Nicotine & Tobacco Research, 2015, 1156–1160 doi:10.1093/ntr/ntu230 Brief report Advance Access publication October 30, 2014
Brief report
Characterizing Concurrent Tobacco Product Use Among Homeless Cigarette Smokers Daniel H. Kish BS1, Lorraine R. Reitzel PhD1, Darla E. Kendzor PhD2,3, Hiroe Okamoto AA1, Michael S. Businelle PhD2,3 Downloaded from http://ntr.oxfordjournals.org/ at University of Sussex on June 6, 2016
1 Department of Educational Psychology, College of Education, University of Houston, Houston, TX; 2University of Texas School of Public Health, Dallas, TX; 3Population Science and Cancer Control Program, UT Southwestern Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
Corresponding Author: Lorraine R. Reitzel, PhD, Department of Educational Psychology, College of Education, University of Houston, 491 Farish Hall, Houston, TX 77204-5029, USA. Telephone: 713-743-6679; Fax: 713-743-4996; E-mail: [email protected]
Abstract Introduction: Cigarette smoking prevalence rates are high among homeless adults (>70%); however, little is known about concurrent tobacco or other nicotine product use (i.e., concurrent use [CU]) in this population. CU may impact smoking quit rates and confer greater risk of health problems within this vulnerable population. This study characterized CU in a sample of homeless smokers and compared cigarette-only smokers (C-OS) to concurrent users (CUs) on participant characteristics and factors known to be associated with smoking cessation. Methods: Participants were 178 adult conventional cigarette smokers from a homeless shelter in Dallas, TX. Sociodemographic characteristics, number of homelessness episodes, tobacco dependence, and items characterizing use of several tobacco/nicotine products over the last 30 days including use frequency, reasons for use, and perceived health risks were described. Sociodemographic characteristics, number of homelessness episodes, tobacco dependence, stress, readiness to quit (RTQ) smoking, and number of smoking quit attempts in the last year were compared between the C-OS and CUs groups using t tests and chi-square tests. Results: CU was prevalent (n = 91; 51.1%), and 49.5% of CUs reported the use of ≥2 products in addition to conventional cigarettes. Compared with C-OS, CUs were younger and had more homelessness episodes, higher expired breath carbon monoxide levels, and higher stress (ps < .05). Groups did not differ on sex, race, other dependence indicators, RTQ, or previous quit attempts. Conclusions: CU is common among homeless smokers. CUs and C-OS did not differ in their RTQ smoking, though greater stress among the CUs may represent a hurdle for cessation.
Introduction Over 70% of homeless adults report current cigarette smoking, which is almost four times the national average.1 Homeless smokers may also be more likely than domiciled smokers to be poly-tobacco or poly-product users, as financial and supply limitations could result in more opportunistic product selection. Concurrent product use (CU) has been a popular subject of investigation especially with the advent of new and emerging nicotine/tobacco products, such as electronic cigarettes and snus. To our knowledge, no studies have reported the rates of CU among homeless smokers. CU may impact
smoking quit rates and cessation2–5 and confer greater risk for health problems.6,7 However, little is known about the ways in which concurrent users (CUs) differ from conventional cigarette-only smokers (C-OS), including their reasons for use, perceived risk of use, and readiness to quit (RTQ) smoking. A better understanding of the prevalence of CU, and how CUs may differ from C-OS, is necessary to better characterize the cessation intervention needs of homeless smokers. The current study characterized the prevalence of, frequency of, reasons for, and perceptions of risk to health from other product use over the past 30 days in a sample of sheltered homeless
© The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
1156
Nicotine & Tobacco Research, 2015, Vol. 17, No. 9 adult conventional cigarette smokers. Further, CUs and C-OS were compared on sociodemographic and homelessness variables, tobacco dependence, stress, RTQ, and quit attempts over the last year.
Methods Participants Participants comprised a convenience sample of homeless Englishspeaking adults recruited from a single shelter, who were literate at the 7th grade level as indicated by a score of ≥4 on the Rapid Estimate of Adult Literacy in Medicine-Short Form.8 Of the 238 individuals participating in this wave of a larger study focused on homeless health, 178 (74.8%) were self-reported conventional cigarette smokers.
