Abstract
Introduction:
Young adults who smoke cigarettes often report heavy episodic drinking (HED) and co-use of other psychoactive substances which may complicate efforts to quit cigarette smoking. The current study examined factors associated with readiness to quit cigarette smoking among young adults who smoke and engage in HED.
Methods:
One hundred seventy-nine young adults aged 18 to 25 who reported regular cigarette smoking and past month HED enrolled in the 90-day Facebook-based Smoking Tobacco and Drinking (STAND) intervention study. Analyses compared baseline differences in patterns of cigarette smoking and alcohol and cannabis use, thoughts about abstinence, use of nicotine replacement therapy (NRT), sociodemographic characteristics, and other health behaviors between participants who were ready to quit cigarette smoking in the next 30 days and those who were not.
Results:
Participants were 40.2% female, 49.7% male, 10.1% non-binary, and 80.4% Non-Hispanic White. They reported on average moderate nicotine dependence (FTCD), moderate risk for alcohol use disorder (AUDIT), and occasional or regular cannabis use. Readiness to quit cigarette smoking in the next 30 days (33.5%) was positively associated with age (p=.021), NRT use in the past 30 days (p=.037) and perceived importance to also reduce alcohol use (p=.033).
Conclusions:
Findings indicate that readiness to quit cigarette smoking among young adults who drink is positively associated with importance to reduce alcohol use, but not with use patterns or levels of dependence. Interventions addressing polysubstance use may be better suited to help young adults reduce or quit cigarette smoking once they signal readiness for behavior change.
Keywords: Cigarettes, smoking cessation, tobacco, alcohol, cannabis
Introduction
Despite increased tobacco control efforts and a growing number of interventions for cigarette smoking cessation, about one quarter of young adults in the United States smoke cigarettes regularly.1 A similar proportion of young adults use electronic nicotine delivery systems (ENDS).2 Co-use of cigarettes and alcohol3–5 or cannabis6,7 is pleasurable, and thus, prevalent among young adults and may complicate efforts to quit cigarette smoking. Other health behavior issues such as pre-cessation stress management, depressed mood, insufficient exercise, and sleeping problems can act as additional barriers for quitting cigarette smoking.8 Importantly, interventions addressing cigarette smoking should be tailored to readiness to quit and consider current patterns of other substance use, applying a holistic and personalized approach9 to account for dynamic changes in use during young adulthood.
The current analysis examined factors associated with readiness to quit cigarette smoking among young adults who reported regular cigarette smoking and past month heavy episodic drinking (HED) when enrolling in the Facebook-based Smoking Tobacco and Drinking (STAND) intervention study.10 Identifying baseline tobacco, alcohol, and cannabis use patterns and attitudes; sociodemographic characteristics, and health behaviors associated with readiness to quit cigarette smoking may inform understanding of engagement with motivation-focused interventions addressing use of multiple substances.
Methods
Participants and Procedures.
English-speaking young adults aged 18 to 25 who had smoked ≥100 cigarettes in their lifetime, currently smoked cigarettes on 4 or more days per week, reported at least one HED occasion in the past month (4+ drinks for women; 5+ drinks for men), and used Facebook at least 4 times a week were recruited via Facebook.10 Smoking criteria were liberal so that young adults who smoke less than daily and were not planning to quit were eligible, considering the adverse health effects from smoking and benefits of any reduction in use.11 Individuals who reported that they were ready to quit in the next 30 days received intervention content about making and enacting a quit strategy, while those who were not ready to quit received intervention content focused on exploring motivations and barriers to quitting. Overall, 4,274 people were screened for inclusion, 1,097 were eligible, 219 verified their identity online by submitting a picture of their ID or driver’s license via Facebook messenger, and 179 completed the baseline questionnaire prior to randomization to the tobacco and alcohol-focused experimental intervention group (STAND: Smoking Tobacco and Drinking)10 or the tobacco-focused control group (TSP: Tobacco Status Project intervention).11 Participants were assigned to one of 14 Facebook groups of 3 to 19 people in the same intervention condition and stage of change. The University of California, San Francisco (UCSF) Institutional Review Board approved all study procedures.
Stage of change for quitting smoking.
