35 in designing and implementing interventions for various tobacco products. For example, interventions can focus on building resistance to negative influences and peer pressure, improving decision-making skills and assertiveness36, and employing ‘quit buddies’ or peers who are former tobacco users37 to provide support for those trying to quit. In addition, our findings also show that concerns with family responsibilities, such as pregnancy or childcare duties, can be a powerful motivation for cessation for users of different tobacco products. Further research should explore how to incorporate such motivation into risk communication strategies and counseling for current users.
In addition, health concerns emerged as a major reason for cessation of cigarettes, LCCs, smokeless tobacco, and hookahs. The extant literature has also established that health concerns are the primary motivation for quit attempts by cigarette users38. Our study extends the relevance of this issue to young adult users of other tobacco products, and future studies should continue to investigate how experiences of current health problems or perceived risks of health problems in the future play a role in cessation attempts and success.
Additionally, participants discussed use of tobacco products and other substances, such as alcohol or marijuana, as an influence on continued use. These co-use patterns of college students and young adults in the United States have also been noted in previous studies39-41. Interventions thus should jointly target these behaviors, and additional research is needed to identify effective models for co-occurrence prevention and treatment41. Furthermore, while the qualitative nature of our study prevents us from providing estimates of prevalence data, we do note that a high proportion of participants were poly-tobacco users, i.e. using more than one product. The trend of increasing poly-tobacco use in young adults has also been noted in the literature42, and these findings point to a need for tobacco treatment strategies that target both single product tobacco users and poly-tobacco users43.
Finally, the study also suggests directions for future policy and regulations regarding cigarettes and ATPs. First, the Tobacco 21 laws, which seek to raise the minimum legal age of cigarette purchase to 21 years, can potentially have great effects on reducing initiation rates, not only among adolescents but also among young adults aged 18-20 years44. Evidence shows that Tobacco 21 laws are ready to go to scale, as they are effective, garner public support, and have minimal effect on retailers45,46. In addition, while the Family Smoking Prevention and Tobacco Control Act of 2009 put into place a ban on flavored cigarettes47, currently few federal regulations exist for flavors of non-cigarette products. In our study, flavors and tastes were brought up as a reason for initiation of all products except for cigarettes, and were also an influence on continued use of e-cigarettes and hookahs. Evidence also shows that young adults who are most likely to use flavored products may also be those most at risk of developing established use patterns that persist throughout their life time48. Therefore, tobacco control policymakers should pay attention to these findings in deciding measures to control sale of flavored non-cigarette products, which can help curtail uptake and continuation of use in young adults. Additionally, participants also discussed low regulations on environmental access and low costs of ATPs. Many products, for example smokeless tobacco, are indeed currently marketed for use where cigarettes are not allowed49. These results suggest a need for policy that limits accessibility to different tobacco products. For example, policy can further restrict indoor use of products and increase tax or prices on these products. These actions can help reduce prevalence of use among young adults.
Limitations
The following limitations should be considered when interpreting results from this study. First, these are qualitative findings from a sample of 60 tobacco users in the state of Georgia, and are not intended to be generalizable. Rather, our findings serve to inform future generalizable studies on a larger scale50. Second, our findings are based on self-reported data from a relatively small sample of users and do not include biochemical verification of tobacco use or follow-back verification of the number of days of use in the past month. Third, these findings are limited to a specific adult age range (18-25 years). Future studies could seek to identify and compare themes among older adult tobacco users.
CONCLUSIONS
The increasing popularity of ATPs in the United States is concerning. Young adult college students are one of the groups with the highest use prevalence of these products. This study provides data on reasons for initiation, continuation, and potential cessation of use of different tobacco products among this population. Future research should take into account interpersonal influences on these different stages of use and cessation, and explore how to incorporate health concerns and perceived health risks into counseling for cessation. In addition, we highlight a need for regulatory action that limits diversification and accessibility of different tobacco products.
