Jessica M. Rath

Patterns of Tobacco Use and Dual Use in US Young Adults: The Missing Link between Youth Prevention and Adult Cessation

Few studies address the developmental transition from youth tobacco use uptake to regular adulthood use, especially for noncigarette tobacco products. The current study uses online panel data from the Legacy Young Adult Cohort Study to describe the prevalence of cigarette, other tobacco product, and dual use in a nationally representative sample of young adults aged 18–34 (N = 4,201). Of the 23% of young adults who were current tobacco users, 30% reported dual use. Ever use, first product used, and current use were highest for cigarettes, cigars, little cigars, and hookah. Thirty-two percent of ever tobacco users reported tobacco product initiation after the age of 18 and 39% of regular users reported progressing to regular use during young adulthood. This study highlights the need for improved monitoring of polytobacco use across the life course and developing tailored efforts for young adults to prevent progression and further reduce overall population prevalence.

Flavored Tobacco Product Use Among U.S. Young Adults

BACKGROUND Passage of the U.S. Family Smoking Prevention and Tobacco Control Act in 2009 led to a ban on the sale of flavored cigarettes, largely because of studies showing targeting of these products to youth and young adults. There are no current restrictions on the marketing or sale of noncigarette or new nontraditional smokeless tobacco products (such as snus and dissolvable products), which are available in more than 45 flavors. PURPOSE To determine the prevalence of flavored tobacco use, dual use of flavored and menthol tobacco products, and sociodemographic predictors of flavored tobacco product use in young adults aged 18-34 years (N=4196). METHODS The current study utilizes data from Legacys Young Adult Cohort Study, a nationally representative sample collected in January 2012. Data were analyzed using Stata IC 11.0 in June 2012. RESULTS Overall, 18.5% of tobacco users report using flavored products, and dual use of menthol and flavored product use ranged from 1% (nicotine products) to 72% (chewing tobacco). In a multivariable model controlling for menthol use, younger adults were more likely to use flavored tobacco products (OR=1.89, 95% CI=1.14, 3.11), and those with a high school education had decreased use of flavored products (OR=0.56; 95% CI=0.32, 0.97). CONCLUSIONS Differences in use may be due to the continued targeted advertising of flavored products to young adults and minorities. Those most likely to use flavored products are also those most at risk of developing established tobacco-use patterns that persist through their lifetime.

The Next Generation of Users: Prevalence and Longitudinal Patterns of Tobacco Use Among US Young Adults

OBJECTIVES We monitored the prevalence and patterns of use of the array of tobacco products available to young adults, who are at risk for initiation and progression to established tobacco use. METHODS We used data from waves 1 to 3 of GfKs KnowledgePanel (2011-2012), a nationally representative cohort of young adults aged 18 to 34 years (n = 2144). We examined prevalence and patterns of tobacco product use over time, associated demographics, and state-level tobacco policy. We used multivariable logistic regression to determine predictors of initiation of cigarettes as well as noncombustible and other combustible products. RESULTS The prevalence of ever tobacco use rose from 57.28% at wave 1 to 67.43% at wave 3. Use of multiple products was the most common pattern (66.39% of tobacco users by wave 3). Predictors of initiation differed by product type and included age, race/ethnicity, policy, and use of other tobacco products. CONCLUSIONS Tobacco use is high among young adults and many are using multiple products. Efforts to implement policy and educate young adults about the risks associated with new and emerging products are critical to prevent increased initiation of tobacco use.

The association between alcohol, marijuana use, and new and emerging tobacco products in a young adult population.

BACKGROUND Young adults have the highest rates of alcohol, tobacco, and other drug use relative to any other age group. Few studies have examined the co-occurrence of substance use with new and emerging tobacco products in this vulnerable group, or the underlying personality factors that may explain these associations. To address this gap, this study examined the association of current alcohol and marijuana use with the use of cigarettes and emerging tobacco products in a nationally representative sample of young adults. METHODS Data were drawn from 18 to 24year olds in Wave 4 (January 2013; n=1609) of the Legacy Young Adult Cohort, a nationally-representative sample of men and women. Never, ever (lifetime), and past 30-day use of little cigars/cigarillos (LCCs), hookah, e-cigarettes, and cigarettes were assessed separately in current (everyday or some days) alcohol and marijuana users. RESULTS Using weighted estimates, multivariable multinomial logistic regression models showed that current alcohol and marijuana use were associated with lifetime and past 30-day use of cigarettes, LCCs, e-cigarettes, and hookah, with different magnitudes of association found across each product. Post-hoc exploratory analyses showed that sensation-seeking traits moderated the relationship of alcohol (but not marijuana) use to current use of select tobacco products. DISCUSSION Marijuana and alcohol use may enhance risk for emerging tobacco products use in young adulthood. Prevention and intervention programs may need to target poly-use of alcohol, marijuana, and tobacco rather than focusing on a single risk behavior during these critical years.

