“I got a little addiction”: Adolescent and young adult cigarillo users’ self-perceptions of addiction

Abstract

Background:

While prior research has informed how cigarette smokers understand and apply the term addiction, little is known about how this term is used by cigarillo smokers. This is an important area of study given the decline in cigarette use and increase in cigar product consumption.

Purpose/Objectives:

This paper examines how cigarillo smokers self-identify in terms of addiction and the association of this identification with tobacco use, quitting experiences, and level of nicotine dependence.

Methods:

Transcripts from semi-structured interviews conducted in 2015–2016 with 57 participants (aged 14–28) about cigarillo use and beliefs were analyzed using a phenomenological approach to examine themes around addiction and cessation experiences. Analyses were limited to participants endorsing having a habit. Quantitative analyses were conducted to assess associations with demographics, tobacco use, addiction, cessation, and nicotine dependence for two groups: participants endorsing having an addiction to cigarillos and those who did not.

Results:

All participants described the term addiction similarly. Participants with an addiction had significantly higher nicotine dependence and self-rating of addiction than those without an addiction. Although most quitting experiences did not differ between the two groups, participants who did not identify as addicted felt that they could quit smoking cigarillos at any time.

Conclusions:

Variations in identification with addiction are not associated with differences in definitions, use and quit experiences. Understanding self-perceptions of addiction can inform targeted communication to encourage cessation and the use of cessation resources.

1. Introduction

Use of the word “addiction” is common among substance users and the general public. Understanding how “addiction” is used is important, particularly when examining self-report data. Among cigarette smokers, research has examined how smokers understand the term addiction and apply it to themselves. Studies looking at the concept of addiction have found that it is described in terms of a lack of control (Rothwell and Lamarque, 2011), need for the product (Amos et al., 2006), and inability to quit (Arnett, 2000; Halpern-Felsher et al., 2004; Milam et al., 2000; Moffat and Johnson, 2001; Nichter et al., 1997). Additionally, definitions of addiction are similar between adults and adolescents (Chassin et al., 2007). Cigarette smokers vary in their endorsement of addiction (Amos et al., 2006; Bancroft et al., 2003; Rothwell and Lamarque, 2011), which could be related to previous experiences of quitting (Amos et al., 2006; O’Loughlin et al., 2002). Many do not identify as being addicted (Rothwell and Lamarque, 2011).

Cigarette smokers who do not self-identify as having an addiction often label their use as a habit (Rothwell and Lamarque, 2011). Those who endorse having a habit but not an addiction also have a perceived ability to control use and quit (Amos et al., 2006; Bancroft et al., 2003). Additionally, those who do not feel addicted are more likely to report that they would not use cessation services or quit aids (Amos et al., 2006). Although individuals self-identifying as having a habit but not endorsing an addiction reported a perceived ability to quit, they also reported urges to smoke (Amos et al., 2006), which is a marker of dependence (Fidler et al., 2011).

Cigarillo smokers also vary in their endorsement of addiction (Antognoli et al., 2018; Nyman et al., 2016). In a prior study, we found that adult cigarillo users felt addiction to cigarillos is possible and define addiction in terms of control (Antognoli et al., 2018). Another study found that cigarillo use is seen as less addictive and easier to quit than cigarettes (Sterling et al., 2016).

This study delved deeper into the findings described in Antognoli et al. (2018) with both young adults and adolescents to further explore the themes around the endorsement of addiction among cigarillo users. This is an important area of study as cigarette use has been declining, while cigar use has increased (Boon, 2017) and among adolescents and adults, cigarillos are the most prevalent cigar product used (Corey et al., 2018; Kasza et al., 2017). Further, research has found that the nicotine concentration in cigars is similar to that in cigarettes (Koszowski et al., 2018), demonstrating the addictive potential of these products.

Little is known about the relationship between how an individual classifies themselves in terms of addiction and their actual use of tobacco products and dependence on nicotine. This paper examines how adolescent and young adult cigarillo smokers self-identify in terms of whether or not they are addicted and the association of this identification with use patterns, quitting experiences, and level of nicotine dependence.

