Motivation to Quit Cigarettes and Alternative Tobacco Products: Prevalence and Correlates Among Youth Experiencing Homelessness

Abstract

Objectives:

Use of alternative tobacco products, as well as regular cigarettes, is widespread among unaccompanied youth experiencing homelessness. However, little is known about their level of motivation for quitting use of these products, factors associated with motivation to quit, or how these might vary by type of tobacco product.

Methods:

Unaccompanied homeless youth were sampled from 25 street and service sites in Los Angeles County (N=469). All participants were past month tobacco users who completed a survey on their tobacco-related behaviors and cognitions, including motivation to quit, as well as background characteristics.

Results:

Among self-reported users of each product, motivation to quit in the next 30 days was highest for regular cigarettes (33%), followed by e-cigarettes/vaporizers (30%), little cigars/cigarillos (25%), cigars (20%), and natural cigarettes (20%). Between 33-49% of youth, depending on product, were not thinking about quitting at all. Correlates of lower motivation to quit differed somewhat by product type, with the most consistent being race, more frequent use, lower perceived riskiness of the product, and using the product because of its good taste or smell.

Conclusions:

Results from this study identify a set of psychosocial and behavioral factors, some that are common across tobacco products and others that are product-specific, that may be particularly important to address in efforts to reduce tobacco use among youth experiencing homelessness. Future regulations on the sale of flavored tobacco products may also serve to increase motivation to quit in this population.

Introduction

Tobacco use is widespread among unaccompanied youth experiencing homelessness, with studies reporting smoking rates of 70% or higher (Baer et al., 2003; Bousman et al., 2005; Wenzel et al., 2010). Further, among homeless youth tobacco users, rates of use for alternative tobacco products (ATPs) - such as electronic nicotine delivery systems (ENDS), cigars, little cigars and cigarillos (LCCs), and hookah – are alarmingly high (Tucker et al., 2019) and exceed those for non-homeless young people (Jamal et al., 2017) and other at-risk youth such as those transitioning from foster care (Braciszewski et al., 2019). For example, a study of 292 young cigarette smokers experiencing homelessness found that 51% had used e-cigarettes, 46% LCCs, and 31% hookah in the past 30 days (Tucker et al., 2014). Although certain ATPs are often perceived as posing fewer health risks than combustible cigarettes, these tobacco products are certainly not harm-free (National Academies of Sciences, 2018). As such, reducing use of all types of tobacco among youth experiencing homelessness should be a public health priority. However, there is little relevant information on quitting, especially in the case of ATPs, to guide cessation interventions and programs for this vulnerable and historically underserved population. Identifying the factors associated with motivation to quit, including how these factors may differ by type of tobacco product, is an important initial step.

Studies of non-homeless tobacco users, which have mostly focused on combustible cigarette use, have identified a number of factors associated with motivation to quit or quitting behavior. For example, research has found sociodemographic differences, such as lower intentions to quit among non-Hispanic whites than blacks or Hispanics (Soulakova et al., 2017). Social factors are relevant as well, with lower intentions to quit reported by smokers who have a greater number of smoking friends (Hitchman et al., 2014). In terms of tobacco-related cognitions, young people are more likely to attempt to quit or actually quit smoking if they hold more negative attitudes toward smoking (Cengelli et al., 2012; Klein et al., 2013), including about its health risks (Wellman et al., 2018). Higher smoking quantity and nicotine dependence (Klein et al., 2013; Scherphof et al., 2013), as well as mental health symptoms (Brook et al., 2010), have also been associated with a lower likelihood of quitting among young smokers. In addition, specific product features appear to be relevant; for example, motivation to quit is lower among young people who use flavored tobacco products compared to non-flavored products (Huang et al., 2017). Although some of the factors identified in studies of non-homeless young people are likely relevant to those experiencing homelessness, it should not simply be assumed that this is the case. There may be correlates of motivation to quit that are unique to youth experiencing homelessness (e.g., severity of homelessness) or particularly important in this population (e.g., cost considerations, perceived stress, exposure to other tobacco users) given their level of poverty, exposure to harsh living environments, and relatively high rates of mental health and substance use problems (Pedersen et al., 2018). Only one study to date has examined motivation to quit tobacco use among youth experiencing homelessness, which focused solely on cigarette smoking (Tucker et al., 2015). Motivation to quit smoking was significantly higher among youth who were older, black or Hispanic (vs. non-Hispanic white), and had been asked about smoking by a service provider, as well as marginally more likely among those with more negative smoking attitudes and greater quitting confidence. Consistent with other research (Klein et al., 2013; Scherphof et al., 2013), motivation to quit was lower among smokers who were more nicotine dependent. Although informative, other factors potentially relevant to motivation to quit, such as perceived stress (Villanti et al., 2016) and reasons for using the product (Antognoli et al., 2018; Sussan et al., 2017), were not examined in this study.

