To what extent is use of little cigars and cigarillos (LCC) creating nicotine dependence among adolescents and young adults? In Cleveland, the use of LCC among adolescents exceeds the use of cigarettes, and LCC sales have increased nationally by 76% over the past 20 years even as cigarette sales have declined. Adolescents and young adults ages 18-29 are the most prevalent users. Despite this increase in use, little has been done to effectively measure nicotine dependence in LCC smokers. The nicotine dependence measures that have been developed and tested are validated for cigarette use only. To date, no nicotine dependence measure has been adapted or created for LCC users.
PRCHN Associate Director Sue Flocke, PhD, has received a National Institutes of Health (NIH) grant to address the lack of a nicotine dependence measure for LCC through a four-year, multi-phase study. The grant was awarded from a joint initiative by the NIH and Food & Drug Administration (FDA) to encourage research projects that could inform regulation for tobacco products not currently regulated by the FDA such as LCC. Dr. Flocke has assembled a team of experts from a wide range of disciplines, among them epidemiology, psychiatry, communication sciences, and psychometrics.
The study aims to
- 1) Use mixed-methods to adapt existing items and develop new items for a measure of nicotine dependence symptoms appropriate for LCC users and multiple tobacco product users (MP)
- 2) Test and validate the measure in a broader sample of LCC and MP users
- 3) Assess the prevalence of nicotine dependence symptoms among adolescent LCC and MP users by including the measure in the Youth Risk Behavior Survey (YRBS).
Phase One
The first phase of the Little Cigar Study consists of in-depth interviews with young adults and teens who smoke little cigars to understand LCC smoking patterns, practices, and beliefs about addiction. These interviews will help Dr. Flocke and her team understand the patterns of use in LCC smokers and help identify nuances unique to LCC use that will, in turn, inform the development of items to measure nicotine dependence. So far, data from 30 young adults ages 18-28 and 14 adolescents ages 14-17 have been collected. Analysis of these qualitative data is led by Elizabeth Antognoli, PhD, a medical anthropologist. Preliminary analyses have revealed key themes of use and possible indicators of nicotine dependence.
Of the 30 adults interviewed thus far:
- 80% were African-American
- 56% were female
- Users smoked a median of 20 LCC/week
- The mean age was 23
The interviews reveal rich narratives on the sociocultural context of LCC use. While some users smoke alone, many from the study sample emphasized LCC use as a social activity to “hype the fun” as one participant put it. Many participants reported sharing cigars or smoking a single LCC across multiple sessions. Nearly half (43%) reported also using marijuana blunts, a cigarillo shell or tobacco leaf filled with marijuana. Blunt use in social settings and in conjunction with LCC use was commonly reported. Almost 70% of participants also smoked cigarettes. Not surprisingly, the smoking patterns of little cigar users are quite different from those of cigarette smokers, which will have important implications for nicotine dependence measurement as well as policy and interventions.
Subsequent Study Phases
In the second phase of the study, findings from the interviews will inform a survey-based measure of nicotine dependence that will be widely administered in an online survey. The team intends to collect data from approximately 250 LCC users ages 14-28 in order to test the reliability of the measure. For Phase 3 of the study, urine samples will be collected from a subgroup of survey participants to test the association of their nicotine dependence symptom scores with levels of nicotine exposure as indicated by biomarkers in their urine sample. This will help further validate the measure and create a link between self-reported nicotine dependence symptoms and nicotine exposure.
The final measure will be administered through the Youth Risk Behavior Survey (YRBS), which the PRCHN administers annually to Cuyahoga County high school students (in odd-numbered years) and middle school students (in even-numbered years). This will assess the incidence of LCC and multiple tobacco product use and nicotine dependence symptoms in adolescents. Administering the nicotine dependence measure through the YRBS will give a more accurate picture of just how many teens are using LCC, how much they are smoking, and the prevalence of nicotine dependence symptoms. Accurately assessing nicotine dependence among LCC users can inform clinical treatment decisions as well as labeling and sales regulation.
The Little Cigar Study team will present these and other qualitative findings at the American Society for Preventive Oncology Annual Meeting in March 2016.