Procedure
Measures Sociodemographic Characteristics Sociodemographics included age, sex, and race. The number of discrete homeless episodes over the lifetime was also collected. Tobacco Variables Tobacco dependence variables included the number of (conventional) cigarettes smoked per day (CPD), expired breath carbon monoxide (CO), years smoked, and time to the first cigarette of the day (TTF).
month, how often have you felt that you were unable to control the important things in your life?” Responses were summed with a potential range of 0–16; higher scores indicated greater perceived stress. The Urban Life Stress Scale (ULSS) is a 21-item self-report checklist of potential sources of chronic stress that may be experienced by people living in urban settings.10 Items include “In your day to day life, how much stress do you generally experience related to using public services?” and “In your day to day life, how much stress do you generally experience related to crime and violence?” with responses rated on a 5-point Likert scale where 1 = no stress, 2 = little stress, 3 = some stress, 4 = a lot of stress, and 5 = extreme stress. Responses were summed with a potential range of 21–105; higher scores indicated greater stress. Readiness to Quit RTQ is a 1-item measure of motivation to quit cigarette smoking, which asks participants to endorse thoughts about quitting on a 10-point scale, where 1 = “I have no interest in quitting” and 10 = “I have quit smoking and I will never smoke again”.11 Previous Quit Attempts Previous quit attempts were assessed with: “In the past year, how many times have you successfully quit smoking for at least 24 hours?” Participants were further instructed to only include times when they wanted to quit smoking as opposed to when they wanted to smoke but could not afford conventional cigarettes.
Analysis Participant characteristics, CU, reasons for use, and perceived health risks were examined with descriptive statistics. Differences between C-OS and CUs on sociodemographic and homeless variables, dependence, stress, RTQ, and previous quit attempts were assessed with chi-square and t tests.
Results Concurrent Use The use of the following products in the past 30 days was assessed: (a) snus; (b) roll-your-own cigarettes (RYO); (c) tobacco from a hookah or a waterpipe; (d) dissolvable tobacco products like Ariva/ Stonewall/Camel/Camel Orbs/Camel Sticks; (e) electronic cigarettes or e-cigarettes, such as Ruyan or NJOY; (f) cigars; (g) little cigars/ cigarillos/bidis (LCCB); (h) chewing tobacco, dip, or snuff; and/or (i) other tobacco products. Those endorsing CU were also asked the frequency of use, reasons for use, and risks to health from use. Reasons for use included the following options (multiple endorsements were permitted): to help cut down/quit (conventional) cigarettes, cheaper than cigarettes, and less harmful to health than cigarettes. Risk to health from use was assessed by asking: “How much do you think people risk harming their health when they use (insert relevant/endorsed product)?” Response options included: no risk, little risk or some risk, and a lot of risk or extreme of risk. Stress The Perceived Stress Scale-4 (PSS) is a 4-item self-report scale that was designed to assess the degree to which respondents perceive their lives to be stressful.9 Respondents are asked to indicate how often they experienced certain situations, such as “In the last
Participants (N = 178; 75.3% male) were 45.6 (±10.2) years old on average and largely African American/other race/s (68%). They smoked 12 (±6.5) CPD, had been smoking for 20.5 (±12.2) years, and 34.8% smoked within 5 min of waking. Participants reported 3.1 (±3.2) quit attempts in the past year and 2.7 (±2.4) lifetime homelessness episodes (see Table 1). Half of the sample (51.1%) reported CU. CU varied by product with LCCB (49.5%), cigars (41.8%), and RYO (38.5%) being the most common, largely due to relative affordability. Among CUs, 49.5% reported the use of two or more products in addition to conventional cigarettes. Daily CU was endorsed by 24.4% of LCCB, 23.7% of cigar, 18.2% of e-cigarette, and 8.6% of RYO users. No other products were used daily. CUs of other tobacco products almost universally recognized the associated health risks. In contrast, e-cigarette use was less common (12.1%), was used to cut down/ quit cigarettes (81.8%), and largely associated with little/some or no perceived health risks (90.9%) (see Table 2). CUs were significantly younger than C-OS (43.7 vs. 47.6; p = .011) and reported more homelessness episodes (3.2 vs. 2.2; p = .005), higher CO levels (17.7 vs. 14.5; p = .033), and higher stress (PSS: 7.6 vs. 6.5; p = .022; ULSS: 55.4 vs. 50.2; p = .033). CUs and C-OS were not different in sex, race, CPD, years of smoking, TTF, RTQ, or previous quit attempts (see Table 1).