Compared to the literature on combustible cigarettes, virtually nothing is known about interest in quitting alternative tobacco products among youth experiencing homelessness, reflecting the broader lack of research in this area among young people in general. Yet the correlates of motivation to quit ATPs may be distinct in some ways from those for combustible cigarettes, as well as differ across types of ATPs. For example, ATPs are sometimes used as a way of cutting down or quitting smoking (Glantz & Bareham, 2018) and youth experiencing homelessness may be less motivated to quit an ATP if they use it for this reason. Youth may also be less motivated to quit an ATP if they perceive use of the product to be more prevalent or socially accepted, both of which have been shown to vary across certain ATPs (Noland et al., 2016). There is also variability in the perceived harm of different tobacco products (Berg, Stratton, et al., 2015; Getachew et al., 2018), and these perceptions may be more strongly associated with motivation to quit certain products than others. Aside from a few studies identifying the reasons why e-cigarette users discontinue vaping (Biener et al., 2015; Pepper et al., 2014), much remains to be learned about motivations to quit use of ATPs (National Academies of Sciences, 2018).

The Present Study

This study addresses an important gap in the literature by examining motivations for quitting cigarettes and different ATPs in a probability sample of 469 tobacco users experiencing homelessness who were recruited from 25 service and street sites throughout Los Angeles County, which has one of the largest homeless populations in the U.S. (Los Angeles Homeless Services Authority, 2017). It significantly extends the one previous study of motivation to quit among youth experiencing homelessness (Tucker et al., 2014), which focused exclusively on cigarette smokers, by examining motivations to quit a range of different tobacco products commonly used by homeless youth. In addition to describing level of motivation to quit each type of product among youth who have used the product in the past 30 days, we identify the product-specific correlates of their motivation to quit. We examine sociodemographic correlates of motivation to quit (e.g., sexual orientation, gender, race/ethnicity, age, monthly income, sleeping outdoors), as this can inform efforts to identify subgroups of youth experiencing homelessness who may be particularly unmotivated to quit tobacco products (and thus potentially in need of additional outreach and intervention to enhance their motivation). In addition, we examine a range of variables that, as reviewed earlier, prior research with non-homeless tobacco users suggests are relevant to motivation to quit, such as mental health problems, heaviness of use, product perceptions, exposure to other users, and reasons for using the product. If found to be relevant, these may be potentially fruitful targets for intervention efforts to increase youth’s motivation to quit. Finally, we explore whether there are sexual orientation differences in motivation to quit, given that sexual minority youth are overrepresented in the homeless youth population (Wenzel et al., 2010), have relatively high rates of tobacco use (Centers for Disease Control and Prevention, 2018), and lack effective tobacco use cessation programs (Baskerville et al., 2017).

Method

Participants

Participants were 469 unaccompanied youth experiencing homelessness who were sampled from 25 service and street sites in Los Angeles County. Youth were eligible if they (a) were between the ages of 13-25; (b) were not currently living with a parent or guardian; (c) were not getting most of their support for food and housing from family or a guardian; (d) spent the previous night in a shelter, outdoor or public place, hotel or motel room rented with friends (because of no place else to go), or other place not intended as a domicile; and e) had used any type of cigarette, e-cigarette, or other tobacco product or electronic nicotine delivery system (ENDS) in the past 30 days (note that only 6% of youth were ineligible solely for this reason). Demographic characteristics of the full sample are presented in Table 1. Verbal informed consent was obtained from all individual participants included in the study.

Table 1.

Sample Characteristics (N=469)

Variable	% (N) / Mean (SD)
Gender
Cisgender/transgender female	29.1% (146)
Cisgender/transgender male	70.9% (323)
Sexual orientation
Straight/heterosexual	71.2% (254)
LGBQA	28.9% (215)
Race/Ethnicity
White	29.1% (144)
Hispanic	22.9% (100)
Black	32.8% (154)
Multi/Other	15.3% (71)
Age (in years)	21.8 (2.3)
Slept outdoors, past 30 days	72.7% (352)
Perceived stress (range = 4-20)	10.6 (3.4)
Withdrawal symptoms (range = 1-4)	2.01 (0.9)

Notes. Unweighted Ns and weighted percentages, means, and SDs are reported.

