Affect Predicts Small Cigar Use in a National Sample of US Young Adults

Kymberle L. Sterling, DrPH, MPH Dina M. Jones, MPH Ban Majeed, PhD Amy L. Nyman, MA Scott R. Weaver, PhD

Objectives. Affect is an important dimension of risk perceptions, which are proximal determi- nants of little cigar and cigarillo (LCC) . We examined the association among affect, risk perceptions, and current LCC use and susceptibility in a national probability sample of US young adults, aged 18-29. Methods. Structural equation models examined the effect of affect, via risk perceptions, on LCC current use and susceptibility for 772 young adults who took the 2015 To- bacco Products and Risk Perceptions Survey, which asked about affect for images related to LCCs and health risks of daily LCC use. Results. Positive affect toward LCCs was associated with lower perceived risks of daily LCC smoking (p < .001). Lower perceived risks were associated with high- er probability of current LCC smoking (p = .008) among young adults who were aware of LCCs and with susceptibility to use among young adult never LCC users (p < .001). A direct effect of positive affect on current LCC use (p < .02) and susceptibility to use LCCs also was found.Conclu - sions. Future research should investigate how regulatory policy or enforcement actions can be used to regulate LCC components (eg, flavoring, advertising, etc) that influence affect and risk perceptions.

Key words: little cigar; cigarillo; risk perception; young adults, Tob Regul Sci.™ 2019;5(3):253-263 DOI: https://doi.org/10.18001/TRS.5.3.4

s smoking continues to decline, used concurrently with or other tobacco use of other combustible tobacco prod- products.6-8 Though reasons for LCC use are not ucts, such as cigars, has increased among well documented, some young adults report using youngA adults.1 Cigars are a heterogenous tobacco LCCs for their social benefit.9 Some LCC smokers product with several types: little cigars, filtered ci- with a history of cigarette use may use LCCs to gars and cigarillos, and large or premium cigars.2 complement or substitute their cigarette smoking Little cigars, filtered cigars, and cigarillos (also while others may use the products to help them known as LCCs) are cigarette-like products that quit cigarette smoking.10 Regardless, LCC use is are often flavored,3 heavily marketed, and inex- likely to cause nicotine addiction in tobacco-naïve pensive alternatives to cigarettes.4 According to smokers or maintain it in current smokers and lead the 2013-2014 Population Assessment of Tobacco to detrimental health effects, particularly if product and Health (PATH) study, 10.7% of 18-24-year- use is sustained over long periods of time or dual olds were current cigarillo smokers and 3.5% were used with other tobacco products. current filtered cigar smokers.5 LCCs are often Young adult LCC users report positive affect for

Kymberle L. Sterling, Associate Professor, University of Texas Health Sciences Center, School of Public Health, Dallas Regional Campus, Dallas, TX. Dina Jones, Georgia State University, School of Public Health, Tobacco Regulatory Sciences Center, Atlanta, GA. Ban Majeed, Assistant Professor, Augusta University, Medical College of Georgia, Augusta, GA. Amy Nyman, Georgia State University, School of Public Health, Tobacco Regulatory Sciences Center, Atlanta, GA. Scott R. Weaver, Assistant Professor, Georgia State University, School of Public Health, Tobacco Regulatory Sciences Center, Atlanta, GA. Correspondence Dr Sterling; [email protected]

Tob Regul Sci.™ 2019;5(3):253-263 253 Affect Predicts Small Cigar Use in a National Sample of US Young Adults

