Understanding Nicotine Dependence and Addiction

Nicotine & Tobacco Research, 2018, 377–382 doi:10.1093/ntr/ntx008 Original investigation Received August 19, 2016; Editorial Decision January 3, 2017; Accepted January 6, 2017

Original investigation

Understanding Nicotine Dependence and Addiction Among Young Adults Who Smoke Cigarillos: A Qualitative Study Elizabeth Antognoli PhD1, David Cavallo PhD2, Erika Trapl PhD3, Mary Step PhD4, Sarah Koopman Gonzalez MA3, Rose Perez BA1, Susan Flocke PhD1,3 Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, OH; Department of Nutrition, Case Western Reserve University, Cleveland, OH; 3Prevention Research Center for Healthy Neighborhoods, Case Western Reserve University, Cleveland, OH; 4Department of Social and Behavioral Sciences, College of Public Health, Kent State University, Kent, OH

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Corresponding Author: Elizabeth Antognoli, PhD, Department of Family Medicine and Community Health, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106–7136, USA. Telephone: 216-368-0878; Fax: 216-368-4348; E-mail: [email protected]

Abstract Introduction: Cigarillo use is increasing, particularly among young adults. Nicotine dependence (ND) is important for understanding smoking behavior and cessation, but the development of measures of ND has focused almost exclusively on cigarette smokers. We examined smoking patterns, preferences, and beliefs of cigarillo users to better understand their experience of addiction and expression of ND symptoms. Methods: Using purposive sampling, we conducted in-depth interviews between June 2015 and January 2016 with 30 young adults aged 18–28 who reported smoking ≥1 cigarillo per week. Interviews were based on a semi-structured guide designed to capture participants’ smoking levels and patterns as well as their experiences of smoking and addiction. Interviews were audiorecorded and transcribed. Analysis was guided by a phenomenological approach designed to identify emergent themes. Results: Participants had a mean age of 23, with a majority being female (56%) and African American (80%). The median number of cigarillos smoked per week was 20; 70% also smoked cigarettes, and 43% also smoked marijuana blunts. Our analysis highlighted the complexity of measuring cigarillo use due to product manipulation, sharing, and multiple product use. Participants expressed a preference for smoking in a social group where cigarillos were shared, and not smoking an entire cigarillo at once when alone. Most cigarillo users did not consider themselves to be addicted. Conclusions: Cigarillo users express unique smoking practices and beliefs that signify the need for a more product-inclusive measure of ND, and can inform the development of tobacco cessation interventions tailored to cigarillo users. Implications: The increasing use of cigarillos among young adults has significant public health consequences. Addressing this issue requires accurate measurement and effective treatment of dependence on cigarillo products. The results of this study directly inform the development of a revised measure of ND, and can contribute to the efficacy of cessation interventions for cigarillo users.

© The Author(s) 2017. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].

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Introduction Tobacco use is still the leading cause of preventable morbidity and mortality worldwide, but the relative consumption of specific products is changing. Between 2000 and 2015 cigar consumption increased 100 percent while cigarette consumption declined by 40%.1 Cigar products are frequently divided into the following three categories: filtered, cigarette-sized little cigars, mid-sized cigarillos, and large, traditional cigars. National data indicate that, among the one in 20 adults who smoke cigar products, 62% (an estimated 10.9 million people) usually smoke cigarillos.2,3 Young adults have the highest rates of overall tobacco use, and the increasing use of cigarillos is thought to be a major contributor to these rates.4–7 Further, African Americans and lower income groups report higher rates of cigarillo use compared to whites and higher income groups.2,6,8 Nicotine dependence (ND) is considered a key motivator of smoking behavior, and a primary reason that smokers have difficulty quitting.9,10 Measuring ND among cigarillo users is therefore an important precursor to addressing this growing public health concern. Studies have confirmed that cigarillos deliver quantities of nicotine that can initiate or sustain dependence, as well as carbon monoxide and other toxicants which lead to coronary heart disease, aortic aneurism, and several types of cancer.11–14 The development of ND is a complex progression involving the interaction of biochemical processes and the smoking behaviors, perceptions, and experiences of the smoker.10,15–17 Measures of ND typically rely on self-report of dependence symptoms, which are grounded in the sociocultural context of tobacco use, such as when, where, and how often it is smoked, methods of smoking, and norms and expectations around use.10,15,16,18 Several measures of ND have been developed and extensively tested, however these measures were constructed to assess ND symptoms associated with cigarette use. To our knowledge, no one has developed an ND measure that is inclusive of cigarillos use. A growing body of research suggests that cigarillo users’ practices and beliefs substantially differ from those of cigarette-only users, and therefore current measures of ND may not be sensitive to expressions of dependence among cigarillo users.19–21 Further, understanding the unique experiences of cigarillo users is an important precursor to developing efficacious smoking cessation interventions for this population. In this study we examine the smoking patterns, preferences, attitudes, and beliefs of cigarillo users in order to better understand the expression of ND, and to inform the development of a measure of ND relevant for the growing population of cigarillo users.