Study Design

We recruited a probability sample of youth experiencing homelessness from service sites and street venues in Los Angeles County between August 2017 and April 2018. We selected recruitment sites by developing two sampling frames: one for service sites (using local directories of services for homeless persons that listed shelters and drop-in centers) and one for street venues (developed with the help of service providers and outreach agencies, as well as informed by our previous studies of this population and knowledge of local hotspots). Service sites were considered eligible if they were in the study area and the majority of their clientele was ages 13 to 25 and English speaking; the research team identified 12 such sites (2 overnight shelters, 10 drop-in centers) that were eligible and agreed to participate. In addition, 13 street sites (e.g., sidewalks, parks, alleys, beaches) in the study area were identified where homeless youth congregate. All sites were investigated multiple times and at various times of day to obtain an estimate of the average number of youth served daily by the service sites and the average number of youth that “hang out” at the street venues in a given day. Information collected through site investigations was used to assign a quota for the number of completed interviews to be achieved at each site which was approximately proportional to the size of a site. A probability sample of youth experiencing homelessness from the 25 study sites was then drawn, with trained survey research staff using strategies specific to the type of site to select the youths to be approached, screened and surveyed.

Procedures

The sample was obtained through two data collection efforts: a main sample and a supplemental sample that focused on sexual minority youth. For the main sample, 613 youth were approached for eligibility screening (19 refused, 224 screened ineligible, and 370 screened eligible). Of the 370 youth that screened eligible, 357 completed the survey. Three of the 357 completers were subsequently dropped from the dataset due to poor quality data, resulting in a final sample size of 354 for the main sample. Near the end of the main data collection we conducted a supplemental data collection to increase the number of sexual minority youth in our sample and thus provide adequate statistical power to test for differences in ATP use by sexual orientation. For the sake of efficiency, we focused our efforts on 10 of the original 25 sites that yielded the highest recruitment of sexual minority participants during the main data collection. An item was added to the screening form that asked which term best described their sexual orientation: straight/heterosexual or LGBTQ (lesbian, gay, bisexual, transgender, questioning). Youth who identified as LGBTQ, and met all other eligibility criteria, were invited to participate. This supplemental data collection involved approaching 420 youth for eligibility screening (19 refused, 280 screened ineligible, and 121 screened eligible). Of the 121 LGBTQ youth that screened eligible, 115 completed the survey. All participants completed a self-administered paper-pencil survey that was in English and written at an 8^th grade reading level. The survey took approximately 40 minutes to complete, with trained survey research staff available to provided assistance (this was needed in less than 7% of cases). Youth received $3 for the eligibility screening and $20 for the survey. This research was approved by RAND’s institutional review board.

Measures

Motivation to quit.

Quitting motivation was assessed with a modified contemplation ladder (Biener & Abrams, 1991; Niaura & Shadel, 2003). Separate items asked whether participants were seriously thinking about quitting regular cigarettes, natural cigarettes (e.g., American Spirit), e-cigarettes or vaporizer filled with a tobacco/nicotine product, cigars, little cigars or cigarillos, hookah to smoke tobacco, and chewing tobacco or snuff. Response options included: yes, within the next 30 days (=4); yes, within the next 6 months (=3); yes, within the next 12 months (=2); no, I am not thinking about quitting this product (=1); and I do not use this product (=0). Due to small sample sizes for hookah (n=57) and chewing tobacco (n=23), these products were not included in the analyses.

Background characteristics.

These included whether they identified as cisgender/transgender male or cisgender/transgender female, race/ethnicity [non-Hispanic white (reference) vs. Hispanic, black, and multiracial/other)], age, sexual orientation (straight/heterosexual vs. lesbian, gay, bisexual, questioning or asexual), and whether they had slept outdoors in the past 30 days (as an indicator of homelessness severity; 0=no, 1=yes). Perceived stress was assessed by the 4-item Perceived Stress Scale (α=0.53) (Cohen, Kamarck, & Mermelstein, 1983).

Tobacco use.