Downloaded from http://ntr.oxfordjournals.org/ at University of Sussex on June 6, 2016
Enrolled participants completed questionnaires using a computeradministered, self-report format in August of 2013 whereby they were read questions by a computerized program and entered their responses via computer keyboard. Participants received a $20 WalMart gift card for study completion. All procedures were approved by the Institutional Review Boards at the University of Texas Health Science Center and the University of Houston. Informed consent was obtained from all participants.
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1158 Table 1. Participant Characteristics and Differences by Product Use Status Whole sample (N = 178)
Cigarette-only smokers (N = 87)
Concurrent product users (N = 91)
Participant characteristics
M (SD) or % (N)
M (SD) or % (N)
M (SD) or % (N)
Age Sex Male Female Race White African American/other No. of Homeless episodes Cigarettes smoked per day Expired breath CO Years smoked Time to first cigarette 1 option)
Table 2. Reasons for Use and Risk Perceptions Among Concurrent Tobacco Product Users (N = 91)
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Funding This work was supported by institutional funding provided by the University of Texas Health Science Center, School of Public Health (to MSB) and the University of Texas MD Anderson Cancer Center (to LRR). Data analysis and manuscript preparation were additionally supported through grant MRSGT-10-10401-CPHPS (to DEK) and MRSGT-12-114-01-CPPB (to MSB) awarded by the American Cancer Society. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the sponsoring organizations.
Declaration of Interests None declared.
References 1. Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J Prev Med. 2010;39:164–172. 2. Frost-Pineda K, Appleton S, Fisher M, Fox K, Gaworski CL. Does dual use jeopardize the potential role of smokeless tobacco in harm reduction? Nicotine Tob Res. 2010;12:1055–1067. 3. Tomar SL, Alpert HR, Connolly GN. Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys. Tob Control. 2010;19:104–109. 4. Walsh MM, Langer TJ, Kavanagh N, et al. Smokeless tobacco cessation cluster randomized trial with rural high school males: intervention interaction with baseline smoking. Nicotine Tob Res. 2010;12:543–550. 5. Young D, Borland R, Hammond D, et al. Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15:76–82. 6. Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006;368:647–658. 7. Wetter DW, McClure JB, de Moor C, et al. Concomitant use of cigarettes and smokeless tobacco: prevalence, correlates, and predictors of tobacco cessation. Prev Med. 2002;34:638–648. 8. Arozullah AM, Yarnold PR, Bennett CL, et al. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care. 2007;45:1026–1033.
9. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385. 10. Jaffee KD, Liu GC, Canty-Mitchell J, Qi RA, Austin J, Swigonski N. Race, urban community stressors, and behavioral and emotional problems of children with special health care needs. Psychiatr Serv. 2005;56:63–69. 11. Abrams DB, Niaura R, Brown RA, Emmons KM, Goldstein MG, Monti PM. The Tobacco Treatment Handbook: A Guide to Best Practices. 1st ed. New York: Guilford Press; 2003. 12. Backinger CL, Fagan P, O’Connell ME, et al. Use of other tobacco products among U.S. adult cigarette smokers: prevalence, trends and correlates. Addict Behav. 2008;33:472–489. 13. Lee YO, Hebert CJ, Nonnemaker JM, Kim AE. Multiple tobacco product use among adults in the United States: cigarettes, cigars, electronic cigarettes, hookah, smokeless tobacco, and snus. Prev Med. 2014;62:14–19. 14. Baggett TP, Tobey ML, Rigotti NA. Tobacco use among homeless people– addressing the neglected addiction. N Engl J Med. 2013;369:201–204. 15. Lee TC, Hanlon JG, Ben-David J, et al. Risk factors for cardiovascular disease in homeless adults. Circulation. 2005;111:2629–2635. 16. Snyder LD, Eisner MD. Obstructive lung disease among the urban homeless. Chest. 2004;125:1719. 17. Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction. 2011;106:2017–2028. 18. Goniewicz ML, Lingas EO, Hajek P. Patterns of electronic cigarette use and user beliefs about their safety and benefits: an internet survey. Drug Alcohol Rev. 2013;32:133–140. 19. Kralikova E, Novak J, West O, Kmetova A, Hajek P. Do e-cigarettes have the potential to compete with conventional cigarettes? A survey of conventional cigarette smokers’ experiences with e-cigarettes. Chest. 2013;144:1609. 20. Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking-cessation: tool results from an online survey. Am J Prev Med. 2011;40:472–475. 