Substance Use & Misuse, 49:700–707, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2013.863345
ORIGINAL ARTICLE
Dual Tobacco Use among College Students: Contexts of Use, Self-Perceptions, and Attitudes Toward Quitting Mary Beth Miller1 , William V. Lechner1 , Ellen Meier1 , Raymond P. Tucker1 and Josh L. Wiener2 1
Department of Psychology, Oklahoma State University, Stillwater, Oklahoma, USA; 2 Department of Marketing, Oklahoma State University, Stillwater, Oklahoma, USA outcomes are directly related to the duration and level of tobacco exposure (U.S. Department of Health and Human Services, 2010b). Thus, understanding characteristics and situations that place individuals at highest risk for tobacco use may be integral to the effectiveness of tobacco cessation efforts. Despite consistent reports that dual use is most common among young adults between the ages of 18 and approximately 30 years (Bombard, Pederson, Nelson, & Malarcher, 2007; McClave-Regan & Berkowitz, 2011; Tomar et al., 2010), research regarding the prevalence and patterns of dual tobacco use among college students has been limited (Rigotti, Lee & Wechsler, 2000). College students comprise a unique population, whose patterns and motives for tobacco use may differ from those of adolescents or adults (Bowen & Kurz, 2012). A nationally representative survey of over 14,000 American college students suggested that the majority of college students who use tobacco products use more than one product (Rigotti et al., 2000). The authors found that dual tobacco use is more common among men, despite equivalent rates of cigarette use across sexes, and that dual users are more likely to be single and White, to engage in other high-risk behaviors (e.g., heavy drinking), and to value social life over educational, athletic, or religious goals. Though these factors are important in identifying individuals who are at risk for dual use, no studies of which the authors are aware have identified the situations or contexts in which dual users may choose to use different substances. The present study sought to expand previous studies by comparing patterns of tobacco use among college students who use both cigarettes and SLT (dual users), those who use single forms of tobacco (sole users), and those who abstain from tobacco (nonusers). This study also builds on previous research by examining the situations related to use of separate substances among dual users. It is expected that tobacco use and nonuse will vary with ethnicity, age, academic class, and fraternity/sorority
Aggressive marketing of smokeless tobacco (SLT) appears to have led to an increase in dual tobacco use. The current study examines the situational contexts, self-perceptions, and cessation attitudes/behaviors that relate to dual use. Participants (N = 1,242) at a large, Southwestern university completed a self-report measure of demographic and tobacco use variables in 2010. Data were analyzed using chi-square and one-way ANOVA techniques. Findings suggest that type of tobacco use varies by setting and that dual users are more likely than sole users to perceive themselves as regular tobacco users. Limitations and implications for future research and interventions are discussed. Keywords cigarettes, smoking, smokeless tobacco, dual use, college students
Aggressive marketing and production of tobacco products by manufacturers may impede national health objectives to reduce current rates of tobacco use in the United States (U.S. Department of Health and Human Services, 2010a) by increasing the potential for dual use of cigarettes and SLT (Carpenter, Connolly, Ayo-Yusuf, & Wayne, 2009; Ebbert, Montori, Erwin, & Stead, 2011; Tomar, Alpert, & Connolly, 2010). Dual tobacco use has been associated with increased health risk both physically and psychologically when compared to use of single tobacco products. Specifically, dual users report symptoms of pain, nausea, craving, irritability, depression, anxiety, sleep disturbance, and decreased concentration to a greater extent than single users when attempting to quit or cut back on tobacco use (Post, Gilljam, Rosendahl, Brember, & Galanti, 2010). Dual users seem less amenable to tobacco cessation, despite greater numbers of quit attempts (McClaveRegan & Berkowitz, 2011; Wetter et al., 2002), and report more symptoms of dependence than those who only use either cigarettes or SLT (Post et al., 2010). These results are concerning, given evidence that the severity of health
Address correspondence to Mary Beth Miller, Department of Psychology, Oklahoma State University, 118 North Murray, Stillwater, OK, 74078 USA. E-mail: [email protected]
700
DUAL TOBACCO USE AMONG COLLEGE STUDENTS
membership. Self-perceptions of addiction are expected to be strongest among dual users, and dual users are also expected to report using different forms of tobacco based on situational context (e.g., studying versus socializing). Understanding these factors may aid in the development of more integrated, effective intervention and prevention strategies for high-risk tobacco use, which in turn may alter the trajectory of long-term use among dual using college students.