Participants were asked to report on the number of days they used each product in the past 30 days (1=0 days, 2=1-2 days, 3=3-5 days, 4=6-9 days, 5=10-19 days, 6=20-29 days, 7=all 30 days). Separate items asked about e-cigarette and personal vaporizer use (instructing participants to not consider use of these devices to use marijuana); for participants who reported using both, frequency of ENDS use is the average of these two items. Withdrawal symptoms were assessed generally with the 8-item Minnesota Nicotine Withdrawal Scale (Hughes, 1992; Toll et al., 2007) (α=0.91). For the ATPs, participants were also asked whether they had ever used the product “to cut down on or quit smoking regular cigarettes” (Berg et al., 2015; Brown et al., 2014; Kasza et al., 2014).

Product-related social factors, perceptions of risk, and reasons for use.

We assessed exposure to users of each ATP by asking, “How often are you around or with people who use each of the following products?”, which was rated on a 4-point scale (1=never to 4= often). Perception of health risks for each product was assessed on a 4-point scale (1=not at all risky to 4=very risky) (Romer & Jamieson, 2001). Finally, in reference to cigarettes (regular or natural), ENDS, LCCs, and cigars, we asked whether they had used the product for each of the following reasons (Etter & Bullen, 2011; Soldz & Dorsey, 2005; United States Department of Health Human Services, 2018): (a) You can use it in places where cigarettes smoking is not allowed (this was not asked of cigarettes); (b) I like socializing while using it; (c) It tastes good; (d) It smells good; (e) You get more nicotine for the cost, compared to other tobacco products; and (f) It gives you a good buzz. Responses to “smells good” and “tastes good” were consistently highly correlated across products (r=0.57 to 0.75) and thus an average score was used in the regression models.

Analytic Approach

Departures from proportionate-to-size sampling due to changes in the sampling rates during the fielding period, differential non-response rates across sites, and differential rates of visits to service sites and street venues among homeless youth require the use of weights to adjust estimates and correct for potential bias due to respondents’ differential inclusion probabilities. All analyses incorporate these weights and account for the modest design effect that they induce, using the linearization of standard errors (Skinner, 1989). Missing data ranged from 0–4% of cases and was imputed using the mean/mode of all non-missing responses.

We first conducted linear regression analyses to examine bivariate associations between each variable of interest and participants’ reported motivation to quit use of a specific tobacco product. The sample for each analysis was restricted to participants who both reported using the product in the past 30 days and reported using the product on the motivation to quit item. For each outcome we then conducted a multivariable regression model. Given our sample sizes and concerns about multicollinearity of covariates, only variables which had a bivariate association with product use at p<.10 were included in each multivariable model.

For each variable included in the multivariable models, we explored whether sexual orientation moderated its association with motivation to quit the tobacco product. We conducted separate linear regression analyses for each variable that included the variable of interest, sexual orientation, and the interaction term.

Results

In our sample of past month tobacco users, the weighted percentage of participants who reported using the product was 83% (n=395) for regular cigarettes, 49% (n=245) for natural cigarettes, 37% (n=164) for LCCs, 28% (n=132) for cigars, and 23% (n=113) for ENDS. Table 2 presents distributions on the motivation to quit item for each of these products. Among these self-reported users of each product, motivation to quit in the next 30 days was highest for regular cigarettes (32.5%), followed by ENDS (29.5%), LCCs (24.6%), natural cigarettes (20.4%), and cigars (19.5%). In contrast, not thinking about quitting was highest for cigars (48.8%), followed by LCCs (45.4%), natural cigarettes (40.1%), ENDS (38.1%), and regular cigarettes (32.6%).

Table 2.

Descriptive results for product-specific motivation to quit among users

Are you seriously thinking about quitting your use of…	Cigarettes	Natural cigarettes	ENDS	LCCs	Cigars
	% (N)	% (N)	% (N)	% (N)	% (N)
Yes, within the next 30 days	32.5% (131)	20.4% (55)	29.5% (30)	24.6% (43)	19.5% (34)
Yes, within the next 6 months	17.3% (63)	19.2% (46)	16.6% (18)	5.5% (19)	10.1% (16)
Yes, within the next 12 months	17.7% (67)	20.3% (48)	15.9% (16)	24.5% (32)	21.6% (25)
No, I am not thinking about quitting	32.6% (134)	40.1% (96)	38.1% (49)	45.4% (70)	48.8% (57)
Total N a	395	245	113	164	132

Note. Weighted percentages and unweighted Ns are reported.

^aResults are based on participants who reported using the product in the past 30 days and did not endorse the “I do not use this product” response option for the motivation to quit item.

