Youth Tobacco Cessation Quitting Intentions and Past-Year Quit Attempts Cindy Tworek, PhD, MPH, Gillian L. Schauer, MPH, Charles C. Wu, MPH, Ann M. Malarcher, PhD, Kia J. Jackson, PhD, Allison C. Hoffman, PhD Background: Despite declining use of conventional tobacco products, youth use of non-cigarette tobacco has become prevalent; however, quitting behaviors remain largely unexplored. Purpose: To examine nationally representative data on quit intentions and past-year attempts to quit all tobacco use among current youth tobacco users. Methods: In 2013, data were analyzed from the 2012 National Youth Tobacco Survey (NYTS). Weighted prevalence estimates of quit intentions and past-year quit attempts for current youth tobacco users are presented.

Results: Prevalence of quit intentions and past-year attempts to quit all tobacco use were 52.8% and 51.5%, respectively, among current youth tobacco users. Among non–mutually exclusive groups, current cigarette smokers had the highest prevalence of quit intentions (56.8%) and past-year quit attempts (52.5%), whereas current hookah users had the lowest prevalence of quit intentions (41.5%) and past-year quit attempts (43.7%). Quit intentions among black, non-Hispanics (65.0%) and Hispanics (60.4%) were significantly higher versus white, non-Hispanics (47.5%). Youth reporting parental advice against tobacco had significantly higher prevalence of quit intentions (56.7%) and past-year quit attempts (55.0%) than those not reporting parental advice. Youth who agreed all tobacco products are dangerous (58.5%) had significantly higher prevalence of quit intentions than those who disagreed (37.0%). Conclusions: Continued efforts are needed to better understand youth motivation for quitting all tobacco products. Public health messaging about the dangers of all tobacco and cessation efforts should be aimed at the full range of tobacco products, not just cigarettes, and tailored to meet the needs of youth polytobacco users. (Am J Prev Med 2014;47(2S1):S15–S27) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Introduction

Y

outh tobacco use remains a major public health problem. Although use of conventional tobacco has declined in the past decade, non-cigarette tobacco and polytobacco use among youth have become prevalent.1,2 Although clinician counseling is effective in increasing cigarette smoking cessation,3,4 effective From the Office of Science, Center for Tobacco Products (Tworek, Jackson, Hoffman), Food and Drug Administration, Rockville, Maryland; Office of Extramural Research (Wu), NIH, Bethesda, Maryland; and the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion (Schauer, Malarcher), CDC, Atlanta, Georgia Address correspondence to: Cindy Tworek, PhD, MPH, Food and Drug Administration, Center for Tobacco Products, Office of Science, 9200 Corporate Blvd, Rockville MD 20850. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2014.05.009

evidence-based youth cessation programs are lacking, particularly for non-cigarette tobacco.5,6 Three out of four youth cigarette smokers continue into adulthood, even if they intend to quit within a few years of initiation.2 Among high school students in 2012, approximately 14.0% smoked cigarettes in the last month, 12.6% smoked cigars, 6.4% used smokeless tobacco, 5.4% used hookah, 4.5% used pipe tobacco, 4.3% used roll-yourown tobacco, and 2.8% used electronic cigarettes.7 Youth use of non-cigarette tobacco has increased recently2,8,9; however, relatively little is known about cessation among youth who use non-cigarette tobacco products.5,6 Recent nationally representative data suggest 50% of youth and adolescents who currently smoke cigarettes have tried to quit in the past year.10 Quitting prevalence was higher among female versus male students (54% vs 47%), and higher among tenth-graders versus 12th-

Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Am J Prev Med 2014;47(2S1):S15–S27 S15

S16

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27 10

graders (56% vs 47%). National high school data indicate that nearly 70% of students who ever smoked cigarettes daily have tried to quit, with only about 12% succeeding.11 Prevalence of successful quitting did not differ by sex or race/ethnicity. Youth smoking-cessation literature suggests that social and environmental factors can affect youth quitting. For example, smoking restrictions or household bans can reduce likelihood of youth smoking and increase cessation.2 Studies12–14 also suggest that perceived negative health effects, available cessation resources, prior quit attempts, and quit intentions are correlated with quit attempts; while lower addiction levels, lower smoking frequency, longer time to first cigarette, higher self-efficacy, and using cessation resources are correlated with successful cigarette smoking cessation. Less is known about correlates of quit attempts and cessation for non-cigarette tobacco in adolescents and young adults. Prior research15 reported that reductions in smokeless tobacco (SLT) use among male adolescents were not due to parental pressures but, similar to cigarette smokers, to health concerns. Unfortunately, much existing research on youth tobacco cessation may not reflect new non-cigarette tobacco products. Updated nationally representative data about current youth cigarette and non-cigarette tobacco cessation behaviors can inform education, messaging, and cessation interventions. Several organizations have prioritized youth tobaccocessation surveillance and interventions. Healthy People 2020 includes an objective focused on increasing youth tobacco-cessation attempts.16 The Youth Tobacco Cessation Collaborative (YTCC, 1998–2011), established in 1998 to help youth quit tobacco, identified research goals and objectives including how intermediate quitting behaviors, such as quit intentions and attempts, are related to successful youth cessation.17 Youth tobacco-cessation data, including cigarette and non-cigarette tobacco and polytobacco use, may also inform the U.S. Food and Drug Administration (FDA) in its efforts to reduce youth tobacco use under the Family Smoking Prevention and Tobacco Control Act. This study’s purpose is to describe the prevalence of quitting behaviors (quit intentions and past-year quit attempts) of cigarette and non-cigarette tobacco products among current youth tobacco users. These NYTS 2012 data include overall weighted prevalence estimates and prevalence estimates by tobacco product type, sociodemographics, and tobacco use characteristics.

