Cigarillo use among High-Risk Urban Young Adults

Abstract

In the U.S., cigar use doubled from 5.0 to 10.6 billion cigars consumed annually between 1997 and 2007, driven in large part by increased sales of cigarette-sized “little cigars” and narrow, mid-sized “cigarillos.” The present study examined prevalence of cigarillo use as well as attitudes, knowledge and behaviors related to cigarillo use among a sample of predominantly urban African American young adults 18–24 not in school and not employed. Survey data were collected from 131 young adults attending education and job training centers in Baltimore, Maryland and from 78 young adults attending education, job training, or recreational programs in Washington, D.C. In Baltimore, 22% of young adults had smoked a cigarillo in the past 30 days, compared with nearly 63% in D.C. Both populations were heavily exposed to cigarillo advertising and marketing. Cigarillo use in this urban young adult population is a growing public health problem and undermines the progress made in decreasing cigarette use.

While U.S. cigarette consumption fell 25% between 1997 and 2007, cigar use doubled from 5.0 to 10.6 billion cigars annually.¹ The increase in cigar use has been driven largely by the burgeoning sales of cigarette-sized “little cigars” (up 238%) and narrow, mid-sized “cigarillos” (up 148%).¹ Like cigarettes, cigars cause lung, oral, esophageal, and laryngeal cancer.² Cigarillos may be especially popular with youth and young adults, as they are sold in a variety of flavors (including apple, strawberry, grape, chocolate and vanilla) and can legally be sold in small, inexpensive packages (e.g., two for $0.99) or singly. Cigars and cigarettes are taxed differently, with state taxes on cigars often being lower than those on cigarettes.³ Low cigar prices have been shown to be associated with higher youth smoking rates. While the 2009 Family Smoking Prevention and Tobacco Control Act prohibits the sale of flavored cigarettes and imposes various marketing restrictions on cigarettes and smokeless tobacco products, the Act contains no provisions relating to cigars.⁴ Rather, the Act gives the Food and Drug Administration (FDA) power to assert jurisdiction over and regulate cigars. The agency has not yet done either.

The most recent National Survey on Drug Use and Health shows that 11.2% of young adults ages 18–25 years smoked a cigar in the past month.⁵ Cigar use peaks at 14.2% among ages 18–19.³ Among high school students, the National Youth Tobacco Survey finds that 11.6% report past month cigar use.⁶ These may be underestimates as recent studies have shown that many adolescents refer to cigarillos by their brand name (e.g., Black & Mild, Swisher Sweets) and do not consider them cigars.^7–10 While national surveys rarely differentiate between the different sizes of cigars, some smaller surveys have done so.^7,11 A survey of 684 students at a historically Black university in the southeast US found that 18.5% had smoked cigarillos in the past month.⁸ Focus groups at the same university found that cigarillos were preferred over cigarettes because of their smoother taste, pleasant smell, and association with higher social status.⁸ Other focus groups have found that cigarillos are considered safer because they are perceived as being more natural, they are not mentioned in anti-smoking ads, and they do not carry warning labels when purchased individually.^8.9 The present study focuses on the prevalence, attitudes, knowledge and behaviors related to the use of cigarillos in a vulnerable and hard-to-reach population of African American young adults who are not in college. Young adults who are not in college, unemployed, or economically disadvantaged are particularly vulnerable to tobacco use and subsequent dependence.^11–13 Unemployed, college-age young adults who did not complete high school are also unlikely to be served effectively by traditional programs targeting Healthy People 2020 goals such as increasing preventive health education in secondary schools and among college students. Similarly, they are unlikely to be served by worksite employee health programs and interventions offered in primary health care settings. Further, a preponderance of research has focused on secondary school or college populations; excluding those young adults who are at the greatest risk for initiating smoking and becoming habitual smokers.^11–12

Methods

Design and sample

This investigation was a cross-sectional survey of African American young adults in Baltimore, Maryland, and Washington, D.C. (DC). Participants represented a convenience sample drawn from community organizations that provided services to young adults. The young adults in Baltimore City were recruited from The Baltimore Youth Opportunity (YO!) Centers and Civic Works. These centers provide education, life skills, and employment training and internships to young adults (18–24 years old) not in school or college. The young adults in DC were recruited from The Latin American Youth Center (LAYC) and the DC Department of Parks and Recreation. The LAYC provides education, health promotion, and workforce investment to young adults throughout the DC area; the center clients are predominately Latino (55%) and 45% African American. The Workforce Investment program at LAYC targets young adults with high school diplomas; these young adults were invited to participate in this study. Participants in the study were between 18 and 24 years of age. Data were collected in Baltimore from August to December of 2008 and in DC August of 2008 through July of 2009.