2. Methods

2.1. Data collection

From June 2015 to April 2016, we recruited 60 participants to participate in a semi-structured interview about cigarillo use patterns and beliefs, providing sufficient variability for the proposed quantitative and qualitative analyses (Guest et al., 2006; Wilson Vanvoorhis and Morgan, 2007). Inclusion criteria was use of at least one cigarillo a week and being between the ages of 14–28. We monitored participant age to ensure a balanced distribution across the range. Recruitment of participants included canvassing and posting flyers at areas frequented by the target population, including bus stops, recreation centers, college campuses, high schools, gas stations, convenience stores, libraries, and teen clinics. Participants could either contact researchers through email, phone or in-person to enroll in the study. Upon contact, if eligible for the study, the researcher went through a verbal consent procedure, and upon consent, the individual was enrolled in the study to complete an interview either by phone or in person. Interviews ranged from 20 to 60 min in duration and participants received a $25 electronic gift card. The study was approved by the Institutional Review Board at Case Western Reserve University.

Four interviewers were trained in conducting qualitative interviews and practiced interviewing with feedback on data collection techniques throughout the data collection period. Interviews were audio-recorded. In addition to open-ended questions about participant’s cigarillo initiation, patterns around the use of cigarillos and cigarettes throughout the day and week, preferences and behaviors around cigarillo use, experiences of addiction and craving, as well as quitting experiences, the interview also collected demographic, quantity and type of tobacco products smoked per day, and nicotine dependence data. The interview guide included questions to examine concepts related to nicotine dependence as described in O’Loughlin et al. (2002) including understandings and feelings of addiction, experiences of withdraw and cravings, and loss of autonomy. While many terms are utilized when speaking about cigarillos (Dickinson et al., 2016), recruitment was based on cigarillo (untipped or tipped) use and interviewers clarified with participants which products were being discussed. This paper focuses on participants’ responses to questions around addiction.

2.2. Measures

The following items were quantified from the qualitative interviews.

2.2.1. Defining addicted groups

Participants were asked when smoking cigarillos became a habit. While this question assumed an individual would respond in a way affirming their habit, with the participant answering the question with an age (e.g., “Seventeen, when I first started smoking them.”), some responded in a way refuting that they have a habit (e.g., “It’s not a habit. Like if it’s there, then I’m just gon’ hit it, but it’s not a habit.”). Participants who answered the habit item in a way affirming their habit were placed into two groups based on their response to a question about whether they had ever felt addicted to cigarillos, which was adapted for this study from an item on the Hooked on Nicotine Checklist (DiFranza et al., 2002). Those who responded that they felt addicted are referred to as the Addicted group and those who answered that they didn’t are referred to as the Not Addicted group in this paper. One participant did not respond to this question and was removed from the analyses presented here. For the analyses, the sample was limited to the 57 participants who did report a habit to better understand self-perceptions of addiction and experiences of use among those who self-identify as having a habit.

2.2.2. Demographic data

Demographic factors included participants’ self-reported age and gender as male or female.

2.2.3. Cigarillo initiation

Cigarillo initiation included participants’ starting age and habit age. Participants were asked, for example, “What age did you smoke your first little cigar or cigarillo?” and “When did this become a habit?”. Participants were asked to provide an age for both questions.

2.2.4. Tobacco use

Participants were asked questions to estimate the number of cigarillos smoked Monday through Thursday and Friday through Sunday to assess differential use between weekdays and weekends. A participant’s total cigarillo use per week was calculated by the sum of the participant’s answers. Participants were also asked to indicate whether they currently use cigarettes. If a participant used cigarettes, they were asked to estimate how many cigarettes they use per week. The participant’s total tobacco use per week was calculated by the sum of their cigarillo total per week and cigarette total per week.

2.2.5. Dependence

Participants were asked to rate their own addiction to cigarillos on a scale of 1–100 where 1 is not addicted and 100 is extremely addicted. This item was adapted for this study from an item on the Cigarette Dependence Scale (Etter et al., 2003). The interviews also assessed nicotine dependence using the PROMIS Nicotine Dependence scale (Shadel et al., 2014), with all questions edited to be product neutral to assess dependence for all nicotine products (i.e., the word “cigarettes” changed to “tobacco products”). The 32 nicotine dependence questions (two sets of questions with five answer choices with scales of Never=0 to Always=4 and Not at all=0 to Very Much=4) were summed for a total score ranging from 0 to 128, with higher scores indicating higher level of nicotine dependence.