Methods Overview of the Study This research represents the first phase of a larger project to develop a measure of ND that is inclusive of cigarillo users. We used qualitative methods to ground our understanding of ND in the experiences of those with deep understanding of cigarillo smoking behavior and practices. In-depth interviews were conducted to elicit participants’ experiences and perceptions of cigarillo use to better understand symptoms of dependence. The study, conducted from June 2015 to January 2016, was approved by the Institutional Review Board of Case Western Reserve University.

Participants and Recruitment Participant eligibility criteria consisted of being aged 18–28 and having smoked ≥1 cigarillo in the past week. Cigarillo users were recruited through canvassing and posting fliers in areas where these


individuals were frequently observed, within the greater Cleveland, Ohio, metropolitan area, including bus stops, recreation centers, college campuses, gas stations and convenience stores. Fliers and study cards briefly described study aims and procedures, and invited those interested to contact staff via email or phone. A devoted toll-free number for the study was available, as was a study website with frequently asked questions and contact information. Additional recruitment occurred via word-of-mouth from current participants.

Study Procedures Research staff assessed enrollment eligibility for interested individuals via telephone. Once an individual was determined to be eligible, verbal informed consent was obtained. The participant was interviewed by phone either immediately following consent or scheduled for a later time. Study interviewers received training in qualitative data collection, including practice interviewing and ongoing feedback on their interviewing techniques. All interviews were audio-recorded. Interviews were conducted using a semi-structured interview guide. To begin the interview, demographic and smoking characteristics, and product use and terminology were identified. Based on growing literature regarding the confusion and variability associated with terms like “cigarillo,”22,23 care was taken to elicit specific information on which products were used, when and how often each is used, and “how” each was used. For example, we know that the practice of “blunting” wherein an untipped cigarillo is emptied of all or some of its tobacco and filled with marijuana, is a common occurrence.7,24,25 Therefore, we included several probing questions to ascertain details around this practice. The rest of the interview guide was designed to capture participants’ experiences of smoking in relation to key conceptual elements of ND symptoms, including loss of autonomy, withdrawal symptoms and feeling addicted.26 Comprising six dimensions, the questions elicited participants’ smoking patterns and levels, feelings and sensations when smoking and when smoking is prohibited, physical and mental experiences of craving, feelings of addiction and associated social meanings, and the desire to quit. Interviews lasted between 20 and 45 minutes. Participants were provided a $25 gift card (via text or email code) as compensation for their time.

Data Analysis All interview audio-recordings were transcribed verbatim. Guided by a phenomenological approach, which seeks to understand how people make meaning of their lived experience, analysis consisted of careful and repeated reading of each transcript to identify salient themes of cigarillo use. This iterative, inductive process decontextualizes the data by separating it from the original context of individual cases and assigning a code to each theme, or unit of meaning. Next these codes are analyzed for patterns and organized around central themes and relationships drawn across all the cases and narratives.27,28 Coding was guided by input from the seven members of the research team who met regularly to review narrative passages, discuss themes and patterns, and interpret findings. Analysis was conducted by two experienced coders who met regularly to reconcile coding discrepancies. NVivo 10 was used to assist with qualitative data organization and analysis.29

Results Demographic and Smoking Characteristics In our sample of 30 young adults, participants had a mean age of 23, were mostly female (56%), and African American (80%) (Table 1).

