argumentative essay 6 to 8 page

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W hereas the United States has made vast progress in reducing smoking prevalence in the last 20 years, the most recent Sur-

geon General’s report, “The Health Consequences of Smoking – 50 Years of Progress,” indicates that tobacco use is still the number one cause of pre- ventable morbidity and mortality.1 Young adults aged 18-25 report the highest rates of overall to- bacco use2,3 compared to adolescents (12-17) and adults older than 25.1,4 Traditional cigarettes are the most common tobacco product young adults use;1,5,6 however, research indicates reductions in adult cigarette use. Despite these reductions, alternative tobacco use is also on the rise and suspected to play a major role in rising smoking rates among young adults.7,8 McMillen, Maduka, and Winickoff7 report that 18.2% of young adults have at least tried an alternative tobacco product in their lifetime. Increased sales of cigars over the last 2 decades are further evidence of alternative

tobacco product use.9 Additionally, national data collected in 2012 indicate that between 23.83% and 32.91% of young adults smoke little cigar/ cigarillo products (LCC).10

A key factor associated with increased use of ci- gars includes misperceptions that cigars are less harmful (than cigarettes).11-13 In particular, 40% of college-aged young adults believe that cigars and cigarillos are less harmful than cigarette smok- ing;14 however, irrefutable evidence indicates that cigar tobacco contain carcinogens,15 thereby in- creasing risk of cancers of the lung, oral cavity, larynx, lung, and esophagus.16,17 Additional fac- tors linked to increased LCC use include product flavorings (eg, chocolate, cherry), cheaper prices, smoother taste, factors such as tobacco industry marketing and advertising in popular and heavily frequented venues (eg, bars and clubs), and easy access.6,13,18-22

African Americans (AAs) and lower income groups report higher rates of LCC use compared to non-Hispanic Whites.9,18,23-26 AA college students are considered the fastest growing subpopulation of college student smokers.27 These trends are un- fortunate, as AA youth tend to smoke at lower rates on average (14% among high school and 8% among middle school students) compared to non-Hispanic

Maegan Stephens, Lecturer, Motolani E. Ogunsanya, Doctoral Candidate, Kentya H. Ford, Assistant Professor, Benita A. Bamgbade, Graduate Student, and Ming-Ching Liang, Doctor- al Candidate, The University of Texas at Austin, Austin, TX. Correspondence Dr Ford; [email protected]

Little Cigar and Cigarillo Beliefs and Behaviors among African-American Young Adults

Maegan Stephens, MA; Motolani E. Ogunsanya, B.Pharmacy, MS; Kentya H. Ford, DrPH; Benita A. Bamgbade, PharmD; Ming-Ching Liang, MA

Objectives: To inform the development of future research and culturally-target- ed interventions to address little cigar and cigarillo (LCC) use among an at-risk population: African-American (AA) young adults. Additionally, this project assess- es LCC use and perception differences between college- and non-college at- tending AA young adults who use LCCs. Methods: Separate focus groups with col- lege and non-college attending AA young adult LCC users assessed participants’ attitudes, norms, and perceived behav- ioral controls regarding LCC use, which was guided by the Theory of Planned Behavior. A thematic analysis following standard qualitative methods procedures revealed 5 themes. Results: Participants

shared overwhelmingly positive atti- tudes toward LCC use, ubiquitous use in their communities, and limited bar- riers to use. Additionally, participants had difficulty separating LCC and mari- juana use practices because LCCs often served as carriers for marijuana. There were no substantive differences between the college and non-college samples with respect to overall themes. Conclusions: Future research should assess LCC in- tended versus altered use and create cul- turally relevant intervention measures.