21. Bullen C, Williman J, Howe C, et al. Study protocol for a randomised controlled trial of electronic cigarettes versus nicotine patch for smoking cessation. BMC Public Health. 2013;13:210. 22. Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the missing link between youth prevention and adult cessation. J Environ Public Health, 2012;2012:1–9. 23. Agaku IT, Filippidis FT, Vardavas CI, et al. Poly-tobacco use among adults in 44 countries during 2008-2012: evidence for an integrative and comprehensive approach in tobacco control. Drug Alcohol Depend. 2014;139:60–70. 24. CDC. Calls to poison centers for exposures to electronic cigarettes – United States, September 2010-February 2014. Morb Mortal Wkly Rep. 2014;63:292–293. 25. Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014;23:133–139. 26. Slopen N, Kontos EZ, Ryff CD, Ayanian JZ, Albert MA, Williams DR. Psychosocial stress and cigarette smoking persistence, cessation, and relapse over 9-10 years: a prospective study of middle-aged adults in the United States. Cancer Causes Control. 2013;24:1849–1863. 27. Laugesen M, Epton M, Frampton C, Glover M, Lea R. Hand-rolled cigarette smoking patterns compared with factory-made cigarette smoking in New Zealand men. BMC Public Health. 2009;9:194. 28. Foulds J, Steinberg MB, Williams JM, Ziedonis DM. Developments in pharmacotherapy for tobacco dependence: past, present and future. Drug Alcohol Rev. 2006;25:59–71. 29. Aloot CB, Vredevoe DL, Brecht ML. Evaluation of high-risk smoking practices used by the homeless. Cancer Nurs. 1993;16:123–130. 30. Okuyemi KS, Caldwell AR, Thomas JL, et al. Homelessness and smoking cessation: insights from focus groups. Nicotine Tob Res. 2006;8:287–296.
Downloaded from http://ntr.oxfordjournals.org/ at University of Sussex on June 6, 2016
cigarette-butt smoking.29,30 As well, more information on the use of alternative tobacco products among non- and former homeless smokers would be informative to the literature. In this sample,
Brief report
Characterizing Concurrent Tobacco Product Use Among Homeless Cigarette Smokers Daniel H. Kish BS1, Lorraine R. Reitzel PhD1, Darla E. Kendzor PhD2,3, Hiroe Okamoto AA1, Michael S. Businelle PhD2,3 Downloaded from http://ntr.oxfordjournals.org/ at University of Sussex on June 6, 2016
1 Department of Educational Psychology, College of Education, University of Houston, Houston, TX; 2University of Texas School of Public Health, Dallas, TX; 3Population Science and Cancer Control Program, UT Southwestern Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
Corresponding Author: Lorraine R. Reitzel, PhD, Department of Educational Psychology, College of Education, University of Houston, 491 Farish Hall, Houston, TX 77204-5029, USA. Telephone: 713-743-6679; Fax: 713-743-4996; E-mail: [email protected]
Abstract Introduction: Cigarette smoking prevalence rates are high among homeless adults (>70%); however, little is known about concurrent tobacco or other nicotine product use (i.e., concurrent use [CU]) in this population. CU may impact smoking quit rates and confer greater risk of health problems within this vulnerable population. This study characterized CU in a sample of homeless smokers and compared cigarette-only smokers (C-OS) to concurrent users (CUs) on participant characteristics and factors known to be associated with smoking cessation. Methods: Participants were 178 adult conventional cigarette smokers from a homeless shelter in Dallas, TX. Sociodemographic characteristics, number of homelessness episodes, tobacco dependence, and items characterizing use of several tobacco/nicotine products over the last 30 days including use frequency, reasons for use, and perceived health risks were described. Sociodemographic characteristics, number of homelessness episodes, tobacco dependence, stress, readiness to quit (RTQ) smoking, and number of smoking quit attempts in the last year were compared between the C-OS and CUs groups using t tests and chi-square tests. Results: CU was prevalent (n = 91; 51.1%), and 49.5% of CUs reported the use of ≥2 products in addition to conventional cigarettes. Compared with C-OS, CUs were younger and had more homelessness episodes, higher expired breath carbon monoxide levels, and higher stress (ps < .05). Groups did not differ on sex, race, other dependence indicators, RTQ, or previous quit attempts. Conclusions: CU is common among homeless smokers. CUs and C-OS did not differ in their RTQ smoking, though greater stress among the CUs may represent a hurdle for cessation.