Methods Sample The NYTS is an ongoing, nationally representative, cross-sectional school-based survey of middle school (Grades 6–8) and high

school (Grades 9–12) students in the U.S. The NYTS began in 1999, and has been conducted annually since 2011. The sampling frame uses a stratified three-stage cluster design and includes public, Catholic, and other private and charter school students enrolled in regular middle and high schools in the 50 states and District of Columbia. Data are collected via paper questionnaires, self-administered in the classroom. Participation is voluntary at the school and student levels; parental permission is obtained for student participation, which is anonymous. The NYTS protocol is approved by the CDC’s Human Research Protection Office. Details of NYTS data collection processes and sampling methods are available elsewhere.18 In 2012, surveys were collected between January and March 2012 and completed by 24,658 students (91.7% of those eligible) from 228 participating sampled schools (participation rate¼73.6%). This study analyzed quit intentions and quit attempts among youth currently using any tobacco product. Analyses excluded youth who did not report using at least one tobacco product in the past 30 days, or did not answer quitting questions, yielding sample sizes of 2,667 for quit intentions and 2,720 for quit attempts.

Measures Current tobacco users were defined as youth who used any tobacco product on at least 1 of the past 30 days. Tobacco products include cigarettes, cigars, SLT, e-cigarettes, hookah, pipe tobacco, rollyour-own tobacco, bidis, kreteks, snus, dissolvable tobacco, and any other new tobacco product. Polytobacco use was defined as reporting use of two or more tobacco products on at least 1 of the past 30 days, and youth missing any responses for a tobacco product were assumed to be non-users. Outcomes of interest were tobacco quit intentions and past-year tobacco quit attempts. Behavioral theory has linked intention with subsequent behavior, making this an important intermediate outcome measure in the behavioral quitting pathway. Quit intentions were measured by the question Are you seriously thinking about quitting the use of all tobacco products? Responses were dichotomized as yes/no (yes: within the next 30-days/6 months/year/not within the year; no: I am not thinking about quitting the use of all tobacco products). Past-year quit attempts were measured by the question During the past 12 months, how many times have you stopped using all tobacco products for 1 day or longer because you were trying to quit all tobacco products for good? Responses were dichotomized as yes/ no with at least one attempt coded “yes” and I did not try to quit coded “no.” Other variables included sex; race/ethnicity; school type (high school/middle school as a proxy for age group); craving for a tobacco product; any household tobacco use; youth-reported parental/guardian advice against tobacco use; and harm perception of tobacco products. Craving was measured by the question During the past 30-days, have you had a strong craving or felt like you really needed to use a tobacco product of any kind? and coded yes/no. Any household tobacco use was measured by the question Does anyone who lives with you now: smoke cigarettes…use any other form of tobacco, with any positive response coded “yes” and the response No one who lives with me now uses any form of tobacco coded “no.” Parental advice against tobacco use was measured by the question During the past 12 months, have your parents or guardians talked with you… about not using any type of tobacco www.ajpmonline.org

August 2014

Table 1. Prevalence of quit intentions for all tobacco among current youth tobacco usersa overall and by tobacco type, 2012 National Youth Tobacco Survey Overall (any tobacco user)

Cigarette user

Cigar user

Smokeless tobacco user

Sample size (n)b

% (SE)

Sample size (n)b

% (SE)

Sample size (n)b

% (SE)

Sample size (n)b

% (SE)

2,667

52.8 (1.39)

1,791

56.8 (1.37)

1,348

48.4 (1.82)

835

44.9 (2.08)

Male

1,641

50.3 (1.85)

1,044

54.3 (1.96)

919

46.0 (2.15)

703

43.8 (2.24)

Female

1,023

56.7 (1.96)

746

60.3 (2.16)

429

53.5 (3.24)

132

50.9 (6.28)

1,410

47.5* (1.66)

980

52.7 (1.53)

648

43.0* (2.31)

521

OVERALL Sex

Race/ethnicity

*

*

42.6 (2.50) c

c

Black, non-Hispanic

250

65.0 (3.21)

123

71.6 (5.36)

172

62.5 (3.98)

Hispanic

641

60.4* (2.03)

431

60.6 (2.78)

345

54.1 (3.34)

155

52.8 (4.64)

Other, non-Hispanic

313

53.2 (3.51)

219

61.5 (3.92)

159

43.8 (4.53)

107

42.0 (5.53)

529

59.7 (3.40)

321

61.6 (3.14)

227

54.4 (5.65)

170

47.1 (4.28)

2,120

51.4 (1.45)

1,457

56.0 (1.43)

1,107

47.5 (1.92)

655

44.9 (2.20)

Yes

1,303

54.1 (1.91)

1,064

56.7 (2.00)

667

51.5 (2.32)

521

42.0 (2.97)

No

1,334

51.6 (2.07)

710

57.2 (2.41)

666

45.5 (2.51)

307

49.3 (3.77)

1,884

51.6 (1.44)

1,446

54.5 (1.46)

1,181

48.2 (1.86)

709

45.6 (2.14)

783

55.8 (2.41)

345

65.8 (3.02)

167

50.2 (5.15)

126

41.3 (5.42)

1,717

53.6 (1.58)

1,185

56.7 (1.78)

843

48.8 (2.04)

565

43.2 (2.42)

841

51.6 (2.22)

528

57.4 (2.36)

444

47.5 (2.68)

231

48.3 (4.32)

School type Middle school High school Craving to use a tobacco product

Multiple types of tobacco products used Yes No (single product)

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

White, non-Hispanic (ref)

Any household tobacco use Yes No

Youth reported parents advise against tobacco use Yes

1,451

56.7* (1.71)

1,011

62.8* (1.61)

745

53.8 (2.39)

450

52.0* (3.26)

No

1,131

47.5* (1.90)

719

48.2* (2.13)

>562

41.0 (2.89)

361

35.4* (2.92) (continued on next page)

S17

454 37.0* (2.51) 689 Disagree

Current tobacco user is defined as youth who used any of the following tobacco products on at least 1 day in the past 30 days: cigarettes, cigars, smokeless tobacco, e-cigarettes, hookah, pipe tobacco, roll-your-own tobacco, bidis, kreteks, snus, dissolvable tobacco, and any other new tobacco product. b The sum of a variable may not add up to overall n because of missing values. c Estimates are suppressed due to small cell size (no50) or large relative SE (Z40%). n The p-value for the two-sample t-test of differences in prevalence is o0.000625.

a

33.3* (3.33) 302 33.0* (2.98) 385

519 54.4* (2.03) 941 63.9* (1.61) 1,297 58.5* (1.58) 1,926 Agree

All tobacco products are dangerous

37.6* (2.86)

51.3* (2.61)

% (SE) Sample size (n)b Sample size (n)b Sample size (n)b % (SE) Sample size (n)b

Cigarette user

% (SE)

Cigar user

% (SE)

Smokeless tobacco user

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

Overall (any tobacco user)

Table 1. Prevalence of quit intentions for all tobacco among current youth tobacco usersa overall and by tobacco type, 2012 National Youth Tobacco Survey (continued)

S18

product? and coded yes/no. Tobacco harm perception was measured by agreement with the statement All tobacco products are dangerous. Responses were grouped by strongly agree/agree and strongly disagree/disagree.