Key words: little cigars; cigarillos; Afri- can Americans; young adults; Theory of Planned Behavior

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Whites;27-29 AAs also are more likely to report lower SES, unemployment, and be non-college attend- ing, factors, which increase their vulnerability to tobacco use, subsequent dependence,30,31 and in- creased health disparities. Moreover, further dis- parities occur because of AAs’ limited access to care, less cessation, less preventive care provided by healthcare professionals, and unique exposures to differential and culturally-linked tobacco con- tent via direct advertising and marketing in neigh- borhoods,32-34 each of which increases their risk of tobacco-related morbidity and mortality.35,36

Although the literature is growing, limited re- search has been conducted to understand specific trends and demographic profiles of cigar variety (in- cluding large cigars and LCCs) use-patterns among young adults in general, and particularly among at-risk populations, such as AA young adults. A brief survey of 684 AA college students attending a historically black college and university found that 18.5% had smoked cigarillos in the past 30 days. Qualitative data from the same sample found that students preferred cigarillos over traditional ciga- rettes because of their smoother taste, association with higher social status, pleasant smell, variety of flavors available, ability to provide a better buzz, and for social reasons.37 The data showed that the extent of use among AA young adults may not be accurate as AA youth reported cigarillos by their brand name (eg, Black and Mild); thus, rates may be underestimated. Researchers also have found higher availability and more outdoor advertising of little cigars in areas with high populations of AA young adults.33 Unique psychosocial, socio-cultur- al, and environmental influences that might con- tribute to smoking beliefs and norms that increase prevalence among young adult smokers should be considered.

Some studies have provided foundational knowl- edge of perceived cigar use, beliefs, norms, and exposures (eg, marketing, ads);33,38-40 however, lim- ited research has explored a theoretically-based model for understanding factors linked with LCC use among AA young adults. Also, whereas there is important research focused on youth and col- lege-age populations, limited research has target- ed non-college attending young adults who are at great risk of initiating LCC smoking and becoming habitual smokers.41 Compared to their college at- tending peers, non-college attending young adults overall have a greater risk of cigarette and marijua- na use42,43 and are less likely to attempt to quit.44 Whether young AA adults are attending colleges, historically black colleges, universities, or not at- tending post-secondary education, all are at in- creased risk for smoking cigars11 and also may be at increased risk of negative health consequences.1 These findings are disturbing because other factors such as mistrust of the healthcare system, limited health-seeking behaviors, and higher rates of un- treated mental illness,45,46 put them at increased risk of tobacco-related disparities.47

Furthermore, health risks are exacerbated be- cause many smokers report dual or poly-use of tobacco products.48,49 Rath et al50 found that 23% of 18-34 year-old young adults engaged in current tobacco use, with 30% reporting dual use. Increase in concurrent tobacco use among young adults represents a major public health problem and calls for increased research and public health preven- tion efforts targeting young adults.

Building from existing exploratory research tar- geting beliefs and perceptions of LCC use and risk perceptions,25,37 the present study, guided by the Theory of Planned Behavior (TPB),51 was undertak- en to explore culturally-linked beliefs of little cigar and cigarillo use among African-American young adults. This study builds on existing research on LCC perceptions and seeks to understand the po- tential differences between college and non-college attending AA young adults. The TPB allows for a situation-specific and salient belief-based model for understanding how key proximal determinants (attitudes toward behavior, subjective norms, and perceived behavioral control) are linked to inten- tion to engage in behavior, and in turn, contrib- ute to actual behavior (TPB factors are not directly linked to actual behavior).

TPB is based on 3 determinants. First, attitude has been described as a “learned predisposition” to respond in a consistently favorable or unfavorable manner with respect to a given object.51 Second, subjective norm (SN) is a person’s own estimate of the societal pressure to engage or not engage in a behavior of interest.51,52 SN differs from attitude as the former is determined by normative beliefs, not by behavioral beliefs. Third, perceived control represents the degree to which an individual be- lieves being able to engage in the behavior. It is determined by control beliefs which are, in turn, determined by the power of both situational and internal factors that might enable or hinder the individual from enacting in the behavior.51 The theoretical constructs underlying TPB have been shown to be effective in explaining behaviors such as prostate cancer screenings, giving a gift, voting, recycling, exercising, alcohol abstinence, weight loss, and tobacco use and cessation.53-60 Also, the TBP has been applied to explain behaviors within African-American groups;54 however, this study fo- cuses on a priori assignments of TPB constructs. A more complete understanding of these factors could allow the development of focused interven- tions that may be successful at promoting desired behaviors among AA young adults LCC users.