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Half were employed, while a quarter went to school and a quarter were neither employed nor in school. With regard to smoking characteristics (Table 2), all participants expressed that, when smoking a cigarillo filled with tobacco, only the tipped cigarillos called Black & Milds (referred to as “Milds”) were used. Twenty-three (77%) had ever tried flavored varieties of cigarillos, and 8 (27%) preferred flavored over regular cigarillos. The median number of cigarillos reported smoked per week was 20, with a range of 4–140. Most (70%) said they always inhaled when they smoked cigarillos; 4 (13%) only puffed, and 5 (17%) sometimes inhaled and sometimes puffed. As one participant explained, “I inhale on it when I’m stressed, and when I’m just relaxing, I just puff on it.” Twenty-one (70%) participants also reported smoking cigarettes; as described below, participants were clear in their distinction between practices of smoking cigarettes and smoking cigarillos. Product Manipulation Thirteen (43%) of the tipped cigarillo smokers also reported smoking untipped cigarillos, but only when used as marijuana blunts (Table 2). A marijuana “blunt” refers to an untipped cigarillo from which the tobacco has been removed and replaced with marijuana

or a combination of marijuana and tobacco. In this sample, participants preferred making marijuana blunts using a flavored variety of untipped cigarillos, which they referred to as a “shell” or as the brand name, such as “Swisher.” Favorite flavors were mango, peach, and tropical. The flavor of the tobacco paper was felt to help to improve the flavor of a marijuana blunt. Another commonly reported product manipulation practice was to “freak” a tipped cigarillo before smoking, which consists of removing the tip, emptying the tobacco leaf, removing the paper liner or “cancer stick,” refilling the shell with some or all of the tobacco leaf and reattaching the tip. Twenty-four (80%) participants reported that they usually freaked their cigarillos before smoking them. The most common reasons for freaking included (1) to improve the “smoothness” and reduce the “harshness” (2) to extend the burning time and (3) to reduce the harmful effects caused by the “cancer stick”. Of interest is the practice of freaking a cigarillo before one plans on smoking it, so that it is ready when wanted: “Well usually I freak it before I go to sleep, so when I wake up, all I got to do is really just wake up and light it.” (ID22, male, aged 25)

Smoking Patterns and Social Context Table 1. Demographic Characteristics (n = 30) Demographic characteristics

n (%)

Female Age (years), mean (SD) Race African American White Asian Biracial Occupation Neither school nor work Work School Work and school Education Some high school High school graduate Some college, no degree

17 (56) 23 (2) 24 (80) 4 (13) 1 (3) 1 (3) 7 (23) 15 (5) 7 (23) 1 (3) 1 (3) 14 (47) 11 (37)

Table 2. Smoking Characteristics (n = 30) Smoking characteristics Age at first cigarillo, median years, (SD) Cigarillos smoked per week, Smoked Monday–Thursday Smoked Friday–Sunday Smoking products Cigarillo only Cigarillo and cigarette Flavored cigarillo Ever tried flavor Prefer flavored Marijuana blunt use Cigarillo smoking preferences Inhale Puff Inhale and puff Usually “freak” cigarillo

Median (range) 16 (3) 20 (4–140) 9 (1–80) 10 (2–60) n (%) 9 (30) 21 (70) 23 (77) 8 (27) 13 (43) 21 (70) 4 (13) 5 (17) 24 (80)


The salience of the social context of cigarillo use was conveyed in a number of ways. First, most participants reported that they initially smoked a cigarillo when it was passed to them in the context of a group of friends and/or family members. This pattern seemed to continue, as most participants expressed a strong tendency and preference for smoking with one or more other people. A few “only” smoked when with others (n = 3). Most participants reported smoking more on weekends or after work or school, when they were hanging out with friends. Secondly, there are norms for how a cigarillo is smoked when in the company of others who also smoke them. The typical scenario was for an individual to produce a cigarillo, freak it, take a few puffs, and then pass it to the next person. In this fashion, the cigarillo is passed to each person in the group until it is finished. This activity was acknowledged by many as an important part of socializing, even bonding, with peers. The following narratives illustrate these observations: “I smoke Milds (tipped cigarillos) in my hood, when I’m out and about on my free time, not like you know during school or during work. Just only on my free time. I do it with my gang, and you know it’s just like a leisure thing, where you can bond at the same time.” (ID05, male, aged 23) “If I’m with other people, if they smoke Milds, then we’ll probably have two or three and then like we’ll go back and forth with it like a regular thing.” (ID08, female, aged 19)