Data Analysis Prevalence estimates, SEs, and sample sizes (n) are presented for the overall current tobacco user study sample, and within seven non– mutually exclusive tobacco user categories (cigarettes, cigars, SLT, electronic cigarettes [e-cigarettes], hookah, pipe tobacco, and rollyour-own tobacco), stratified by sociodemographic and tobaccorelated variables of interest (sex, race/ethnicity, school type, craving, multiple product use, household tobacco use, youth-reported parental advice against tobacco use, and perception of tobacco harm). Bidis, kreteks, snus, dissolvables, and other new tobacco products were not included as separate tobacco user categories because sample sizes were considerably smaller than the seven products examined. Each current tobacco use category is non–mutually exclusive, so a student who indicates current use of one product could be using any of the other six products. Because approximately 70% of current tobacco users with information about quit intentions and past-year quit attempts had used more than one product, mutually exclusive tobacco product categories with sufficient sample size to yield reliable estimates could not be constructed. Final student weights were applied to reflect initial selection probabilities, non-response adjustment, weight trimming, and poststratification to national student population estimates.18 SEs are presented for prevalences as estimates of variability. Formal statistical tests for differences within subgroups (e.g., male versus female respondents), accounting for multiple comparisons using a Bonferroni adjustment, were conducted in lieu of conventional 95% CIs. Subgroup analyses accounted for the entire study population in variance estimation, instead of creating respective subsets of data, and estimated variance using the Taylor Linearization Method, assuming a with-replacement (small sampling fraction) design. Differences in prevalence between subpopulations were examined using weighted two-sample t-tests. To account for multiple comparisons of overall tobacco use and seven tobacco use categories, each with ten comparisons, a Bonferroni adjusted α-level of 0.000625 (0.05/80) was used to determine significance. Missing values were excluded and not presented as a separate stratum. The proportion of missing data for study measures was no more than 5%; thus, missing data analysis was not conducted. Frequencies and SEs with characteristics for quit intentions and past-year quit attempts among single and multiple tobacco product users are also presented. Analyses were conducted in 2013, using SAS-callable SUDAAN, version 11.0 (RTI International, Research Triangle Park NC).

Results In the complete 2012 NYTS sample, 17.3% of youth used at least one tobacco product in the past 30 days, and approximately 57.9% were polytobacco users in the past 30 days. For the total NYTS 2012 sample, overall prevalence of quit intentions was 7.3% (SE¼0.38) and overall prevalence of making a past-year quit attempt was 8.2% (SE¼0.42). Cigarettes were the most prevalent www.ajpmonline.org

August 2014

Table 2. Prevalence of quit intentions for all tobacco among current youth tobacco usersa by tobacco type, 2012 National Youth Tobacco Survey Electronic cigarette user

Hookah user

Pipe

b

b

b

Sample size (n)

% (SE)

Sample size (n)b

% (SE)

641

47.2 (2.39)

614

53.7 (2.32)

42.6 (3.18)

386

45.7 (3.20)

370

50.3 (3.39)

269

38.9 (3.13)

255

49.5 (3.59)

244

58.9 (3.79)

42.9 (3.35)

% (SE)

Sample size (n)

394

50.9 (3.42)

Male

260

Female

OVERALL

Roll-your-own tobacco user

% (SE)

Sample size (n)

653

41.5 (2.56)

49.0 (3.86)

383

134

55.0 (5.42)

217

48.5 (3.93)

Sex

Race/ethnicity 334

36.9 (2.80)

285

*

306

52.3 (3.05)

*

—

—

—

—

—*

100

50.6 (6.75)

216

49.0 (4.19)

221

54.5 (3.69)

160

55.0 (4.18)

56

59.6 (5.47)

64

36.4 (6.78)

74

41.0 (6.95)

86

41.1 (5.89)

83

51.4 (7.85)

103

54.9 (7.16)

158

51.6 (4.85)

164

51.5 (5.25)

304

51.6 (3.59)

543

39.1 (2.65)

473

46.0 (2.89)

440

55.1 (2.56)

Yes

259

51.7 (3.80)

312

45.3 (3.62)

376

48.5 (2.89)

400

51.6 (3.06)

No

130

50.4 (5.97)

337

37.9 (3.57)

256

45.8 (3.45)

207

57.3 (3.66)

383

51.7 (3.55)

580

41.6 (2.63)

627

46.6 (2.35)

594

53.3 (2.32)

c

c

73

41.3 (7.27)

c

c

c

c

Yes

269

51.0 (4.22)

401

42.4 (2.74)

422

48.9 (2.85)

441

51.6 (2.79)

No

107

51.0 (5.44)

223

38.2 (4.10)

186

43.4 (3.98)

150

57.3 (4.34)

Black, non-Hispanic Hispanic Other, non-Hispanic

—

*

—

*

*

*

—

*

School type Middle school High school Craving to use a tobacco product

Multiple types of tobacco products used Yes No (single product)

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

White, non-Hispanic (ref)

Any household tobacco use

Youth reported parents advise against tobacco use Yes

223

54.9 (3.99)

359

45.2 (3.00)

343

57.0* (3.19)

326

61.1* (3.00)

No

157

43.9 (5.35)

270

34.9 (3.32)

276

33.5* (3.46)

