Phantom smoking among young adult bar patrons

Social smoker identity and associations with smoking and quitting behaviour: A cross-sectional study in England

BACKGROUND

'Social smoking' typically occurs predominantly or exclusively in the presence of others who are smoking. Relatively little is known about changes in the prevalence of 'social smoking identity' over time and its association with other smoking-related correlates.

METHODS

Data were from the Smoking Toolkit Study, a nationally-representative cross-sectional survey in England. Participants were 26,774 adults who currently smoked or had quit in the past year, surveyed between February-2014 and April-2021. We estimated the proportion identifying as having a social smoking identity, changes over time, and associations with smoking in social situations, cigarette dependence, motivation to stop, quit attempts and success.

RESULTS

Of adults who currently smoked or had quit in the past year, 34.0% (95% Confidence Interval (CI)=33.5-34.6) identified as having a social smoking identity. There was a near linear increase in this proportion from 31.9% (95%CI=29.7-34.2) in February-2014 to 36.5% (95%CI=34.1-38.9) in April-2021. Adults who currenty smoked identifying as having a social smoking identity were less cigarette dependent (adjusted B=0.34, 95%CI=0.31-0.37) and more motivated to stop (aOR=1.20, 95%CI=1.15-1.26) than those who did not. Adults who currently smoked or had quit in the past year identifying as having a social smoking identity reported more smoking in social situations (aOR=6.45, 95%CI=6.13-6.80) and past-year quit attempts (aOR=1.22, 95%CI=1.14-1.30) than those who did not. Quit success was not associated with having a social smoking identity among adults who currently smoked or had quit in the past year and who had attempted to quit (aOR=0.90, 95%CI=0.79-1.02).

CONCLUSIONS

An increasing proportion, over a third, of adults who currently smoked or had quit in the past year in England identify as having a social smoking identity. Despite being associated with lower dependence, greater motivation to quit and more quit attempts, social smoking identity is not associated with greater quit success, suggesting a complex interplay between identity and smoking-related behaviours.

Methods for Population Research on Substance Use and Consequences

This chapter reviews the array of methods used in contemporary research on population-level research on substance use and its consequences. We argue that there are critical questions that can best - or in some cases, only - be addressed at the level of a population. We then describe the major categories of data collection methods used in population research, including surveys, ecological momentary assessment, administrative data, audit methods, and unobtrusive assessment of substance use. Two categories of measures are then discussed: measures of an individual's use of substances and related problems and measures of harm to others caused by one's use. We then review factors that may be considered causes or correlates of substance use and consequences, including both individual and environmental factors. We close with a few thoughts on the accumulation of knowledge and its translation to policy and practice.

"Phantom smokers": Young cigarillo users who do not identify as smokers

INTRODUCTION

Many young consumers of non-cigarette tobacco products, such as cigarillos, do not identify as smokers. These "phantom smokers" tend to underestimate risks to health and feel little urgency to quit. This study examines the prevalence and characteristics of phantom smoker status among young cigarillo users.

METHODS

An online survey was conducted among 14-28 year olds who smoke at least 2 cigarillos per week. Phantom smoker status was determined by a negative response to "Do you consider yourself a smoker?" Other variables included smoking frequency, group smoking and sharing, and confidence in ability to quit. Associations between smoker identity and these variables were tested using chi square, independent samples t-tests and multivariable logistic regression.

RESULTS

Of 1089 respondents, 242 (22%) were identified as phantom smokers. Phantoms smoked half as many cigarillos per week as identified smokers (M = 4.75, SD = 5.11 vs. M = 11.33, SD = 0.88, p < .001) and phantoms were more likely to smoke only when sharing (39.7% vs 21.8%, p < .001). While 59.5% of identified smokers also smoked cigarettes, only 33.5% of phantoms did so (p < .001). Most phantom smokers (83.8%) were unconcerned about addiction. Phantoms also expressed greater confidence in their ability to quit (M = 4.40, SD = 0.98) than did identified smokers (M = 3.72, SD = 1.25, p < .001).