METHODS Following IRB approval, 43 college attending

AA young adult LCC users and 26 non-college at- tending AA young adult LCC users (18-25 years old) participated in separate focus groups. College attending LCC users were recruited from a large southwestern university via flyers and university electronic message boards. Non-college attending

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LCC users were recruited via flyers in a local com- munity center and through established commu- nity leaders. The focus groups were held in private meeting facilities at a university and a community center, respectively. Refreshments and bus tickets were offered to participants. Additionally, partici- pants received monetary compensation in the form of gift cards at the completion of the focus groups. Focus groups continued until the point of satu- ration – 5 focus groups per participant category, when participants were no longer sharing new in- formation.

The focus group protocol was created following the TPB. Questions assessing participants’ at- titudes toward LCC and tobacco use, their sub- jective norms, and their perceived behaviors (per- ceived behavioral control) were included in the guide. Each of the project’s researchers reviewed the protocol and an outside qualitative methods expert provided final suggestions (Appendix A). Trained moderators conducted each of the 10 fo- cus groups using a semi-structured approach. Moderators asked additional probing questions and adjusted question order to fit the conversa- tion and maintain a conversational environment. In addition to the moderator, at least one of the other researchers served as a note-taker in each focus group. At the beginning of the focus group, each participant completed a brief questionnaire regarding demographic information and tobacco use behaviors.

Data Analysis

Qualitative data collection and analysis are in- separable processes, with the first step of analysis beginning during each group session. At the end of each focus group, the moderator provided a brief summary of key points that emerged from the dis- cussions and asked participants if this summary reflected their perception of what occurred. Field notes from each session were used to record the context and impressions at the time. Each focus group was audio-recorded and a trained transcrip- tion specialist provided verbatim transcripts, ex- cluding participant identities (M = 74 minutes), resulting in approximately 350 pages of single- spaced text for analysis. Two of the researchers conducted an independent thematic analysis in which they: (1) assessed participants comments in light of TPB; (2) created over-arching themes based on recurring participants’ responses; and (3) se- lected participant remarks that were aligned with the various themes and sub-themes.61 Next, the 2 researchers compared themes and sub-themes until they arrived at a consensus regarding the final theme list. Finally, a third researcher, who read all the transcripts, provided a validity check on the final themes and sub-themes.

RESULTS

The average age of the college attending sample was 20.85 years old (±1.78 years), with 42.2% fe-

male participants. The average age for first smok- ing a LCC was 16.10 years old (± 2.84 years) for the college attending sample. The average age of the non-college attending sample was 21.08 years (± 2.53 years), with 61.54% female participants. The average age for first smoking a LCC was 15.50 years old (± 1.82 years) for the non-college attend- ing sample. There were no substantive thematic differences based on sex or between the college attending and non-college attending samples. The only difference between the 2 samples was the lan- guage choice among participants in the different groups.

The majority LCC brand of choice in both sam- ples was Swisher Sweets. With respect to other to- bacco use, 53.49% of the college attending sample reported using a hookah in the past 30 days and 25.58% reported using cigarettes. In the non-col- lege attending sample, 15.38% reported using a hookah in the past 30 days and 38.46% reported using cigarettes.

Data analysis revealed 5 overarching themes regarding AA young adult LCC use. The first 2 themes, Unable to Separate LCC from Marijuana and LCC Types, emerged from the data and were prevalent in all 10 focus groups. The remaining themes (attitudes, subjunctive norms, and per- ceived behavioral controls) followed from analysis in light of the Theory of Planned Behavior.