269

43.1* (3.64) (continued on next page)

S19

198 27.3* (4.85) 123 Disagree

Current tobacco user is defined as youth who used any of the following tobacco products on at least 1 day in the past 30 days: cigarettes, cigars, smokeless tobacco, e-cigarettes, hookah, pipe tobacco, roll-your-own tobacco, bidis, kreteks, snus, dissolvable tobacco, and any other new tobacco product. b The sum of a variable may not add up to overall n because of missing values. c Estimates are suppressed due to small cell size (no50) or large relative SE (Z40%). n The p-value for the two-sample t test of differences in prevalence is o0.000625.

a

33.9* (3.83) 210 31.5* (3.70) 253

392 57.0* (2.71) 373 45.8 (2.89) 442 61.0* (4.07) Agree

All tobacco products are dangerous

262

29.9 (4.18)

63.4* (2.64)

% (SE) Sample size (n)b Sample size (n)b Sample size (n)b % (SE) Sample size (n)b

Hookah user

% (SE)

Pipe

% (SE)

Roll-your-own tobacco user

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

Electronic cigarette user

Table 2. Prevalence of quit intentions for all tobacco among current youth tobacco usersa by tobacco type, 2012 National Youth Tobacco Survey (continued)

S20

tobacco product used in the past 30 days, with 9.4% use; followed by cigars (8.4%); SLT (4.4%); hookah (3.6%); pipe tobacco (3.4%); roll-your-own tobacco (3.4%); and e-cigarettes (2.1%).

Quit Intentions Prevalence of intending to quit all tobacco was 52.8% among all current youth tobacco users (Tables 1 and 2). Prevalence of intending to quit all tobacco among current youth single tobacco product users was 55.8%, while prevalence among current youth multiple tobacco product users was 51.6% (Table 3). Current youth cigarette smokers had the highest prevalence of intending to quit (56.8%), followed by roll-your-own tobacco users (53.7%); e-cigarette users (50.9%); cigar users (48.4%); pipe tobacco users (47.2%); SLT users (44.9%); and hookah users (41.5%). Overall prevalence of quit intentions among black, nonHispanic youth (65.0%) and Hispanic youth (60.4%) were each significantly higher compared to white, non-Hispanic youth (47.5%, po0.000625 for both). Among youth cigar users, prevalence of quit intentions among black, nonHispanics (62.5%) was significantly different from white, non-Hispanics (43.0%, po0.000625). Overall, youth reporting parental advice against tobacco had significantly higher prevalence of quit intentions than youth not reporting receiving parental advice (56.7% vs 47.5%, po0.000625). This significant difference was observed among cigarette users (62.8% vs 48.2%); SLT users (52.0% vs 35.4%); pipe tobacco users (57.0% vs 33.5%); and rollyour-own tobacco users (61.1% vs 43.1%). Overall prevalence of quit intentions among youth who agreed that all tobacco products are dangerous (58.5%) was significantly higher than youth who disagreed with this statement (37.0%, po0.000625). This significant difference was observed among cigarette users (63.9% vs 37.6%); cigar users (54.4% vs 33.0%); SLT users (51.3% vs 33.3%); e-cigarette users (61.0% vs 27.3%); pipe tobacco users (57.0% vs 31.5%); and roll-your-own tobacco users (63.4% vs 33.9%).

Quit Attempts Overall prevalence of making a past-year quit attempt of all tobacco was 51.5% among all current tobacco users. Prevalence of making a past-year quit attempt for all tobacco among current youth single tobacco product users was 51.6%, while prevalence among current youth multiple tobacco product users was 51.4% (Table 3). Current youth cigarette smokers (52.5%) and roll-your-own tobacco users (52.6%) had the highest prevalence of making a past-year quit attempt, followed by pipe tobacco users (50.8%); SLT users (50.5%); e-cigarette users (48.4%); cigar users (48.0%); and hookah users (43.7%) (Tables 4 and 5). www.ajpmonline.org

August 2014

Table 3. Quit intentions and past-year quit attempts among single and multiple tobacco product users by student characteristics, 2012 National Youth Tobacco Survey Quit intentions Single tobacco product use (use only 1 tobacco product)

Quit attempts

Multiple tobacco product use (use 2 or more tobacco products)

Single tobacco product use (use only 1 tobacco product)

Multiple tobacco product use (use 2 or more tobacco products)

Sample size (n)a

% (SE)

Sample size (n)a

% (SE)

Sample size (n)a

% (SE)

Sample size (n)a

% (SE)

783

55.8 (2.41)

1,884

51.6 (1.44)

837

51.6 (2.25)

1,883

51.4 (1.45)

Male

437

52.0 (3.36)

1,204

49.7 (1.87)

465

54.1 (3.08)

1,204

49.7 (1.74)

Female

343

59.8 (3.23)

680

55.1 (2.21)

369

47.7 (3.02)

679

54.6 (2.15)

White, non-Hispanic

407

48.4 (3.16)

1,003

47.2 (1.67)

435

46.3 (2.96)

1,011

49.0 (1.78)

Black, non-Hispanic

104

66.4 (3.53)

146

64.2 (5.59)

108

68.3 (4.62)

144

58.9 (5.35)

Hispanic

172

67.2 (4.76)

469

57.9 (2.43)

180

53.1 (5.06)

458

54.5 (3.03)

85

55.7 (7.37)

228

52.1 (3.91)

97

57.0 (6.57)

234

50.9 (3.30)

Middle school

163

66.9 (5.45)

366

56.3 (3.55)

154

57.9 (4.76)

350

56.6 (3.25)

High school

617

53.1 (2.50)

1,503

50.7 (1.57)

678

50.3 (2.50)

1,519

50.7 (1.47)

Yes

260

55.6 (3.78)

1,043

53.6 (1.95)

272

60.2 (3.36)

1,026

54.0 (1.89)

No

513

55.9 (3.13)

821

49.0 (2.40)

555

47.2 (3.15)

838

48.4 (2.21)

Yes

483

59.0 (2.93)

1,234

51.4 (1.64)

507

54.1 (2.53)

1,227

51.6 (1.81)

