Patterns of cigarillo use among Canadian young adults in two urban settings.

Yates, Erika A. ; Dubray, Jolene ; Schwartz, Robert 等

Cigarillo smoke contains levels of toxicants comparable to those of cigarette smoke; (1,2) the deleterious health effects associated with smoking cigarillos are many and include lung, oral cavity, and esophageal cancers. (3,4) Despite these documented health risks, cigarillo smoking is a major form of tobacco use among Canadian young adults. In 2011, nearly half (47%) of Canadians aged 20 to 24 years reported having ever smoked cigarillos; (5) 7% of Canadian young adults (20-24 years) reported having smoked cigarillos in the previous 30 days. (6) Furthermore, sales of cigarillos in Canada have increased dramatically in the past decade, from 53 million units sold in 2001 to 467 million units sold in 2009, (1) as has been the case in the United States. (7)

Previous research conducted in the US suggests that cigarillo use and polytobacco use is higher among males and younger adults, (8) is a social activity, (9) and may be associated with risk-taking behaviour. (8) To date, no studies have focused specifically on cigarillo smoking among young adults in Canada. Thus, the objectives of this first-blush analysis were to characterize cigarillo use, initiation, and co-use; and to explore beliefs regarding the health implications consequent to cigarillo use in a small sample of Canadian young adults prior to the implementation of federal restrictions (10) on the sale of single and flavoured cigarillos.

METHODS

Sample

A convenience sample of cigarillo users from the Greater Toronto Area (GTA), Ontario and Edmonton, Alberta were recruited through advertisements in local entertainment newspapers, local online classifieds, posters, and by word of mouth. The GTA sample was recruited between September 2009 and February 2010; the Edmonton sample was recruited in June 2010. Eligible participants reported having smoked cigarillos in the previous 30 days, resided in either survey site, and were between 19 and 29 years of age. Respondents received $15 as compensation for completing the 30-minute online survey. A total of 133 young adults (GTA: n=101; Edmonton: n=32) completed the online survey.

Initially intended to be a case-control design comparing cigarillo usage between provinces with (Ontario: Bill 124) (11) and without (Alberta) legislation barring the sale of flavoured and single cigarillos, similar federal legislation (Bill C-32) (10) enacted during data collection nullified this study design. Still, analysis of the combined GTA and Edmonton sample provides insight into cigarillo usage among young adults in two major Canadian metropolitan areas.

Measures

The online survey assessed patterns of cigarillo use, cigarette and cannabis use, age of initiation, and beliefs regarding the health consequences associated with smoking cigarillos. Co-users of cigarillos and cigarettes were those who indicated currently smoking cigarettes every day or occasionally.

Definitions distinguishing little cigars, cigarillos, and large cigars often overlap, (10,12) and the terms little cigar and cigarillo are at times used interchangeably in health research. In this study, cigarillos were cigar products (tobacco in the form of a tube, wrapped in natural or reconstituted tobacco leaf) weighing no more than 1.4 g or containing a cigarette-like filter.

Analysis

Frequencies were computed for categorical data; medians were computed in lieu of means where data were skewed for a more accurate measure of central tendency. The Wilcoxon signed rank sum test was used to assess significant differences between medians for age of initiation and for risk of cancer attributed to smoking cigarillos and cigarettes. Data analysis was conducted using SAS version 9.1.

The University of Toronto Research Ethics Board and the Alberta Cancer Research Ethics Committee reviewed and approved all study procedures.

RESULTS

Sample demographic characteristics are presented in Table 1. The mean age of respondents was 23.6 years ([+ or -]3.2), and the majority were male (75%). Though many respondents indicated having some (34%) or having completed post-secondary education (28%), most reported an annual income of less than $30,000 (71%).

Forty-eight percent of respondents reported smoking cigarillos on a weekly basis and 32% on a monthly basis; cigarillo use was common in social settings, during leisure time, and with friends (Figure 1). Most respondents reported smoking flavoured cigarillos (77%), being co-users of cigarillos and cigarettes (82%), and currently using cannabis (72%). Daily cigarillo use was less common than daily cigarette use (20% vs. 48%, respectively), and respondents were older when they began smoking cigarillos than when they began smoking cigarettes (median age 18 vs. 16 years, respectively; p<0.0001) and began using cannabis (median age 18 vs. 16 years, respectively; p<0.0001).