LCCs.9,11,12 Affect is a subtle form of emotion, de- to understand how affect for LCC smoking im- fined by positive (ie, liking) or negative (ie, dislik- ages and risk perceptions of health effects associated ing) evaluative feelings toward an external stimulus with LCC smoking influenced: (1) current LCC (eg, a cigarillo, the act of smoking, or images of use among the entire sample of LCC-aware young cigarillos and smoking). Nyman et al found that adults regardless of use status (including those who adult current LCC smokers endorsed several af- were ever LCC users and never users); and (2) sus- fective reasons for LCC use, including “feeling ceptibility to smoke LCCs among young adults relaxed,” “enjoy the smell,” or “gives me a good who were aware but were never users of LCC. We buzz.”13 In a prior study, Sterling et al reported that hypothesized that: (1) affect is associated with cur- sweet and fruit flavored LCCs and the visual, smell, rent LCC use and susceptibility to smoke LCCs; and taste cues of LCC packaging impacted young and (2) this relationship would be mediated by risk adult cigarette-only and dual cigarette and LCC perceptions about the health effects of LCC tobacco smokers’ affect for LCCs.14 Affect is important to use. Testing this relationship may provide insight understanding the appeal of LCCs and their up- into the affective, cognitive and behavioral aspects take among young adults.15 of the smoking uptake and continuation process. Perceptions of risk are also important predic- tors of LCC smoking behavior.16,17 Several studies METHODS have shown that some young adults endorse low Study Procedures perceived risks of LCCs, with many reporting that We obtained data for this study from the 2015 any cigar use (including LCCs) is less harmful than 18-21 Tobacco Products and Risk Perceptions Survey, cigarette use. Notably, Sterling et al found that conducted by the Georgia State University Tobacco positive affect towards LCCs was an important Center of Regulatory Science. This survey is an an- dimension for the formation of risk perceptions nual, cross-sectional survey of a probability sample among young adult dual cigarette and LCC smok- 14 drawn and representative oversample of pre-identi- ers. These findings are consistent with Slovic’s risk fied cigarette smokers from GfK’s Knowledge Pan- perception research, which suggests that smokers el. GfK’s Knowledge Panel is a probability-based give very little conscious thought to risk. Though web panel designed to be representative of non-in- aware that smoking causes some amount of harm, stitutionalized US adults. Data collection occurred smokers have very limited and often unrealistic through August and September 2015. Participants knowledge of the risks and consequences of smok- completed the main survey in 25 minutes and re- ing. Rather, their risk decisions are motivated by ceived a cash-equivalent of $5 for their participa- affect (ie, positive or negative evaluative feelings to- tion or $10 if they had not completed the survey ward smoking) instead of an analysis of facts and within the first 13 days of data collection. consequences.22 Slovic’s theory is consistent with studies that suggest that young adult smokers re- Overall, we invited 8135 KnowledgePanel mem- port affective reasons for smoking LCCs (ie, fun to bers to participate in the survey: 7194 members for smoke) and that they have superficial knowledge of the general population sample, of which 76.4% the dangers of LCC smoking (ie, less harmful than completed the screener survey and 5497 quali- cigarettes).9,12,20 The US Food and Drug Admin- fied for the main survey; and 941 members for the istration (FDA) is seeking research to understand smoker augment sample, of which 72.6% com- consumers’ perception of LCCs to inform future pleted the screener and 594 qualified for the main regulatory actions.23 Building on prior studies and survey by confirming their current smoking status. Slovic’s risk perception research findings24 as a guid- Of the 6091 qualified completers, 40 cases were ing conceptual framework, we tested the association excluded due to refusing to answer more than one- among affect, risk perceptions, and LCC smoking half of the substantive survey questions, yielding behavior among a national probability sample of 6051 cases. A final stage completion rate of 76.0% US young adults, aged 18-29 years. Our rationale and a qualification rate of 98.5% were obtained. for examining all young adults (regardless of ciga- rette smoking history) is that this group is more Study Sample Description susceptible to LCC use.25 Specifically, we sought Data for the current study come from young