We assessed readiness to quit cigarette smoking within the next 30 days (yes/no) corresponding to the Transtheoretical Model of Health Behavior Change stage of preparation vs. contemplation or pre-contemplation.12 According to this model, “in preparation” for smoking cessation is defined by reporting readiness to quit smoking in the next 30 days and at least one quit attempt in the past 12 months. For this study, participants did not have to have a prior year quit attempt to be considered ready to quit. People who were ready to quit cigarette smoking in the next 30 days were oversampled by quota to enroll enough participants to fill 6 of the 14 Facebook groups (3 groups for each intervention arm).
Sociodemographic characteristics and health behaviors.
Age, gender identity (female, male, non-binary), region, race/ethnicity, income, and years of education completed were assessed to account for potential disparities in access to health behavior change resources and information. Assessments of regular exercise, effective stress-management, and sleep habits were drawn from the Staging Health Risk Assessment.14 Regular exercise was defined as 150 minutes moderate or 75 minutes vigorous intensity aerobic or cardio per week. Practicing effective stress management was defined as regular relaxation, physical activity, and social activities. Having good sleep habits was defined as sleeping at least 7 hours per night, maintaining a regular bed and wake time, avoiding caffeine, alcohol, nicotine, spicy foods, and heavy meals within 4 hours of bedtime, creating a dark, quiet, comfortable sleep environment. Finally, depressed mood in the last two weeks was measured using the short form of the Patient Health Questionnaire (PHQ-2, range 0–6 with a threshold of 3 meaning that further screening for major depression is indicated).15
Tobacco/nicotine use.
We assessed participants’ average number of cigarettes smoked per day and number of cigarettes smoked in the past week. The Fagerstrom Test for Cigarette Dependence (FTCD)16 was used to measure cigarette dependence. Further, participants were asked about their use of other tobacco products (e.g., chew, cigars) and nicotine vaping in the past 30 days (yes/no).
Thoughts about abstinence and prior quit attempts.
The Thoughts about Abstinence Scale measured desire, expected success, and difficulty to quit smoking rated on a 10-point scale.17 Participants reported the number of quit attempts in the past 12 months and the use of nicotine replacement therapy (NRT) in the past 30 days (yes/no).
Alcohol use.
We assessed the number of days of HED (4+ drinks on a single occasion for women; 5+ drinks on a single occasion for men) in the past month. The Alcohol Use Disorder Identification Test (AUDIT) was administered to assess alcohol use and related problems.18 We asked participants whether they thought about reducing their drinking (never, sometimes, already decided, already tried).19 Further, participants were asked whether their drinking followed the NIAAA standards for low-risk alcohol use, defined as no more than 3 drinks per day and 7 per week for women and no more than 4 per day and 14 per week for men (no/don’t intend, no/but intend in the next 6 months, no/but intend in the next 30 days, yes/but for less than 6 months, yes/for more than 6 months; the latter two “yes” drinking follows the low-risk standards options were categorized as low-risk drinking). Co-use of alcohol and tobacco was assessed by asking participants if they used tobacco while or within several hours of drinking within the past 30 days, and participants could indicate their percentage of smoking episodes while under the influence of alcohol (0–100%). We measured motivation to cut down and stop alcohol use by adapting the Thoughts about Abstinence Scale for alcohol use, on a scale of 1–10.
Cannabis use.
Participants indicated on how many days in the past month (0, 1–9, 10–19, 20–29, 30+) they had used cannabis and how cannabis was used (smoked, vaped, ingested, dabbed; yes/no).
Statistical Analyses.
Differences in patterns of cigarette smoking and alcohol use, thoughts about abstinence, and other health behaviors were compared between participants who were ready to quit cigarette use in the next 30 days and those who were not, using X2-tests and Fisher’s Exact Test with Freeman Halton Extension for nominal variables and t-tests for the comparison of means.
Results
Sample characteristics.
The sample characteristics, tobacco use patterns, and health behaviors stratified by readiness to quit smoking are shown in Table 1. Two fifths of the sample identified as female (40.2%) and one in ten as non-binary (10.1%). The majority was White and Non-Hispanic, and all U.S. regions were represented. About half of the participants earned less than $10,000 a year.
Table 1.