CONCLUSIONS

Despite regular cigarillo use, over 20% of respondents did not identify as smokers. Cigarillo smoking, along with non-daily and shared use, should be routinely assessed among youth. Phantom smokers' lack of concern about addiction and high confidence in their ability to quit may render conventional messages about smoking risk ineffective.

Correlates of smoker identity among intermittent and light daily young adult smokers: Findings from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study

Identifying as a 'smoker' has been associated with many cigarette smoking-related behaviors, including less frequent and intense cigarette use. Additional smoking behaviors (e.g., use of cannabis or cigars) also may contribute to self-identification as a 'smoker'. This study compared correlates of identifying as a 'smoker' and measurement strategies for non-daily cigarette consumption among young-adult intermittent and light daily smokers. Using data from Wave 1 of the PATH Study, different measurements of past 30-day non-daily cigarette use were evaluated. Weighted logistic regression models were used to compare associations with self-identification as a smoker among 18-24 year-old intermittent and light daily smokers (n = 1531). Use of other smoked products (combustible tobacco, cannabis) and other documented correlates of smoker identity were evaluated. As frequency of monthly smoking increased, self-identification as a smoker increased (1-5 days = 24%, 6-19 days = 48%, 20-29 days = 78%, light daily smokers = 93%, daily smokers using >5 cigarettes per day = 99%). Self-reported smoking status 12 months ago significantly contributed to current identification as a smoker. Smoking cigars daily or using cannabis in the past 30 days were each positively associated with smoker identity. Different measurement approaches to non-daily cigarette use offer different advantages in terms of interpretability and granularity of information. Compared to daily smokers, non-daily smokers exhibit significant variability in identifying as a smoker, and systematic correlates of smoker identification are apparent. These findings may serve to enhance understanding of non-daily smokers and potential targets for intervention among this growing subpopulation of tobacco users.

Examining Differences in Breath Alcohol Concentration (BrAC) Levels and Hazardous Drinking by Smoking Status Among a Sample of College Student Bar Patrons

While the association between current smoking and alcohol consumption is well known, the relationship between social smoking and alcohol consumption is less understood. The purpose of this study was to examine the association between smoking status and two alcohol consumption measures in a sample of college student bar patrons. The data used in this study was collected in fall 2015. Study participants (N = 415) were college student bar patrons who agreed to complete an interview that assessed smoking status (i.e., regular smoker, social smoker, non-smoker) and two alcohol consumption measures: (1) breath alcohol concentration (BrAC) levels (using a handheld breathalyzer device) and (2) hazardous drinking scores (using the AUDIT-C scale). We conducted one-way ANOVAs with Bonferroni correction to examine differences in BrAC levels and hazardous drinking scores by smoking status. Among sample participants, 25.3% were regular smokers, 14.7% were social smokers, and 60.0% were non-smokers. Smokers had significantly higher BrAC levels than social smokers and non-smokers. Regular smokers also had significantly higher hazardous drinking scores than social smokers and non-smokers. The BrAC levels and hazardous drinking scores of social smokers and non-smokers were not significantly different. The drinking habits of social smokers reflected those of non-smokers and being a regular smoker was associated with higher drinking levels than the rest of the sample. Because of the association found between alcohol consumption and regular smoking, combining efforts to reduce these behaviors in college students might be advantageous.

Smoking Trajectory Classes and Impact of Social Smoking Identity in Two Cohorts of U.S. Young Adults

This study describes cigarette smoking trajectories, the influence of social smoker self-identification (SSID), and correlates of these trajectories in two cohorts of U.S. young adults: a sample from the Chicago metropolitan area (Social Emotional Contexts of Adolescent and Young Adult Smoking Patterns [SECAP], n = 893) and a national sample (Truth Initiative Young Adult Cohort Study [YA Cohort], n = 1,491). Using latent class growth analyses and growth mixture models, five smoking trajectories were identified in each sample: in SECAP: nonsmoking (n = 658, 73.7%), declining smoking (n = 20, 2.2%), moderate/stable smoking (n = 114, 12.8%), high/stable smoking (n = 79, 8.9%), and escalating smoking (n = 22, 2.5%); and in YA Cohort: nonsmoking (n = 1,215, 81.5%), slowly declining smoking (n = 52, 3.5%), rapidly declining smoking (n = 50, 3.4%), stable smoking (n = 139, 9%), and escalating smoking (n = 35, 2.4%). SSID was most prevalent in moderate/stable smoking (35.5% SECAP), rapidly declining smoking (25.2% YA Cohort), and nonsmoking. Understanding nuances of how smoking identity is formed and used to limit or facilitate smoking behavior in young adults will allow for more effective interventions to reduce tobacco use.