No

274

51.0 (3.95)

567

51.8 (2.47)

299

46.6 (3.64)

576

50.0 (2.89)

OVERALL Sex

Other, non-Hispanic School type

Craving to use a tobacco product

Any household tobacco use

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

Race/ethnicity

Youth reported parents advise against tobacco use Yes

408

55.1 (3.17)

1,043

57.3 (1.86)

426

53.9 (2.97)

1,039

55.5 (1.71)

No

351

57.0 (3.30)

780

43.3 (2.09)

382

48.8 (3.14)

781

44.6 (2.43)

All tobacco products are dangerous 603

59.4 (2.60)

1,323

58.1 (1.73)

650

52.6 (2.58)

1,340

54.0 (1.66)

Disagree

168

43.8 (4.65)

521

34.9 (2.64)

173

47.6 (4.66)

504

45.0 (3.22)

The sum of a variable may not add up to overall n because of missing values.

S21

a

Agree

S22

Table 4. Prevalence of past-year quit attempts for all tobacco among current youth tobacco usersa overall and by tobacco type, 2012 National Youth Tobacco Survey Overall (any tobacco user)

Cigarette user

Cigar user

b

b

b

Sample size (n)

% (SE)

Sample size (n)b

% (SE)

1,374

48.0 (1.76)

838

50.5 (1.91)

50.8 (2.11)

936

47.5 (2.01)

710

49.4 (2.02)

741

54.8 (1.83)

438

49.0 (2.83)

128

56.7 (5.44)

981

49.7 (1.75)

668

44.4 (2.37)

522

51.0 (2.32)

% (SE)

Sample size (n)

2,720

51.5 (1.31)

Male

1,669

Female

OVERALL

Smokeless tobacco user

% (SE)

Sample size (n)

1,794

52.5 (1.45)

50.9 (1.61)

1,052

1,048

52.2 (1.85)

1,446

48.2 (1.68)

Sex

White, non-Hispanic (ref)

c

c

Black, non-Hispanic

252

62.7 (4.19)

124

62.3 (5.61)

168

58.8 (4.28)

Hispanic

638

54.1 (2.29)

430

54.4 (2.57)

343

49.2 (3.55)

155

47.9 (4.76)

Other, non-Hispanic

331

52.9 (2.85)

221

54.8 (3.69)

173

48.2 (3.94)

108

45.2 (5.07)

504

57.0 (3.03)

306

57.4 (2.92)

217

51.4 (5.00)

163

46.6 (3.92)

2,197

50.6 (1.29)

1,476

51.8 (1.43)

1,143

47.7 (1.78)

663

51.6 (2.01)

Yes

1,298

55.4 (1.62)

1,052

55.5 (2.03)

658

50.9 (2.30)

512

49.6 (2.84)

No

1,393

47.9 (2.01)

724

48.6 (2.31)

702

44.8 (2.40)

318

52.4 (2.71)

1,883

51.4 (1.45)

1,435

52.0 (1.60)

1,177

48.2 (1.74)

706

49.5 (2.29)

837

51.6 (2.25)

359

54.1 (3.35)

197

46.8 (4.53)

132

55.6 (3.75)

1,734

52.3 (1.55)

1,190

53.9 (1.85)

840

48.2 (2.22)

559

47.1 (2.32)

875

48.9 (2.43)

526

47.9 (2.84)

471

46.2 (2.81)

239

55.6 (3.91)

55.0* (1.56)

1,008

57.2* (1.76)

752

51.7 (2.10)

448

54.8 (2.86)

575

41.6 (2.80)

363

School type Middle school High school Craving to use a tobacco product

Multiple types of tobacco products used Yes No (single product) Any household tobacco use Yes

www.ajpmonline.org

No

Youth reported parents advise against tobacco use Yes No

1,465 1,163

*

46.0 (1.89)

721

*

44.5 (2.34)

43.7 (2.79) (continued on next page)

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

Race/ethnicity

Current tobacco user is defined as youth who used any of the following tobacco products on at least 1 day in the past 30 days: cigarettes, cigars, smokeless tobacco, e-cigarettes, hookah, pipe tobacco, roll-your-own tobacco, bidis, kreteks, snus, dissolvable tobacco, and any other new tobacco product. The sum of a variable may not add up to overall n because of missing values. c Estimates are suppressed due to small cell size (no50) or large relative SE (Z40%). n The p-value for the two-sample t test of differences in prevalence is o0.000625. b

a

297 40.4 (3.58) 379 45.7 (3.54) 448 45.7 (2.81) 677

1,306 53.5 (1.54) Agree

1,990

% (SE) Sample size (n)

All tobacco products are dangerous

Disagree

971 55.0 (1.60)

% (SE) Sample size (n)

b b

August 2014

43.0 (3.58)

54.1 (2.38) 528 51.0 (1.98)

% (SE) Sample size (n)b

Smokeless tobacco user

% (SE) Sample size (n)

b

Cigar user Cigarette user Overall (any tobacco user)

Table 4. Prevalence of past-year quit attempts for all tobacco among current youth tobacco usersa overall and by tobacco type, 2012 National Youth Tobacco Survey (continued)

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

S23

Overall, youth reporting parental advice against tobacco use had significantly higher prevalence of making a pastyear quit attempt (55.0%) than those who did not report parental advice against tobacco (46.0%, po0.000625). Significant differences were observed among cigarette users (57.2% vs 44.5%, respectively, po0.000625) and hookah users (49.0% vs 34.7%, respectively, po0.000625). Among e-cigarette users, youth who agreed that all tobacco products are dangerous (55.4%) had a significantly higher prevalence of making a past-year quit attempt than those who disagreed with the statement (32.7%, po0.000625).

