Alternative Tobacco Use among College Students: Who is at Highest Risk?

Tobacco use remains the leading cause of preventable morbidity and mortality in the US1 with tobacco-related illness responsible for over 400,000 deaths annually.2,3 The predominant form of tobacco use in the US is cigarette smoking, with an estimated 44.5 million adult current cigarette smokers.4,5 Alternative tobacco products, which include cigars, chewing tobacco, and snuff (smokeless tobacco), as well as newer products such as hookah (waterpipe) are highly available in the US market and are increasingly being promoted as potentially less harmful cigarette alternatives.4 These other forms of tobacco product are increasingly being used as a substitute for cigarette smoking or in addition to cigarettes.6-8 A greater tobacco product variety, increased promotion, and explicit or implicit claims of harm reduction may encourage the use of other tobacco products in addition to or as a substitute for cigarettes.7 Data from O'Connor et al7 revealed that use of other tobacco products was most strongly related to beliefs about the reduced harm of these products. Furthermore, policies designed to preserve clean indoor air may have a further impact on the types of tobacco products that smokers choose.4 Unfortunately, however, all of these tobacco products contain carcinogens and are associated with important health consequences as no tobacco product is free of harm.4,6,9,10 Alternative tobacco use, however, occurs more often in combination with cigarette smoking than in isolation.11 Among college students aged 18–24 years, 51.3% of students who used tobacco reported concurrent use.4,11 Between 2.5% and 5.0% of US cigarette smokers also use smokeless tobacco (SLT), and 3%–4% concurrently smoke cigarettes and cigars.7,12 Rigotti et al11 found among current smokeless tobacco users that 30.6% used only smokeless tobacco, whereas 62.3% also smoked cigarettes. Of current cigar smokers, 33.4% smoked only cigars, whereas 61.4% smoked both cigars and cigarettes.11 Concurrent users experience higher intermediate levels of mortality, are more likely to ingest more nicotine on a daily basis, are less likely than single-form users to stop using tobacco,4,13 and are at higher risk for acute myocardial infarction.14 Thus, the consequences of using multiple forms of tobacco may be additive or synergistic.4,13 Whereas daily tobacco consumption in the US is declining,8,15 nondaily smoking (smoking on some days but not every day) is increasing in prevalence.15,16 Among the categories of cigarette smokers, nondaily smokers have been shown to be more likely than daily smokers or nonsmokers to use alternative tobacco products concurrently.17 Nondaily smoking comprises about one fourth of all smokers (and growing).15,18-20 Furthermore, nondaily smoking may be a stable pattern of chronic low-level consumption, a transitory condition between daily smoking and quitting,21-23 or a transitional phase to heavier or regular cigarette use.19,24 Little is known about differences in alternative tobacco product use among subsets of nondaily smokers – that is, those nondaily smokers who were previously daily smokers (ie, former daily nondaily smokers [FDNS]) versus those nondaily smokers who were never daily smokers (ie, never daily non-daily smokers [NDNS]). FDNS make up as many as half of nondaily smokers and have been linked with increased readiness to quit cigarette smoking when compared to NDNS.25 In addition, prior studies have reported similar smoking behaviors among FDNS and NDNS across all situations regardless of whether the situations were social and sporadic or more routine.26 Despite what is known about concurrent use of cigarettes and alternative tobacco products, little research has focused on concurrent use among nondaily versus daily cigarette smokers, concurrent use among several differing tobacco products, or use of alternative tobacco products in relation to more unique psychosocial factors not frequently assessed in larger national data sets (eg, perceptions of smokers, attitudes about tobacco, sensation seeking). Given the aforementioned literature and the gaps in the literature, this study aims to: (1) examine concurrent use of cigarettes, alternative tobacco products, and marijuana among college students; and (2) examine smoking status (ie, nonsmoker, nondaily smoker [former daily vs. never daily], daily smoker) and psychosocial characteristics in relation to alternative tobacco product use, controlling for other substance use and sociodemographics among college students. By so doing, the current research will identify the categories of college students at highest risk for alternative tobacco use.