Unable to Separate LCC from Marijuana Overwhelmingly, participants in both the college

and non-college attending sample had trouble sep- arating LCC use from marijuana use. One of the first questions the moderator asked participants was: “What do you think of when I say cigarillos?” Common responses included the following exam- ples:

College attending: Ok, I think of weed or mari- juana.

College attending: Me too.

Non-college attending: Most people that smoke White Owls--they smoke--they’re using it for weed, ya know what I’m saying?

Additionally, many participants sat with blank stares or responded with muddled laughter when asked the question. Throughout the course of all the focus groups, both the participants and mod- erator asked clarification as to whether the conver- sation was about LCC’s “intended use” or “altered use” (non-college attending). Most participants seemed confused with questions about LCC use in the intended form. As one participant noted: “No- body smokes them like cigars, period” (non-college attending). From the moderator perspective, he/ she continually questioned if the examples partici- pants provided (eg, memorable experiences) were from times they were smoking LCCs as intended or

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if they were referring to marijuana inside the LCC. Almost exclusively, participants initially provided examples regarding LCC altered use until the mod- erator probed for LCC intended use.

LCC Types A second area of discord between the moderator

and participants, as well as amongst participants themselves, were the differences among little ci- gars, mini cigars, and cigarillos. The following ex- change illustrates the confusion:

Moderator: What about little cigars? What do you think about when I say little cigars?

College attending: It’s just weird that you say it.

College attending: Yeah.

Moderator: It’s weird?

College attending: Yeah.

Moderator: So there’s nothing like little cigars?

College attending: No there is and mini cigarillos but just cigarillos and we call those rillos.

Moderator: So the cigarillos are called rillos.

College attending: Yeah, and then the mini cigars are called minis.

College attending: I think the little cigars you’ve been talking about are cigarillos.

College attending: No those cigars are technically minis. Cigarillos are bigger than cigarettes.

**group laughter**

A similar sentiment is evident in a different focus group:

College attending: I’ve never heard someone say little cigar that just sounds weird to me. I would not know what they were talking about specifically.

Another distinction developed, as participants in various focus groups discussed how a popular brand, Black and Mild, fit into the discussion:

College attending: Well I would actually smoke those (Black and Mild) and these (Swisher Sweets) I would alter them and that’s kind of the difference.

College attending: I mean, I think the Black and Mild is just a Black and Mild…

Non-college attending: Black and Milds, that just smell good. It’s like an incense. It’s like you can light it up and just let it burn cuz it smells good.”

As a non-college attending participant noted, cigarillos are for marijuana, “unless [they are smoking] Black and Mild” because Black and Mild tobacco products are meant to be smoked in their intended form. The participants in this study noted that cigars are “something old people smoke” (non- college attending), little cigars are also referred to as mini cigars (or minis), cigarillos (referred to as rillos) are meant to be smoked in an altered form (but white people smoke them as they are intend- ed), and Black and Mild products are something completely different from any of the other types.

Advantages versus Disadvantages (Attitudes)

The Theory of Planned Behavior accounts for the role of positive and negative attitudes in shaping behavior. To arrive at participants’ attitudes re- garding LCCs, moderators asked for advantages and disadvantages to specific products and uses. Additionally, data analysts assessed the transcripts for other advantages and disadvantages that were mentioned throughout the focus groups. Three distinct advantages included LCC features, health benefits, and effects on mood. First, features that made LCCs advantageous included burning qual- ity, taste, and smell. As previously mentioned, par- ticipants often spoke of LCCs as carriers for mari- juana, which is evident in the response: “Regular paper burn and crack faster but ‘rillos roll better, more support, and longer” (non-college attending). This sentiment was also shared within the college attending sample: “For the people who are altering their use the advantage of the cigarillos is it burns more.” LCCs also provide a way to mask the taste of poor quality marijuana: “Cuz what blunts are is that that’s the taste. It’s like the flavor. That’s why they have flavor ones (LCCs). Reggie (a type of mar- ijuana) is a bad taste” (non-college attending). The smell of LCCs was also mentioned as an advantage because they emit an incense-like fragrance (on- college attending).