Predictors of Retention in an Adult Text Messaging Smoking Cessation Intervention Program: Cohort Study

BACKGROUND

Mobile health tools such as text messaging programs can support smoking cessation. However, high rates of disengagement from these tools decrease their effectiveness.

OBJECTIVE

The purpose of this study was to identify user characteristics associated with retention in an adult text messaging smoking cessation intervention.

METHODS

Adults initiating a quit attempt using the publicly available program SmokefreeTXT between March 6 and June 21, 2016 (n=6215), were included. Data were collected to assess nicotine dependence, frequency of being around other smokers, time of the day for cigarette cravings, extrinsic and intrinsic motivation to quit smoking, confidence in quitting, and long-term intention to be smoke free. Multivariable survival analysis modeling for time to opt out was conducted to identify characteristics associated with opting out over the course of the intervention, adjusting for age, sex, and smoking frequency, reset of the quit date by the user, and the number of days enrolled before initiating the quit attempt. Among those who opted out, multivariable multinomial logistic regression analysis was used to identify predictors of opting out early (within 3 days and between 4 and 7 days into the quit attempt) compared to opting out late (more than 7 days into the quit attempt), adjusting for the same confounders.

RESULTS

Survival analyses indicated that younger age, female sex, higher levels of nicotine dependence, lower intention to be smoke free, and enrolling in SmokefreeTXT ≤1 week before initiating the quit attempt were associated with an increased risk of opting out. For example, users who smoked within 5 minutes of waking up were 1.17 times more likely to opt out than those who smoked more than 5 minutes after waking up (95% CI 1.01-1.35). Among users who opted out from SmokefreeTXT, logistic regression modeling indicated that compared to users who were never or rarely around other smokers, those who were sometimes around other smokers had 1.96 times more likely to opt out within the first 3 days of the quit attempt (95% CI 1.18-3.25). In addition, compared to users with high levels of long-term quit intention, users with lower levels of intention had 1.80 times the odds of opting out between 4 and 7 days into the quit attempt (95% CI 1.02-3.18). Users who reset their quit date after initiating a quit attempt were less likely to opt out at either time point compared with those who did not reset their quit date.

CONCLUSIONS

Several user characteristics are associated with retention in an adult text messaging smoking cessation program. These results provide guidance on potential characteristics that should be addressed in future text messaging smoking cessation programs. Providing additional support to users with these characteristics may increase retention in text messaging programs and ultimately lead to smoking cessation.

Preventing Smoking Progression in Young Adults: the Concept of Prevescalation

As adolescents cross the threshold to young adulthood, they encounter more opportunities to engage in or accelerate previously discouraged or prohibited behaviors. Young adults, therefore, are more apt to initiate cigarette smoking and, more importantly, to accelerate their use if they tried and experimented as an adolescent. Preventing the escalation and entrenchment of smoking in the young adult years is critically important to reducing tobacco's long-term health toll. However, traditional interventions for youth have focused on preventing smoking initiation, and interventions for adults have focused on smoking cessation; both have failed to address the needs of young adults. We introduce the concept of "prevescalation" to capture the need and opportunity to prevent the escalation of risk behaviors that typically occur during young adulthood, with a focus on the example of cigarette smoking. Prevescalation negates the notion that prevention has failed if tobacco experimentation occurs during adolescence and focuses on understanding and interrupting transitions between experimentation with tobacco products and established tobacco use that largely occur during young adulthood. However, since risk behaviors often co-occur in young people, the core concept of prevescalation may apply to other behaviors that co-occur and become harder to change in later adulthood. We present a new framework for conceptualizing, developing, and evaluating interventions that better fit the unique behavioral, psychosocial, and socio-environmental characteristics of the young adult years. We discuss the need to target this transitional phase, what we know about behavioral pathways and predictors of cigarette smoking, potential intervention considerations, and research challenges.