Table 3 presents descriptive information on ATP-specific behaviors, social factors and perceptions. Frequency of use tended to be relatively high, ranging from a mean rating of 3.8 for ENDS (i.e., 6-9 days in past month) to 5.8 for regular cigarettes (i.e., 20-29 days in past month). Using these products within 30 minutes of waking was common, ranging from 41% for LCCs to 59% for cigarettes. Many participants reported using ATP products to cut down on or quit their use of regular cigarettes, ranging from 38% for LCCs to 64% for ENDS. There was consistency across ATPs in perceptions of health risks posed by use of the product, with average scores ranging from 2.8 to 3.1 (“somewhat risky”). For social factors, most ATP users reported that they were “often” around or with people who used the product (ranging from 51% for ENDS to 72% for natural cigarettes) and, on average, perceived that 6 out of 10 people their age used the various ATPs. Across products, most youth reported that they liked socializing while using the product (58%-64%) and that the product gives them a “good buzz” (56%-60%), whereas about one-third indicated that they get more nicotine for the cost compared to other tobacco products (33%-39%). However, there was much more variability across products in using the product because it can be used in places where smoking is not allowed (24%-72%), because it tastes good (50%-74%), and because it smells good (37%-67%).

Table 3.

Descriptive results for product-specific variables, excluding those who indicated that they did not use the product

	Cigarettes (N=395)	Natural cigarettes (N=245)	ENDS (N=113)	LCCs (N=164)	Cigars (N=132)
Variable	% or Mean (SD)	% or Mean (SD)	% or Mean (SD)	% or Mean (SD)	% or Mean (SD)
Frequency of past 30 day use b	5.8 (1.5)	5.1 (1.6)	3.8 (1.7)	4.5 (2.1)	4.6 (2.0)
Used to quit cigarettes	N/A	51.4%	64.0%	37.7%	43.6%
Perceived riskiness c	N/A	2.9 (1.0)	2.8 (1.0)	3.1 (1.0)	3.1 (0.9)
How often around or with others that use the product d	N/A	3.6 (0.8)	3.3 (0.8)	3.4 (0.8)	3.3 (0.9)
You can use it in places where cigarette smoking is not allowed	N/A	N/A	72.3%	26.0%	24.0%
I like socializing while using it a	58.3%	58.3%	60.7%	64.0%	61.8%
It tastes good a	50.3%	50.3%	74.2%	61.9%	65.8%
It smells good a	36.6%	36.6%	67.3%	57.2%	56.8%
You get more nicotine for the cost, compared to other tobacco products a	33.0%	33.0%	38.8%	36.9%	35.8%
It gives you a good buzz a	56.1%	56.1%	57.7%	59.5%	58.3%

Note.

^aValues for cigarettes and natural cigarettes are the same because a single item was used to ask about cigarettes in general.

^b1=0 days, 2=1-2 days, 3=3-5 days, 4=6-9 days, 5=10-19 days, 6=20-29 days, 7=all 30 days.

^c1=not at all, 2=a little, 3=somewhat, 4=very.

^d1=never, 2=hardly ever, 3=sometimes, 4=often.

Table 4 shows bivariate associations between motivation to quit each product with background characteristics, as well as product-specific behaviors, social factors, risk perceptions, and reasons for use (as relevant). For regular cigarettes, motivation to quit was higher among black youth (vs. white), but lower among those who smoked more frequently, experienced more withdrawal symptoms (p<.10), used cigarettes for the good taste/smell, and used cigarettes to get more nicotine for the cost. When these variables were entered into a multivariable model, motivation to quit remained marginally higher among black youth (β=.15, p<.10), and significantly lower among those who smoked more frequently (β=−.23, p<.05) and used cigarettes for the good taste/smell (β=−.23, p<.05).

Table 4.