Discussion Youth cessation efforts have traditionally focused on quitting cigarettes and include a variety of comprehensive tobacco control policies, such as increased price, smokefree air laws, mass media campaigns, and cessation interventions in healthcare and school settings.2–4,6,19,20 Important study findings include prevalence estimates for quit intentions and quit attempts of all tobacco by users of non-cigarette products, which are strikingly similar for both quitting behavior outcomes. Descriptive findings suggest that the prevalence of intention to quit all tobacco is highest among youth cigarette smokers and lowest among youth hookah users. Prevalence of quit attempts varies by different tobacco product users, with hookah users having the lowest prevalence of making a past-year quit attempt. Importantly, data suggest that e-cigarette users have lower prevalence of intending to quit all tobacco and lower prevalence of past-year quit attempts compared to cigarette smokers. These categories overlap, as a large proportion of e-cigarette users are dual cigarette users. Youth e-cigarette users who agreed that all tobacco products are dangerous had a significantly higher prevalence of making a past-year quit attempt than those who disagreed with that statement. These findings can be compared to the recent study of Dutra and Glantz21 on e-cigarettes and conventional cigarettes using NYTS data, which showed that use of e-cigarettes was associated with higher odds of: ever/current cigarette smoking and established smoking, in addition to higher odds of planning to quit among current smokers; and lower odds of abstinence from conventional cigarettes among experimenters. The current results imply that youth are not using e-cigarettes solely as cessation aids, as a majority of e-cigarette users report multiple tobacco product use, but do not report making a quit attempt in the past year. This study finds that minority youth have higher prevalence of quit intentions for all tobacco than white youth. These findings are similar to nationally representative data from the Youth Risk Behavioral Surveillance

S24

Table 5. Prevalence of past-year quit attempts for all tobacco among current youth tobacco usersa by tobacco type, 2012 National Youth Tobacco Survey Electronic cigarette user Quit attempt

Sample size (n)b

OVERALL

% (SE)

Hookah user

Pipe

Roll-your-own tobacco user

Sample size (n)b

% (SE)

Sample size (n)b

% (SE)

Sample size (n)b

% (SE)

397

48.4 (3.82)

670

43.7 (2.45)

642

50.8 (2.65)

610

52.6 (2.52)

Male

260

46.0 (5.00)

385

46.9 (2.97)

385

49.0 (3.50)

362

47.6 (3.45)

Female

137

53.1 (4.98)

284

38.4 (3.54)

257

53.8 (4.06)

248

60.1 (3.93)

218

47.6 (4.52)

347

42.7 (3.07)

287

53.4 (3.58)

303

50.5 (3.61)

Black, non-Hispanic

c

c

c

c

c

c

c

c

Hispanic

99

48.9 (6.65)

214

43.7 (4.06)

221

50.0 (4.12)

156

52.5 (4.67)

Other, non-Hispanic

57

53.7 (7.47)

71

42.1 (6.87)

80

42.7 (6.05)

87

45.3 (5.86)

81

50.5 (7.01)

99

48.5 (6.41)

152

52.4 (4.87)

157

51.2 (4.20)

309

48.7 (3.86)

562

43.0 (2.64)

481

50.7 (2.78)

443

54.0 (2.65)

Yes

261

48.5 (4.54)

311

50.3 (3.09)

365

52.9 (3.17)

396

52.8 (3.32)

No

131

48.5 (5.61)

356

38.2 (3.53)

268

48.1 (3.69)

207

52.6 (3.88)

385

48.3 (3.62)

595

45.4 (2.64)

627

50.4 (2.73)

593

52.1 (2.56)

c

c

75

29.6 (6.98)

c

c

c

c

Yes

270

48.0 (4.18)

409

45.0 (2.90)

422

50.7 (3.10)

438

51.8 (3.05)

No

107

47.1 (5.08)

230

40.4 (4.13)

186

49.3 (4.50)

150

52.6 (4.05)

50.4 (4.61)

370

49.0* (2.86)

337

57.7 (3.28)

320

59.7 (3.15)

281

40.0 (4.03)

271

41.9 (3.86)

Sex

White, non-Hispanic (ref)

School type Middle school High school Craving to use a tobacco product

Multiple types of tobacco products used Yes No (single product) Any household tobacco use

www.ajpmonline.org

Youth reported parents advise against tobacco use Yes No

220 162

42.2 (4.90)

275

*

34.7 (3.30)

(continued on next page)

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

Race/ethnicity

Current tobacco user is defined as youth who used any of the following tobacco products on at least 1 day in the past 30 days: cigarettes, cigars, smokeless tobacco, e-cigarettes, hookah, pipe tobacco, roll-your-own tobacco, bidis, kreteks, snus, dissolvable tobacco, and any other new tobacco product. The sum of a variable may not add up to overall n because of missing values. c Estimates are suppressed due to small cell size (no50) or large relative SE (Z40%). n The p-value for the two-sample t test of differences in prevalence is o0.000625. b

42.1 (4.48) 202 43.8 (4.03) 247 197 32.7 * (5.13) Disagree

121

39.4 (4.34)

396 54.8 (2.96) 381 459 55.4 * (4.33) 268

45.3 (2.79) All tobacco products are dangerous

Agree

% (SE) Sample size (n)b % (SE) Sample size (n)b Quit attempt

August 2014

a

57.7 (2.85)

% (SE) Sample size (n)b Sample size (n)b

% (SE)

Roll-your-own tobacco user Pipe Hookah user Electronic cigarette user

Table 5. Prevalence of past-year quit attempts for all tobacco among current youth tobacco usersa by tobacco type, 2012 National Youth Tobacco Survey (continued)