254 Sterling et al adult survey respondents, aged 18-29 years old (N smoke little cigars, cigarillos, or filtered cigars ev- = 948, or 15.6% of 6051 respondents). Of the 948 ery day? The conditions included lung cancer; lung respondents, 50.6% were male and 55.2% identi- disease other than lung cancer (such as COPD and fied as white, non-Hispanic, 12.2% identified as emphysema); heart disease; become addicted; and black, non-Hispanic, 21.4% identified as Hispan- early/premature death. Response options for each ic, and 11.2% identified as being a member of an condition ranged from 0 - 7, with 0 = “no chance” “other” racial/ethnic group. and 7 = “very good chance.” “I don’t know” re- sponses were coded as ‘9’. Measures LCC awareness, lifetime and current use. Respondent characteristics. Respondent char- Awareness of LCCs was assessed by asking respon- acteristics including sex, age, race/ethnicity, educa- dents if they had heard of any type of little cigars, tional attainment (less than high school education, cigarillos, or filtered cigars before taking the survey. high school diploma, some college, bachelor’s de- Respondents were provided with brand names of gree or higher), annual household income (a con- popular LCC brands (eg, Black & Mild, Swisher tinuous variable from less than $5000 to $175,000 Sweets) and also were shown non-brand specific or more), US Census region, perceived health images of little cigars, cigarillos, and filtered cigars status, and sexual orientation were obtained from to facilitation recognition of the products. Life- profile surveys administered by GfK to Knowl- time LCC use was assessed by asking respondents edgePanel panelists. who were aware of LCCs, if they had ever smoked Affective measures. Respondents were asked LCCs, even one or 2 puffs. Respondents who re- 2 questions: “When you hear the phrase little ci- ported that they had never smoked LCCs in their gars, cigarillos, or filtered cigars, what is the first lifetime were considered never LCC smokers; those thought or image that comes to mind? Please just who had ever smoked were considered lifetime list one thought or image.” The image and thought smokers. responses generated from this open-ended ques- To assess current LCC smoking, lifetime LCC tion were qualitatively analyzed and categorized smokers were asked: “Do you now use little cigars, as “good,” “bad,” or neutral. Additional details cigarillos, or filtered cigars every day, some days, about study findings related to this question can be rarely, or not at all?’’ Young adults who responded found in a manuscript by Majeed et al.26 Next, par- “every day” or “some days” were considered cur- ticipants were asked corresponding items to assess rent smokers, while those who responded “rarely” affect: “How do you feel about this thought or im- or “not at all” were not considered current smokers. age? Please rate this thought or image and not the Based on responses, we created a current LCC use phrase ‘little cigars, cigarillos, or filtered cigars’ it- variable with dichotomized response options: yes self.” Response options included 1 = “very good,” 2 (ie, those who reported smoking LCCs “every day” = “somewhat good,” 3 = “both good and bad,” 4 = or “somedays”) and no (ie, those who reported us- “somewhat bad,” and 5 = “very bad.” The question ing LCCs “rarely” or “not at all”). was repeated, asking respondents to rate their feel- Susceptibility to LCC smoking was assessed by ings about the second thought or image that comes asking never LCC smokers: “Do you think you will to mind. These measures of affect have been used in try a little cigar, cigarillo, or filtered cigar soon?” prior studies that have assessed perceptions of risk “Have you ever been curious about smoking a little among young people and have been validated for cigar, cigarillo, or filtered cigar?” and “If one of this target group.24 your best friends were to offer you a little cigar, cig- LCC risk perception. We asked respondents arillo, or filtered cigar, would you try it?” Response about the risk of experiencing health outcomes options included 1 = “definitely yes,” 2 = “probably because of daily LCC smoking. Respondents were yes,” 3 = “probably not,” and 4 = “definitely not.” asked to: “Imagine that you just began smoking Cigarette smoking status. Respondents who little cigars, cigarillos, or filtered cigars every day. reported smoking at least 100 cigarettes in their What do you think your chances are of having each lifetime were asked: “Do you currently smoke ciga- of the following happen to you if you continue to rettes every day, some days, or not at all?’’ Those