For those who also smoked cigarettes, a contrast was made between the contexts in which cigarillos and cigarettes were smoked: “For Black & Mild, it’s usually when I’m, you know after work or school and like by my friends. That’s when I smoke them…But cigarettes, I usually smoke them alone.” (ID21, male, aged 23)

As mentioned, when smoked in a group, a cigarillo is passed among individuals, such that one individual does not consume the entire cigarillo by oneself. When smoking alone, individuals most commonly put the cigarillo out after taking several puffs, to be re-lit at one or more later times. Smoking a cigarillo when alone is typically done during three or more sessions. Smoking an entire cigarillo at once by oneself was seen as unusual and/or unpleasant:

380 “If you smoke a whole Mild all up at once, then that’s horrible. I don’t smoke a Mild to the face, ‘cause it’s eight cigarettes. So yeah, one Mild will last me approximately half the day. Now it might even last me the whole day, for real, ‘cause a Mild is a lot.” (ID06, female, aged 22) “I cannot smoke the whole thing. I can’t do it” (ID08, female, aged 19)

When asked about how to tell if someone is addicted to smoking cigarillos, smoking the entire thing at once was mentioned by several participants. Lastly, the amount and frequency of cigarillo use appears to be affected by the social context. As mentioned, the initial cigarillo smoking experience was often among a group of friends who were passing it around. This creates an easy opening for an individual to try out a cigarillo. As time goes on, individuals continue to smoke cigarillos when they are in a group that is passing them around. The occasion of friends getting together then becomes an occasion for smoking a cigarillo. Additionally, several individuals (n = 11) reported smoking “more” when with friends: “The amount (of Milds I smoke) kind of doubles on a Friday, just because that’s the weekend and you know we’re just hanging out.” (ID07, female, aged 26)

This tendency to associate smoking cigarillos with one’s peers also has repercussions for those who are trying to quit or cut down on their smoking: “If I’m alone, I’ll look at it before I actually, you know, light it, because I’ll be hesitant.” (ID25, male, aged 24) “‘Cause I’m trying to quit. But if I’m around friends and they be like ‘Oh, well let’s get a Mild,’ I’ll be like ‘Okay….Like if I’m going out, then yeah.” (ID24, female, aged 23)

Co-Use of Cigarillos and Marijuana Blunts As mentioned, a significant proportion of participants (43%) smoked marijuana blunts in addition to cigarillos. Commonly, a cigarillo was smoked before and/or after a marijuana blunt was smoked, within the same general time period or session. It is relevant to note that the process of rolling a blunt follows a process parallel to freaking a cigarillo. Both involve emptying the cigarillo of tobacco and then refilling the shell with either tobacco or marijuana. Further, smoking a marijuana blunt follows a similar process as smoking a cigarillo: an individual takes a few “hits” and then passes it along to the next person. In addition to a parallel process for preparing and smoking, cigarillos and marijuana blunts were felt to have a similar effect, with a cigarillo sometimes serving as a substitute when marijuana is unavailable: “Most of the time I have strong cravings to smoke when I’m feeling like overwhelmed or stressed out and stuff. That’s mostly when I’ll feel like I have to smoke something, either a blunt or a Black & Mild. It’s like you’re looking for something to calm you down, and when you hit the Black & Mild or you hit the blunt, it’s like a big relaxation.” (ID29, female, aged 23) “Well if it ain’t no bud around, then I’ll blaze up a Mild, because that’s the closest thing to it.” (ID05, male, aged 23)

Similarly, cigarillos were seen as extending or increasing the effect of the marijuana. “Right after I smoke my blunt, I’ll smoke a Mild like right behind it, and it’s like it kind of extends the high, I guess, if you will.” (ID22, male, aged 25)


Nicotine & Tobacco Research, 2018, Vol. 20, No. 3 “And I don’t know if this matters, but after I smoke a blunt, I always smoke a cigarette or a Black & Mild.” (ID18, male, aged 23)