2.2.6. Cessation behavior

To examine behaviors related to cessation, participants were asked to indicate whether or not they are currently trying to cut back on their cigarillo use, if they are currently using any quit aids, such as the patch, gum, or lozenges, and if they have ever quit smoking cigarillos.

2.3. Data analysis

The measures described above were asked within the scope of the semi-structured interview, which allowed for participants to provide more in-depth discussion around their answers, with the exception of the PROMIS Nicotine Dependence Scale, which was administered orally to the participant at the end of the interview. The quantified demographic, cigarillo initiation, tobacco use, dependence, and cessation behavior measures were examined by the Addicted group. The narrative around these topic areas were examined qualitatively.

For this study, the qualitative interviews were analyzed to examine themes around perceptions of addiction, use patterns, and cessation experiences. A phenomenological approach was used to examine participants’ lived experiences of cigarillo use. Interviews were transcribed verbatim. An initial codebook was developed and applied by two qualitative researchers. The two researchers met regularly to discuss discrepancies in coding and interpretation. An iterative process was used for the qualitative analysis of interview data to examine relationships and patterns within and between coded themes. This involved multiple readings of the interviews, summaries of a priori and emergent themes, and confirmation of emergent themes. Examples of codes that were examined for themes for this study included Smoking Experience Cravings, Smoking Experience Addiction, and Smoking Experience Quitting/Cutting Back. The primary analyst for the study presented here was SKG. Preliminary findings were shared with the team for corroboration and refinement of interpretations. QSR International’s NVivo 11 Software (QSR International (2015)) was used to organize the qualitative data analysis.

Means for each group were calculated for the following variables: participant age, starting age, habit age, rating of addiction, nicotine dependence scores, tobacco total/week, cigarillototal/week. Means were compared using one-way ANOVA and Welch’s Test to testfor statistically significant differences between the groups. To explore associations with addiction group, we used Pearson chi-square tests (gender, cigarette use, and trying to cut back on cigarillo use) or Fisher’s exact test (using quit aids and ever quit) for variables with small cell sizes. For each addiction group, Nicotine Dependence scores were split into quartiles to examine patterns within each quartile and understand themes for participants who may be outliers within the group (i.e., participants in the highest quartile but who did not endorse being addicted). Statistical analyses were conducted with SPSS v24 (IBM Corp, 2016). Significance level was set to 0.05.

3. Results

The results are presented in four areas: (1) group characteristics; (2) meanings of addiction; (3) dependence, self-rating of addiction, and tobacco use; and (4) quitting experiences. For each of these sections, findings from quantitative analyses will be discussed before findings from qualitative analyses.

3.1. Group characteristics

Two individuals in the full sample reported not having a habit. Of the 57 participants who were placed into the two groups, 38 (64.4%) were in the Addicted group and 19 (32.2%) were in the Not Addicted group. In both the Addicted and Not Addicted groups, the majority of participants identified as Black or African American (73.7% and 63.2%, respectively). Overall, participants did not differ significantly by mean age, starting age, habit age, or by gender or current cigarette use (Table 1).

Table 1.

Demographic Characteristics by group.

Measure	Addicted Group		Not Addicted Group		p-value
	N = 38		N = 19
	Mean	Range	Mean	Range
Participant Age	20.45	14–28	18.95	15–25	.144a
Starting Ageb	15.32	5–20.5	14.68	11–23	.413a
Habit Agec	16.61	13–22	15.92	12–23.5	.313a
	%		%
Male	44.7%		68.4%		.091d
Currently Uses Cigarettes	55.3%		47.4%		.574d

^aWelch’s Test

^bAge participant first smoked a cigarillo.

^cAge when smoking cigarillos became a habit.