Results of bivariate linear regression analyses examining correlates of motivation to quit different tobacco products

	Cigarettes (N=395)	Natural cigarettes (N=245)	ENDS (N=113)	LCCs (N=164)	Cigars (N=132)
Variable	β (SE)	β (SE)	β (SE)	β (SE)	β (SE)
Background variables
LGBQA (vs. straight)	0.01 (0.18)	0.06 (0.21)	−0.16 (0.34)	0.02 (0.28)	0.01 (0.31)
Female (vs. male)	0.09 (0.17)	0.05 (0.23)	0.001 (0.37)	−0.06 (0.28)	−0.04 (0.31)
Hispanic (vs. White)	0.02 (0.21)	−0.02 (0.26)	0.003 (0.40)	0.14 (0.32)	0.02 (0.30)
Black (vs. White)	0.24 (0.21) *	0.25 (0.26) *	0.25 (0.38) #	0.24 (0.31) *	0.27 (0.33) #
Multiracial/other (vs. White)	0.04 (0.26)	0.09 (0.29)	0.003 (0.43)	0.06 (0.37)	0.16 (0.40)
Age (in years)	−0.01 (0.04)	0.02 (0.04)	0.22 (0.06) *	0.09 (0.04)	0.09 (0.05)
Slept outdoors	−0.08 (0.20)	−0.13 (0.24) #	−0.11 (0.38)	−0.13 (0.30)	−0.21 (0.36) #
Perceived stress	−0.03 (0.02)	0.02 (0.03)	−0.21 (0.05) #	0.03 (0.04)	0.06 (0.04)
Product-related variables
Frequency of past 30 day use	−0.27 (0.05) *	−0.19 (0.05) *	−0.31 (0.08) *	−0.18 (0.06) #	−0.12 (0.06)
Withdrawal symptoms	−0.11 (0.09) #	−0.14 (0.12)	−0.33 (0.16) *	−0.04 (0.13)	−0.01 (0.14)
Used to quit cigarettes	N/A	−0.15 (0.19) #	0.03 (0.32)	0.10 (0.26)	−0.02 (0.26)
Perceived riskiness	N/A	0.17 (0.09) *	0.25 (0.15) *	0.21 (0.11) *	0.20 (0.13) #
Around others who use it	N/A	−0.13 (0.13)	−0.16 (0.20)	−0.14 (0.16)	−0.05 (0.15)
Reasons for use
Can use it in more places	N/A	N/A	−0.20 (0.32) #	−0.26 (0.22) *	−0.10 (0.27)
Like socializing while using	−0.02 (0.16)	−0.07 (0.20)	−0.26 (0.30) *	0.12 (0.24)	−0.01 (0.27)
Tastes/smells good a	−0.28 (0.18) *	−0.24 (0.21) *	−0.17 (0.35)	−0.24 (0.26) *	−0.35 (0.30) *
More nicotine for the cost	−0.14 (0.17) *	−0.14 (0.20) #	−0.13 (0.30)	−0.11 (0.24)	0.03 (0.27)
Gives you good buzz	−0.07 (0.16)	−0.04 (0.21)	−0.05 (0.30)	−0.04 (0.25)	−0.03 (0.26)

Notes.

^#p < .10.

^*p < .05.

^aSimilar results were found when taste and smell items were examined separately. ENDS = e-cigarettes and personal vaporizers. LCCs = little cigars/cigarillos.

Among natural cigarette users, motivation to quit was higher among black youth (vs. white) and those who perceived natural cigarettes to pose greater health risks, but lower among those who slept outdoors (p<.10) and were more frequent natural cigarette smokers. In addition, motivation was lower among those who used natural cigarettes to quit smoking regular cigarettes (p<.10), for the good taste/smell, and to get more nicotine for the cost (p<.10). When these variables were entered into a multivariable model, motivation to quit remained significantly higher among black youth (β=.22, p<.05), but lower for those who used natural cigarettes for the good taste/smell (β=−.19, p<.05) and marginally lower among those who slept outdoors (β=−.12, p<.10).

In the case of ENDS, motivation to quit was higher among black youth (p<.10) and older participants, as well as those who perceived ENDS to pose greater health risks. However, motivation to quit ENDS use was lower among those who reported more stress (p<.10), were more frequent ENDS users, experienced more nicotine withdrawal symptoms, used ENDS because they could vape in places where cigarette smoking is not allowed (p<.10), and used ENDS because they liked socializing while using it. When these variables were entered into a multivariable model, motivation to quit remained significantly higher among older participants (β=.21, p<.05) and significantly lower among those who experienced more nicotine withdrawal symptoms (β=−.24, p<.05).

For LCC users, motivation to quit was significantly higher among black youth (vs. white) and those who perceived LCCs to pose greater health risks, but significantly lower among those who used LCCs because they could use it in places where cigarette smoking is not allowed and because of the good taste/smell. Motivation was also marginally lower among more frequent users of LCCs. When all variables were included in a multivariable model, motivation to quit remained significantly higher among black youth (β=.28, p<.05), and was marginally higher among Hispanics (β=.20, p=.05), compared to Whites. In addition, motivation to quit remained significantly higher among those who perceived LCCs to pose greater health risks (β=.21, p<.05), but lower among those who used LCCs because they could use it in places where cigarette smoking is not allowed (β=−.24, p<.05).