Introduction Over 70% of homeless adults report current cigarette smoking, which is almost four times the national average.1 Homeless smokers may also be more likely than domiciled smokers to be poly-tobacco or poly-product users, as financial and supply limitations could result in more opportunistic product selection. Concurrent product use (CU) has been a popular subject of investigation especially with the advent of new and emerging nicotine/tobacco products, such as electronic cigarettes and snus. To our knowledge, no studies have reported the rates of CU among homeless smokers. CU may impact
smoking quit rates and cessation2–5 and confer greater risk for health problems.6,7 However, little is known about the ways in which concurrent users (CUs) differ from conventional cigarette-only smokers (C-OS), including their reasons for use, perceived risk of use, and readiness to quit (RTQ) smoking. A better understanding of the prevalence of CU, and how CUs may differ from C-OS, is necessary to better characterize the cessation intervention needs of homeless smokers. The current study characterized the prevalence of, frequency of, reasons for, and perceptions of risk to health from other product use over the past 30 days in a sample of sheltered homeless
© The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
1156
Nicotine & Tobacco Research, 2015, Vol. 17, No. 9 adult conventional cigarette smokers. Further, CUs and C-OS were compared on sociodemographic and homelessness variables, tobacco dependence, stress, RTQ, and quit attempts over the last year.
Methods Participants Participants comprised a convenience sample of homeless Englishspeaking adults recruited from a single shelter, who were literate at the 7th grade level as indicated by a score of ≥4 on the Rapid Estimate of Adult Literacy in Medicine-Short Form.8 Of the 238 individuals participating in this wave of a larger study focused on homeless health, 178 (74.8%) were self-reported conventional cigarette smokers.
Procedure
Measures Sociodemographic Characteristics Sociodemographics included age, sex, and race. The number of discrete homeless episodes over the lifetime was also collected. Tobacco Variables Tobacco dependence variables included the number of (conventional) cigarettes smoked per day (CPD), expired breath carbon monoxide (CO), years smoked, and time to the first cigarette of the day (TTF).
month, how often have you felt that you were unable to control the important things in your life?” Responses were summed with a potential range of 0–16; higher scores indicated greater perceived stress. The Urban Life Stress Scale (ULSS) is a 21-item self-report checklist of potential sources of chronic stress that may be experienced by people living in urban settings.10 Items include “In your day to day life, how much stress do you generally experience related to using public services?” and “In your day to day life, how much stress do you generally experience related to crime and violence?” with responses rated on a 5-point Likert scale where 1 = no stress, 2 = little stress, 3 = some stress, 4 = a lot of stress, and 5 = extreme stress. Responses were summed with a potential range of 21–105; higher scores indicated greater stress. Readiness to Quit RTQ is a 1-item measure of motivation to quit cigarette smoking, which asks participants to endorse thoughts about quitting on a 10-point scale, where 1 = “I have no interest in quitting” and 10 = “I have quit smoking and I will never smoke again”.11 Previous Quit Attempts Previous quit attempts were assessed with: “In the past year, how many times have you successfully quit smoking for at least 24 hours?” Participants were further instructed to only include times when they wanted to quit smoking as opposed to when they wanted to smoke but could not afford conventional cigarettes.
Analysis Participant characteristics, CU, reasons for use, and perceived health risks were examined with descriptive statistics. Differences between C-OS and CUs on sociodemographic and homeless variables, dependence, stress, RTQ, and previous quit attempts were assessed with chi-square and t tests.