Tob Regul Sci.™ 2019;5(3):253-263 DOI: https://doi.org/10.18001/TRS.5.3.4 255 Affect Predicts Small Cigar Use in a National Sample of US Young Adults who responded “every day” or “some days” were in the analysis if they have at least one non-miss- considered current cigarette smokers, whereas ing data point, assuming missing at random given those who responded “not at all” were considered observed covariates for the WLSMV estimator. former cigarette smokers. Those who reported that Responses of “don’t know” for the risk perception they had not smoked at least 100 cigarettes in their items were modeled as missing data for all analyses. lifetime were considered never cigarette smokers. RESULTS Data Analysis Participant Sociodemographic and Smoking Testing the conceptual model is a 2-step pro- Characteristics cess.27 First a measurement model, that includes Table 1 presents the sociodemographic and items that assessed affect, risk perceptions, and sus- smoking characteristics of our young adult sample. ceptibility, was tested to establish factorial validity Weighted percentages and unweighted sample sizes of the constructs. We did not assess the factorial are presented in the table. Of the total sample of validity of current LCC use, as it was measured by 948 young adult respondents, the majority (81.4%, a single item. We used ordinal confirmatory factor N = 772) were aware of LCCs. Over half of these analysis (CFA)28 to examine the factorial validity respondents were men; the majority (57.6%) were of the measurement models for the affect, risk per- white; and 39.0% had earned a high school diplo- ceptions, and susceptibility constructs. A mean- and ma or less. Among those who were aware of LCCs, variance-adjusted weighted least squares estimator 44.5% had ever used LCCs in their lifetime, 5.9% (WLSMV) was used for the CFA models. Using were current LCC users (defined as those who have criteria suggested by Hu and Bentler,29 model fit used LCCs ‘every day’ or ‘some days’) and roughly was assessed by examining the chi-square test of 17% were currently smoking cigarettes. Among exact fit; root mean square error of approximation those who was aware of LCCs but never used them [RMSEA]; comparative fit index [CFI]; and the (N = 404), the majority were women; 58.5% were magnitude and consistency of factor loadings. white; 38.1% had earned a high school diploma In the second stage, we used structural equation or less, and roughly 6% were currently smoking modeling (SEM) to estimate the parameters of the cigarettes. hypothesized mediation model, which tested the ef- fect of affect, via risk perceptions, on (1) current Measurement Model LCC use for young adults who were aware of LCCs The CFA measurement model for affect toward and may have had a history of LCC use, and (2) LCCs, risk perceptions of daily LCC use and sus- susceptibility to use LCCs among young adults who ceptibility to use LCCs among all young adults who were aware of LCCs but had never used them. The were aware of LCCs had an excellent fit to the data models were adjusted for covariates, including sex, [χ2(32) = 55.6, p < .01; RMSEA=0.04, CFI=1.00]. age, race/ethnicity, education, income and ciga- Standardized parameter estimates for the models rette smoking. Along with covarying for cigarette are presented in Table 2. Standardized factor load- smoking, we examined the association among ciga- ings ranged from 0.84 to 0.99. The measurement rette smoking status, affect and risk perceptions for model indicated that the positive affect factor was LCCs. A probit link function was used to model the negatively correlated with risk perceptions factor (r probability of being a current LCC smoker or sus- = -0.25, p < .001) and positively correlated with ceptible to LCC use as a function of affect, risk per- the susceptibility to use LCCs factor (r = 0.31, p = ceptions, and covariates. The chi-square test of exact .001). The risk perceptions factor was also negative fit, RMSEA, and CFI were used to assess model fit. correlated with the susceptibility factor (r = -0.26, All analyses reported were conducted in MPlus p < .01). statistical software (v. 7.4, Muthén, 2010) and were weighted to account for the complex sampling de- sign and generate estimates generalizable to the sub- Association among Affect, Risk Perceptions, population of US young adults who are aware of and Current LCC Smoking Behavior LCCs. Participants with missing data are included The conceptual model that depicted the relation-