"Tell them you smoke, you'll get more breaks": a qualitative study of occupational and social contexts of young adult smoking in Scotland

OBJECTIVE

To explore young adults' perceptions and experiences of smoking and their smoking trajectories in the context of their social and occupational histories and transitions, in a country with advanced tobacco control.

DESIGN

Indepth qualitative interviews using day and life grids to explore participants' smoking behaviour and trajectories in relation to their educational, occupational and social histories and transitions.

SETTING

Scotland.

PARTICIPANTS

Fifteen ever-smokers aged 20-24 years old in 2016-2017.

RESULTS

Participants had varied and complex educational/employment histories. Becoming and/or remaining a smoker was often related to social context and educational/occupational transitions. In several contexts smoking and becoming a smoker had perceived benefits. These included getting work breaks and dealing with stress and boredom, which were common in the low-paid, unskilled jobs undertaken by participants. In some social contexts smoking was used as a marker of time out and sociability.

CONCLUSIONS

The findings indicate that while increased tobacco control, including smokefree policies, and social disapproval of smoking discourage smoking uptake and increase motivations to quit among young adults, in some social and occupational contexts smoking still has perceived benefits. This finding helps explain why smoking uptake continues into the mid-20s. It also highlights the importance of policies that reduce the perceived desirability of smoking and that create more positive working environments for young adults which address the types of working hours and conditions that may encourage smoking.

"Vive Sin Tabaco… ¡Decídete!" Feasibility and Acceptability of an e-Health Smoking Cessation Informed Decision-Making Tool Integrated in Primary Healthcare in Mexico

Introduction: While smoking remains one of the leading causes of death in Mexico, uptake of evidence-based cessation therapy remains low. Widespread use of mobile devices and internet in Mexico has created new avenues for providing access to cessation treatment. Methods: We assessed the feasibility and acceptability of "Vive Sin Tabaco… ¡Decídete!" (English: Live without Tobacco…. Decide!), a web-based, informed decision-making tool designed to help Mexican smokers develop a quit plan and take advantage of cessation resources. We invited 164 smokers in two primary care clinics. Measures included physical, situational, and psychological nicotine dependence, interest in using pharmacotherapy and counseling, smoking status at 3 months, and satisfaction with the program. Results: Most participants were light smokers and reported low-to-moderate nicotine dependence. Immediately after using ¡Vive Sin Tabaco… ¡Decídete!, the majority were interested in quitting, set a quit date, and reported interest in using pharmacotherapy and cessation counseling. Follow-up rate at 3 months was 81.5%; seven-day point prevalence abstinence was 19.1% using intention-to-treat analysis. Conclusion: Integration of e-Health tools in primary healthcare settings has the potential to improve knowledge about cessation treatments among smokers and integrate smoking cessation into routine of care.

Recruiting Hard-to-Reach Populations for Survey Research: Using Facebook and Instagram Advertisements and In-Person Intercept in LGBT Bars and Nightclubs to Recruit LGBT Young Adults

Background

Tobacco public education campaigns focus increasingly on hard-to-reach populations at higher risk for smoking, prompting campaign creators and evaluators to develop strategies to reach hard-to-reach populations in virtual and physical spaces where they spend time.

Objective

The aim of this study was to describe two novel recruitment strategies (in-person intercept interviews in lesbian, gay, bisexual, and transgender [LGBT] social venues and targeted social media ads) and compares characteristics of participants recruited via these strategies for the US Food and Drug Administration’s This Free Life campaign evaluation targeting LGBT young adults who smoke cigarettes occasionally.

Methods

We recruited LGBT adults aged 18-24 years in the United States via Facebook and Instagram ads (N=1709, mean age 20.94, SD 1.94) or intercept in LGBT social venues (N=2348, mean age 21.98, SD 1.69) for the baseline evaluation survey. Covariates related to recruitment strategy were age; race or ethnicity; LGBT identity; education; pride event attendance; and alcohol, cigarette, and social media use.