Among cigar users, motivation to quit was higher among black youth relative to whites (p<.10) and those who perceived cigars to pose greater health risks (p<.10), but lower among those who slept outdoors (p<.10) and used cigars because of the good taste/smell. When these variables were included in a multivariable model, only using cigars because of the good taste/smell remained associated with motivation to quit (β=−.27, p<.05).

Sexual orientation was not significantly associated with motivation to quit any of the tobacco products we examined. For each predictor variable that was included in a multivariable model, we explored whether sexual orientation moderated its association with motivation to quit that product. We did this by conducting a separate linear regression analysis for each predictor variable, which included only the variable of interest, sexual orientation, and the interaction term. There were only a few significant interactions with sexual orientation, and we conducted stratified analyses to better understand these interactions. Results indicated that perceived riskiness was significantly associated with higher motivation to quit natural cigarettes among sexual minority youth only (sexual minority: β=.45, p<.0001; heterosexual: β=.06, p=.61), whereas perceived stress was significantly associated with lower motivation to quit ENDS among heterosexual youth only (sexual minority: β=.16, p=.44; heterosexual: β=−.34, p=.006). The other significant interactions involved race/ethnicity. Black and multiracial/other youth (relative to whites) were significantly more motivated to quit regular cigarettes among sexual minority youth (black: β=.45, p=.002; multiracial/other: β=.27, p=0.02), but not heterosexual youth (black: β=.17, p=.052; multiracial/other: β=−.05, p=.62). Hispanic and black youth (relative to whites) were significantly more motivated to quit LCCs among heterosexual youth (Hispanic: β=.27, p=0.03; black: β=.35, p=0.01), but not sexual minority youth (Hispanic: β=−.25, p=.17; black: β=−.04, p=.86). Finally, multiracial/other youth (relative to whites) were significantly more motivated to quit cigars among LGBQA youth (β=.67, p<.001), but not heterosexual youth (β=.01, p=.96).

Discussion

In this probability sample of homeless youth tobacco users, 1 in 3 past month cigarette smokers reported that they were seriously thinking about quitting smoking within the next 30 days. Further, their interest in quitting tobacco extended to alternative tobacco products, with 20-30% reporting that they were ready to quit their use of natural cigarettes, ENDS, LCC, and cigars. These results are encouraging and speak to the urgent need for programs to address tobacco use in this population (Shadel et al., 2015). For these smokers who are motivated to quit, action-oriented treatment approaches, such as provision of services that include behavioral approaches (e.g., stimulus control, coping skills training) and adjuvant pharmacological treatment, could be used to support their cessation efforts (Fiore et al., 2009). A recent study found that about 60% of homeless youth smokers reported interest in trying counseling and/or pharmacological options to help them quit smoking (Tucker et al., 2015), and such approaches have shown promise in studies of older smokers experiencing homelessness (Okuyemi et al., 2006). However, treatments for cigarette smoking (Fiore et al., 2009), as well as ATPs such as smokeless tobacco (Ebbert et al., 2015), are much better established than they are for cigars, cigarillos, and ENDS. Thus, research needs to develop and refine treatments designed to promote cessation of ATPs, and in particular for youth experiencing homelessness. At the same time, most youth in our sample were not ready to make a quit attempt. For these smokers who are unmotivated to quit, action-oriented treatment strategies might not be a good fit. Interventions designed to improve readiness to quit cigarettes, such as motivational interviewing, have shown promise for quitting cigarettes (Lai et al., 2010), and could potentially be of use for helping to motivate unmotivated youth to stop smoking cigarettes. These types of motivational interventions would have to be adapted and tested for their efficacy in motivating cessation of ATPs.