Several people related that they had started smoking marijuana, and soon after began smoking cigarillos: Interviewer: When do you think smoking (cigarillos) became a habit? Participant: I think ‘cause I started smoking weed, you know, and you know after you smoke weed, you want to smoke some tobacco. So I guess the more and more I smoked weed, the more and more I smoked tobacco. (ID20, male, aged 20) Interviewer: Okay, and how’d that happen? How’d you get started? Participant: Being in high school, and I guess it was a thing to do…that the Mild was supposed to boost your high, so that’s really how I just kept going with the Milds. (ID22, male, aged 25)

Beliefs and Experiences of Addiction There was widespread agreement that it is possible to become addicted to cigarillos. Out of 30 participants, 28 (93%) believed that it was possible to become addicted to cigarillos. However, when asked if they themselves felt addicted, only 11 (37%) said “yes”; 6 (20%) expressed that they were slightly addicted (eg, “a little,” “not that addicted”), and 13 (43%) said “no.” When asked to rate their addiction on a scale of 1–100, where 1 was not at all addicted and 100 was highly addicted, the range was from 5 to 90, with a mean of 52. Individuals distanced themselves from the idea of being addicted by employing a rhetoric of autonomy or control. Smoking cigarillos was discussed as something that was a choice, done because it was enjoyable rather than because one was addicted. Some participants contrasted this with cigarette use, which was seen as more addicting: “‘Cause like cigarettes, there’s no doubt I’m addicted. Like I can tell, but with Black & Mild, it’s like I always feel like I have a choice, or like an option not to do it.” (ID21, male, aged 23) “It’s like if I want something smooth and to relax me, I’m a get a Mild, but if I’m just trying to feed my nicotine addiction, I’m a smoke a cigarette.” (ID06, female, aged 22)

In the same vein, when asked about how one could tell if a person was addicted to cigarillos, various descriptions of individuals who were out of control, or having intense feelings were described: “They get frustrated. They get real angry and evil when they ain’t got no Mild.” (ID13, female, aged 28) “I believe people can become addicted, ‘cause I actually know someone. They get upset when they can’t. You know if they don’t have the dollar to buy their little cigar, they’ll get upset.” (ID08, female, aged 19)

Discussion In this study of 30 young adult cigarillo users, we identified specific practices, beliefs and preferences that could influence how ND is expressed, and appear to differ from those associated with cigarette use. The practice of smoking cigarillos is rooted in the social context. Participants reported that their use of cigarillos often began in a group setting where they were passed and shared among friends, and continues to be an important part of their social life. This is illustrated by the 70% who smoked both cigarillos and cigarettes,