^dPearson Chi-Square Test

3.2. Meanings of addiction

Descriptions of the term “addiction” were examined to better understand whether there were differences in the understanding of the term, which may affect an individual’s self-identity. The sub-themes that emerged around participants’ understandings of addiction did not differ between the two groups. Addiction was described by individuals in both groups using concepts similar to Nicotine Dependence to tobacco (Fagerstrom and Schneider, 1989; Shadel et al., 2014), including unable to control use, needing or having to have the product, not being able to go without, not being able to stop use, continuous use, and choosing to not control the use. Table 2 provides example quotes of the subthemes from each group.

Table 2.

Sub-Themes for Meanings of Addiction.

Sub-Theme	Addicted Group Participant Responses	Not Addicted Group Participant Responses
Unable to Control	Something that’s hard to take control of. Something that’s hard to challenge. (026 – Addicted group; Addiction Rating 75, Nicotine Dependence score 32)a	When you smoke something a lot that you can’t control it and you can’t get rid of it. (1003 – Not Addicted group, Addiction Rating 75, Nicotine Dependence score 18)a
Need	Kind of like that’s what you need, like you have to have it. Kind of like your day kind of be kind of off because you don’t have it. (007 – Addicted group, Addiction Rating 50, Nicotine Dependence score 38)a	If they’re just going out of their way to get them, and if they’re like ‘Oh man, I need to smoke right now. I need to do this. I need to go get, go to the store and get a Black & Mild.’ (004 – Not Addicted group, Addiction Rating 10, Nicotine Dependence score 18)b
Have to Have	When you feel the urge to want something all the time and you have to have it. In your head, you have to have it and you can’t go throughout your day without it. (1025 – Addicted group, Addiction Rating 10, Nicotine Dependence score 68)a	Like you’ve got to have it. You can’t stop thinking about it. You just got to get your hand on one and you’ll do anything to get one. (010 – Not Addicted group, Addiction Rating 5, Nicotine Dependence score 15)a
Can’t Go Without	When you can’t go an hour without that, or you can’t go not even a day without. (1027 – Addicted group, Addiction Rating 25, Nicotine Dependence score 58)a	To want something like really, really bad, like to want where you feel like you can’t live without that thing, and that’s how. Yeah. (030 – Not Addicted group, Addiction Rating 40, Nicotine Dependence score 50)a
Can’t Stop	Like when you can’t stop doing that. You’re just constantly, you know, going back. (008 – Addicted group, Addiction Rating 50, Nicotine Dependence score 61)a	To be addicted is like not having the control over it. Like if you want to stop and your body just feel like you can’t stop, like you need it, and if you actually like go through withdrawal. (029 – Not Addicted group, Addiction Rating 35, Nicotine Dependence score 8)a
Choosing Not to Control	I guess it means to be you know something you can’t... I mean you can control it, but you choose not to, like to not control it, but you have the option but you just can’t choose the other option, you know, addiction. (020 – Addicted group, Addiction Rating 30, Nicotine Dependence score 61)a	Yes and no. It’s kind of more like a how strong mentally you are. It’s like a, like you can control it. (004 – Not Addicted group, Addiction Rating 10, Nicotine Dependence score 18)c
Continuous Use	‘Cause they’re smoking them a lot and constantly getting them, and smoking them all the time, ‘cause I done seen people just sit there and smoke a whole one. That’s a lot. (011 – Addicted group, Addiction Rating 50, Nicotine Dependence score 81)b	Chain smoking really. (1017 – Not Addicted group, Addiction Rating 50, Nicotine Dependence score 48)a

^aResponse to interviewer question about meaning of addiction.

^bResponse to interviewer question about how to tell if someone is addicted to cigarillos.

^cResponse to interviewer question about whether someone can become addicted to cigarillos.

Although these two groups used similar terms to describe addiction, some participants in both groups also used the terms habit and addiction interchangeably. When asked about what addiction means in general, a participant said, “You kind of crave something. It’s a habit of yours, you know” (024 – Addicted group, Addiction Rating 80, Nicotine Dependence score 86). Another participant expressed a similar thought when asked about how to tell if someone is addicted to cigarillos:

I think if it’s a really habitual thing if they smoke it every day, if they are really like looking forward to it or saying ‘I need it,’ or can’t wait to like you know… Just like a cigarette, like ‘I can’t wait to smoke a cigarette.’ I mean I think that if you feel like you can’t go without it, then I think that you’re addicted. (018 – Not Addicted group, Addiction Rating 10, Nicotine Dependence score 81).

