Background and aim In recent years, new non-traditional, potentially reduced exposure products (PREPs), claiming to contain fewer harmful chemicals than the traditional products, have been introduced in the market. Little is known about socioeconomic, demographic and smoking-related determinants of the likelihood of using these products among smokers. The aim of this study was to examine these determinants.
Methods Data from the 2006–2007 Tobacco Use Supplement to the Current Population Survey was used. We limited the analysis to current smokers (n=40 724). Multivariate logistic regression analyses were conducted to estimate the association between covariates and the probability of the use of PREPs.
Results We found that younger age, lower education, higher nicotine addiction and having an intention to quit are associated with higher likelihood of the use of PREPs. The likelihood of using these products was found to be higher among respondents who are unemployed or have a service, production, sales or farming occupation than those with a professional occupation. Smokers living in the midwest, south or west, were found to have a greater likelihood of the use of PREPs than those living in the northeast.
Conclusions Because there is little evidence to suggest that PREPs are less harmful that other tobacco products, their marketing as harm-minimising products should be regulated. Smokers, in particular those who are younger, have a lower socioeconomic status, and are more nicotine-dependent, should be the target of educational programmes that reveal the actual harm of PREPs.
- Harm Reduction
- Socioeconomic status
- Advertising and Promotion
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There are more than 7000 chemicals in cigarette smoke, including carcinogens, and a number of toxicants responsible for major diseases.1 In response to increasing scientific evidence about the harmful effects of tobacco smoke, the tobacco industry has begun manufacturing and selling tobacco products claimed to have reduced harmful chemicals.2 This trend began with the introduction of filters in the 1950s followed by the ‘light’ and low ‘tar cigarettes in the 1960s and 1970s,3 and continued with modifications, such as use of reconstituted or expanded tobacco, porous cigarette paper, to reduce the tar and nicotine yield of cigarettes.4 Since the 1990s, products sometimes referred to as potentially reduced exposure products, or PREPs,2 have been introduced in the market, and are being promoted as an alternative to conventional cigarettes with claims of reduced risk of disease and exposure to harmful chemicals.5 Pederson et al,5 characterised PREPs as those tobacco products which are engineered nicotine delivery devices that heat tobacco rather than burning it, and certain non-standard smokeless tobacco products, such as chewable tobacco packets or lozenges. We considered the products Eclipse, Accord, Arriva, Exalt, Revel, Omni, Advance and Marlboro Ultrasmooth, in our study. Eclipse is a smokeless cigarette in which tobacco is heated instead of burning, and so is Accord, which uses a battery-operated charger and puff-activated lighter to heat the tobacco.5 Arriva is a lozenge, whereas Exalt and Revel are smokeless tobacco products; all consumed orally.5 Advance and Omni, are modified tobacco products.6 Marlboro Ultrasmooth is a cigarette that uses carbon filter, a design apparently adapted to reduce harmful ingredients.5 There have been studies on the clinical effects of these products on smokers,7 their toxicology,8 and on the smokers’ awareness, beliefs, perceptions and attitudes5 ,6 ,9 ,10 about these products, but little is known about the determinants of the use of these products.
It is known that lower socioeconomic status is associated with a higher prevalence of smoking,11–13 but literature about such socioeconomic variations in the use of PREPs is scant. Hund et al,6 found no significant association of use of PREPs with sociodemographic variables, including education and total household income, but found that the interest in trying PREPs was higher among those with lower household income. On the other hand, some researchers have found no significant socioeconomic differences in either the use9 ,14 of, or interest9 in, trying PREPs. Some studies found that smokers’ perceptions of less health risks of such products was more likely among those with lower educational level,14 ,15 whereas some others found no association of educational level with the beliefs of risks from such products.10 We examined the association of socioeconomic status with the use of PREPs adjusting for some additional variables, such as nicotine dependence and intention to quit, adding to the literature on this topic that could help resolve some of these inconsistencies.