A second LCC benefit was the health advantage because “it’s more healthier than tobacco” (non- college attending). Although about one-fourth of the college attending sample and nearly 40% of the non-college attending sample had smoked ciga- rettes in the previous 30 days, there was near con- sensus that tobacco smoke was “gross,” “nasty,” and “will kill you” (non-college attending). Addition- ally, participants noted the difference in addiction potential between LCCs and other products.

It’s that addictiveness of the papers. I know a lot of people who don’t like smoking papers be- cause they can’t roll papers and they, say, get addicted to smoking weed out of the papers be- cause it’s not really the same kind of high; it’s a little bit different (college attending).

Third, LCCs (both in their altered and unaltered form), act as a mood enhancer and improver for participants, particularly with respect to stress:

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I think that’s for a lot of people, most people do it to relieve stress. I know a lot of people smoke in the altered form like Bob Marley with the Rastafar- ians in that religion they say the reason they do that is because of it put you in a happy state—so- cial state. If any of y’all have any stories you do it in an altered form you really can’t think of any timeswhen you’re angry or you got into a con- flict (college attending).

When asked how LCCs made them feel, one group of participants listed the following descrip- tions:

College attending: Relaxed.

College attending: Relaxed and chill.

College attending: Pleasant.

College attending: Euphoric.

College attending: I agree with everything every- body said.

In one of the few responses that was specific to LCC use, a participant recalled her first LCC memory, which highlights LCCs as a coping mechanism. (Thematic analysis reveals that participants con- sider Black and Mild separate for LCCs, but for the purpose of this theme, a Black and Mild example is provided.)

College attending: I guess the first thing I thought of was the first time I smoked a Black and Mild, which was my first interaction with smoking. It was a bad experience. It was because my friend at the time was going through whatever and she bought Black and Milds for that reason and me and her friend tried to comfort her and we were in her car and we were just--I don’t know, I don’t know why I did it.

Whereas participants easily shared advantages to LCC use, they did note disadvantages includ- ing health concerns and somatic issues. When the moderator asked, “Are there any other disadvan- tages that you can think of for using rillos?” the following conversation took place:

Non-college attending: Nothing besides really health—

Non-college attending: Yeah, that’s it.

Non-college attending: -- in the long run. You know those Blacks are like 10 cigarettes, they say.

Non-college attending: Oh yeah.

Non-college attending: And that’s strong. It makes you cough. Chest be hurting and stuff sometimes.

Non-college attending: Yeah they--

Non-college attending: Now those are--

Non-college attending: You be coughing up blood too.

Non-college attending: mmhmm. After you smoke so long.

As an alternative to using LCCs for marijuana, a college attending participant stated that papers were a healthier option whereas a non-college at- tending participant explained, “that’s why white people just smoke outta bongs.” In addition to health concerns, participants found that LCCs “make your lips black” (college attending), makes one’s “nails turn brown” (non-college attending), can negatively impact reproduction (non-college attending), and that the smell “stays in you clothes longer” than other products (college at- tending).

Pervasive and Social Use Practices (Subjunctive Norms)

Subjective norms speak to the societal pressure of an individual’s experiences with regard to a spe- cific behavior, or the lack thereof. LCCs pervasive use in the family and communal groups, as well as the socializing experience accompanying use, sug- gest that participants find LCC use common and rarely criticized. When asked to recall their first ex- perience with LCCs, many participants told stories involving family members.

So the first time for me I was actually in Atlan- ta—Decatur to be exact. I went down to see my dad after like 7 years, and this was when I was around 22, and I went down there for about a week and the first day I was there I was at my grandma’s house and we were sitting down. It was nice and he was like “do you mind if I light this blunt.” For all of you that don’t know what a blunt is – a White Owl that’s altered more. So we hit. We were smoking those White Owls in their altered form. I had a great time that week (college attending).