Nicotine & Tobacco Research, 2018, Vol. 20, No. 3 who reported that the former are associated with relaxation, social bonding, and the “choice” to smoke, and the latter are associated with smoking by oneself and the “need” to smoke. It may be that the desire to relieve stress described by many users is met by the social interaction with friends as much as by the pharmacological properties of the tobacco.30 Young adults live in a peer-oriented world, and smoking in a group can have positive meaning and impact through increasing solidarity, and relieving stress and social tension. The ubiquity of cigarillo use among friends could also mean that these relationships enable or reinforce their use, as those in our and other studies have reported,23 and thus provide a potent barrier to quitting. This perception of choosing rather than needing to smoke cigarillos was also expressed in the context of beliefs about addiction. We found that most cigarillo users considered themselves to be not or only slightly addicted to cigarillos. Similar to other studies, we found that, for cigarillo users who also smoked cigarettes, cigarillos were perceived as less addictive than cigarettes.31–35 Addiction was associated with loss of control or autonomy, characteristics which individuals tended to downplay with regard to their own behavior. Instead, participants emphasized the enjoyment and socially gratifying aspects of smoking cigarillos. They expressed control and autonomy by choosing to inhale or puff, smoking only the desired amount of a cigarillo, and considering their use of cigarillos not as an addiction but as a choice. These findings suggest that cigarillo users may be less likely to consider cigarillo use as problematic. Consequently, development of interventions tailored to young adult cigarillos users should incorporate strategies to address the social needs of users, as well as education about addiction and other risks of cigarillo use. In our sample, the number of cigarillos smoked per week ranged from 4 to 140. The individual who reported smoking 140 per week was an outlier, as the next largest number reported was 70 per week. However, variability in reporting draws attention to the complexity of accurate measurement of tobacco consumption, which is critical when assessing ND. When smoking in a group, the norm is for a cigarillo to be passed and shared with others; when smoking alone, a cigarillo is typically put out and relit several times. Future research assessing cigarillo consumption should take into account the nuances of smoking behavior that may affect actual consumption, such as practices of sharing a cigarillo in a group. Establishing an accurate measurement of cigarillo tobacco consumption is also complicated by different terminology and smoking methods.7,22,25,36 No one in our sample used the term “cigarillo” but instead used the brand name of the product. Participants reported smoking tipped and untipped cigarillos, however the latter were used exclusively for rolling marijuana blunts. Because marijuana blunts may include loose tobacco along with the marijuana, and are wrapped in tobacco leaf, they contain some amount of nicotine. Further, the common practice of “freaking” a cigarillo may result in less than the original amount of tobacco being replaced and smoked. Clarification on “how” cigarillos are used will be important for future research to specify. Consistent with findings from other studies, we found that a significant number of young adult cigarillo users (43%) also use marijuana blunts, marijuana blunts are often used in conjunction with cigarillos, and that they are felt to extend or increase the effects of marijuana.23,25,32,37,38 Preparing a marijuana blunt parallels the process of freaking a cigarillo, and can be seen as an important part of the ritual of preparing to smoke. The rituals and norms for smoking preparation and for passing and sharing the cigarillo/ marijuana blunt likely contribute to the enjoyment derived from


381 using cigarillos. Marijuana use may support and reinforce the use of cigarillos, as others have argued is the case with cigarette smoking, and contribute to the difficulties that many young people experience when trying to quit.39 Consequently, assessing the degree to which individuals use cigarillos in conjunction and/or as a replacement for marijuana is called for. In sum, our findings have several important implications for developing a measure of ND for cigarillo users. First, significant dual use of cigarettes and cigarillos, and differences in practices associated with each, necessitate a measure of ND that is relevant for both products. Secondly, accurate measurement of tobacco exposure will require assessing product manipulation practices (eg, freaking), product use habits (as a tobacco-only product or in conjunction with marijuana), and social context (smoked alone or shared among friends). Finally, our findings suggest assessing ND among cigarillos users could benefit from including social markers of ND, such as an individual’s willingness to share their product when in a group, or their preference for the amount of cigarillo to smoke at a time.

Limitations These data were collected in a geographically bound area for the purpose of canvassing and conducting the in-depth interviews. Caution should therefore be taken when generalizing these results to other populations. However, the discoveries about the patterns of sharing, multiple product use, and beliefs about addiction are robust and represent important insights to assessing frequency of use and symptoms of ND. Further understanding these patterns and the prevalence of them in other contexts and among other groups that frequently use cigarillos, like adolescents, is of great interest. Expanding the sampling frame to other geographic regions and age groups is warranted. Also, because this study had a cross-sectional design, we are unable to comment on how smoking patterns and beliefs may change over time.

Conclusions We have described beliefs and practices that signify the need for a measure of ND that is inclusive of cigarillo users, and suggest the utility of the development of tobacco cessation interventions specifically tailored to cigarillo users. Additionally, we have illustrated some of the complexities of measuring tobacco intake among cigarillos users, and suggested approaches to increase accuracy. One next step would be to modify a reliable and validated measure of ND for use with cigarillo users, incorporating items that pertain specifically to the unique behaviors and norms described here. A more accurate measure of ND for cigarillo users, as well as a consideration of some of the unique beliefs and practices that seem to play a role in maintaining and encouraging cigarillo use, could go a long way in addressing this growing public health concern.

Funding This work was supported by the Center for Tobacco Products at the United States Food and Drug Administration/National Cancer Institute at the National Institutes of Health (R01CA190130).

Declaration of Interests None declared.

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Acknowledgments The authors would like to thank Erica Wolfish, Aaron Womer, and Rashon Braxton for their assistance in conducting the interviews on which this manuscript is based.