Survey instrument

The 110-item quantitative survey was adapted from several national surveys; additional questions were derived from focus groups with the target population, especially those related to cigarillos and loose cigarettes.^{5, 14} The survey consisted of questions related to demographic characteristics including self-reported age and gender, level of education, race/ethnicity, tobacco acquisition and use, age of initiation, exposure to tobacco advertising, and smoking cessation. The survey also included questions related to knowledge, attitudes, and beliefs about tobacco use. The questions relating to cigarillo use (which were referred to as little cigars in the survey) included Black & Mild as a brand-specific example. The section for cigarillo use was prefaced by the following statement, “The next questions ask about smoking little cigars like Black & Mild, Phillies blunts, or other brands. Please answer the question for the type of little cigar you use the most.” Each of the questions in the section included Black & Mild in parentheses as an example (e.g., During the past 30 days [one month], how many little cigars [Black & Mild] have you smoked?). There was also a multiple-choice question to determine the participant’s preference in cigarillo brand, which included seven cigarillo brands including the opportunity to write-in cigarillo brands that were not listed. The prevalence of current (past 30 days) cigarillo use was ascertained via two questions: “During the past 30 days (one month), on how many days did you smoke little cigars (Black & Mild)?” and “During the past 30 days (one month), how many little cigars (Black & Mild) have you smoked?” Some questions required that respondents circle an answer while others had them fill in a blank for the response.

Recruitment and data collection

Participants were recruited from community-based organizations which serve socially and economically disadvantaged communities. Multiple recruitment strategies were used, including flyers and referrals from center staff. In DC, participants were also recruited through referrals from current participants (i.e., snowball recruitment). Surveys were completed at the study centers in private settings to increase truthful reporting. Upon completion of the survey, respondents were provided with an incentive of $20 for participants in Baltimore and $30 for DC participants to compensate them for their time; the general prevailing rates for participant compensation at the respective sites. The Johns Hopkins and Howard University Review Boards for the Protection of Human Subjects approved the study.

Statistical analysis

Stata 11.2 was used to conduct statistical analyses.¹⁵ Univariate analyses were conducted to examine demographic characteristics. Analyses were also conducted to examine the prevalence, mean age of initiation, knowledge, attitudes and other behaviors related to the use of cigarillos. Pearson chi-square and independent sample t-tests were used assess differences between participants in Baltimore and DC.

Results

Table 1 includes the demographics and tobacco use of the participants from each city. The young adults in Baltimore City were predominately African American (94.7%); 55.4% of the sample was female and the mean age was 19.2 years. The majority of the participants from Baltimore did not have a high school diploma or GED (59.7%) and 45.7% had a weekly income below $50. The participants in Washington, DC were similar in terms of gender (46.3% female) and race (88.8% African American). However, the DC participants had higher incomes and more education (38.7% had a high school diploma or GED and 30.1% had some college or vocational education) (χ²; p<.05) compared with participants in Baltimore. Given differences in participant recruitment (i.e., snowball sampling) and demographic characteristics between the young adults in Baltimore and DC, analyses were stratified by location instead of combining the samples.

Table 1.

Demographic, Smoking Prevalence, & Contextual Factors

	Baltimore n =131	DC n =80	p
Gender
Female	72 (55.4)	37 (46.3)	.198
Male	58 (44.6)	43 (53.8)
African American	124 (94.7)	71 (88.8)	.088
Mean age (SD)	19.2 (1.2)	20.3 (1.9)	<.01
Education
Less than High School Diploma	77 (59.7)	25 (31.2)	<.01
High School Diploma/GED	14 (10.9)	31 (38.7)
Vocational/Some College or more	38 (29.4)	24 (30.1)
Weekly income
Less than $50	59 (45.7)	20 (25.0)	.019
$50–100	18 (14.0)	10 (12.5)
More than $100	52 (34.3)	50 (62.5)
Cigarette use
Never	63 (48.1)	11 (13.8)	<.01
Current	63 (48.1)	56 (70.0)
Former	5 (3.8)	13 (16.2)
Mean Age initiating Little Cigar Use (SD)	15.5 (2.6)	15.3 (3.1)	.991
Lifetime Little Cigar use	72 (55.0)	74 (92.5)	<.01
Current Little Cigar use	29 (22.1)	50 (62.5)	<.01
Friends/Associates smoking little cigars	98 (74.8)	72 (91.1)*	<.01
Little Cigar Advertising locations:**
in stores	82 (62.6)	49 (62.8)	.974
in magazines	48 (36.6)	31 (39.7)	.655
in bars & clubs	61 (46.6)	31 (39.7)	.337
Seen little cigars used:**
in music videos	57 (43.5)	40 (51.3)	.276
by music artists	65 (49.6)	40 (51.3)	.816
in movies	80 (61.1)	53 (67.9)	.317
on television	85 (64.9)	56 (71.8)	.302
at bars & clubs	88 (67.2)	48 (61.5)	.408