Another participant could not recall which product was used but was able to share that following the return of a sibling from the military, the 2 of them shared a bonding experience. The experiences were not limited to family members.

Mine would probably have to be my best friend’s mom. She loves the rillos and I was s p e n d - ing the weekend with them and I had done something to kind of piss her off. I was like “What can I do to make this up to her,” and so we went to the convenience store and I bought her a pack and when we came back she said, “Yeah she was really pissed off but since you bought me a pack like it’s cool,” so we

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sat there and smoked on her porch and talked (college attending).

LCC use was so pervasive for the participants in this study that they responded, “Everybody ap- prove. Everybody smokes” (non-college attending). Not only is the practice nearly universal to these participants, but the experience itself “is a social thing” (college attending). As one college attending participant shared:

It’s probably nonexistent if I’m not with other people, unless it’s like me and one or 2 other people, and probably if it is 3 people then yeah, I probably would use a cigarillo. Other than that, there really is no need.

Again, this participant was referring to altering a cigarillo with marijuana. Overall, participants considered LCCs best for sharing marijuana; oth- erwise, they would use a different altered form.

Enabling Mechanisms versus Barriers (Perceived Behavioral Control)

The Theory of Planned Behavior states that both the situational and internal control factors could influence the degree to which an individual engag- es in a behavior. Participants were asked to share such factors, from both an enabling and barrier perspective. The low cost and ubiquitous nature of LCCs were shared as enabling mechanisms. First, one participant enthusiastically responded: “It’s like a dollar! It’s $1.07. It ain’t expensive to go buy them. We got jobs. It’s easy” (non-college attending). Although different brands have different costs, “they have one called Good Times. That’s when you don’t have that much money. You get 3 for a dollar” (non-college attending). Second, according to participants, LCCs are everywhere. “Like every gas station and corner store there’s like a corner store on every...it’s easy. I mean, gas...I walk to the corner store” (college attending). Multiple focus groups mentioned a “candy lady” who sells LCCS, among other convenience store-like products.

Non-college attending: Like if I’m at home, and my candy lady is next door to me, and she sells them...

Non-college attending: That was just my next ex- ample.

**group laughter**

Non-college attending: She’s open 24 hours and she do sell them but they a dollar so you only get one. If she had this pack (referring to a pack on the table) she make $2 off it.

A separate focus group corroborated the example: “They sell it in the neighborhood. It’s the candy lady in the neighborhood that sells chips, candy, Starburst…” (Non-college attending).

Not only did participants report their being read- ily availability, they stated that the practice of us- ing LCCS was also ubiquitous.

Non-college attending: Everybody. It doesn’t mat- ter. White people, black people, age.

Non-college attending: There is no social group. Everybody. I say 85% of young people from age 13-25, 85% of people are smoking weed anyway.

Moderator: And most of them are using [cigaril- los]?

Non-college attending: --Probably more than that but--

Non-college attending: That’s like the estimate.

Moderator: And most of them are going to use these little cigars to roll and they are not going to use papers?

Non-college attending: Yes.

Even with the enabling mechanisms, partici- pants did name barriers to LCC use including cost, stereotyping, and the law. Although partici- pants shared that using LCCs for marijuana was relatively inexpensive, it was “not the most cost- effective way to smoke” (college attending). Other options, such as rolling papers, would provide less cost; however, participants agreed that there was a physical and social difference between using LCCs and papers. Cost in general was also a concern for some:

My reason is it’s too much sometimes. Some- times it’s too expensive plus… And other times I feel like I really need to stop like when school was over like the last day of school I was like I’m not gonna smoke no more (Non- college attending).

A second barrier to LCC use was the stereotyping that other, usually non-smokers, would have of the participants. One participant clarified near the end of the focus group:

Y’all don’t know me. When I say I smoke, I don’t blow a whole load of money over it. For me, I don’t wanna do that because that’s not how I would like to present myself in public or at work (Non-college attending).