256 Sterling et al

Table 1 Sociodemographic and Smoking Characteristics of a National Probability Sample of Young Adults, Aged 18-29 Years Young adults who are aware of Young adults who are aware of Characteristics LCCs LCCs but never used them (N = 772) (N = 404) Unweighted N Weighted % Unweighted N Weighted % Sex Men 457 52.5 153 46.8 Women 315 47.5 251 53.2 Race/Ethnicity White, non-Hispanic 487 57.6 254 58.5 Black, non-Hispanic 85 13.4 47 12.4 Hispanic 128 20.2 68 20.5 Other 72 8.8 35 8.6 Education Less than high school 68 17.1 37 17.4 High school 174 21.9 93 20.7 Some college 287 34.7 138 35.9 Bachelor’s degree or higher 243 26.3 136 26.0 Cigarette Smoking Current Smokers 190 17.1 44 6.5 Former Smokers 91 12.7 21 4.7 Never Smokers 491 70.1 339 88.8 Ever LCC Smoking Yes 368 44.5 No 404 55.5 Current LCC Use Yes 42 5.9 No 729 94.1 Curious about LCCs Definitely not 312 75.9 Probably not 51 13.6 Probably yes 39 10.2 Definitely yes 2 0.3 Try LCCs soon Definitely not 332 81.9 Probably not 61 14.5 Probably yes 10 3.3 Definitely yes 1 0.3 If a friend offered an LCC, would you try it? Definitely not 301 74.4 Probably not 69 16.6 Probably yes 32 8.9 Definitely yes 1 0.1

Tob Regul Sci.™ 2019;5(3):253-263 DOI: https://doi.org/10.18001/TRS.5.3.4 257 Affect Predicts Small Cigar Use in a National Sample of US Young Adults

Table 2 Standardized Parameter Estimates for Items assessing the Affect, Risk Perception, and Susceptibility Constructs among Young Adults who were Aware of LCCs Construct Items Factor Loadings Think about the first thought or image that comes to mind when you hear the phrase Affect little cigars, cigarillos, or filtered cigars. How do you feel about that thought or im- 0.98 age? Think about the second thought or image that comes to mind when you hear the phrase little cigars, cigarillos, or filtered cigars. How do you feel about that thought 0.85 or image? Chances of lung cancer if you continue to smoke little cigars, cigarillos, or filtered Risk Perception 0.97 cigars daily? Chances of lung disease other than lung cancer (such as COPD and emphysema) if 0.98 you continue to smoke little cigars, cigarillos, or filtered cigars daily? Chances of heart disease if you continue to smoke little cigars, cigarillos, or filtered 0.95 cigars daily? Chances of becoming addicted if you continue to smoke little cigars, cigarillos, or 0.85 filtered cigars daily? Chances of early/premature death if you continue to smoke little cigars, cigarillos, or 0.94 filtered cigars daily?

LCC Smoking Have you ever been curious about smoking a little cigar, cigarillo, or filtered cigar? 0.85 Susceptibility

Do you think you will try a little cigar, cigarillo, or filtered cigar soon? 0.99 If one of your best friends were to offer you a little cigar, cigarillo, or filtered cigar, 0.92 would you try it? ship among affect towards LCCs, perceptions of health risks, we examined the association among health risks for daily LCC use, and current LCC these variables. A positive association was found smoking had very good fit to the data among adults between current cigarette use and current LCC use who were aware of LCCs and may have had a his- (p < .05). We categorized current cigarette smok- tory of LCC use [χ2(78) = 111.5, p = .008; RMSEA ers into the following groups: current daily smok- = 0.03, CFI=1.00] (Figure 1). As hypothesized, an ers, non-daily smokers, former smokers and never indirect effect of positive affect on current LCC smokers (which was the reference group). Daily smoking via risk perceptions was supported, ad- cigarette smokers (vs never smokers) had more justing for sociodemographic covariates and ciga- positive affect for LCCs (p < .001). Daily cigarette rette smoking status. Specifically, positive affect smoking (vs never smoking) was also associated toward LCCs was significantly associated with with lower perceived risk for LCCs; this relation- lower perceived risks of daily LCC smoking (p < ship was not significant, however. Non-daily ciga- .001). In turn, lower perceived risks of daily LCC rette smokers (vs never smokers) had more positive smoking was associated with higher probability affect for LCCs (p < .001). Non-daily smoking (vs of current LCC smoking (p = .008). In addition, never smoking) was also significantly associated a direct effect of positive affect towards LCCs on with lower perceived risk (p < .001). Education current LCC use was also found (p < .02). More level was not associated with affect or risk percep- positive affect towards LCCs use was associated tions of LCCs. Having some level of college experi- with a higher probability of current LCC use. Be- ence (p < .05) or a bachelor’s degree or higher (p cause cigarette smoking and socioeconomic status < .01) was negatively associated with current LCC (indicated by income and education) may have a use. Income was not significantly associated with distinct relationship to affect and perceptions of affect but was associated with higher perceived risk