References 1. Campaign for Tobacco-Free Kids. The Rise of Cigars and Cigar-Smoking Harms. Washington, DC; 2016. www.tobaccofreekids.org/research/ factsheets/pdf/0333.pdf. Accessed December 6, 2016. 2. Agaku IT, King BA, Husten CG, et al.; Centers for Disease Control and Prevention (CDC). Tobacco product use among adults–United States, 2012-2013. MMWR Morb Mortal Wkly Rep. 2014;63(25):542–547. 3. Corey CG, King BA, Coleman BN, et al.; Centers for Disease Control and Prevention. Little filtered cigar, cigarillo, and premium cigar smoking among adults–United States, 2012-2013. MMWR Morb Mortal Wkly Rep. 2014;63(30):650–654. 4. Richardson A, Rath J, Ganz O, Xiao H, Vallone D. Primary and dual users of little cigars/cigarillos and large cigars: demographic and tobacco use profiles. Nicotine Tob Res. 2013;15(10):1729–1736. 5. Richardson A, Williams V, Rath J, Villanti AC, Vallone D. The next generation of users: prevalence and longitudinal patterns of tobacco use among US young adults. Am J Public Health. 2014;104(8):1429–1436. 6. Milam AJ, Bone LR, Byron MJ, et al. Cigarillo use among high-risk urban young adults. J Health Care Poor Underserved. 2013;24(4):1657–1665. 7. Nasim A, Guy MC, Soule EK, Cobb CO, Blank MD, Eissenberg T. Characteristics and patterns of Black & Mild use among African American smokers. Nicotine Tob Res. 2016;18(5):842–849. 8. Borawski EA, Brooks A, Colabianchi N, et al. Adult use of cigars, little cigars, and cigarillos in Cuyahoga County, Ohio: a cross-sectional study. Nicotine Tob Res. 2010;12(6):669–673. 9. Shadel WG, Edelen MO, Tucker JS, Stucky BD, Hansen M, Cai L. Development of the PROMIS nicotine dependence item banks. Nicotine Tob Res. 2014;16(suppl 3):S190–S201. 10. Shadel WG, Shiffman S, Niaura R, Nichter M, Abrams DB. Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth. Drug Alcohol Depend. 2000;59(suppl 1):9–22. doi:10.1016/S0376-8716(99)00162-3. 11. Fabian LA, Canlas LL, Potts J, Pickworth WB. Ad lib smoking of Black & Mild cigarillos and cigarettes. Nicotine Tob Res. 2012;14(3):368–371. 12. Pickworth WB, Rosenberry ZR, Koszowski B. Toxicant exposure from smoking a little cigar: further support for product regulation. Tob Control. 2016. doi:10.1136/tobaccocontrol-2015–052633. 13. Kaufman NJ, Castrucci BC, Mowery PD, Gerlach KK, Emont S, Orleans CT. Predictors of change on the smoking uptake continuum among adolescents. Arch Pediatr Adolesc Med. 2002;156(6):581–587. 14. Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health. 2015;15:390. 15. Unger JB, Cruz T, Shakib S, et al. Exploring the cultural context of tobacco use: a transdisciplinary framework. Nicotine Tob Res. 2003;5(suppl 1):S101–S117. 16. Nichter M, Nichter M, Thompson PJ, Shiffman S, Moscicki A-B. Using qualitative research to inform survey development on nicotine dependence among adolescents. Drug Alcohol Depend. 2002;68(suppl 1):S41–56. www.ncbi.nlm.nih.gov/pubmed/12324174. April 12, 2016. 17. Rosenthal DG, Weitzman M, Benowitz NL. Nicotine addiction: mechanisms and consequences. Int J Ment Health. 2011;40(1):22–38. doi:10.2753/IMH0020-7411400102. 18. Poland B, Frohlich K, Haines RJ, Mykhalovskiy E, Rock M, Sparks R. The social context of smoking: the next frontier in tobacco control? Tob Control. 2006;15(1):59–63.