Results Concurrent Use The use of the following products in the past 30 days was assessed: (a) snus; (b) roll-your-own cigarettes (RYO); (c) tobacco from a hookah or a waterpipe; (d) dissolvable tobacco products like Ariva/ Stonewall/Camel/Camel Orbs/Camel Sticks; (e) electronic cigarettes or e-cigarettes, such as Ruyan or NJOY; (f) cigars; (g) little cigars/ cigarillos/bidis (LCCB); (h) chewing tobacco, dip, or snuff; and/or (i) other tobacco products. Those endorsing CU were also asked the frequency of use, reasons for use, and risks to health from use. Reasons for use included the following options (multiple endorsements were permitted): to help cut down/quit (conventional) cigarettes, cheaper than cigarettes, and less harmful to health than cigarettes. Risk to health from use was assessed by asking: “How much do you think people risk harming their health when they use (insert relevant/endorsed product)?” Response options included: no risk, little risk or some risk, and a lot of risk or extreme of risk. Stress The Perceived Stress Scale-4 (PSS) is a 4-item self-report scale that was designed to assess the degree to which respondents perceive their lives to be stressful.9 Respondents are asked to indicate how often they experienced certain situations, such as “In the last
Participants (N = 178; 75.3% male) were 45.6 (±10.2) years old on average and largely African American/other race/s (68%). They smoked 12 (±6.5) CPD, had been smoking for 20.5 (±12.2) years, and 34.8% smoked within 5 min of waking. Participants reported 3.1 (±3.2) quit attempts in the past year and 2.7 (±2.4) lifetime homelessness episodes (see Table 1). Half of the sample (51.1%) reported CU. CU varied by product with LCCB (49.5%), cigars (41.8%), and RYO (38.5%) being the most common, largely due to relative affordability. Among CUs, 49.5% reported the use of two or more products in addition to conventional cigarettes. Daily CU was endorsed by 24.4% of LCCB, 23.7% of cigar, 18.2% of e-cigarette, and 8.6% of RYO users. No other products were used daily. CUs of other tobacco products almost universally recognized the associated health risks. In contrast, e-cigarette use was less common (12.1%), was used to cut down/ quit cigarettes (81.8%), and largely associated with little/some or no perceived health risks (90.9%) (see Table 2). CUs were significantly younger than C-OS (43.7 vs. 47.6; p = .011) and reported more homelessness episodes (3.2 vs. 2.2; p = .005), higher CO levels (17.7 vs. 14.5; p = .033), and higher stress (PSS: 7.6 vs. 6.5; p = .022; ULSS: 55.4 vs. 50.2; p = .033). CUs and C-OS were not different in sex, race, CPD, years of smoking, TTF, RTQ, or previous quit attempts (see Table 1).
Downloaded from http://ntr.oxfordjournals.org/ at University of Sussex on June 6, 2016
Enrolled participants completed questionnaires using a computeradministered, self-report format in August of 2013 whereby they were read questions by a computerized program and entered their responses via computer keyboard. Participants received a $20 WalMart gift card for study completion. All procedures were approved by the Institutional Review Boards at the University of Texas Health Science Center and the University of Houston. Informed consent was obtained from all participants.
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Nicotine & Tobacco Research, 2015, Vol. 17, No. 9
1158 Table 1. Participant Characteristics and Differences by Product Use Status Whole sample (N = 178)
Cigarette-only smokers (N = 87)
Concurrent product users (N = 91)
Participant characteristics
M (SD) or % (N)
M (SD) or % (N)
M (SD) or % (N)
Age Sex Male Female Race White African American/other No. of Homeless episodes Cigarettes smoked per day Expired breath CO Years smoked Time to first cigarette 1 option)
Table 2. Reasons for Use and Risk Perceptions Among Concurrent Tobacco Product Users (N = 91)
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Funding This work was supported by institutional funding provided by the University of Texas Health Science Center, School of Public Health (to MSB) and the University of Texas MD Anderson Cancer Center (to LRR). Data analysis and manuscript preparation were additionally supported through grant MRSGT-10-10401-CPHPS (to DEK) and MRSGT-12-114-01-CPPB (to MSB) awarded by the American Cancer Society. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the sponsoring organizations.
Declaration of Interests None declared.
References 1. Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J Prev Med. 2010;39:164–172. 2. Frost-Pineda K, Appleton S, Fisher M, Fox K, Gaworski CL. Does dual use jeopardize the potential role of smokeless tobacco in harm reduction? Nicotine Tob Res. 2010;12:1055–1067. 3. Tomar SL, Alpert HR, Connolly GN. Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys. Tob Control. 2010;19:104–109. 4. Walsh MM, Langer TJ, Kavanagh N, et al. Smokeless tobacco cessation cluster randomized trial with rural high school males: intervention interaction with baseline smoking. Nicotine Tob Res. 2010;12:543–550. 5. Young D, Borland R, Hammond D, et al. Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15:76–82. 6. Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006;368:647–658. 7. Wetter DW, McClure JB, de Moor C, et al. Concomitant use of cigarettes and smokeless tobacco: prevalence, correlates, and predictors of tobacco cessation. Prev Med. 2002;34:638–648. 8. Arozullah AM, Yarnold PR, Bennett CL, et al. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care. 2007;45:1026–1033.
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cigarette-butt smoking.29,30 As well, more information on the use of alternative tobacco products among non- and former homeless smokers would be informative to the literature. In this sample,