Additionally, participants often joked of friends and acquaintances they knew who smoked exces- sively and whose productivity deteriorated. They even mentioned how they attempted to quit smok- ing at times because it disrupted their own lives. These instances, however, were in reference to

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smoking marijuana. Third, the law was repeatedly mentioned as a barrier to LCC use (again, in an altered form): “They are not illegal but the product itself is not illegal, but it is what you put in it” (non- college attending). The confusion between LCCs for tobacco and for marijuana extended in another ex- ample about law enforcement:

Non-college attending: This one time I smoked a Black (Black and Mild) in my car, and I got pulled over and they said it smelled like weed but it was a Black. So they searched my car and I was really mad.

Moderator: What ended up happening? They just searched your car--

Non-college attending: They just searched my car. The Black was in my ashtray but they didn’t know.

DISCUSSION This qualitative study was guided by the Theory

of Planned Behavior to explore attitudes, subjective norms, and perceived behavioral controls related to LCC use among AA young adults. According to the Theory of Planned Behavior, the more favor- able the attitude and subjective norm toward the behavior, and the higher the perceived behavioral control, the higher an individual’s intention should be in engaging in the behavior of interest.51 The thematic analysis reveals that participants over- whelmingly hold positive attitudes about LCCs, encounter norms that approve of the behavior, and experience situational control factors that make engaging in LCC use easy. Perhaps these results are not entirely surprising given the recruitment material asked for LCC users; still, the details in each theme reveal important information for fu- ture research as well as intervention materials and methods.

The first 2 themes in this analysis were not di- rectly related to TPB but do provide important in- formation for researchers and practitioners. First, the conflation of LCC use for marijuana use is cru- cial for those conducting LCC research and those interested in intervention measures. Research is needed to address possible misreporting of LCC use in its intended form to prevent underestimat- ing use and to identify other users who could ben- efit from LCC use intervention. Second, whereas participants were confused by the term “little ci- gar,” the literature and survey measures often use this term. Future research should continue to be clear about the differences among little cigars, minis, cigarillos (rillos), and Black and Mild (which appears to be a category all its own),62,63 as well as how individuals actually use these products. The present study adds to this growing body of litera- ture as it notes that the cultural perceptions sur- rounding these product differences are real. These cultural cues may be the key to uncovering use patterns across groups.

One of the advantages that appears to lead to increased LCC use is the health perception sur- rounding the products, as previous research also indicates.14 Whereas participants disagreed as to whether Black and Mild products were better or worse than cigarettes, most participants shared that they were aware of the negative health effects of cigarettes. Additionally, participants overwhelm- ingly believed that LCC use in the altered form was a healthier option than cigarettes, and their atti- tudes about LCCS are reflected in their use behav- iors. Intervention materials need to address the negative health impacts associated with LCC use, both in the intended and altered form.

The themes associated with subjunctive norms regarding LCC use show that participants witness positive cultural practices. LCC use was ubiqui- tous for the participants in this study, and they shared how family, friends, and community re- lationships enabled use more than controlled it. Sociological research has shown how cultural pat- terns are not always static; instead, they are con- tingent on geographical and identity difference.64

The qualitative analysis in this study uncovers identification structures that are not always vis- ible. Practitioners need to develop neighborhood specific intervention measures that address the deep cultural connections between LCC attitudes, norms, and behaviors.

There are a few limitations of this analysis that are important to address. This study provides qualitative data that cannot make cause and ef- fect claims. Additionally, the sample was limited to LCC users in one geographic region; the find- ings may not represent actual differences between AA young adult non-users and users and are not representative of all users. Still, the themes offer important next steps for researchers concerned with LCCs, young adults, and African-American tobacco users. Interestingly, there was no sub- stantive difference between the participants, which surprised the researchers. These findings suggest that LCC use patterns are less concerned with ed- ucation level and other traditional socioeconomic indicators, and are instead, influenced by underly- ing cultural practices.