There are marked racial/ethnic differences in smoking prevalence,16 but little is known about how race/ethnicity is associated with the likelihood of use of PREPs. Hund et al6 found that, even though the awareness of these products was higher among African–Americans (63.9%) than Caucasians (39.9%) or Hispanics (28.7%), there were no racial/ethnic differences in either the use or interest in the use of these products. A study on the perceptions of PREPs among current smokers found that, non-Caucasians were more likely than Caucasians to believe that PREPs are less harmful for health than the regular cigarettes, but there were no racial differences in the interest in purchasing such products.14
Several surveys on regional variations in smoking prevalence in the USA have found that the prevalence of smoking was higher in the southern and midwestern regions than western and northeastern regions.17 ,18 However, the only study on regional variations in the use of PREPs that we were able to find, showed no significant association between the use of these products and region of residence.6 Further exploring of such regional variations is necessary to see if it follows a similar pattern as smoking so as to identify areas of focus for preventive measures. According to a recent report by the Centers for Disease Control,18 the current smoking rates do not vary much by different age groups. However, considering that the tobacco industry has always targeted younger adults for advertising,19 it is possible that such tactics might be used in relation to PREPs, resulting in increased use of these products among the young.5 The association of age and the use of PREPs has never been examined.
It has been shown that among those with an intention to quit, the perception of ‘less harm’ with light cigarettes is one of the reasons for their use of these cigarettes20 and for the continuation of smoking.14 Considering that PREPs are being promoted as being less harmful,21 those with an intention to quit might be more likely to use this product as an aid9 or substitute14 to quitting. Some researchers have suggested that those smokers with an intention to quit could succeed in quitting by switching to PREPs.5 Furthermore, it has been suggested that the marketing of PREPs as harm-reduction products is likely to appeal to the heavy smokers (high nicotine dependent) without an intention to quit, who might switch to this product as an alternative to quitting.9 In light of these findings, it is critical to know whether those who are highly nicotine dependent, but without an intention to quit, and those with an intention to quit, are more likely to use PREPs. Not much is known about the likelihood of use of PREPs by this vulnerable demographic, especially when accounting for many of the important covarites of smoking.
The aim of this study was to examine sociodemographic and smoking-related determinants of the use of PREPs among current smokers in the USA.
We used data from the 2006–2007 Tobacco Use Supplement to the Current Population Survey (TUS-CPS), sponsored by the National Cancer Institute and administered by the US Census Bureau in May 2006, August 2006 and January 2007.22 TUS-CPS is administered as a part of the CPS, which is a monthly national survey of representative households by the US Census Bureau and the Bureau of Labor Statistics. The TUS-CPS utilises a multistage probability sampling of individuals 15 years and older, from a sample of approximately 56 000 housing units, in turn selected from the about 792 primary sampling units. The average response rate for CPS for the 3 months that the surveys were administered, was 92%, whereas for the TUS it was 83% with approximately 75% of the data collected through self-response and the remaining responses being proxy responses. We limited the analysis to current smokers, 18 years and older. Current smokers were those who responded to the question, ‘Do you now smoke cigarettes every day, some days, or not at all?’ with either ‘every day’ or ‘some days’ (n=40 724).
Measurement of outcome: use of PREPs among current smokers
Respondents were informed ‘Now I'm going to ask about your use of new tobacco products that are sometimes claimed to have fewer harmful chemicals’, and then were asked, ‘Have you ever tried a product called …?’, for each of the eight PREPs; Eclipse, Accord, Arriva, Exalt, Revel, Omni, Advance and Marlboro Ultrasmooth. We created a dichotomous outcome variable for the use of PREPs that distinguished those who had responded ‘yes’ to the above question, from those who had said ‘no’.
Measurement of covariates
Age of respondents was categorised as 18–24, 25–39, 40–54 and 55+ years. Based on two separate questions about the race and Hispanic origin of the respondents, race/ethnicity was categorised as: non-Hispanic white, non-Hispanic black, Hispanic, non-Hispanic American Indian/Alaskan Native, non-Hispanic Asian/Hawaiian/Pacific Islander and other. Education was categorised as less than high school, high school diploma and some college, and bachelors or higher degree. Categories for occupation were professional, service, sales, farming, construction, production, unemployed and not in labour force (retired, students or disabled). Poverty status was calculated as a ratio of family income to the poverty threshold for a given family size for each of the survey years, and categorised as ≤100%, >100% and ≤200%, >200% and ≤300%, >300% and ‘no income information’, for those whose income information was not available. Other sociodemographic covariates included age, sex and region of residence.