^*n=79;

^**n= 78 for DC

Nearly 50.0% of the Baltimore sample had smoked at least one cigarette in the past 30 days; the prevalence of past-month cigarette use among the DC sample was 70.0%. Past-month cigarillo use was 22.1% in Baltimore and 62.5% in DC, although the mean age of initiating cigarillo use was similar (15.5 years for Baltimore; 15.3 years for DC). Black & Mild was the most popular brand of cigarillo among current cigarillo users in both cities (65.5% in Baltimore and 62.0% in DC). Among the current cigarillo smokers, 31.0% in Baltimore and 36.7% in DC started smoking cigarillos before cigarettes. There was concurrent use of cigarillos and cigarettes in Baltimore and DC; 34.9% of current cigarette smokers in Baltimore also smoked cigarillos in the past month, the rate was 57.1% in DC. The vast majority of young adults in both cities (74.8% in Baltimore and 91.1% in DC) had friends/associates who smoke cigarillos.

Advertising and exposure to cigarillos was high in both populations. The majority of young adults in both cities had seen advertisements for cigarillos in stores. Nearly 47.0% of young adults in Baltimore had seen advertisements in bars and clubs, 36.7% had seen advertisements in magazines, and 62.6% reported seeing cigarillo advertisements in stores. In DC, 39.7% of young adults had seen advertisements in bars and clubs and magazines and 62.8% reported seeing advertisements for cigarillos in stores. Forty-four percent of respondents from Baltimore reported seeing cigarillos used in music videos and 49.6% reported seeing cigarillos used by music artists. More than 50% of young adults in DC had seen cigarillos used in music videos and by music artists. The majority (>60.0%) of young adults in both cities reported seeing cigarillos used in movies, television, and bars and clubs.

Young adults in both cities were generally unaware of the harms and contents of cigarillos (Table 2). Fifty-nine percent of the young adults in Baltimore and 47.3% of the young adults in DC were unaware that cigarillos contain nicotine. In Baltimore, 41.2% of young adults disagreed that cigarillos cause cancer; 9.2% did not know if cigarillos caused cancer. In DC, only 22.8% of the young adults disagreed that cigarillos caused cancer and 3.8% did not know if cigarillos caused cancer. A large percentage of young adults in both cities did not know if cigarillos were less addictive, safer, or contained fewer chemicals than cigarettes.

Table 2.

Beliefs about little cigars (n = 131 in Baltimore, n =79 in Washington, DC)

Question		Agree/Strongly agree (%)	Don’t know (%)	Disagree/Strongly disagree (%)	p
Removing the filter paper reduces the risk of cancer	Baltimore	43 (32.8)	23 (17.6)	65 (49.6)	.014
	Washington DC*	24 (30.8)	27 (34.6)	27 (34.6)
Little cigars have nicotine	Baltimore	54 (41.2)	15 (11.5)	62 (47.3)	.027
	Washington DC	41 (51.9)	15 (19.0)	23 (29.1)
Little cigars are safer than cigarettes	Baltimore	12 (9.2)	62 (47.4)	57 (43.4)	.219
	Washington DC	10 (12.6)	44 (55.8)	25 (31.6)
Little cigars are less addictive than cigarettes	Baltimore	21 (16.0)	45 (34.4)	65 (49.6)	<.001
	Washington DC	30 (38.0)	30 (38.0)	19 (24.0)
Little cigars contain less chemicals than cigarettes	Baltimore	19 (14.5)	45 (34.4)	67 (51.1)	.050
	Washington DC*	20 (25.6)	30 (38.5)	28 (35.9)
Little cigars cause cancer	Baltimore	65 (49.6)	12 (9.2)	54 (41.2)	.003
	Washington DC	58 (73.4)	3 (3.8)	18 (22.8)