The primary reasons reported for smoking cigarillos were because of the flavour (56%) and to replace smoking cigarettes (30%; Table 2). Though the majority reported inhaling when smoking cigarillos (72%), many indicated that they were not at all addicted to cigarillos (52%; Table 2). Furthermore, 38% of respondents rated their own risk of developing cancer in the next 20 years from cigarettes as greater than the risk attributable to cigarillos (median rating 7 and 5 out of 10, respectively; p<0.0001).

DISCUSSION

Findings from this study highlight advanced use of tobacco products and concurrent cannabis use. In this sample, concurrent use of cigarillos and cigarettes was commonplace (82%). This finding exceeds previous estimates of polytobacco use among young adults (22-26%). (8,13,14) The rate of concurrent cannabis use observed in this sample (72%) also exceeds earlier reports (27-33%). (8) That cigarillo users reported using both cigarettes and cannabis concurrently is not surprising, as cigar use among US college students has been shown to be associated with the use of other tobacco products and marijuana; (13) and Canadian young adults who are polytobacco users are more likely than cigarette only smokers to use other substances like alcohol and illicit drugs. (14) Additionally, this sample was composed mainly of young adult males, which may further account for the exceedingly high polytobacco and cannabis usage reported herein. (8,14,15)

Respondents reported having smoked their first cigarette significantly earlier in life than smoking their first cigarillo, suggesting that cigarillo smoking is associated with more advanced use of cigarettes. (13,16) The majority of respondents in this study and in others (9,17,18) also reported inhaling while smoking cigarillos--0a practice more common among former or current cigarette smokers. (3) Notably, the amount of nicotine absorbed from inhaling cigarillo smoke is enough to initiate or sustain nicotine dependence, (3,17,19,20) especially among co-users of cigarillos and cigarettes. (3,19) Nevertheless, many respondents reported being not at all addicted to cigarillos despite smoking cigarettes concurrently and inhaling while smoking, suggesting a possible misperception regarding the contribution of smoking cigarillos to nicotine dependence.

Similarly, respondents generally underestimated the health risks associated with cigarillo use. The possibility that respondents may consider smoking cigarillos as less harmful than smoking cigarettes has been documented elsewhere, (9,21-24) and is worrisome considering that the risk of lung cancer associated with cigarillo and cigarette use has been shown to be equivalent. (25) What's more, tobacco smokers who use marijuana have fewer quit attempts and are less likely to quit smoking tobacco, especially if using marijuana on a daily basis. (26)

These findings and others (9,27) also point to a considerable social component to cigarillo use which may reinforce the potential influence of peers on the uptake and maintenance of cigarillo smoking.

Finally, a possible omission in tobacco use prevalence estimates has been reported previously: individuals who use alternative forms of tobacco but do not smoke cigarettes are not considered current or ever smokers using standard definitions. (28,29) Estimates from 2007 indicate that 4% of Canadians aged 20-24 years currently smoke cigarillos, but not cigarettes. (28) A study of high school students reported similar findings. (16) In this sample, 18% of respondents reported smoking cigarillos but not cigarettes--a finding that reinforces the likelihood that current and ever tobacco use are being underestimated in both the young adult and total populations in Canada.

Limitations

Due to the convenience method used to recruit participants, whether individuals who chose to participate in this study differed in any way from individuals who chose not to participate is not known. Additionally, data collection was conducted by self-report; thus, the data may have been subject to underreporting, as well as social desirability bias. Furthermore, young adults who speak French only were likely missed as the online questionnaire was offered only in English. Finally, the conclusions in this study are not generalizable as this sample is not representative of the general population of 19-29 year olds in Canada. Indeed, considering the high rates of both current polytobacco and concurrent marijuana use observed in this sample, it may be that this study has captured the usage trends of a group of individuals more highly involved in tobacco and illicit drug use. The extent of this combination of advanced tobacco and cannabis use in the general Canadian young adult population is not known and warrants further investigation.

CONCLUSION AND IMPLICATIONS

Notable findings suggest that among Canadian young adults, polytobacco use and concurrent cannabis use is common, awareness of the associated health risks is lacking, cigarillo use is predominantly a social behaviour, and common reasons for cigarillo smoking are to replace cigarette smoking and for the flavour. Considering the prevalence of cigarillo smoking among young adults and the established risks of adverse health associated with cigarillo and polytobacco use, future research should seek to more systematically examine patterns and attitudes regarding cigarillo use, using nationally-representative data in order to further characterize use in this high-risk group.