258 Sterling et al

Figure 1 Standardized Path Coefficients for the Mediational Model of Affect towards LCC, Risk Perceptions for Daily LCC Use, and Current LCC Smoking among Young Adults (N = 772)

Note. Ovals denote latent factors and rectangles denote observed variables in the model. LCC use status was dichotomized as 1 = currently smoker, either some days or everyday versus 0 = currently smoking rarely or former/never smoker (referent). For visual clarity, only the structural model is shown; the measurement model for the latent factors is not shown. Path estimates shown for the paths leading to current LCC use are partially standardized probit coefficients. The estimate for the path leading from the affect factor to the risk perceptions factor is a fully standardized linear coefficient. Coefficients were obtained using a mean- and variance-adjusted weighted least squares estimator. All estimates are statistically sig- nificant (p < .05). Confidence intervals (95%) are shown in parentheses. χ2(78) = 111.5, p = .008; RMSEA = 0.02, 90% CI = .013-.033; CFI = 1.0.

(p < .01). However, income was not directly associ- fect of positive affect on LCC smoking susceptibil- ated with LCC use. ity via risk perceptions was supported, adjusting for sociodemographic covariates and cigarette smoking Association among Affect, Risk Perceptions, status. Specifically, positive affect toward LCCs was and Susceptibility to Smoke LCCs significantly associated with lower perceived risks The conceptual model that depicted the relation- of daily LCC smoking (p < .001). In turn, lower ship among affect towards LCCs, perceptions of perceived risks with daily LCC smoking was associ- ated with greater susceptibility to use LCCs among health risks for daily LCC use, and susceptibility to use LCCs among never LCC smokers who were those who are aware of but never used LCCs (p < aware of LCC use had very good fit to the data .001). In addition, a direct effect of positive affect towards LCCs on LCC smoking susceptibility was [χ2(116) = 128.6, p = .20; RMSEA = 0.02, CFI = 1.00] (Figure 2). As hypothesized, an indirect ef- also found (p = .001). More positive affect towards

Tob Regul Sci.™ 2019;5(3):253-263 DOI: https://doi.org/10.18001/TRS.5.3.4 259 Affect Predicts Small Cigar Use in a National Sample of US Young Adults

Figure 2 Standardized Path Coefficients for the Mediational Model of Affect towards LCCs, Risk Perceptions for Daily LCC Use, and Susceptibility to Smoke LCCs among Young Adult Never LCC Smokers (N = 404)

Note. Ovals denote latent factors and rectangles denote observed variables in the model. For visual clarity, only the struc- tural model is shown; the measurement model for the latent factors is not shown. Fully standardized coefficients were obtained using a mean- and variance-adjusted weighted least squares estimator. All estimates are statistically signifi- cant (p < .001). Confidence intervals (95%) are shown in parentheses. χ2(116) = 128.6, p = .20; RMSEA = 0.02, 90% CI = .000-.031; CFI = 1.0.