^*n=78

Discussion

This preliminary investigation examined cigarillo use as well as individual (e.g., education and knowledge) and contextual (e.g.. marketing and exposure) factors related to cigarillo use in a hard-to-reach population of young adults. The prevalence of cigarillo use in both cities was higher than the national average. The prevalence of cigarillo use in this study was 22% in Baltimore and 63% in DC, far above the 11.2% national average for ages 18–25.⁵ There were also high rates of polytobacco use in Baltimore and DC which is a growing trend among adolescents and young adults.^16–19 Research suggests that dual use of cigarettes and cigarillos may lead to future nicotine dependence and other substance use (e.g., alcohol use, marijuana use).^16,20 Young adults were exposed to cigarillos primarily through peers, music videos, bars, magazines, and television. Research has shown that media portrayals of substance use are associated with an increase in both experimentation and usage among young adults.²¹

Even more concerning is the misperceptions held by some young adults including college students, that smoking cigarillos might be a safer alternative to cigarette smoking.^22,23 Some studies have reported that a majority of young adults were unsure if smoking cigarillos was more or less harmful than using cigarillos.²⁴ Young adults were also more aware of flavored cigars, which could be due to the advertising targeting this age group and the use of these products in movies and through social media.

This use of two cities with slightly different demographic characteristics offers additional insight about cigarillo use. The young adults in DC were more educated, had higher incomes, and were more knowledgeable about the harms associated with cigarillo use compared to the young adults in Baltimore. However, the young adults in DC had a higher prevalence of past month cigarette and cigarillo use, contrary to several other published studies in this area. These preliminary findings suggest that campaigns simply targeting knowledge are not sufficient for behavior change and that the relationship between socioeconomic indicators and smoking may be more complex in this population. Policy-level interventions that alter the availability and cost of cigarillos may be more effective strategies with this population to reduce cigarillo use in this population.²⁵

Understanding how these products fit into the socio-cultural frame of urban life for African American young adults as well as sustain their cigarette use will be important to developing intervention strategies that will effectively reach this population.

There were a few noteworthy study limitations. The convenience sampling used in this investigation limits generalizability. Also, while the young adults in both cities were recruited at educational and job training centers, the DC sample collection also included snowball sampling, which may explain the higher prevalence of tobacco use, as smokers were more likely to have friends who also smoke. This explanation of the stark differences is underscored by the fact that DC and Maryland had identical tobacco tax rates in 2008 ($2.00 per pack). Moreover, from 2006–2009, DC had a tobacco prevention and control campaign funded by a $10 million grant from tobacco settlement funds. However, the use of two cities highlights the fact that cigarillo use is not simply a problem in one community; rather this may be a national problem facing many urban centers. Secondly, this investigation did not explore which specific magazines or types stores had advertisements for cigarillos. Identifying specific magazines and types stores will allow for future interventions to prevent and/or decrease the use of cigarillos in this population.

This preliminary investigation examined cigarillo use in an understudied population of young adults. Currently these products are not automatically regulated under the FDA. While the law gives the FDA broad authority to act on all tobacco products, currently, the law’s provisions are specifically directed at cigarettes and smokeless tobacco products. However, the FDA does have the ability to expand its authority to regulate cigar products.⁴ These data could be useful in coming to understand how cigarillos and little cigars relate to race/ethnicity and that they are a product that requires regulation.

National surveys often miss the population sampled here, as they are not in school and not working. In addition, many surveys do not ask in-depth questions about cigar usage, especially concerning the knowledge, attitudes and practices related to these products. Data from this investigation support the overall finding from the national surveys that the use of cigars in the young adult population is increasing. The 2012 Surgeon General’s report found that youths and young adult cigar use is nearly at the same rate as cigarette use.²⁶ This increase in cigar use is a public health concern since switching from cigarettes to other, lower-taxed, combustible tobacco products blunts the effect of increasing prices, one of the most effective ways to reduce smoking and prevent youth smoking initiation.

This study provides a more detailed understanding of cigarillo use among African American young adults and points to additional health concerns faced by this already vulnerable population. This study also used brand-specific examples when referring to cigarillo use, knowledge, and attitudes. Prior investigations have shown that many youth refer to cigarillos by their brand name and do not consider them cigars producing underestimates in cigar use. Policy-makers need to focus on the growing trend in cigarillo use, especially among vulnerable populations such as low-income, urban African Americans. Media campaigns raising awareness about the health risks of cigarillos may also be merited, as well as health warnings and packaging restriction.