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

S25

11

system (YRBS) and mirror adult data, indicating that black non-Hispanics are significantly more likely to intend to quit.22 Prevalence estimates suggest that black, non-Hispanic youth may be particularly motivated to quit; however, more research and applied interventions are needed to ensure that quit intentions among these youth result in successful cessation. The present results also suggest the importance of parental advice against tobacco use, which should be further explored for applicability to youth-focused cessation interventions with parental involvement. Youth whose parents advised against tobacco use have significantly higher prevalence of quit intentions for all tobacco, overall and among youth who currently use cigarettes, SLT, pipe tobacco, and roll-your-own tobacco; as well as of quit attempts among cigarette and hookah users. These findings are consistent with research suggesting the importance of parental attitudes about smoking to protect against adolescent tobacco use.2 The present findings suggest the importance of tobacco product harm perception among youth. Prevalence of quit intentions was higher among youth perceiving all tobacco products as dangerous. Youth may differ in harm perceptions of cigarette and non-cigarette tobacco, which this study did not assess. For example, studies23–27 have found that a high prevalence of young adult hookah users perceive it as less harmful and less addictive than cigarettes. Similarly, cigar,28–30 SLT,31,32 and e-cigarette use31,33 are often influenced by peer use and perceived as less harmful and less addictive than cigarette smoking, particularly in younger populations. Factors associated with cessation among non-cigarette tobacco users are poorly understood, compared to factors associated with cessation among cigarette smokers. As non-cigarette tobacco use increases among U.S. adolescents,2,32 information about youth cessation-related behaviors is needed. A recent study among adults by Popova and Ling34 suggests that although non-cigarette tobacco, such as SLT and electronic cigarettes, are attractive to smokers who want to quit, they do not promote cessation. Table 3 depicts frequencies suggesting that among youth who currently use multiple tobacco products, only approximately half report making a past-year quit attempt. Knowledge of how and why youth use noncigarette tobacco products can inform education, messaging, and comprehensive tobacco-cessation programs, as well as future regulatory efforts.

Limitations The present study findings have limitations. NYTS is a cross-sectional survey, making it impossible to assess causal relationships between quitting outcomes and

S26

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

associated factors. It is difficult to correctly chart progression from tobacco initiation and established use to quitting, given the definition of current user based on any use in the past 30 days, which likely includes experimenters. Findings may reflect experimental or sporadic youth tobacco use patterns. It is possible some youth experimenters do not self-identify as “smokers” or “tobacco users,” making quitting irrelevant to them. Only current tobacco users are examined; those who had successfully quit tobacco more than 30 days ago are not captured within analyses. Therefore, past-year quit attempts represent “failed” quit attempts, as there is no information on successful youth quit attempts for all tobacco products. Also, cessation questions were asked of all tobacco use in general, so youth interest in quitting a particular tobacco product could not be assessed. It is unclear whether youth polytobacco users responded to quitting questions for all tobacco with a particular product in mind. Future research should explore quit intentions and attempts for specific tobacco products. Study data may have limitations in representing all youth, especially tobacco users, as data were not collected from dropouts or homeschooled youth. Data apply to youths who attend school and are not representative of this entire age group. However, 2011 Current Population Survey data indicate that 98.5% of U.S. youths aged 10– 13 years and 97.1% of those aged 14–17 years were enrolled in traditional school.35 Hence, the present findings are likely generalizable to most youths. Analyses did not include mutually exclusive tobacco user groups because available data were too small for many tobacco user categories owing to the extent of polytobacco use. Comparisons cannot be made across tobacco use categories with respect to significant differences among prevalence estimates. Future analyses can pool data from subsequent waves to assess quitting across mutually exclusive tobacco user groups and polyusers, providing insight for cessation by tobacco type and combinations of multiple tobacco products.

of quit intentions or quit attempts than single tobacco product users. This is particularly important because of the relatively high degree of non-cigarette tobacco use and polytobacco use among youth. Additional research should explore how and why youth quitting differs by tobacco type, sociodemographics, and tobacco use characteristics across tobacco user categories to develop more effective messaging and education for quitting all tobacco. Findings suggest the importance of evidence-based interventions, such as mass media campaigns on dangers of tobacco, and other community-based efforts, to encourage complete youth cessation of all tobacco products.36–40 Future research should emphasize better ways to communicate the dangers of tobacco, especially among parents and youth. Public health messaging about the dangers of all tobacco and cessation efforts should be aimed at the full range of tobacco products, not just cigarettes, and tailored to meet the needs of youth polytobacco users. Publication of this article was supported by the U.S. Food and Drug Administration, Center for Tobacco Products. The authors acknowledge members of the U.S. Food and Drug Administration’s (FDA’s) Center for Tobacco Products who provided critical input to this manuscript: Catherine Corey, Benjamin Apelberg, Cathy Backinger, Deborah Neveleff, George Rochester, Nikolas Pharris-Ciurej, Won Lee, and Becky Bunnell from the CDC’s Office on Smoking and Health, in addition to Sue Curry as Guest Editor for the American Journal of Preventive Medicine. Disclaimer: The findings and conclusions in this report are those of the authors. The information in this article is not a formal dissemination of information by either the FDA or CDC and does not represent either agency’s positions or policies. Charles C. Wu completed all work on this project and paper while working at the Center for Tobacco Products, FDA. No financial disclosures were reported by the authors of this paper.

References Conclusions The findings of this study present differences in youth prevalence of quit intentions and past-year quit attempts for all tobacco and reflect higher prevalence of quit intentions among minority youth, youth receiving parental advice against tobacco, and youth who agreed all tobacco products are dangerous. Despite the suggestion that non-conventional tobacco products could encourage quitting behavior, we did not find that youth using multiple tobacco products reported higher prevalence

1. Saunders C, Geletko K. Adolescent cigarette smokers’ and noncigarette smokers’ use of alternative tobacco products. Nicotine Tob Res 2012;14(8):977–85. 2. USDHHS. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta GA: CDC, 2012. www. surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/ full-report.pdf. 3. Fiore MC, Jaen CR, Baker TB, et al. Clinical practice guideline. Treating tobacco use and dependence: 2008 Update. Washington DC: USDHHS, 2008. ncbi.nlm.nih.gov/books/NBK63952/. 4. Patnode CD, O’Connor E, Whitlock EP, Perdue LA, Soh C, Hollis J. Primary care-relevant interventions for tobacco use prevention and cessation in children and adolescents: a systematic evidence review for

www.ajpmonline.org

Tworek et al / Am J Prev Med 2014;47(2S1):S15–S27

5.

6. 7. 8. 9. 10. 11. 12. 13.

14.

15.

16.

17. 18.

19.

20. 21.