Nicotine & Tobacco Research, 2018, Vol. 20, No. 3 19. Strong DR, Messer K, Hartman SJ, et al. Measurement of multiple nicotine dependence domains among cigarette, non-cigarette and polytobacco users: Insights from item response theory. Drug Alcohol Depend. 2015;152(1):185–193. 20. De Leon E, Smith KC, Cohen JE. Dependence measures for non-cigarette tobacco products within the context of the global epidemic: a systematic review. Tob Control. 2014;23(3):197–203. 21. Trapl ES, O’Rourke-Suchoff D, Yoder LD, Cofie LE, Frank JL, Fryer CS. Youth acquisition and situational use of cigars, cigarillos, and little cigars: a cross-sectional study. Am J Prev Med. 2017;52(1):e9–e16. 22. Dickinson DM, Johnson SE, Coleman BN, Tworek C, Tessman GK, Alexander J. The language of cigar use: focus group findings on cigar product terminology. Nicotine Tob Res. 2016;18(5):850–856. doi:10.1093/ntr/ ntv285. 23. Stephens M, Ogunsanya ME, Ford KH, Bamgbade BA, Liang MC. Little cigar and cigarillo beliefs and behaviors among African-American young adults. Am J Health Behav. 2015;39(4):519–528. 24. Montgomery L, Oluwoye O. The truth about marijuana is all rolled up in a blunt: prevalence and predictors of blunt use among young African– American adults. J Subst Use. 2016;21(4):374–380. doi:10.3109/1465989 1.2015.1037365. 25. Koopman Gonzalez SJ, Cofie LE, Trapl ES. I just use it for weed: the modification of little cigars and cigarillos by young adult African American male users. J Ethn Subst Abuse. 2015;7:1–14. doi:10.1080/15332640.201 5.1081117. 26. O’Loughlin J, Kishchuk N, DiFranza J, Tremblay M, Paradis G. The hardest thing is the habit: a qualitative investigation of adolescent smokers’ experience of nicotine dependence. Nicotine Tob Res. 2002;4(2):201–209. 27. Creswell JW. Qualitative Inquiry and Research Design: Choosing among Five Traditions. New York, NY: Sage publications; 2012. 28. Ayres L, Kavanaugh K, Knafl KA. Within-case and across-case approaches to qualitative data analysis. Qual Health Res. 2003;13(6):871–883. 29. NVivo Qualitative Analysis Software. Version 10. Doncaster, Australia: QSR International; 2012. 30. Dunlap E, Benoit E, Sifaneck SJ, Johnson BD. Social constructions of dependency by blunts smokers: qualitative reports. Int J Drug Policy. 2006;17(3):171–182. 31. Delnevo CD, Giovenco DP, Ambrose BK, Corey CG, Conway KP. Preference for flavoured cigar brands among youth, young adults and adults in the USA. Tob Control. 2015;24(4):389–394. 32. Sterling K, Berg CJ, Thomas AN, Glantz SA, Ahluwalia JS. Factors associated with small cigar use among college students. Am J Health Behav. 2013;37(3):325–333. 33. Jolly DH. Exploring the use of little cigars by students at a historically black university. Prev Chronic Dis. 2008;5(3):A82. 34. Sterling KL, Fryer CS, Fagan P. The most natural tobacco used: a qualitative investigation of young adult smokers’ risk perceptions of flavored little cigars and cigarillos. Nicotine Tob Res. 2015;18(5): 827–833. doi:10.1093/ntr/ntv151. 35. Cohn A, Cobb CO, Niaura RS, Richardson A. The other combustible products: prevalence and correlates of little cigar/cigarillo use among cigarette smokers. Nicotine Tob Res. 2015;17(12):1473–1481. 36. Trapl ES, Koopman Gonzalez SJ, Cofie L, Yoder LD, Frank J, Sterling KL. Cigar product modification among high school youth. Nicotine Tob Res. 2018;20:370–376. doi:10.1093/ntr/ntw328. 37. Dunlap E, Johnson BD, Benoit E, Sifaneck S. Sessions, cyphers, and parties: settings for informal social controls of blunt smoking. J Ethn Subst Abuse. 2005;4(3–4):43–79. 38. Cohn A, Villanti A, Richardson A, et al. The association between alcohol, marijuana use, and new and emerging tobacco products in a young adult population. Addict Behav. 2015;48:79–88. 39. Highet G. The role of cannabis in supporting young people’s cigarette smoking: a qualitative exploration. Health Educ Res. 2004;19(6):635–643.