Tobacco Use by Sexual Identity Among Young Adults in the United States

INTRODUCTION National surveillance data are needed for the lesbian, gay, bisexual, and transgender population, a group which has been shown to have unique health needs. METHODS This study uses data from Legacys Young Adult Cohort Study, a nationally representative sample collected in the summer of 2011 to examine patterns of tobacco use by sexual identity. RESULTS Homosexual and bisexual past 30-day cigarette use (35% and 27%, respectively) was higher than heterosexual past 30-day cigarette use (18%; p = .004). The prevalence of any current tobacco use among heterosexuals was 22% compared with 35% in homosexuals and 31% in bisexuals (p = .04). Prevalence of dual use was 30% among heterosexuals, 43% among homosexuals, and 35% among bisexuals. High school education (OR = 4.27), current alcohol use (OR = 12.64), and current other drug use (OR = 9.67) were significant predictors of current cigarette use among lesbian, gay, and bisexual respondents. Strong predictors of other tobacco product use were Black race (OR = 6.95), current alcohol use (OR = 11.70), and current other drug use (OR = 7.42). CONCLUSIONS Prevalence estimates for tobacco use were higher among young adults who self-identify as sexual minorities compared with those who identify as heterosexuals. Tobacco use is strongly associated with alcohol and other drug use in this population. This study highlights the significant disparities in tobacco use behaviors among sexual minority populations and the critical need to conduct surveillance among these groups.

Race/Ethnicity, Nativity, and Tobacco Use Among U.S. Young Adults: Results From a Nationally Representative Survey

INTRODUCTION A growing body of research documents racial/ethnic disparities in U.S. cigarette smoking. To date, however, few studies have examined the influence of nativity, in addition to race/ethnicity, on current and ever use of cigarettes as well as other tobacco products among young adults. Here, racial/ethnic and nativity disparities in tobacco use and self-identified smoking status are documented for U.S. women and men aged 18-34, both unadjusted and adjusted for socioeconomic status. METHODS The Legacy Young Adult Cohort Study (N = 3,696) was used to examine gender-specific tobacco use and smoking status differences among foreign-born Hispanics, U.S.-born Hispanics, U.S.-born non-Hispanic Blacks, and U.S.-born non-Hispanic Whites. Prevalence estimates and multivariable models of ever tobacco use, current tobacco use, and self-identified smoking status were calculated. RESULTS U.S.-born Hispanics, Blacks, and Whites exhibit the highest levels of ever and current use across a range of tobacco products, whereas foreign-born Hispanics, particularly women, exhibit the lowest ever and current use of most products and are least likely to describe themselves as smokers. Controlling for socioeconomic covariates, current tobacco use is generally lower for most minority groups relative to Whites. Social or occasional smoking, however, is higher among U.S.-born Hispanics and Blacks. CONCLUSIONS The high level of tobacco use among U.S.-born young adults foreshadows substantial tobacco-related morbidity and mortality in the coming decades. Foreign-born Hispanic young adults, particularly women, exhibit the lowest levels of tobacco use. Future studies of tobacco use must differentiate racial/ethnic groups by nativity to better understand patterns of tobacco use.

Primary and dual users of little cigars/cigarillos and large cigars: Demographic and tobacco use profiles

BACKGROUND Although cigarettes are regulated through the Family Smoking Prevention and Tobacco Control Act, cigars are currently not regulated and tend to be lower in price. Despite the rising use of cigars in the United States, little is known about the prevalence of use of little cigars/cigarillos (LCCs) versus large cigars (LCs) and the profile of these distinct cigar users. METHODS This study uses data from Legacys Young Adult Cohort, a nationally representative study of 4,215 young adults, ages 18-34. Cigar use was divided into three groups: ever use of LCCs only, ever use of LCs only, and ever dual users. Multinomial regression was used to determine the differential demographic characteristics and tobacco use behaviors associated with the three cigar-use groups. RESULTS Ever cigar use was reported by 37.9% (n = 1,596) of the young adult cohort. Of the cigar smokers, 21.5% (n = 344) had used only LCCs, 32.3% (n = 515) had used only LCs, and 46.2% (n = 737) were dual users of both. In comparison with LC-only users, LCC-only users were more like to be younger (relative risk ratio [RRR] = 0.40, p < .001 for 25-34 vs. 18-24 years), female (RRR = 4.92, p < .001), non-Hispanic Black (RRR = 2.91, p < .001), and smoke cigarettes daily. Dual users were more likely than LC-only users to be female (RRR = 1.61, p = .03), non-Hispanic Black (RRR = 2.06, p = .04), and use a higher numbers of tobacco products (RRR = 4.44, p < .001). CONCLUSIONS Cigar use is prevalent among young adults with the highest proportion using both LCCs and LCs. Interventions to curb use should consider the differential demographic and tobacco use patterns of cigar users.