For participants in both groups, their descriptions of addiction did not differ, including the use of the term habit.

3.3. Nicotine dependence, self-rating of addiction, and tobacco use

We also examined whether these two groups differed in terms of their Nicotine Dependence score, self-rating of addiction, and tobacco use. When the means of these variables for the two groups were compared, the mean self-rating of addiction and Nicotine Dependence score were significantly higher for Addicted participants than Not Addicted participants (p = .001) (Table 3).

Table 3.

Dependence, Rating of Addiction, Use Patterns and Cessation by Group.

Measure	Addicted Group N = 38		Not Addicted Group N = 19		p-valuea
	Mean	SD	Mean	SD
Nicotine Dependence scoreb	70.97	21.87	41.44	29.37	.001 c
Rating of Addictiond	56.70	24.88	32.47	23.92	.001 c
Cigarillo Total/Weeke	24.83	24.63	14.84	15.92	.071c
Cigarette Total/Weekf,g	25.50	23.65	48.86	48.33	.258c
Tobacco Total/Weekh	38.92	30.63	32.84	39.11	.558c
	N (%)		N (%)
Currently trying to cut back on cigarillos	23 (67.6%)		11 (61.1%)		.637i
Currently using quit aids	3 (11.1%)		1 (7.1%)		1.000j
Ever quit cigarillos	28 (75.7%)		15 (78.9%)		1.000j

^aBold indicates significant at p < .05.

^bSum from 32 nicotine dependence questions from PROMIS Nicotine Dependence scale (Shadel et al., 2014) with all questions edited to be product neutral with a score range of 0–128. Higher scores indicated higher level of nicotine dependence.

^cWelch’s Test

^dParticipant’s self-rating of addiction to cigarillos from 1 (not addicted) to 100 (extremely addicted).

^eSum of participant’s estimate of the number of cigarillos smoked Monday through Thursday and estimate of the number of cigarillos smoked Friday through Sunday.

^fParticipant’s estimate of the number of cigarettes smoked per week.

^gAmong current cigarette users

^hSum of cigarillo total per week and cigarette total per week.

ⁱPearson Chi-Square

^jFisher’s Exact Test

Although there was a difference in self-rated addiction and dependence scores, the groups did not differ significantly on their mean weekly cigarillo use, weekly cigarette use, or overall total tobacco weekly usage (Table 3). As there was no significant difference in the percent of participants in each group who were also dual cigarette users (Table 1), we also examined whether Nicotine Dependence scores, tobacco product use, and cigarillo use varied by cigarillo-only and dual product users (results not presented in tables). For the 57 participants, when single product users were compared to dual cigarillo and cigarette smokers, there was no significant difference for cigarillo total per week (p = .636), rating of addiction (p = .598), and Nicotine Dependence scores (p = .95). There was a significant difference in tobacco total per week (p .0001).

The self-rating of addiction to cigarillos was significantly lower for Not Addicted participants. As this is a self-rating of addiction, it is not surprising that participants in the Not Addicted group would rate themselves low on this scale. While participants in the Not Addicted group had a significantly lower Nicotine Dependence score, it is of note that these scores indicate some level of addiction and dependence. This may be explained in part by some participants in the Not Addicted group who qualified their addiction in the interview, indicating they had an addiction but just not much of one.

I think like 10–15, ‘cause I really ain’t that addicted, ‘cause I could stop it, if I wanted. (1029 – Not Addicted group, Addiction Rating 12.5, Nicotine Dependence score 22).

I got a little addiction to me, but I don’t got like that bad of addiction. (019 – Not Addicted group, Addiction Rating 40, Nicotine Dependence score 75).

Across both groups there was a wide variability in Nicotine Dependence scores. We examined the narratives of the participants in the top quartile of Nicotine Dependence scores for the Not Addicted group to better understand the context of their self-assessment of addiction. Three of the participants were dual cigarillo and cigarette users, and reported relatively high cigarette use (range from 70 to 120 cigarettes per week) while cigarillo use ranged from 4 to 20 cigarillos per week. Of note, these participants reported cigarettes as their preferred product and the product they are addicted to.