For any motivational or cessation treatment to reach maximal efficacy, it is important to incorporate factors known to be relevant to the target population as much as possible (Fiore et al., 2009). In our sample of homeless youth tobacco users, three variables emerged as relatively consistent correlates of lower motivation to quit across different types of products. First, youth were less motivated to quit various tobacco products if they perceived less health risks from using the product. A recently completed qualitative study of youth experiencing homelessness indicated that the very serious health dangers associated with cigar, LCC, and natural cigarette use are underappreciated by this population (Shadel et al., 2018) and in need of correction. Together, these results suggest that educating youth experiencing homelessness about the adverse health effects of all tobacco products (some of which are marketed as safer alternatives) should figure prominently in efforts to improve their motivation to quit. Second, across several tobacco products, youth were less motivated to quit if they used the product more frequently. This suggests that general strategies for helping homeless youth increase their motivation for quitting tobacco products may need to include helping them disassociate product use from their daily routine, such as through stimulus control strategies. Third, the appeal of flavored products was a relatively consistent correlate of lower motivation to quit across products, more so than other reasons for using the product. Indeed, the product-specific correlates of motivation that emerged mostly had to do with non-sensory reasons for using particular products, such as their cost or social benefits. As such, some tailoring of interventions to product type is likely warranted in this population. For example, addressing the socializing benefits of using ENDS could contribute to increased levels of motivation to stop using those products among youth experiencing homelessness, but may not be as important for increasing their motivation to quit LCCs or regular cigars.

Many of the factors examined in this study were selected due to their established relevance to motivation to quit or cessation-related outcomes in samples of non-homeless tobacco users (e.g., Cengelli et al., 2012; Hitchman et al., 2014; Klein et al., 2013; Scherphof et al., 2013; Wellman et al., 2018). Thus, it is also important to mention which of these factors were largely irrelevant to motivation to quit in our sample of young people experiencing homelessness. These included nicotine dependence and withdrawal symptoms, using the product to cut down on or quit smoking, as well as perceived prevalence and exposure to other smokers. The lack of associations with exposure to other tobacco users is especially interesting, as this was among the strongest correlates of ATP use in other analyses from this project (Tucker et al., 2019). This difference may be at least partly due to smaller sample sizes in the present analyses, but may also indicate that exposure to other tobacco users has more of an impact on whether these youth decide to use the product than their motivation to stop using it.

Finally, there is little evidence from this study that motivation quit varies by homelessness severity or other sociodemographic characteristics. In particular, we oversampled sexual minority youth in order to explore sexual orientation differences in motivation to quit and found little evidence of such differences. The general lack of associations with sociodemographic characteristics is consistent with results from our previous study of motivation to quit smoking among youth experiencing homelessness (Tucker et al., 2015), as well as other data from this project indicating that such factors are generally unrelated to the use of cigarettes and ATPs among these youth (Tucker et al., 2019). The exception in the present study involved race/ethnicity, where motivation to quit was higher among Black than White youth across a range of tobacco products. This is similar to findings based on the general population indicating that Whites report weaker intentions to quit smoking (Soulakova et al., 2017). In general, our results suggest that motivation to quit is more similar than different across sociodemographic subgroups of youth experiencing homelessness, and the factors associated with motivation to quit are generally the same for those who self-identify as heterosexual vs. LGBQA.

Limitations

This study is notable in being the first to examine motivation to quit ATPs among homeless youth tobacco users, and its strengths include the probability-based sample and oversampling of sexual minority youth. However, results from this study may not generalize to youth experiencing homelessness in other geographic areas. The study is limited in its exclusive reliance on the cross-sectional design, which precludes drawing any conclusions regarding temporal associations among the study variables. Other limitations include the categorical measure of frequency of tobacco use, as well as the exclusive reliance on quantitative self-report data. Qualitative data would be especially helpful in interpreting a couple of the more unexpected findings (e.g., motivation to quit LCCs was lower among youth who used these products because they believed they could be used in places where cigarette smoking is not allowed). Finally, sample sizes varied across type of tobacco product, with the analyses of ENDS, LCCs and cigars having less statistical power than those for regular and natural cigarettes.

Conclusions

Results from this study are encouraging in that nearly one-third of homeless youth tobacco users reported being motivated to quit most tobacco products. Further a number of potentially fruitful targets for increasing motivation to quit among youth experiencing homelessness were identified, some of which were particular to specific ATPs. Importantly, while some results from this study are consistent with findings from non-homeless samples, others are not; thus, a key take-away from this study is that findings from the existing literature on motivation to quit may not necessarily generalize to young tobacco users experiencing homelessness. More research is needed specifically focusing on reducing tobacco use in this underserved and understudied population. While there are many challenges ahead, including better understanding how to effectively reduce the use of ATPs in this population, particularly in light of the distinct motivations for using different products (Wong et al., 2017), studies such as the present one are a critical first step in laying the foundation for this important ongoing research.