Correlates of Hookah Use and Predictors of Hookah Trial in U.S. Young Adults

INTRODUCTION Hookah, or waterpipe, tobacco smoking has increased among young adults (YAs) in the U.S., but few prospective studies have examined predictors of hookah use. The current study examined correlates of hookah use and predictors of hookah initiation at a 6-month follow-up in a nationally representative, prospective sample of U.S. YAs. METHODS Data were drawn from a subset of participants aged 18-24 years at study entry from two waves of the Legacy Young Adult Cohort Study. Wave 5 was completed in July 2013 by 1,555 participants and 74% (n=1,150) completed follow-up 6 months later in January 2014. Weighted bivariate and multivariable analyses were conducted in June 2014 to estimate the prevalence and correlates of ever and past 30-day hookah use and to examine associations between baseline covariates and hookah initiation 6 months later. RESULTS At baseline (Wave 5), almost 25% of the sample had ever used hookah and 4% reported past 30-day use. Alcohol, marijuana, and cigarette use were more prevalent among ever and past 30-day hookah users than among never users. Eight percent of never users at baseline reported trying hookah at the 6-month follow-up. Significant predictors of hookah trial in a multivariable model included college enrollment; alcohol, marijuana, and cigarette use; and perceptions that hookah is less harmful than cigarettes. CONCLUSIONS Results highlight rapid transitions in hookah use and several risk factors for initiation. Future studies should examine how these factors could be used as intervention targets to reduce tobacco use in this vulnerable age group.

“It's not smoke. It's not tar. It's not 4000 chemicals. Case closed”: Exploring attitudes, beliefs, and perceived social norms of e-cigarette use among adult users

BACKGROUND Electronic cigarette (e-cigarette) use is rapidly increasing among adults in the U.S. The purpose of this qualitative study was to explore consumer perceptions about e-cigarettes, including knowledge, attitudes, beliefs and perceived social norms. METHODS A total of 14 focus groups (N=116) were conducted with current adult e-cigarette users in five U.S. cities from March through May, 2014. Focus groups were segmented by age (young adults aged 18-29 and older adults aged 30 and older) as well as by e-cigarette use status (exclusive e-cigarette users and non-exclusive e-cigarette users). Focus group discussions lasted approximately 60-min and were audio-recorded and transcribed; data were analyzed using a phenomenological approach. RESULTS Participants expressed many positive attitudes towards e-cigarettes and simultaneously reported a lack of information and knowledge about the products. Focus group participants overwhelmingly felt as though the ingredients of e-cigarettes were likely less harmful than conventional cigarettes. Additionally, many described positive reactions from family and friends, especially when e-cigarettes were used in place of conventional cigarettes. CONCLUSIONS Findings from this qualitative study provide insight into consumer knowledge, attitudes and beliefs about e-cigarettes increasing our understanding of why and how they are being used. Such information will help provide insight into the potential public health impact of these emerging products.

Impact of Exposure to Electronic Cigarette Advertising on Susceptibility and Trial of Electronic Cigarettes and Cigarettes in US Young Adults: A Randomized Controlled Trial

INTRODUCTION This study assessed the impact of brief exposure to four electronic cigarette (e-cigarette) print advertisements (ads) on perceptions, intention, and subsequent use of e-cigarettes and cigarettes in US young adults. METHODS A randomized controlled trial was conducted in a national sample of young adults from an online panel survey in 2013. Participants were randomized to ad exposure or control. Curiosity, intentions, and perceptions regarding e-cigarettes were assessed post-exposure and e-cigarette and cigarette use at 6-month follow-up. Analyses were conducted in 2014. RESULTS Approximately 6% of young adults who had never used an e-cigarette at baseline tried an e-cigarette at 6-month follow-up, half of whom were current cigarette smokers at baseline. Compared to the control group, ad exposure was associated with greater curiosity to try an e-cigarette (18.3% exposed vs. 11.3% unexposed, AOR = 1.63, 95% CI = 1.18, 2.26) among never e-cigarette users and greater likelihood of e-cigarette trial at follow-up (3.6% exposed vs. 1.2% unexposed, AOR = 2.85; 95% CI = 1.07, 7.61) among never users of cigarettes and e-cigarettes. Exploratory analyses did not find an association between ad exposure and cigarette trial or past 30-day use among never users, nor cigarette use among smokers over time. Curiosity mediated the relationship between ad exposure and e-cigarette trial among e-cigarette never users. CONCLUSIONS Exposure to e-cigarette ads may enhance curiosity and limited trial of e-cigarettes in never users. Future studies are needed to examine the net effect of curiosity and trial of e-cigarettes on longer-term patterns of tobacco use. IMPLICATIONS This randomized trial provides the first evidence of the effect of e-cigarette advertising on a behavioral outcome in young adults. Compared to the control group, ad exposure was associated with greater curiosity to try an e-cigarette among never e-cigarette users and greater likelihood of e-cigarette trial at follow-up in a small number of never e-cigarette users and greater likelihood of e-cigarette trial at follow-up among never users of cigarettes and e-cigarettes.