22. 23.

the U.S. Preventive Services Task Force. Ann Intern Med 2013;158(4): 253–60. Curry SJ, Mermelstein RJ, Emery SL, et al. A national evaluation of community-based youth cessation programs: end of program and twelve-month outcomes. Am J Community Psychol 2013;51(1–2):15–29. Stanton A, Grimshaw G. Tobacco cessation interventions for young people. Cochrane Database Syst Rev 2013;8:CD003289. CDC. Tobacco product use among middle and high school students—U. S., 2011 and 2012. MMWR Morb Mortal Wkly Rep 2013;62(45):893–7. CDC. Tobacco use among middle and high school students—U.S, 2000–2009. MMWR Morb Mortal Wkly Rep 2010;59(33):1063–8. CDC. Current tobacco use among middle and high school students— U.S., 2011. MMWR Morb Mortal Wkly Rep 2012;61(31):581–5. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance— U.S., 2011. MMWR Surveill Summ 2012;61(4):1–162. CDC. High school students who tried to quit smoking cigarettes—U.S., 2007. MMWR Morb Mortal Wkly Rep 2009;58(16):428–31. Sargent JD, Mott LA, Stevens M. Predictors of smoking cessation in adolescents. Arch Pediatr Adolesc Med 1998;152(4):388–93. Diemert LM, Bondy SJ, Brown KS, Manske S. Young adult smoking cessation: predictors of quit attempts and abstinence. Am J Public Health 2013;103(3):449–53. Mercincavage M, Branstetter SA, Muscat JE, Horn KA. Time to first cigarette predicts cessation outcomes in adolescent smokers. Nicotine Tob Res 2013;15(12):1996–2004. Ary DV, Lichtenstein E, Severson H, Weissman W, Seeley JR. An in-depth analysis of male adolescent smokeless tobacco users: interviews with users and their fathers. J Behav Med 1989;12(5):449–67. CDC, National Center for Chronic Disease Prevention and Health Promotion. Healthy People 2020: tobacco use. TU-7. Increase smoking cessation attempts by adolescent smokers. Atlanta GA: CDC, 2012. www.cdc.gov/tobacco/basic_information/healthy_people/toolkit/pdfs/ hp-factsheet.pdf. Youth Tobacco Cessation Collaborative: 2009 Update. youthtobacco cessation.org. Smoking and Tobacco Use. National Youth Tobacco Survey (NYTS). 2012 NYTS Methodology Report. cdc.gov/tobacco/data_statistics/sur veys/nyts/. Institute for Clinical Systems Improvement. Healthcare guideline: preventive services for children and adolescents. Bloomington MN: Institute for Clinical Systems Institute, 2009. www.icsi.org/_asset/ x1mnv1/PrevServKids.pdf. Guide to Community Preventive Services. Increasing tobacco use cessation: quitline interventions. thecommunityguide.org/tobacco/quitlines.html. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among U.S. adolescents: a cross-sectional study. JAMA Pediatr 2014:In press. Quitting smoking among adults—U.S., 2001–2010. MMWR Morb Mortal Wkly Rep 2011;60(44):1513–9. Smith-Simone S, Maziak W, Ward KD, Eissenberg T. Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U. S. samples. Nicotine Tob Res 2008;10(2):393–8.

August 2014

S27

24. Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Ann Behav Med 2008;36(1): 81–6. 25. Eissenberg T, Ward KD, Smith-Simone S, Maziak W. Waterpipe tobacco smoking on a U.S. college campus: prevalence and correlates. J Adolesc Health 2008;42(5):526–9. 26. Braun RE, Glassman T, Wohlwend J, Whewell A, Reindl DM. Hookah use among college students from a midwest university. J Community Health 2012;37(2):294–8. 27. Ahmed B, Jacob P III, Allen F, Benowitz N. Attitudes and practices of hookah smokers in the San Francisco Bay Area. J Psychoactive Drugs 2011;43(2):146–52. 28. Smith SY, Curbow B, Stillman FA. Harm perception of nicotine products in college freshmen. Nicotine Tob Res 2007;9(9): 977–82. 29. Jolly DH. Exploring the use of little cigars by students at a historically black university. Prev Chronic Dis 2008;5(3):A82. 30. Sterling K, Berg CJ, Thomas AN, Glantz SA, Ahluwalia JS. Factors associated with small cigar use among college students. Am J Health Behav 2013;37(3):325–33. 31. Choi K, Fabian L, Mottey N, Corbett A, Forster J. Young adults’ favorable perceptions of snus, dissolvable tobacco products, and electronic cigarettes: findings from a focus group study. Am J Public Health 2012;102(11):2088–93. 32. Agaku IT, Ayo-Yusuf OA, Vardavas CI, Alpert HR, Connolly GN. Use of conventional and novel smokeless tobacco products among U.S. adolescents. Pediatrics 2013;132(3):e578–e586. 33. Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB. E-cigarette awareness, use, and harm perceptions in U.S. adults. Am J Public Health 2012;102(9):1758–66. 34. Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am J Public Health 2013;103(5):923–30. 35. Davis J, Bauman K. School enrollment in the U.S.: 2011. Suitland MD: U.S. Census Bureau, 2013. www.census.gov/prod/2013pubs/p20-571.pdf. 36. Park HY, Dent C, Abramsohn E, Dietsch B, Mccarthy WJ. Evaluation of California’s in-school tobacco use prevention education (TUPE) activities using a nested school-longitudinal design, 2003–2004 and 2005–2006. Tob Control 2010;19(1S):Si43–Si50. 37. Sy A, Glanz K. Factors influencing teachers’ implementation of an innovative tobacco prevention curriculum for multiethnic youth: Project SPLASH. J Sch Health 2008;78(5):264–73. 38. Hollingworth W, Cohen D, Hawkins J, et al. Reducing smoking in adolescents: cost-effectiveness results from the cluster randomized ASSIST (A Stop Smoking In Schools Trial). Nicotine Tob Res 2012; 14(2):161–8. 39. Jit M, Aveyard P, Barton P, Meads CA. Predicting the life-time benefit of school-based smoking prevention programmes. Addiction 2010; 105(6):1109–16. 40. Sussman S, Levy D, Lich KH, et al. Comparing effects of tobacco use prevention modalities: need for complex system models. Tob Induc Dis 2013;11(1):2.