Gender and racial differences in smoking of long/ultra-long and king size cigarettes among U.S. adult smokers, NHANES 1999–2012
Introduction
The initiation and continuation of tobacco use is driven not only by the pharmacologic addictiveness of tobacco products (i.e., abuse liability), but also by product design features which may increase their attractiveness to consumers and potential consumers (i.e., product appeal). The World Health Organization's (WHO) Framework Convention on Tobacco Control Article 11 calls on member nations to ensure that no tobacco product is promoted by means that are misleading, or likely to create an erroneous impression about its health effects or relative harm (World Health Organization, 2003). Consequently, the use of descriptors such as “light,” “low,” “mild,” or other similar labels on tobacco products has been banned in the U.S., the European Union, as well as several low and middle income countries, including South Africa, Seychelles, Togo, India, Nepal and Philippines (CDC, 2010, European Commission, 2013, Campaign for Tobacco-Free Kids, 2013).
As in several other countries (Euromonitor International, 2013), cigarettes available in the U.S. are categorized into four lengths: regular (68–72 mm); King (79–88 mm); Long (94–101 mm); and ultra-long (110–121 mm), with regular and ultra-long brands accounting for just small segments of the total U.S. domestic market share (3% and 2% respectively in 2011; Federal Trade Commission (FTC), 2013). Although King size cigarettes have dominated the U.S. cigarette market (59% of the total market shares in 2011), long brands have seen a growth in total domestic market shares in recent years (from 30% in 2008 to 37% in 2011; FTC, 2013). Similar upward trends in market shares for long brands have also been reported in several other countries during 2008–2012, including Georgia (2.6%–9.5%), Egypt (8.5%–12.5%), Russia (9.7%–13.2%), Hungary (12.0%–21.0%), and Croatia (13.2%–23.8%). In addition, during 2012, long brands held a relatively large percentage of the cigarette market in the United Kingdom (22.3%), Turkey (27%), South Korea (34%), and Romania (35%) (Euromonitor International, 2013). It is interesting to note the emergence of long and slim design features in novel products such as electronic cigarettes.
These market shifts in favor of long brands in several countries around the world may provide some insight into consumer behavior at a population level, and further highlight the need for more research on risk perceptions and health communication. Previous research has shown that esthetic features of cigarettes including stick color, length, and branding design elements such as patterns and logos may be associated with increased appeal and altered risk perception among smokers (Borland and Savvas, 2013, Kotnowski and Hammond, 2013, Mutti et al., 2011, Ford et al., 2013a). In addition, internal tobacco industry documents have shown that long/ultra-long cigarettes were particularly attractive among certain population subgroups based on the perceptions that such longer brands were more sophisticated and modern products with a particular appeal to limited typological groups such as women, and people of a higher status, and were designed especially to be used in social situations where added length would be fully appreciated both in terms of extended enjoyment and the added status value (Carpenter et al., 2005a, Carpenter et al., 2007).
A closer examination of cigarette design characteristics and their effect on product appeal and smoking susceptibility is important, given the enormous health and economic burden of smoking in the U.S. (CDC, 2008). Furthermore, since targeted tobacco product marketing may result in disparities in tobacco use and its aftermaths, an assessment of demographic differences in receptivity to tobacco marketing may help in formulating tailored policies to reduce such disparities. In addition, more information on cigarette design features in the U.S. is warranted and timely given that product standardization is starting to appear on the international tobacco control agenda, e.g., in Australia, as part of the plain packaging legislation, and in the European Union, as envisaged in the European Commission's draft Tobacco Products Directive (Australian Government, 2013, European Commission, 2013).
While several studies have assessed design features such as packaging, “light cigarettes,” flavors and other smoke-masking design features (Ford et al., 2013a, Behm et al., 2013, Caruso and O’Connor, 2012, Carpenter et al., 2005b, Kennedy et al., 2013), little population-based information exists on cigarette rod length as a design characteristic. To fill this gap in knowledge, this study assessed trends and correlates in current smoking of regular, king size, and long/ultra-long cigarettes among U.S. adults aged ≥20 years during 1999 through 2012 using nationally representative data from the National Health and Nutrition Examination Survey (NHANES).
Section snippets
Sources of data
NHANES is a household interview and examination survey that uses a complex multi-stage probability sampling design to select participants from the non-institutionalized U.S. population (CDC, 1999). We analyzed seven consecutive waves of the NHANES, with overall response rates (%) and sample sizes (n) for the interviewed sample by survey year as follows: 1999/2000 (82.0%; n = 4880), 2001/2002 (84.0%; n = 5411); 2003/2004 (79.0%; n = 5041); 2005/2006 (80.5%; n = 4979); 2007/2008 (78.4%; n = 11,870);
Long/ultra-long cigarettes
A significant decline in the overall prevalence of long/ultra-long cigarette use among all current smokers was observed between 1999 and 2012 (from 43.1% to 38.7%; p < 0.001 for both linear and quadratic trends; Table 1, Fig. 1). Despite this overall decline, during more recent years, the proportion of current smokers who reported smoking long/ultra-long cigarettes has begun to increase (from 29.7% in 2007/2008, to 38.7% in 2011/2012, p = 0.015; Fig. 1).
Significant declines during the 1999 through
Discussion
Our findings indicated that despite the overall declines in current smoking of long/ultra-long cigarettes during 1999 through 2012, the proportion of smokers of long/ultra-long brands increased in recent years. The overall trend line thus showed series of continuing declines between 1999 and 2008 (from 43.1% to 29.7%), whereas an upward trend was observed in more recent years (32.4% during 2009/2010, and 38.7% during 2011/2012). As shown in Fig. 1, this trend shows a striking resemblance to
Conclusions
This study demonstrated that despite the overall declines in current smoking of long/ultra-long cigarettes during 1999 through 2012, the proportion of smokers of long/ultra-long brands has increased in recent years, with over a third of current smokers reporting smoking of long/ultra-long cigarettes during 2011/2012. Notably, smokers of long/ultra-long cigarettes were of specific racial, gender and age characteristics – being more likely to be black rather than white; female rather than male,
Role of funding source
Funding for this study was provided by the National Cancer Institute (grant numbers NCI 3R01 CA125224-03s1rev++, NCI 2R01 CA087477-09A2); the National Cancer Institute had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
AIT designed the study, analyzed the data, and wrote the first draft of the manuscript. CIV, OAA-Y, HA, and GNC contributed to data interpretation and were involved with extensive writing and editing of the paper. All authors contributed to and have approved the final manuscript.
Conflict of interest
The authors have no conflicts of interest relevant to this article to disclose.
Acknowledgements
Dr. Israel Agaku initiated the reported research while affiliated with the Center for Global Tobacco Control at Harvard University. He is currently affiliated with the Centers for Disease Control and Prevention's Office on Smoking and Health. The research in this report was completed and submitted outside of the official duties of his current position and does not reflect the official policies or positions of the Centers for Disease Control and Prevention.
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