Sample characteristics, cigarette smoking and nicotine use behavior of young adults enrolled in the Facebook-based Smoking Tobacco and Drinking (STAND) intervention study at baseline by readiness to quit cigarette smoking.
| Total (N=179) | Ready to quit cigarette smoking (n=60) | Not ready to quit cigarette smoking (n=119) | p-value a | ||||
|---|---|---|---|---|---|---|---|
| n / M | % / SD | n / M | % / SD | n / M | % / SD | ||
| Gender identity | |||||||
| Female | 72 | 40.2% | 24 | 40.0% | 48 | 40.3% | .546 b |
| Male | 89 | 49.7% | 32 | 53.3% | 57 | 47.9% | |
| Transgender or non-binary | 18 | 9.5% | 4 | 6.7% | 14 | 11.8% | |
| Age | 22.1 | 2.20 | 22.6 | 2.11 | 21.8 | 2.20 | .021 |
| Years of school completed | 13.2 | 2.00 | 13.4 | 1.71 | 13.2 | 2.14 | .515 |
| Income < $10,000/year | 79 | 44.1 | 31 | 51.7% | 48 | 40.3% | .150 |
| Health behaviors | |||||||
| Regular exercise, >150 min/week | 77 | 43.0% | 29 | 48.3% | 48 | 40.3% | .308 |
| Effective stress management | 104 | 58.1% | 34 | 56.7% | 70 | 58.8% | .782 |
| Good sleeping patterns, >7 h/night | 69 | 33.5% | 23 | 38.3% | 37 | 31.1% | .333 |
| PHQ-2 score of 3–6 c | 81 | 45.3% | 26 | 43.3% | 55 | 46.2% | .419 |
| Cigarette smoking | |||||||
| FTCD | 5.7 | 1.76 | 5.8 | 1.79 | 5.6 | 1.75 | .583 |
| Daily cigarette smoking | 148 | 82.7% | 51 | 81.5% | 97 | 85.0% | .360 |
| Usual number of cigarettes/day | 10.4 | 6.85 | 10.9 | 7.45 | 10.2 | 6.53 | .572 |
| Cigarettes past 7 days | 72.6 | 53.84 | 72.7 | 65.39 | 72.6 | 47.27 | .994 |
| Quitting cigarette smoking | |||||||
| Quit attempts past 12 months | 6.3 | 26.13 | 6.0 | 15.30 | 6.4 | 30.21 | .931 |
| NRT use past 30 days | 18 | 10.1% | 10 | 16.7% | 8 | 6.7% | .037 |
| Desire to quit, 1–10 | 6.0 | 2.52 | 8.1 | 1.65 | 4.9 | 2.23 | <.001 |
| Expected success, 1–10 | 4.9 | 2.49 | 5.9 | 2.25 | 4.4 | 2.47 | <.001 |
| Expected difficulty, 1–10 | 7.1 | 2.36 | 7.2 | 2.32 | 7.1 | 2.38 | .809 |
| Nicotine use in the past 30 days | |||||||
| Only cigarettes | 25 | 14.0% | 10 | 16.7% | 15 | 12.6% | .459 |
| E-cigarette/vaporizer | 101 | 56.4% | 32 | 53.3% | 69 | 58.0% | .554 |
| Blunt | 88 | 49.2% | 32 | 53.3% | 56 | 47.1% | .428 |
| Cigar | 42 | 23.5% | 15 | 25.0% | 27 | 22.7% | .731 |
| Cigarillos/little cigars | 27 | 15.1% | 10 | 16.7% | 17 | 14.3% | .674 |
| Dip | 13 | 7.3% | 3 | 5.0% | 10 | 8.4% | .408 |
| Chew | 12 | 6.7% | 2 | 3.3% | 10 | 8.4% | .200 |
| Snus | 4 | 2.2% | 1 | 1.7% | 3 | 2.5% | .715 |
| Snuff | 2 | 1.1% | 0 | 0 | 2 | 1.7% | .313 |
X2-tests for nominal variables and t-tests for means
Fisher’s Exact Test with Freeman Halton Extension
Screening for Major Depressive Disorder is indicated by a score of 3 or higher
FTCD = Fagerstrom Test for Cigarette Dependence; NRT = Nicotine Replacement Therapy; M = Mean; PHQ = Patient Health Questionnaire; SD = Standard Deviation.
