TM December 10-12, 2003 National Conference on Tobacco or Health Boston, MA Michelle O’Hegarty, PhD Nisha Gupta, MPH Patricia Richter, PhD, DABT Office on Smoking and Health

TM The purpose of the focus groups was to provide qualitative information on: Perceptions of bidis, herbal cigarettes, shisha, smokeless herbal chew, cigars and clove cigarettes (kreteks) Perceived health risk associated with the use of non-traditional products Factors influencing the use on non-traditional products (e.g., personal, social, environmental) TM

Research Questions What factors influence trial and use of NTPs by young adults? What do young adults consider to be the health risks associated with using these products? Are the factors that influence using NTPs the same among different groups of youth adults? (e.g., White, African American, Hispanic/Latino, college, not in college)

TM Methods In April 2002, ORC Macro and the Centers for Disease Control and Prevention conducted 16 focus groups with male and female young adult smokers between the ages of 18 and 22. Focus groups were conducted in Chattanooga, Tennessee and Dallas, Texas. Participants for the study were recruited by random phone calls placed by the recruiting facility’s telephone center, and newspaper ads. There were 136 participants (68 college smokers and 68 not in college smokers)

TM Methods Focus groups were segmented by college and not in college status and by race, but not by gender. All participants received a $50.00 incentive in appreciation of their time and willingness to participate in the study.

TM Definition and Description of Smokers A smoker was defined as someone who had smoked a cigarette in the past 30 days. 81 of the 136 smokers said they smoked on a daily basis. The majority of the participants said that they began smoking in middle school or high school. Involvement with NTPs was defined as having tried at any time and/or used at least one of the six products chosen for this study.

TM Products Bidis Kreteks (Clove Cigarettes) Shisha Smokeless Herbal Chew Herbal Cigarettes Cigars

TM Kreteks (Clove Cigarettes)

TM Cigars

TM Herbal Cigarettes

TM Shisha Other names for water pipes include: Nirgille (Arab Countries, Turkey) Hookah (India, Persian) Hubble Bubble (Arabic Countries) Gaza (Arabic Countries)

TM Shisha (continued)

TM DATA Analysis The analysis process was divided into three phases which include codebook development, code application and analysis. Transcribed audiotapes of the focus groups were used to facilitate analysis of the discussions. NUD*IST, a qualitative software program, was used to analyze the data.

TM Findings Participants reported using bidis, kreteks, and cigars most often. Reasons for smoking NTPs among focus group participants were influence of family and friends, substitute for cigarettes and curiosity. Reasons for continued use of NTPs include smell, taste, strength, duration, cost and convenience. “[Bidis] taste and they smell good, so it’s more like incense that sticks to you rather than tar.” –White, College

TM Findings “I would probably smoke clove cigarettes 90% of the time just because I make them last longer since they’re stronger.” –White, Not in College “I like Swisher Sweets and Black & Milds. I think they are a little bit smoother but for me they are stronger. I only smoke them when I drink… it kind of intensifies everything else.” –Hispanic, College “[Black & Milds] cost less than cigarettes, that’s the only reason I smoke them now.” –African American, College

TM Findings Participants indicated that they used NTPs at parties, clubs and special occasions, and daily use was rare. “We were in a nightclub and we were drinking and I ran out of cigarettes and a female that was there with us, I asked her for one because she had some. That’s how I tried it [Bidis].” – Hispanic, Not in College NTPs were used by some as substitutions for cigarettes. “Actually I think [I tried them] because I was out of cigarettes and all my friends were smoking [Black & Milds].” –White, Not in College

TM Findings “If I have a Black [& Mild] and a full pack of cigarettes, I will smoke the last Black [& Mild] before I open that pack of cigarettes, because you just get more from smoking the Black [& Mild] than from smoking a cigarette.” –African American, College “I tried Bidis and Black & Milds because we were out of cigarettes and that was our last resort and we had that nicotine addiction. That’s the only time I’ve ever tried it.” –Hispanic, College “A friend of mine left hers [Kreteks] in my car one day. I was drunk and needed a cigarette. And [the Kretek] was there and I smoked it.” –African American, College

TM Findings Swisher Sweets were used to hide and assist in the use of illegal drugs such as marijuana. “…When I started smoking weed, that’s when I got the Swishers. Like he said, [we] split them open and roll a tighty.” –African American, College “…Anybody that buys [Swisher Sweets] they are either just hanging out on a Saturday night and they just don’t want to smoke cigarettes or they’re using it to roll a blunt.” –White, College

TM Young Adults Perceptions of NTPs African-Americans smoke more Swisher sweets and Black & Milds compared to other racial groups. (All groups) Swisher Sweets and Black & Milds are more common among men compared to women. (All groups) Social and Environmental factors influence use. (African American & Hispanic/Latino) College students are more likely to use NTPs compared to people who are not in college. (African American & Hispanic/Latino)

TM Young Adults Perceptions of the Health Risks of NTPs Swisher Sweets and Black and Milds are more harmful than regular cigarettes. (White & Hispanic/Latino) Black and Milds are safer than regular cigarettes. (African American) Herbal cigarettes are safer than regular cigarettes. (Hispanic/Latino) Kreteks are more harmful than regular cigarettes. (White)

TM Differences Between College and Not In College Participants Participants in college were more likely than participants not in college to view the cost and inconvenience of purchasing the products as a reason for not using NTPs. “If I could I would still smoke Swishers, but my friend has the hookup so he buys it [Cloves] every once in a while, but it’s like really expensive and you can only get it in certain places.” –White, College “I don’t dislike them [Cloves], but I wouldn’t go sit up and buy a pack of them…they are too much.” –African American, College

TM Differences Between College and Not In College Participants Not in college participants were more likely than college participants to perceive differences in NTP use among different age groups. “I think when you’re younger is when you try it, but you grow out of it” –White, Not in College Participants not in college were more likely than participants in college to discuss the health risks of NTPs. “I used to smoke [Black & Milds]…but it makes my head hurt and my stomach hurt. They are too strong for me.” –Hispanic Not in College

TM Summary Across Groups There were no racial differences in reasons for trying non- traditional products. Participants reported using bidis, kreteks and cigars most often. Participants indicated that they used NTPs at parties, clubs, and on special occasions--daily use was rare. NTPs were used by some as substitutes for cigarettes. Swisher Sweets were used to hide and assist in the use of illegal drugs such as marijuana. Reasons for continued use of NTPs include smell, taste, strength, duration, cost and convenience.

TM Study Limitations Findings from the study are not generalizable to the population as a whole Recruitment was not completely representative Small sample size

TM Recommendations for Future Studies Conduct quantitative and qualitative research on NTPs in areas where NTPs are known to be easily available and where early adoption of new products and fads occurs. Segment groups by gender to determine differences or similarities in use of NTPs. Select participants who have tried and used several of the NTPs instead of at least one of the NTPs as was the case for this study.

TM Recommendations for Future Studies Conduct message testing with young adults on the health risks associated with NTPs. Include African-Americans in the development and testing of health communication messages that address the health risks associated with the use of Black & Milds and Swisher Sweets.