LCC use was associated with greater susceptibil- LCCs and perceptions of the health risks associ- ity to smoke LCCs. We examined the association ated with daily LCC use predicted susceptibility to among cigarette smoking, socioeconomic status, use LCCs and current LCC use among a national affect and perceptions of health risks, and LCC probability sample of young adults. Our findings susceptibility. Cigarette daily smoking (vs never support Slovic’s prior research by documenting smoking) was not significantly associated with af- that smoking risk decisions are motivated by affect, fect, perceived risk or LCC susceptibility. Similarly, which in turn can lead to smoking behavior.24,30 non-daily smoking (vs never smoking) was not Our findings add to the body of evidence that pro- significantly associated with affect, perceived risk vides the FDA with documentation of an associa- or LCC susceptibility. Education level and income tion between cognitive (ie, risk perceptions) and were not associated with affect, perceived risk or affective factors and LCC smoking among adults. susceptibility to use LCCs. Because the association between cognitive and af- fective factors and LCC smoking behavior has been DISCUSSION documented, future research should identify what Our study found that positive affect towards aspects of the LCCs (eg, its flavoring, packaging,

260 Sterling et al advertising, etc) influence young adults’ cogni- LCCs had lower perceptions of risk of daily LCC tive and affective beliefs about product use. These use. Those with lower perceptions of risk of daily studies may guide thinking on potential regulatory LCC use had greater odds of being a current LCC policy or enforcement actions that can be used to smoker (compared to a never and former user) and prevent or reduce LCC smoking among this vul- greater odds of being susceptible to smoking LCCs nerable population. (compared to being non-susceptible). As hypothesized, a direct association was found The study is not without limitations. First, our between affect and susceptibility to LCC use and measure of risk perception and affect were limited. current LCC smoking. Among young adult never The risk perception measure only assessed perceived LCC users, those who expressed positive affect to- health risks associated with daily use of LCCs. Risk ward LCCs had greater odds of being susceptible perceptions about the health effect associated with to LCC use. For the entire sample of LCC-aware daily LCC use is a conservative measure for this young adults (regardless of use status), those who type of analysis and does not assess a range of risk expressed positive affect toward LCCs had greater perceptions (eg, conditional risk assessments, per- odds of current LCC use. Roughly 17% of young ceptions of tobacco-specific outcomes, etc) as rec- adults who were aware of LCCs were current (ei- ommended by the Institute of Medicine (IOM).35 ther ‘every day’ or ‘some day’) cigarette smokers. Further other published studies suggest that per- Our post hoc analysis found that daily and non- ceptions of risk about LCCs are shaped by numer- daily (ie, some day) cigarette smokers had more ous factors, including but not limited to consumers’ positive affect for LCCs. Prior studies report strong beliefs about the products’ constituents (ie, filters), associations between affect and cigarette smoking;31 the in the LCCs, and LCC pack- nicotine in cigarettes helps smokers’ self-regulate or age descriptors (eg, text, color).12,20,33 With regard relieve negative affect.32 Repeated use of nicotine to affect measurement, young adult respondents also impacts affect and mood processing.32 That in this study were asked about 2 images whereas an association between positive affect and current past studies have used 5 to 6 images to assess the LCC use was found among all current cigarette construct.24 Additional studies using expanded smokers, and among daily and non-daily cigarette measures of affect and perceptions of risk as recom- smokers, may suggest that LCCs provide may an mended by the IOM are needed. Data collected in additional source of nicotine to regulate affect. In a the study were cross-sectional, and causality cannot qualitative study, cigarette smokers who dual used be inferred. As such, study findings should be in- with LCCs reported that characterizing flavors in terpreted with caution. Future prospective studies LCCs and exposure to LCC product labelling and are needed to examine the association among af- advertising produced positive affect, which in turn fect, risk perceptions, and LCC smoking behavior. influenced their continued use of LCCs.14,33 Our In conclusion, affect towards LCCs and risk per- current study goes beyond the prior study by docu- ceptions regarding the health effects of daily LCC menting the mechanism by which affect predicts use were associated with current LCC use and sus- current LCC use among a sample of young adults ceptibility to LCC use among young adults who (of whom some had a history of cigarette smok- are aware of LCCs. Almost one-fifth of our sample ing), and susceptibility to use LCCs among adults were current cigarette smokers. For those young who were never LCC users. adult smokers, positive affect toward LCCs and Current use of LCCs and susceptibility to its use perceptions of reduced risk compared to cigarettes may be explained by affect for LCCs alone or by may fuel dual use of cigarettes and LCCs, as well the mediating effects of risk perceptions of LCC as be impediments to cessation. Our findings have use. Studies suggest that risk perceptions are proxi- implications for intervention development and mal predictors of smoking behavior.16,34 Consis- suggest that both affect and risk perception should tent with a prior study,14 our current study found be included as critical components in interventions that young adults’ affect towards LCCs also influ- to prevent initiation and progression of LCC use ences their perception of risks of LCCs. Specifi- and curtail dual smoking with LCCs among young cally, young adults who endorsed positive affect of adult cigarette smokers.