Human Subjects Statement

This project received approval from the Institu- tional Review Board at the University of Texas at Austin (2013-02-0127).

Conflict of Interest Statement The authors have no conflicts of interest.

Acknowledgments This project was funded by a research grant

awarded to Dr Kentya Ford by University of Texas, Office of the Vice President for Research. Also, this study was supported by the University of Texas, College of Pharmacy. The researchers acknowledge Dr Carolyn Brown for her assistance with the focus

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group protocol and Dr. Kymberle Landrum Sterling for her assistance with study design and methods.

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Appendix A Focus Group Protocol

Opening Moderator: Hello everyone and welcome to this discussion about cigarillos. My name is _________ and I work for the Univer- sity of Texas at Austin. We are trying to gather more information about young people’s use of cigarillos and their exposure to cigarillo messages on social media websites, like YouTube. My colleague ________ will be taking notes.

I will be guiding today’s discussion and look forward to hearing about your experiences. This discussion will take no more than an hour and a half. Please turn the name card in front of you so the others can see your name. That will make it easier for people to refer each other by name during the discussion.

We would like to hear from everyone here. We expect that people will have some similar experiences and opinions to share and some different experiences and opinions. We want to capture all of these, so it is okay to disagree or share a different per- spective than someone else in the group.

Also, we will tape our conversation by audio recorders so that we don’t miss anything that you say. We want to be sure we capture the full range of your opinions on the topic. No names will be used in our report of this conversation.

We would like each person to answer the first question, in turn, while going around the table. The rest of the questions are to be answered as you feel led. Feel free to respond based on what you’ve heard from others. Please remember to respect each person’s response as legitimate and valuable to our discussion. Please turn your cell phone to silent or off so we aren’t distracted during this conversation. Are there any questions or concerns before we begin?

Warming up Moderator: Again, my name is _______ and here is my colleague _______. Thank you for participating in our study. We are excited to hear what you have to say. Before we get started, can you tell us a little about yourself? Tell us how you would like to be addressed in this meeting, your age, and something you like to do in your free time. Great. It seems we have a nice group here. As you know, we are interested in your experience and opinions about little cigars/cigarillo tobacco products.

1. Experiences with regard to use of LCCs: Dual Tobacco Use ● What products do you think of when I say “cigarillos?” What about “little cigar?” ● Which products have you used (Prompt only if they don’t name any: Swisher Sweets, White Owl, Phillies ARE RILLOS. Black and Mild is considered something different)? ● What is your favorite (Brand and Flavor)? ● Take a minute to think about a memorable experience with cigarillos. Tell me about that experience. Probe: What went into your decision to use cigarillos in this instance? (Might have to explain and push on this). ● How do you feel when using cigarillos? Probe: stress relief, quitting, addiction ● If you were interested in not using cigarillos any more, for any purpose, how do you feel about your ability to quit? Probe: quitting confidence, addiction, assistance. ● What are your experiences with other tobacco product(s)? Probe: products smoked before and after. (We are trying to see if there was a gateway but we can’t say gateway).

2. Theory of Planned Behavior Attitudes ● What are advantages of your using cigarillos? (Might have to help with this—why would someone choose to use them?) ● What are the disadvantages of using cigarillos? ● Are there any other things that come to mind when you think about your using cigarillos? Normative Belief (Subjective Norms) ● What individuals or groups would be okay with your using these products? ● What individuals or groups would be okay with your using these products? ● Who do you know that also uses these products? (Ask for descriptions. Follow-up questions based on their responses). Control Beliefs (Perceived Behavioral Control) ● What factors or circumstances make it easy for you to smoke these products? ● What factors or circumstances make it difficult for you to use these products?

Summary Let me just make sure I can recap our discussion: Today we X, Y, Z.

Concluding Questions Does anybody have anything else they would like to say about little cigar/cigarillo use? Thank you very much for your participation.

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