Smoking-related variables used for this study were Heaviness of Smoking Index (HSI) and intention to quit. HSI, a short form of the Fagerstrom Tolerance Questionnaire,23 was used to measure nicotine dependence. HSI was categorised into scores ranging from 0 to 6, and was calculated by summing the points for time to first cigarette smoked after waking and the number of cigarettes smoked daily. For time to first cigarette, the scoring was: <5 min, 3 points; 6–30 min, 2 points; 31–60min, 1 point; and >60 min, 0 points. For the number of cigarettes smoked each day, respondents were asked, ‘On the average, about how many cigarettes do you now smoke each day?’ and were scored as: 1–10, 0 points; 11–20, 1 point; 21–30, 2 points and >31, 3 points. All the current smokers who only smoked ‘some days’ were assigned 0 points for both, time to first cigarette and number of cigarettes smoked each day. Higher HSI scores indicated more nicotine dependence.
Respondent were asked, ‘Are you planning to quit within the next 6 months?’ and those who answered affirmatively were categorised as having an intention to quit.
We used Stata 12.0 for all statistical analyses. We used Pearson χ2 tests to examine the differences in unadjusted percentages between those who had used PREPs and those who did not, across each of the covariates, age, sex, race/ethnicity, education, occupation, region, poverty status, HSI and intention to quit. Multivariate logistic regression was performed to estimate the association of these covariates with the use of PREPs to report the adjusted ORs and 95% CIs of using PREPs. To account for the complex sampling design of TUS-CPS survey, we used sample weights with the ‘svy’ (survey command) function in Stata for point estimates. In multivariate analysis, we used bootstrapping with 10 000 replications for the estimation of SEs in the regression analysis. Bootstrapping is a statistical technique that helps estimate the sampling distribution for a statistic by using multiple resampling with replacements, and this sampling distribution is then used for estimating SEs and CIs for that statistic.24
Table 1 presents the weighted sample characteristics and the percentages of current smokers who had tried PREPs, across the categories of the covariates, with 8.7% in the sample reported having used PREPs. At the bivariate level, age, race/ethnicity, education, occupation, poverty status, region of residence and intention to quit were associated with the use of PREPS. Respondents from the youngest age group of 18–24 years, had a higher percentage (12.74%) of those who had tried PREPs than those who were 25–39 years (9.24%), 40–54 years (7.24%) and 55+ years (6.96%). The percentage of non-Hispanic American Indians and Alaskan Natives who had tried PREPs was higher than any other racial/ethnic groups. The percentage of those with less than high school education who had tried PREPs was higher than those with higher levels of education. A higher percentage of those who were unemployed had tried PREPs than those who were employed or were not in labour force. Among the different occupational categories, those in production and service occupations had higher percentages who had tried these products than those in the professional, sales, farming and construction jobs. Compared with the more affluent respondents, those who were at or below the poverty threshold had a higher percentage who had tried PREPs. Those living in the west, south and midwest had higher percentages who had tried PREPs than those from the northeast. Compared with those with no intention to quit, respondents with an intention to quit had a higher percentage who had tried PREPs. No significant differences in the percentages of current smokers who had tried PREPs were found among different genders or among those with different HSI scores.