Overall, almost half of participants scored 3 or higher on the PHQ-2 (M=2.9, SD=1.91). There was no significant difference between groups in their PHQ-2 score or other health behaviors assessed. Less than half of the participants engaged in regular exercise and about one third reported having good sleeping patterns. Two fifth were not able to practice effective stress management in daily life.
The FTCD score indicated moderate cigarette dependence for both people who were ready to quit and those who were not. Most participants smoked daily and on average 10 cigarettes a day or 73 cigarettes per week. Over half of the participants had used e-cigarettes in the past 30 days.
Alcohol and cannabis use patterns stratified by readiness to quit smoking are shown in Table 2. Participants reported HED on nine days in the past month on average (Table 2). About a third of participants (33.0%) was at high or very high risk of alcohol use disorder based on their AUDIT score. Most participants reported co-use of alcohol and cigarettes in the past month, on average on over 50% of drinking occasions. Almost half of the sample (45.3%) had already decided or tried to drink less and/or limited their consumption according to the NIAAA low risk drinking guidelines.
Table 2.
Alcohol and cannabis use behavior of young adults enrolled in the Facebook-based Smoking Tobacco and Drinking (STAND) intervention study at baseline by readiness to quit cigarette smoking.
| Total (N=179) | Ready to quit cigarette smoking (n=60) | Not ready to quit cigarette smoking (n=119) | p-value a | ||||
|---|---|---|---|---|---|---|---|
| n / M | % / SD | n / M | % / SD | n / M | % / SD | ||
| HED days in the past 30 days | 8.9 | 8.05 | 9.2 | 7.80 | 8.4 | 8.18 | .633 |
| AUDIT score | 12.7 | 7.75 | 11.8 | 7.47 | 13.3 | 7.89 | .284 |
| 0–7 Low risk | 60 | 33.5% | 23 | 38.3% | 37 | 31.1% | .185 |
| 8–15 Moderate risk | 60 | 33.5% | 16 | 26.7% | 44 | 37.0% | |
| 16–19 High risk | 20 | 11.2% | 10 | 16.7% | 10 | 8.4% | |
| 20–40 Dependence | 39 | 21.8% | 11 | 18.3% | 28 | 23.5% | |
| Co-use of alcohol and cigarettes | |||||||
| Co-use past 30 days | 173 | 96.6% | 56 | 93.3% | 117 | 98.3% | .080 |
| % of drinking occasions with co-use | 50.8 | 30.52 | 52.8 | 28.65 | 49.8 | 31.49 | .541 |
| Reducing alcohol use | |||||||
| Never think about drinking less | 44 | 24.6% | 15 | 25.0% | 29 | 24.4% | .321 |
| Sometimes think about drinking less | 54 | 30.2% | 13 | 21.7% | 41 | 34.5% | |
| Decided to drink less | 27 | 15.1% | 11 | 18.3% | 16 | 13.4% | |
| Already tried to drink less | 54 | 30.2% | 21 | 35.0% | 33 | 27.7% | |
| Drinking low risk (NIAAA) | 76 | 42.5% | 27 | 45.0% | 49 | 41.2% | .625 |
| Importance to reduce or stop, 1–10 | 5.1 | 3.12 | 5.8 | 3.26 | 4.7 | 3.00 | .033 |
| Confidence to reduce or stop, 1–10 | 7.1 | 2.69 | 7.6 | 2.51 | 6.9 | 2.75 | .101 |
| Frequency of cannabis use past 30 days | |||||||
| Never | 41 | 22.9% | 11 | 18.3% | 30 | 25.2% | .577 |
| On 1–9 days | 42 | 23.5% | 17 | 28.3% | 25 | 21.0% | |
| On 10–19 days | 18 | 10.1% | 7 | 11.7% | 11 | 9.2% | |
| On 20–29 days | 34 | 19.0% | 9 | 15.0% | 25 | 21.0% | |
| Daily | 44 | 24.6% | 16 | 26.7% | 28 | 23.5% | |
| Form of cannabis used past 30 days | |||||||
| Smoked | 144* | 80.4% | 50 | 83.3% | 94 | 79.0% | .489 |
| Dabbed | 49 | 27.4% | 18 | 30.0% | 31 | 26.1% | .576 |
| Vaped | 48 | 26.8% | 15 | 25.0% | 33 | 27.7% | .697 |
| Ingested | 47 | 25.7% | 18 | 30.0% | 29 | 24.4% | .567 |
X2-tests for nominal variables and t-tests for means
6 people who previously said that they did not use cannabis in the past 30 days said yes to smoking cannabis in the past 30 days.