Tob Regul Sci.™ 2019;5(3):253-263 DOI: https://doi.org/10.18001/TRS.5.3.4 261 Affect Predicts Small Cigar Use in a National Sample of US Young Adults

IMPLICATIONS FOR TOBACCO 4. Cantrell J, Kreslake JM, Ganz O, et al. Marketing little REGULATION cigars and cigarillos: advertising, price, and associations with neighborhood demographics. Am J Public Health. Positive affect toward LCCs and perceptions of 2013;103(10):1902-1909. reduced risk compared to cigarettes are associated 5. Kasza KA, Ambrose BK, Conway KP, et al. Tobacco- with current LCC use and susceptibility to LCC product use by adults and youths in the United States in 2013 and 2014. N Engl J Med. 2017;376(4):342-353. use among a national probability sample of young 6. Cohn A, Cobb CO, Niaura RS, Richardson A. The other adults. Future research should investigate how combustible products: prevalence and correlates of little regulatory policy or enforcement actions can be cigar/cigarillo use among cigarette smokers. Nicotine Tob used to regulate LCC components (eg, flavoring, Res. 2015; 17(12):1473-8141. 7. Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns advertising, etc.) that influence affect and risk per- of tobacco use and dual use in US young adults: the miss- ceptions. Affect and risk perceptions should be ad- ing link between youth prevention and adult cessation. J dressed in future interventions that seek to prevent Environ Public Health. 2012;2012:679134. LCC smoking uptake among young adult never 8. Richardson A, Xiao H, Vallone DM. Primary and dual us- LCC users or halt its progression among those ers of cigars and cigarettes: profiles, tobacco use patterns and relevance to policy. Nicotine Tob Res. 2012;14(8):927- young adults who are ever LCC users. 932. 9. Jolly DH. Exploring the use of little cigars by students at a historically black university. Prev Chronic Dis. Human Subject Statement 2008;5(3):A82. The Institutional Review Board at Georgia State 10. Messer K, White MM, Strong DR, et al. Trends in use of University approved this research. little cigars or cigarillos and cigarettes among U.S. smok- ers, 2002–2011. Nicotine Tob Res. 2015;17(5):515-523. 11. Richter PA, Pederson LL, O’Hegarty MM. Young adult Conflicts of Interest Statement smoker risk perceptions of traditional cigarettes and nontraditional tobacco products. Am J Health Behav. The authors have no conflicts of interest to 2006;30(3):302-312. declare. 12. Richter P, Caraballo R, Pederson LL, Gupta N. Explor- ing use of nontraditional tobacco products through focus groups with young adult smokers. 2002. Prev Chronic Acknowledgements Dis. 2008;5(3):A87. We thank Dr. Paul Slovic for his feedback on the 13. Nyman AL, Sterling KL, Weaver SR, et al. Little Cigars conceptual design of the study. This work was sup- and cigarillos: users, perceptions, and reasons for use. Tob Regul Sci. 2016;2(3):239-251. ported by the National Institutes of Health, Na- 14. Sterling K, Fryer C, Nix M, Fagan P. 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Tob Regul Sci.™ 2019;5(3):253-263 DOI: https://doi.org/10.18001/TRS.5.3.4 263