Results

Lesbian or gay women (adjusted odds ratio, AOR 1.88, 95% CI 1.54-2.29, P<.001), bisexual men and women (AOR 1.46, 95% CI 1.17-1.82, P=.001), gender minorities (AOR 1.68, 95% CI 1.26-2.25, P<.001), and other sexual minorities (AOR 2.48, 95% CI 1.62-3.80, P<.001) were more likely than gay men to be recruited via social media (than intercept). Hispanic (AOR 0.73, 95% CI 0.61-0.89, P=.001) and other or multiracial, non-Hispanic participants (AOR 0.70, 95% CI 0.54-0.90, P=.006) were less likely than white, non-Hispanic participants to be recruited via social media. As age increased, odds of recruitment via social media decreased (AOR 0.76, 95% CI 0.72-0.80, P<.001). Participants with some college education (AOR 1.27, 95% CI 1.03-1.56, P=.03) were more likely than those with a college degree to be recruited via social media. Participants reporting past 30-day alcohol use were less likely to be recruited via social media (AOR 0.33, 95% CI 0.24-0.44, P<.001). Participants who reported past-year pride event attendance were more likely to be recruited via social media (AOR 1.31, 95% CI 1.06-1.64, P=.02), as well as those who used Facebook at least once daily (AOR 1.43, 95% CI 1.14-1.80, P=.002). Participants who reported using Instagram at least once daily were less likely to be recruited via social media (AOR 0.73, 95% CI 0.62-0.86, P<.001). Social media recruitment was faster (incidence rate ratio, IRR=3.31, 95% CI 3.11-3.52, P<.001) and less expensive (2.2% of combined social media and intercept recruitment cost) but had greater data quality issues—a larger percentage of social media respondents were lost because of duplicate and low-quality responses (374/4446, 8.41%) compared with intercept respondents lost to interviewer misrepresentation (15/4446, 0.34%; P<.001).

Conclusions

Social media combined with intercept provided access to important LGBT subpopulations (eg, gender and other sexual minorities) and a more diverse sample. Social media methods have more data quality issues but are faster and less expensive than intercept. Recruiting hard-to-reach populations via audience-tailored strategies enabled recruitment of one of the largest LGBT young adult samples, suggesting these methods’ promise for accessing hard-to-reach populations.

Self-Identified Tobacco Use and Harm Perceptions Among US Youth

BACKGROUND

We investigated tobacco-related self-identity and risk perceptions among adolescent tobacco users.

METHODS

Data were analyzed for 20 675 US sixth- to 12th-graders from the 2016 National Youth Tobacco Survey. Students who reported past-30-day use of a specific tobacco product or ≥2 products but denied having used "any tobacco product" in the past 30 days were classified as not self-identifying as tobacco users. Tobacco product harm perceptions were further assessed across products. Descriptive and multivariable logistic regression analyses were performed.

RESULTS

Among past-30-day users of ≥1 specific tobacco product type, those denying having used any tobacco products in the past 30 days included single-product users of roll-your-own and/or pipe tobacco (82.2%), electronic cigarettes (e-cigarettes) (59.7%), cigars (56.6%), hookah (44.0%), smokeless tobacco (38.5%), and cigarettes (26.5%) as well as poly-tobacco users (12.7%). The odds of denying using any tobacco products were higher among those without symptoms of nicotine dependence than those with symptoms (adjusted odds ratio = 2.16); and those who access their tobacco products via social sources than those who bought them (adjusted odds ratio = 3.81; all P < .05). Among those believing "all tobacco products" were harmful, single-product users of the following believed their own product was not harmful: e-cigarettes (74.6%), hookah (56.0%), smokeless tobacco (41.8%), and cigarettes (15.5%).

CONCLUSIONS

Many of those who used certain tobacco products exclusively did not self-identify as tobacco users. Increasing the sensitivity of questions used to assess youth tobacco use in surveys and clinical settings can mitigate nondisclosure or underreporting of true tobacco use status.

Reasons for quitting smoking in young adult cigarette smokers

BACKGROUND

Although most young adult smokers want to quit smoking, few can do so successfully. Increased understanding of reasons to quit in this age group could help tailor interventions, but few studies document reasons to quit in young adults or examine reasons to quit by smoker characteristics.