AUDIT = Alcohol Use Disorder Identification Test; HED = Heavy Episodic Drinking; M = Mean; SD = Standard Deviation.
Three quarters of participants had used cannabis in the past 30 days. Almost half of them reported cannabis use on 20 or more days in the past 30 days. Smoking cannabis was the most prevalent method of use in both groups but one in four also reported dabbing, vaping, and/or ingesting cannabis in the past month (Table 2).
Differences by readiness to quit.
At baseline, participants who were ready to quit cigarette smoking did not significantly differ in terms of cigarette smoking, dependence, and other nicotine use when compared to those not ready to quit. Participants who were ready to quit smoking (33.5%) were significantly older compared to those who were not ready to quit smoking (p=.021). The use of NRT in the past 30 days was more prevalent among those who were ready to quit (p=.037). Participants who were ready to quit rated their desire to quit significantly higher and were more confident of success when compared to those not ready to quit (p<.001). However, individuals in both groups perceived quitting cigarette smoking to be equally difficult. Participants who were ready to quit cigarette smoking considered it significantly more important to also reduce their drinking (p=.033) but their plans and confidence in their ability to drink less did not differ.
Discussion
This analysis of young adults enrolled in a Facebook-based cigarette smoking and alcohol intervention study examined baseline differences among participants according to their readiness to quit cigarette smoking. One third of participants were ready to quit cigarette smoking. These participants were significantly (1) older, (2) more likely to rate their desire to quit cigarette smoking as high, (3) more confident of expected success to quit cigarette smoking, (4) more likely to have used NRT in the past 30 days, and (5) more likely to rate the importance to reduce alcohol use as high, when compared to those who were not ready to quit. Neither patterns of tobacco, alcohol, or cannabis use nor levels of cigarette or alcohol dependence differed between the two groups.
Several baseline characteristics of the sample may help inform future design of interventions targeting multiple substances. Specifically, FTCD scores indicated on average moderate nicotine dependence. The AUDIT scores indicated on average medium risk for alcohol use disorder, which is also reflected in having on average 9 HED occasions in the past 30 days. Participants reported co-use of cigarettes and alcohol on about half of the drinking occasions. In addition, more than half of the participants reported use of ENDS in the past month. Given that most participants reported prior quit attempts in the past year, the high prevalence of vaping may indicate that young adults consider ENDS as tools for quitting or reducing cigarette smoking.20
Occasional and regular cannabis use via multiple forms of use was prevalent, including non-smoking inhalation methods like vaping and dabbing and non-inhalation edible use. Readiness to quit cigarette smoking was not associated with cannabis use. Few participants reported good sleep and stress management skills and 45.3% scored above the threshold value on the PHQ-2, indicating further screening for major depressive disorder, which is known to be a barrier to successful smoking cessation.
Limitations
Limitations include self-report substance use measures, small sample size, and limited generalizability of the results due to convenience sampling of a specific sub-sample of young adults. Only a fifth of those who were eligible to participate fully enrolled in the study, making the sample highly selective and with limited generalizability to U.S. young adults who smoke cigarettes and drink alcohol. Future studies should explore other forms of community or peer support in addition to internet-based smoking cessation interventions. Finally, detailed and parallel information on the patterns of use of ENDS and other tobacco and cannabis products were not assessed in this study.
Conclusions
Among young adults enrolled in an intervention study, findings showed that readiness to quit cigarette smoking was related to importance of reducing drinking but not to overall nicotine and alcohol use patterns.
Acknowledgments
We thank Mandy Chan, B.A., for assistance in completing the study.
Funding:
NIH/NIDA R34 DA041637 and K01 DA046697; and NIH/NIAAA K24 AA025703.
Footnotes
Declaration of interest: None.
Trial Registration: NCT03163303
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