701
residence) and to determine group differences in solitary versus social use of tobacco. One-way ANOVAs were utilized to examine differences in age, self-perceptions, situations, and variables associated with cessation across groups. Post hoc comparisons were made using Tukey HSD. No imputation procedures were implemented for missing data (e.g., refused responses or those such as, “I don’t know”); therefore, Ns will vary across analyses. RESULTS
METHOD Participants
College students from a large, Southwestern university in the United States were recruited from randomly selected courses during the fall of 2010 as part of a larger research project (Lechner, Meier, Miller, Wiener & FilsAime, 2012). Materials
A self-report measure of demographic and tobacco use variables was developed for the purposes of the larger research project. Demographic questions assessed participants’ age, sex, ethnicity, residence, fraternity or sorority affiliation, and academic class. Items assessing situational contexts of use were rated on a Likert scale ranging from one (strongly disagree) to seven (strongly agree) and included items regarding use while drinking, socializing, or studying/cramming; use when angry; and use as a reward (see Table 2). These items were derived from more comprehensive measures of smoking motives; however, selected items were chosen to decrease the length of the questionnaire, and items were modified to target both smoking and smokeless tobacco (SLT) use. Items assessing self-perceptions of addiction were rated on an identical scale, on which participants rated their agreement with the statements, “I consider myself a regular [smoker / smokeless tobacco user],” and, “I am addicted to [cigarettes / smokeless tobacco].” Variables related to cessation included age of first use, intent to quit, quit attempts, use of assistance in quitting, and confidence in ability to quit (see Table 3). Procedure
Researchers administered questionnaires in a classroom setting. Participants provided informed consent by completing the survey or refused consent by omitting responses to survey items. All procedures were approved by the University’s Institutional Review Board. Response rate was not formally assessed, as consent to participate in the study was contingent upon completion of the survey. Based on observation in the classrooms, however, response rates are estimated to be above 98.0%. Statistical Analysis
SPSS 19.0 was used for data analysis. Chi-squared goodness of fit tests were employed to examine differences in rates of tobacco use among demographic subgroups (e.g., ethnicity, fraternity/sorority membership, class, and
Sample Characteristics
A sample of 1,242 undergraduate students (53.5% female, 81.1% Caucasian) participated in the study. The mean age of participants was 19.23 years, with 43.2% living on campus, 38% off-campus, and 13.7% in fraternity/sorority housing. The sample was 39.9% freshmen, 24.1% sophomores, 26.4% juniors, and 9.5% seniors (see Table 1 for complete demographic data). Students who reported use of tobacco at least once in the past 30 days were classified as current users and were included in analyses as sole smokers (use of only cigarettes), sole SLT users (use of only SLT), and dual users (use of both SLT and cigarettes). Of the 1,242 participants, 50 (4.0%) were dual users of cigarettes and SLT, 59 (4.8%) used only SLT, 154 (12.4%) only smoked cigarettes, and 979 (78.8%) were nonusers. Current tobacco use groups differed significantly in gender, age, residence, fraternity/sorority membership, and academic class; they demonstrated no significant differences in ethnicity (see Table 1). There was a significant relationship between tobacco use and gender, χ 2 (3, N = 1,239) = 96.39, p < .001, with men reporting higher rates of SLT (9.7% vs. .5%) and dual use (7.5% vs. 1.1%) than women. Tobacco use also varied significantly as a function of age, F(3,1234) = 9.05, p < .001, η2 = .02. Post hoc tests indicated that smokers (M = 20.96, SD = 4.53) were significantly older than nonusers (M = 19.71, SD = 2.59; p < .001) but that no other significant differences in age existed between groups. There was a significant relationship between campus housing and current tobacco use, χ 2 (3, N = 1,237) = 57.29, p < .001, with individuals living off campus evincing higher rates of smoking, SLT use, and dual use as compared to individuals living on campus. Tobacco use also varied with fraternity/sorority membership, χ 2 (3, N = 1,239) = 27.75, p < .001, with SLT (8.2% vs. 4.5%) and dual use (13.4% vs. 3.2%) being higher among fraternity members as compared to nonmembers. Finally, there was a significant relationship between tobacco use and academic class, χ 2 (3, N = 1,237) = 30.78, p < .001. Use of all forms of tobacco seemed to increase with progression from freshman to junior years; however, dual use appeared to be less prevalent among seniors than among all other classes (see Table 1 for complete statistical information). One-way ANOVAs also revealed differences between smokers, SLT users, and dual users in age of first use, F(3, 284) = 3.57, p = .015, η2 = .04 (see Table 2). Though Tukey’s post hoc comparisons indicated no significant differences between dual users’ age of onset for smoking