METHODS

In 2011-12, 311 current smokers (age 22-28, M=24.1; 48.9% male, 51.1% female; 50.4% daily smokers) from the Nicotine Dependence in Teens Study completed the Adolescent Reasons for Quitting scale. We assessed differences in the importance of 15 reasons to quit by sex, education, smoking frequency, quit attempt in the past year, perceived difficulty in quitting, and motivation to quit. We also examined differences between participants who discounted the importance of long-term health risks and those who acknowledged such risks.

RESULTS

Concerns about getting sick or still smoking when older were considered very important by >70% of participants. Median scores were higher among daily smokers, those who had tried to quit or who expressed difficulty quitting, and those with strong motivation to quit. Discounters (14.5% of participants) were primarily nondaily, low-consumption smokers. Their Fagerström Test for Nicotine Dependence scores did not differ from non-discounters', and 11% (vs. 35.7% of non-discounters) were ICD-10 tobacco dependent.

CONCLUSIONS

Novel smoking cessation interventions are needed to help young adult smokers quit by capitalizing on their health concerns. Discounters may need educational intervention to better understand the impact of even "light" smoking on their health before or in conjunction with quit interventions.

Identifying "social smoking" U.S. young adults using an empirically-driven approach

The phenomenon of "social smoking" emerged in the past decade as an important area of research, largely due to its high prevalence in young adults. The purpose of this study was to identify classes of young adult ever smokers based on measures of social and contextual influences on tobacco use. Latent class models were developed using social smoking measures, and not the frequency or quantity of tobacco use. Data come from a national sample of young adult ever smokers aged 18-24 (Truth Initiative Young Adult Cohort Study, N=1564). The optimal models identified three latent classes: Class 1 - nonsmokers (52%); Class 2 - social smokers (18%); and Class 3 - smokers (30%). Nearly 60% of the "social smoker" class self-identified as a social smoker, 30% as an ex-smoker/tried smoking, and 12% as a non-smoker. The "social smoker" class was most likely to report using tobacco mainly or only with others. Past 30-day cigarette use was highest in the "smoker" class. Hookah use was highest in the "social smoker" class. Other tobacco and e-cigarette use was similar in the "social smoker" and "smoker" classes. Past 30-day tobacco and e-cigarette use was present for all products in the "non-smoker" class. Young adult social smokers emerge empirically as a sizable, distinct class from other smokers, even without accounting for tobacco use frequency or intensity. The prevalence of hookah use in "social smokers" indicates a group for which the social aspect of tobacco use could drive experimentation and progression to regular use.

Measured, opportunistic, unexpected and naïve quitting: a qualitative grounded theory study of the process of quitting from the ex-smokers' perspective

BACKGROUND

To better understand the process of quitting from the ex-smokers' perspective, and to explore the role spontaneity and planning play in quitting.

METHODS

Qualitative grounded theory study using in-depth interviews with 37 Australian adult ex-smokers (24-68 years; 15 males, 22 females) who quit smoking in the past 6-24 months (26 quit unassisted; 11 used assistance).

RESULTS

Based on participants' accounts of quitting, we propose a typology of quitting experiences: measured, opportunistic, unexpected and naïve. Two key features integral to participants' accounts of their quitting experiences were used as the basis of the typology: (1) the apparent onset of quitting (gradual through to sudden); and (2) the degree to which the smoker appeared to have prepared for quitting (no evidence through to clear evidence of preparation). The resulting 2 × 2 matrix of quitting experiences took into consideration three additional characteristics: (1) the presence or absence of a clearly identifiable trigger; (2) the amount of effort (cognitive and practical) involved in quitting; and (3) the type of cognitive process that characterised the quitting experience (reflective; impulsive; reflective and impulsive).

CONCLUSIONS

Quitting typically included elements of spontaneity (impulsive behaviour) and preparation (reflective behaviour), and, importantly, the investment of time and cognitive effort by participants prior to quitting. Remarkably few participants quit completely out-of-the-blue with little or no preparation. Findings are discussed in relation to stages-of-change theory, catastrophe theory, and dual process theories, focusing on how dual process theories may provide a way of conceptualising how quitting can include elements of both spontaneity and preparation.