Well I’m a firm believer that there are far more addictive substances put in the cigarettes that I smoke than the Black & Mild’s, so ‘cause the thing is, is that like if I don’t smoke a cigarette (or cigarettes, rather) in a day, but I do smoke a Black & Mild, the Black & Mild, even if I smoke an entire Black & Mild in one sitting, it still doesn’t like shake the feeling that like my body is craving. (2031 – Not Addicted group, Addiction Rating 40, Nicotine Dependence score 90).

For the other participant in the top quartile of Nicotine Dependence scores in the Not Addicted group, they reported feeling more addicted to marijuana blunts as opposed to cigarillos.

For all participants in the Not Addicted group, when a reason for not feeling addicted was discussed, their answer was because they could stop using at any time.

Yeah, that’s why I really don’t say I’m addicted to anything, because I know I can stop at any given time, or if I had to like… Ever you know somebody came to me, ‘Oh, you have to stop smoking right now,’ I wouldn’t say right now, but I just, you know. (025 – Not Addicted group, Addiction Rating 1, Nicotine Dependence score 20).

I guess if you let it have that kind of hold on you, I guess, but it’s not like that for me. Like I could stop smoking like today and not feel like I have to smoke a Black & Mild, ‘I got to smoke something.’ Like I don’t have that necessity to smoke. I do it just ‘cause it makes me feel good and it’s like relaxing, and that’s most of the time my peace and quiet time. (029 – Not Addicted group, Addiction Rating 35, Nicotine Dependence score 8).

Overall, participants in the Not Addicted group reported having a significantly lower Nicotine Dependence score than the Addicted group (Table 3). Similarly, the Not Addicted group reported a significantly lower addiction level score. Participants with relatively high Nicotine Dependence scores in the Not Addicted group used and felt addicted to other products. For the Not Addicted group, perceived ability to quit was a reason given for not feeling addicted.

3.4. Quitting experiences

With the belief in their ability to quit as the reason for not being addicted, we also looked at variables related to quitting (Table 3). There were no statistically significant differences between the two groups for quitting cigarillos in the past, currently trying to cut back on their use of cigarillos, and use of quit aids.

For those who had attempted quitting, the length of their quit attempt was between 1 day to 3 years for Addicted participants and between 1 day and 2 years for Not Addicted participants. When describing why their quit attempts were not ultimately successful, participants in both groups described going back to smoking because of stress in their lives.

When I tried to stop smoking, I usually probably either got into an argument with somebody and then I got aggravated and then I just started smoking again. (1001 – Addicted group, Addiction Rating 75, Nicotine Dependence score 59).

‘Cause I got to stressing, catching cases and all this extra stuff. (1012 – Addicted group, Addiction Rating 60, Nicotine Dependence score 62).

My grandma had passed away, so I was really stressed out. So I started smoking again after that. (1029 – Not Addicted group, Addiction Rating 12.5, Nicotine Dependence score 22).

I would quit for maybe a day or so, and then like I would get in one of those intense arguments and then I would just go right back to it. (004 – Not Addicted group, Addiction Rating 10, Nicotine Dependence score 18).

Although both Addicted participants and Not Addicted participants reported stress as a reason for their smoking relapse, only participants in the Addicted group reported starting to use again because of their own craving and having others around them smoking.

It fail miserably because of the smell and craving was too strong (1023 – Addicted group, Addiction Rating 27.5, Nicotine Dependence score 82). Somebody was lighting one up, and I was hesitating and I was like ‘Let me hit that.’ (1026 – Addicted group, Addiction Rating 55, Nicotine Dependence score 82).

It was like I lasted almost 24 h. I almost lasted, but then I sat outside on my front porch and somebody else was smoking. They was smoking a cigarette. Just that smoke smell, and I had the one in my hand. I hit they cigarette and I went and got me a Black & Mild that night. (012 – Addicted group, Addiction Rating 90, Nicotine Dependence score 85).

While many participants in both categories described periods of quitting, some individuals in both categories also discussed how they attempted to quit but ultimately could not.