Table 2 presents the adjusted ORs and 95% CIs for the associations of the covariates with the use of PREPs. As in the bivariate analysis, we found that younger age and lower education were associated with higher likelihood of the use of PREPs. Those in the youngest age group of 18–24 year had 93% higher odds (95% CI 1.65 to 2.26) of having tried PREPs than those in the age group of 55+ years. Those with less than high school education had 26% higher odds (95% CI 1.05 to 1.51) of having tried PREPs than those with a bachelor or higher degree. Consistent with bivariate results, occupation and region were associated with the likelihood of the use of PREPs. Those who were unemployed had greater odds (OR: 1.34, CI 1.10 to 1.65) than those who were in professional jobs. Those from service (OR: 1.15, CI 0.97 to 1.36) and production (OR: 1.10, CI 0.92 to 1.30) occupations had greater odds of having tried these products than those from professional jobs, whereas those from construction (OR: 0.93, CI 0.77 to 1.12) had lower odds of using them. Respondents from the midwest (OR: 1.07, CI 0.94 to 1.23), south (OR: 1.18, CI 1.03 to 1.34) and west (OR: 1.19, CI 1.03 to 1.38) had higher odds of having tried PREPs than those from the northeast. Those with an intention to quit had 20% higher odds (CI 1.10 to 1.31) of having tried PREPs than those without an intention to quit. In multivariate analysis, the difference in having tried PREPs between males and females remained non-significant (p=0.546); differences between different HSI score levels became significant (p<0.001); those among different racial/ethnic groups became non-significant (p=0.065), and those among different poverty levels disappeared (p=0.129). Those with higher HSI scores had greater odds of having tried PREPs than those with the lowest HSI score of 0. Among different racial/ethnic groups, non-Hispanic blacks had the lowest odds (OR: 0.88, CI 0.74 to 1.05) and those in the ‘other’ racial/ethnic category had the highest odds (OR: 1.17, CI 0.87 to 1.57) of having tried PREPs.
In this study, we examined the determinants of the use of PREPs among current smokers. We found that younger age, lower education, higher nicotine addiction and having an intention to quit are associated with higher likelihood of the use of PREPs. The results revealed that the likelihood of using these products is higher among respondents who are unemployed or have a service, production, sales or farming occupation than those with a professional occupation. We also found that smokers living in the midwest, south or west, have greater likelihood of use of PREPs than those from the northeast.
The finding that younger smokers are more likely to try PREPs is consistent with concerns that experimentation with such products is quite likely among young adults.5 On the other hand, it is inconsistent with the finding of perception of lesser health risk of these products among older smokers,15 who might be predicted to be using it more. Many young adults who experiment with smoking, give up smoking in a few years before becoming regular smokers14 but the higher likelihood of use of PREPs among them points to the possibility that the claims of ‘reduced harm’ from these products might be an incentive for this group to take up, continue smoking and become lifelong addicts.
Our result that lesser education was associated with a higher likelihood of PREP use is consistent with the direction of previous findings that a lower educational level was significantly associated with the perception of PREPs as less risky to health.15 The significant association between poverty level and the likelihood of use of PREPs that we observed at the bivariate level disappeared in multivariate analysis. This occurred due to controlling for age. Younger people are more likely to be poor and, as shown here, are more likely to use PREPs. This lack of association was consistent with previous literature6 Inconsistent with previous literature,6 ,9 we found that overall, those from lower socioeconomic groups (less educated, unemployed, non-professional occupations) are more likely to have tried PREPs. This inconsistency might be a result of the use of a more recent data with use of a few different variables, for instance, nicotine dependence and intention to quit, in our study that were not included in these previous studies. Smokers from these groups are known to have longer duration of smoking and face financial hardships.25 The possible use of PREPs by this group as a substitute to regular cigarettes might further prolong their duration of smoking, considering that they perceive these products as ‘safer’14 ,15 than regular cigarettes. Their use of PREPs in addition to the regular cigarettes is likely to add to their financial hardships, as these products cost about as much as regular cigarettes and no less.21 Overall, this is likely to further exacerbate the burden of tobacco use faced by them.
The lower likelihood of the use of PREPs among those from the northeast than those from other regions was inconsistent with previous studies, which did not find any association between region of residence and use of PREPs.6 A possible reason for this inconsistency could be the inclusion of an additional set of PREPs, Arriva, Exalt, Revel, and Marlboro Ultrasmooth, in our study, whose regional availability might be different than the PREPs in those studies. For example, Slater et al,21 found that while Arriva was more likely to be available in the south, Omni was more likely to be available in the midwest and the northeast. Another possible reason for the observed regional difference could be that the prices of PREPs relative to other tobacco products are higher in the northeast. Previous research21 exploring the prices of PREPs in comparison with regular cigarettes only focused on two products, Omni and Arriva. This is an issue that can be investigated in future research.