702
M. B. MILLER ET AL.
TABLE 1. Distribution of participant demographics across tobacco use groups
Variable Prevalence Age: M (SD) Sex Female Male Ethnicity Caucasian Other Residence Off campus On campus Greek membership Greek affiliated Non-Greek affiliated Class standing Freshmen Sophomores Juniors Seniors
N
Nonuser (N = 979) %
Smoker (N = 154) %
SLT User (N = 59) %
Dual User (N = 50) %
1242 —
78.8 19.65 (2.28)1
12.4 23.42 (7.77)1
4.8 20.52 (2.12)
4.0 19.75 (2.75)
663 576
86.0 70.5
12.5 12.3
.5 9.7
1.1 7.5
966 225
78.4 81.8
12.1 11.6
5.3 2.7
4.2 4.0
703 534
71.3 88.6
15.9 7.9
6.7 2.2
6.1 1.3
97 1142
66.0 79.9
12.4 12.4
8.2 4.5
13.4 3.2
494 298 327 118
84.6 77.2 74.6 70.3
8.5 13.4 14.4 21.2
2.6 5.0 6.4 7.6
4.3 4.4 4.6 .8
F/χ 2 (df)
p
η2 /Cramer’s V
— 9.05 (3,1234) 96.39 (3)
—
ORIGINAL ARTICLE
Dual Tobacco Use among College Students: Contexts of Use, Self-Perceptions, and Attitudes Toward Quitting Mary Beth Miller1 , William V. Lechner1 , Ellen Meier1 , Raymond P. Tucker1 and Josh L. Wiener2 1
Department of Psychology, Oklahoma State University, Stillwater, Oklahoma, USA; 2 Department of Marketing, Oklahoma State University, Stillwater, Oklahoma, USA outcomes are directly related to the duration and level of tobacco exposure (U.S. Department of Health and Human Services, 2010b). Thus, understanding characteristics and situations that place individuals at highest risk for tobacco use may be integral to the effectiveness of tobacco cessation efforts. Despite consistent reports that dual use is most common among young adults between the ages of 18 and approximately 30 years (Bombard, Pederson, Nelson, & Malarcher, 2007; McClave-Regan & Berkowitz, 2011; Tomar et al., 2010), research regarding the prevalence and patterns of dual tobacco use among college students has been limited (Rigotti, Lee & Wechsler, 2000). College students comprise a unique population, whose patterns and motives for tobacco use may differ from those of adolescents or adults (Bowen & Kurz, 2012). A nationally representative survey of over 14,000 American college students suggested that the majority of college students who use tobacco products use more than one product (Rigotti et al., 2000). The authors found that dual tobacco use is more common among men, despite equivalent rates of cigarette use across sexes, and that dual users are more likely to be single and White, to engage in other high-risk behaviors (e.g., heavy drinking), and to value social life over educational, athletic, or religious goals. Though these factors are important in identifying individuals who are at risk for dual use, no studies of which the authors are aware have identified the situations or contexts in which dual users may choose to use different substances. The present study sought to expand previous studies by comparing patterns of tobacco use among college students who use both cigarettes and SLT (dual users), those who use single forms of tobacco (sole users), and those who abstain from tobacco (nonusers). This study also builds on previous research by examining the situations related to use of separate substances among dual users. It is expected that tobacco use and nonuse will vary with ethnicity, age, academic class, and fraternity/sorority
Aggressive marketing of smokeless tobacco (SLT) appears to have led to an increase in dual tobacco use. The current study examines the situational contexts, self-perceptions, and cessation attitudes/behaviors that relate to dual use. Participants (N = 1,242) at a large, Southwestern university completed a self-report measure of demographic and tobacco use variables in 2010. Data were analyzed using chi-square and one-way ANOVA techniques. Findings suggest that type of tobacco use varies by setting and that dual users are more likely than sole users to perceive themselves as regular tobacco users. Limitations and implications for future research and interventions are discussed. Keywords cigarettes, smoking, smokeless tobacco, dual use, college students