When I did try to stop before, I think I got to like about two hours and I just had to have one. (027 – Addicted group, Addiction Rating 50, Nicotine Dependence score 115).

It was like a day, and then at the end of that day, I was just like ‘Nope.’ (1021 – Not Addicted group, Addiction Rating N/A, Nicotine Dependence score 62).

Overall, there were no statistically significant differences in quit experiences or in the narratives around quitting between the two groups, except for participants in the Addicted group mentioning craving and being around others in their narratives around relapse.

4. Discussion

Of the 57 participants in this study, only 67% felt that they were addicted, although they reported having a habit, aligning with previous research showing varying endorsement of addiction among smokers (Amos et al., 2006; Antognoli et al., 2018; Bancroft et al., 2003; Nyman et al., 2016; Rothwell and Lamarque, 2011). Expanding on our research with young adult cigarillo users (Antognoli et al., 2018), this study found that among adolescents and young adults, there was a common understanding of what the concept of addiction means, regardless of self-identified addiction status, with participants using terms commonly found in the literature, such as constant use, need to use, an inability to stop, and lack of control over the product (Amos et al., 2006; Antognoli et al., 2018; Arnett, 2000; Halpern-Felsher et al., 2004; Milam et al., 2000; Moffat and Johnson, 2001; Nichter et al., 1997; Rothwell and Lamarque, 2011). The descriptors used by this sample are similar to established concepts of nicotine dependence such as loss of control, inability to stop, and cravings (Fagerstrom and Schneider, 1989; Shadel et al., 2014). These findings demonstrate that the word addiction resonates with this population. Additionally, our findings demonstrate that users can self-identify their level of addiction to the product as those participants who were addicted had higher scores when asked to rate themselves on 0–100 scale of addiction to cigarillos and exhibited higher levels of self-reported Nicotine Dependence compared to those participants who were not addicted.

Other research has shown that among cigarette users, identification as addicted was related to past experiences of the difficulty of quitting smoking (O’Loughlin et al., 2002). In addition, those who see themselves as having a habit but not being addicted may not seek help (Amos et al., 2006). In this study, we also explored if there were variations in quitting experiences based on self-identification with addiction. We found that over half of participants in both groups indicated they wanted to cut back on their use, however both Not Addicted and Addicted participants indicated difficulties with quitting in their past and that stressful events were a common reason for smoking again after a period of cessation. Messaging to encourage smoking cessation informing smokers about the challenges they may face when quitting and encouraging them to seek assistance when ready to quit should also be targeted toward cigarillo smokers.

Our study demonstrated that cigarillo users’ self-identification in terms of addiction may be related to their level of dependence, even though cigarillo and overall tobacco use did not differ in statistically significant ways. As self-ratings of addiction and symptoms of dependence are not strongly correlated with the amount of nicotine an individual consumes (Donny and Dierker, 2007), quantity of use is often a poor indicator of the ability to quit.

Among participants who did not feel addicted, but who had relatively high nicotine dependence scores, a commonality was the use of other nicotine-containing products. Messaging about tobacco harm and recommendations for cessation, which has typically focused on cigarettes and their use, should be inclusive of all nicotine-containing products like cigarillos because while an individual may not feel addicted to one of the products they use and instead may feel addicted to another product, all products are likely contributing to their nicotine dependence.

This study is limited by the focus on one geographic location. Regional variation in patterns of use may exist, but consistent themes derived from this study are valuable for other settings. Specifically, this study demonstrates that variations in identification with addiction are not associated with differences in definitions and although individuals may not currently identify as having an addiction, their use and experiences with quitting are similar to those who identify with an addiction.

This deeper understanding of self-perceptions of addiction can inform targeted communication to encourage cessation and the use of cessation resources, particularly among those who self-identify as having a habit, but not being addicted. Interventions to promote smoking cessation should inform users that even if they don’t feel addicted, quitting now could prevent becoming addicted. The incorporation of cigarillo products into the context of messaging around cessation could dispel any misperceptions of cigarillo use being less addictive than cigarettes (Jolly, 2008) and inform smokers that the use of these products contributes to their overall nicotine dependence.