Received: February 19, 2013 Accepted: November 28, 2013

Acknowledgements of sources of support (funding and otherwise): This work was supported by a Policy Grant from the Canadian Tobacco Control Research Initiative (20633). It was undertaken by the Ontario Tobacco Research Unit which received funding from the Ontario Ministry of Health Promotion and Sport. The authors thank Murray Kaiserman, Fred Ashbury, Shawn O'Connor and Anne Philipneri for contributing to the development and design of this research.

Conflict of Interest: None to declare.

REFERENCES

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Erika A. Yates, MSc, [1] Jolene Dubray, MSc, [1] Robert Schwartz, PhD, [1-3] Maritt Kirst, PhD, [1,2] Ashley Lacombe-Duncan, MSW, [4] Juhee Suwal, PhD, [5] Juanita Hatcher, PhD [5]

Author Affiliations

[1.] Ontario Tobacco Research Unit, Toronto, ON

[2.] Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[3.] Social and Epidemiological Research, Centre for Addiction and Mental Health, Toronto, ON

[4.] The Hospital for Sick Children, Toronto, ON

[5.] Alberta Health Services, Edmonton, AB

Correspondence: Jolene Dubray, Ontario Tobacco Research Unit, c/o Dalla Lana School of Public Health, University of Toronto, 530-155 College Street, Toronto, ON M5T 3M7, Tel: 416-978-3051, Fax: 416-946-0340, E-mail: jolene.dubray@utoronto.ca

Table 1. Demographic characteristics of 19-29 year old
Canadian cigarillo users, N=133

Age, mean [+ or -] SD                           23.6 [+ or -] 3.2
Sex, n (%)
   Male                                            100 (75.2)
   Female                                           33 (24.8)
Education, n (%)
   Less than high school                            16 (12.0)
   Completed high school                            30 (22.6)
   Some post-secondary                              45 (33.8)
   Completed post-secondary                         37 (27.8)
   Other                                             5 (3.8)
Income *, n (%)
   <$20,000                                         56 (47.1)
   $20,000-$29,999                                  28 (23.5)
   [greater than or equal to]$30,000                31 (26.1)
   Don't know                                        4 (3.4)
Type of occupation ([dagger]), n (%)
   Sales and service occupations                    37 (33.0)
   Business, finance and administrative             21 (18.8)
     occupations
   Trades, transport and equipment operators        18 (16.1)
     and related occupations
   Occupations in social science, education,        11 (9.8)
     government service and religion
   Occupations unique to processing                 11 (9.8)
   Occupations in art, culture, recreation           4 (3.6)
     and sport
   Occupations unique to primary industry            4 (3.6)
   Natural and applied sciences and related          3 (2.7)
     occupations
   Management occupations                            2(1.8)
   Health occupations                                1 (0.9)

* N=119

([dagger]) Based on the National Occupational Classification
for Statistics, N=112.

Table 2. Main reasons for smoking cigarillos and beliefs
regarding level of addiction to cigarillos among
19-29 year olds, N=132

Main reasons for smoking cigarillos, n (%) *
  Because of the flavour                                75 (56.4)
  To replace smoking cigarettes                         40 (30.1)
  Because they burn slower than cigarettes              21 (15.8)
  To feed nicotine craving after quitting cigarettes    15 (11.3)
  Because my friends smoke cigarillos                   14 (10.5)
  Because they cost less than cigarettes                13 (9.8)
  Other                                                 13 (9.8)

Perceived level of addiction to cigarillos, n (%)
  Not at all addicted                                   68 (51.5)
  Somewhat addicted                                     53 (40.2)
  Very addicted                                         11 (8.3)

* Respondents were able to choose any response that was
applicable, thus the proportions do not add to 100%; N=133.

Figure 1. Patterns of use among 19-29 year old Canadian cigarillo
users (where, when, and with whom respondents use
cigarillos), N=133

                                        Always-Often   Sometimes-Never

At parties                                  60              40
At concerts/clubs/bars                      48              52
At a friend's house                         35              65
At home                                     29              71
In a vehicle                                29              71
In transit to and/or from school/work       26              74
At school/work, but off property            22              78

On weekends                                 68              32
In the evening                              62              38
During the day                              29              71
Before school/work                          26              74

With friends                                56              44
By myself                                   47              53
With colleagues                             26              74
With family members                         20              80

Note: Table made from bar graph.