Aggressive marketing and production of tobacco products by manufacturers may impede national health objectives to reduce current rates of tobacco use in the United States (U.S. Department of Health and Human Services, 2010a) by increasing the potential for dual use of cigarettes and SLT (Carpenter, Connolly, Ayo-Yusuf, & Wayne, 2009; Ebbert, Montori, Erwin, & Stead, 2011; Tomar, Alpert, & Connolly, 2010). Dual tobacco use has been associated with increased health risk both physically and psychologically when compared to use of single tobacco products. Specifically, dual users report symptoms of pain, nausea, craving, irritability, depression, anxiety, sleep disturbance, and decreased concentration to a greater extent than single users when attempting to quit or cut back on tobacco use (Post, Gilljam, Rosendahl, Brember, & Galanti, 2010). Dual users seem less amenable to tobacco cessation, despite greater numbers of quit attempts (McClaveRegan & Berkowitz, 2011; Wetter et al., 2002), and report more symptoms of dependence than those who only use either cigarettes or SLT (Post et al., 2010). These results are concerning, given evidence that the severity of health
Address correspondence to Mary Beth Miller, Department of Psychology, Oklahoma State University, 118 North Murray, Stillwater, OK, 74078 USA. E-mail: [email protected]
700
DUAL TOBACCO USE AMONG COLLEGE STUDENTS
membership. Self-perceptions of addiction are expected to be strongest among dual users, and dual users are also expected to report using different forms of tobacco based on situational context (e.g., studying versus socializing). Understanding these factors may aid in the development of more integrated, effective intervention and prevention strategies for high-risk tobacco use, which in turn may alter the trajectory of long-term use among dual using college students.
701
residence) and to determine group differences in solitary versus social use of tobacco. One-way ANOVAs were utilized to examine differences in age, self-perceptions, situations, and variables associated with cessation across groups. Post hoc comparisons were made using Tukey HSD. No imputation procedures were implemented for missing data (e.g., refused responses or those such as, “I don’t know”); therefore, Ns will vary across analyses. RESULTS
METHOD Participants
College students from a large, Southwestern university in the United States were recruited from randomly selected courses during the fall of 2010 as part of a larger research project (Lechner, Meier, Miller, Wiener & FilsAime, 2012). Materials
A self-report measure of demographic and tobacco use variables was developed for the purposes of the larger research project. Demographic questions assessed participants’ age, sex, ethnicity, residence, fraternity or sorority affiliation, and academic class. Items assessing situational contexts of use were rated on a Likert scale ranging from one (strongly disagree) to seven (strongly agree) and included items regarding use while drinking, socializing, or studying/cramming; use when angry; and use as a reward (see Table 2). These items were derived from more comprehensive measures of smoking motives; however, selected items were chosen to decrease the length of the questionnaire, and items were modified to target both smoking and smokeless tobacco (SLT) use. Items assessing self-perceptions of addiction were rated on an identical scale, on which participants rated their agreement with the statements, “I consider myself a regular [smoker / smokeless tobacco user],” and, “I am addicted to [cigarettes / smokeless tobacco].” Variables related to cessation included age of first use, intent to quit, quit attempts, use of assistance in quitting, and confidence in ability to quit (see Table 3). Procedure