An important finding of the study, which is consistent with previous research,9 was the higher odds of the use of PREPs among those with an intention to quit. This is probably because smokers with an intention to quit are more likely to believe that these products are less harmful to health,14 and thus, may end up trying and to continue using PREPs instead of quitting.6 However, it should be noted here that the cross-sectional nature of this study does not allow us to account for the temporal sequence of trying the PREP and having the intention to quit. The increased likelihood of the use of PREPs among those with high HSI scores, could be indicative of the beliefs among them about the reduced harm of these products9 and might be an effort on their part to reduce the risks to their health or to reduce their nicotine dependence.5
So far, no substantial evidence has been produced to assure if there is an actual harm reduction achieved with the use of PREPs. The marketing of these products as those with decreased health risk has potential to hamper cessation efforts in those with an intention to quit and is also likely to make them continue smoking longer. Such tactics could very well entice former smokers to pick up smoking again, and for youngsters to try them. The increased likelihood of use of these products by the younger adults is alarming in that it could set a precedence for experimentation and addiction to tobacco products in later life. The marketing and use of these products has implications for public health in that efforts will need to be directed toward policies on advertisements of PREPs and on educating people about the actual harms associated with these products in terms of health and behavioural risks.
Although these products have been commercially unsuccessful,5 the tobacco industry is likely to put in substantial efforts in promoting them in lieu of dwindling smoking prevalence in the USA, and the most likely consumer targets could be the young and the smokers who are willing to cut down or quit. Future research needs to focus on examining the actual harmful contents in these products, the reasons for increased likelihood of use of these products among the young, among those from lower socioeconomic groups, among heavy smokers and among those with an intention to quit. A longitudinal study could shed light on the long-term effects of PREPs on health and smoking behaviour.
Limitations of the study include the cross-sectional design of the TUS-CPS that prevents establishment of causal relationship between covariates and the use of PREPs. A second limitation is the use of self-reported data, which could be an issue especially when it comes to self-portrayal. For instance, some respondents might report higher than actual education or income, which could lead to biased estimation of those variables. Another limitation was the use of proxy responses in TUS-CPS. Proxy responses were collected from another member of the family at the fourth attempt if the individual to be interviewed was not available at the first three attempts. Such proxy responses, especially in relation to the younger age group, could have resulted in under-reporting of smoking and use of PREPs among this group. In addition, there was a large proportion of respondents whose income information was not available, and even though we included them in our analysis as a no-income information category, knowledge of their income could have potentially changed the distribution of the poverty status variable and its subsequent association with the likelihood of use of PREPs. Finally, in addition to the possibility of responses to the questions about PREPs such as Omni, Eclipse and Accord being confounded by the availability of popular consumer products with the same names,26 there is also a possible overestimation of our outcome measure because the use of the PREPs was measured as a positive response to the question about using any one of the eight PREPs.
Despite these limitations, our study provides valuable insights into the characteristics of the smokers most likely to try PREPs. This information could be vital in guiding future research, policies and programmes aimed at marketing, use, prevention and effects of PREPs.
What this paper adds
This paper adds to the existing literature on Potential Reduced Exposure Products which is limited mainly to the perceptions, attitudes, knowledge and beliefs about these products.
As these products are being marketed as less harmful, the knowledge of determinants of probable use of these products is essential to guide future tobacco control policies, especially those aimed at the advertising/marketing of these products.
This paper provides information about the determinants of the use of these products and fills a gap in the knowledge in this area.
Contributors We assure that all authors included on a paper fulfil the criteria of authorship. All have contributed in the conception and design, analysis and interpretation of data, drafting of the article and revising it critically for important intellectual content, and final approval of the version to be published. In addition we also assure that there is no one else who fulfils the criteria but has not been included as an author.
Competing interest All authors have completed the Unified Competing Interest form (available on request from the corresponding author). We declare that no support was received from any organisation for the submitted work, and that there was no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years, neither did we have other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement We declare that we have used secondary data from the TUS-CPS surveys for this research, and there is no additional unpublished data from this study. The secondary data used in this study is available on request from the corresponding author.
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