Researchers administered questionnaires in a classroom setting. Participants provided informed consent by completing the survey or refused consent by omitting responses to survey items. All procedures were approved by the University’s Institutional Review Board. Response rate was not formally assessed, as consent to participate in the study was contingent upon completion of the survey. Based on observation in the classrooms, however, response rates are estimated to be above 98.0%. Statistical Analysis
SPSS 19.0 was used for data analysis. Chi-squared goodness of fit tests were employed to examine differences in rates of tobacco use among demographic subgroups (e.g., ethnicity, fraternity/sorority membership, class, and
Sample Characteristics
A sample of 1,242 undergraduate students (53.5% female, 81.1% Caucasian) participated in the study. The mean age of participants was 19.23 years, with 43.2% living on campus, 38% off-campus, and 13.7% in fraternity/sorority housing. The sample was 39.9% freshmen, 24.1% sophomores, 26.4% juniors, and 9.5% seniors (see Table 1 for complete demographic data). Students who reported use of tobacco at least once in the past 30 days were classified as current users and were included in analyses as sole smokers (use of only cigarettes), sole SLT users (use of only SLT), and dual users (use of both SLT and cigarettes). Of the 1,242 participants, 50 (4.0%) were dual users of cigarettes and SLT, 59 (4.8%) used only SLT, 154 (12.4%) only smoked cigarettes, and 979 (78.8%) were nonusers. Current tobacco use groups differed significantly in gender, age, residence, fraternity/sorority membership, and academic class; they demonstrated no significant differences in ethnicity (see Table 1). There was a significant relationship between tobacco use and gender, χ 2 (3, N = 1,239) = 96.39, p < .001, with men reporting higher rates of SLT (9.7% vs. .5%) and dual use (7.5% vs. 1.1%) than women. Tobacco use also varied significantly as a function of age, F(3,1234) = 9.05, p < .001, η2 = .02. Post hoc tests indicated that smokers (M = 20.96, SD = 4.53) were significantly older than nonusers (M = 19.71, SD = 2.59; p < .001) but that no other significant differences in age existed between groups. There was a significant relationship between campus housing and current tobacco use, χ 2 (3, N = 1,237) = 57.29, p < .001, with individuals living off campus evincing higher rates of smoking, SLT use, and dual use as compared to individuals living on campus. Tobacco use also varied with fraternity/sorority membership, χ 2 (3, N = 1,239) = 27.75, p < .001, with SLT (8.2% vs. 4.5%) and dual use (13.4% vs. 3.2%) being higher among fraternity members as compared to nonmembers. Finally, there was a significant relationship between tobacco use and academic class, χ 2 (3, N = 1,237) = 30.78, p < .001. Use of all forms of tobacco seemed to increase with progression from freshman to junior years; however, dual use appeared to be less prevalent among seniors than among all other classes (see Table 1 for complete statistical information). One-way ANOVAs also revealed differences between smokers, SLT users, and dual users in age of first use, F(3, 284) = 3.57, p = .015, η2 = .04 (see Table 2). Though Tukey’s post hoc comparisons indicated no significant differences between dual users’ age of onset for smoking
702
M. B. MILLER ET AL.
TABLE 1. Distribution of participant demographics across tobacco use groups
Variable Prevalence Age: M (SD) Sex Female Male Ethnicity Caucasian Other Residence Off campus On campus Greek membership Greek affiliated Non-Greek affiliated Class standing Freshmen Sophomores Juniors Seniors
N
Nonuser (N = 979) %
Smoker (N = 154) %
SLT User (N = 59) %
Dual User (N = 50) %
1242 —
78.8 19.65 (2.28)1
12.4 23.42 (7.77)1
4.8 20.52 (2.12)
4.0 19.75 (2.75)
663 576
86.0 70.5
12.5 12.3
.5 9.7
1.1 7.5
966 225
78.4 81.8
12.1 11.6
5.3 2.7
4.2 4.0
703 534
71.3 88.6
15.9 7.9
6.7 2.2
6.1 1.3
97 1142
66.0 79.9
12.4 12.4
8.2 4.5
13.4 3.2
494 298 327 118
84.6 77.2 74.6 70.3
8.5 13.4 14.4 21.2
2.6 5.0 6.4 7.6
4.3 4.4 4.6 .8
F/χ 2 (df)
p
η2 /Cramer’s V
— 9.05 (3,1234) 96.39 (3)
—
