The College Freshman Nicotine Study

1. The College Freshman Nicotine Study Johns Hopkins Bloomberg School of Public Health Stephanie Y. Smith, MPH, PhD Candidate Frances A. Stillman, EdD, EdM Study sponsored by the ASPH/Legacy STEPUP Dissertation Scholarship

2. Outline of Remarks • Background • Design/Sample • Findings

3. Study Objective: To investigate reported use of “reduced risk” (e.g., purported low yield tobacco, medicinal nicotine, and novel nicotine) nicotine delivery products with awareness and risk perception of these products among full-time college freshmen attending the Johns Hopkins University in Baltimore, Maryland • Awareness • Risk Perception • Reported Use

4. Rationale for Study • Prevalence of smoking among college students is higher than national prevalence -- 25.7% vs. 23.3% (Johnston, O’Malley, Bachman, 2002) • Among 18-24 year olds in Baltimore City, MD -- Smoking initiation increased from 24.7% in 2000 to 39.8% in 2002 • (MD Dept of Health and Mental Hygiene, 2002)

5. Why Harm Reduction and “Reduced Risk” Nicotine Delivery Products? • We know that 50% of smokers will never quit; thus, focusing only on cessation ignores half the smokers (Hughes, JR. 1998)

6. Definition of Harm Reduction: A product is harm-reducing if it lowers total tobacco-related mortality and morbidity even though use of that product may involve continued exposure to tobacco-related toxicants.(IOM. Clearing the Smoke, 2001)

7. Medicinal Nicotine Purported Low Yield Tobacco Novel Nicotine Products What ARE “Reduced Risk” Nicotine Delivery Products?

8. Potential Unintended Consequences Low-tar/low-nicotine cigarettes or cigarette-like products might be less-aversive starter products (Hughes, JR. 1998)

9. 1950’s “Filtered” Cigarettes 1970’s “Light” Cigarettes 1970s-1980s Smokeless Tobacco Historical Examples of “Reduced Risk” or “Harm Reducing” Products and Unintended Consequences

10. Specific Aims • To explore awareness and beliefs about nicotine and “reduced risk” nicotine delivery products among full-time college freshmen attending the Johns Hopkins University in Baltimore, Maryland • To test hypotheses comparing the reported use of “reduced risk”nicotine delivery products with psychosocial vulnerabilities (e.g., gender, smoking status) of full-time college freshmen attending the Johns Hopkins University in Baltimore, Maryland

11. Design 1-Year, Two-Phase, Mixed-Method Study Phase I: Qualitative Focus Groups Phase II: Quantitative Risk Perception Survey

12. Phase I Goal: To assess the knowledge, attitudes, and beliefs that college freshmen have pertaining to nicotine, products that contain nicotine, and nicotine addiction. • Data gathered from Phase I will be used to tailor a risk perception survey to be administered in Phase II

13. Phase I Sample • Full-Time College Freshmen Attending the Johns Hopkins University *Smoking Status based on work by Pierce, Choi, and Gilpin (1998)

14. Focus Group Questions • Tell me what you know about nicotine. • Tell me about the types of products that contain nicotine. • Why would your peers want to use these products? • Tell me what you know about nicotine addiction.

15. Phase I: Preliminary Findings • Tell me what you know about nicotine.

16. Phase I: Preliminary Findings • Tell me about the types of products that contain nicotine. Cigarettes Cigars Bidis Chaw/Chew/Dip/Snuff Pipe Gum Patch Inhaler Water Wafers (FG#4) Cloves/Kreteks (FG#4) Lollipops (FG#4) Hookah (FG#123) / Shisha (FG#4)

17. Phase I: Preliminary Findings • Why would your peers want to use these products? Look hot (guys only) Look rugged, dangerous, and gorgeous Status (cigar only) Celebration (cigar only) Victory (cigar only) Leisure Image/Glamour To fit in Make a name for yourself Just to experiment Make smoke rings (they’re cool) Recreation Stress relief Entertainment Meditation Socially Want a buzz Cessation Addicted but in denial Weight loss Look cool

19. Phase I: Preliminary Findings • Why would your peers want to use these products? “It’s all about image – whatever product I use, it’s all about how it makes me look” “Shisha is hot -- it’s not addictive -- it’s social -- it’s meditative -- it smells good -- it tastes good -- it looks cool -- it’s inexpensive cuz you split the cost with friends -- don’t even have to smoke it, just smell it -- the smoke isn’t bad for you” “NRT is for the weak” – All groups associated it with dependency and therefore those who use it are weak, “It’s weak nicotine” “Whatever product you develop to get people off the cigarette…it’s gotta be prevalent, like everywhere and hot beautiful people gotta be using it…ideally it’d mimic the cigarette”

20. Phase I: Preliminary Findings • Tell me what you know about nicotine addiction. “Cigs are the most addictive, then dip, don’t hear much about the other products and serious addiction problems.” “Most people view smoking as unhealthy, so if Big Tobacco (BT) markets NRT then it could be viewed as healthy…with BT’s tarnished image, they could profit from making NRT, they could make a bundle…” “You don’t care who makes it or if it’s regulated or not, you care about which one is cheaper, and which one tastes better” “Put all cigarette taxes into prevention and cessation for <18 year olds…[treatment centers in schools, support groups in schools, in addition to prevention in health classes]”

21. Phase I: In Summary • Awareness High • Knowledge High • Beliefs Use a product socially = no addiction • Use a product by yourself = addiction

23. Study Limitations • Limited generalizability • Phase I qualitative phase lacks ‘saturation’ • Misclassification of smoking status – no biochemical verification • Self-report and social desirability • Convenience sample

24. Study Strengths • Combination of qualitative and quantitative methods • Literature review addresses critical gap Unites multidisciplinary literature First look at risk perception of “reduced risk” nicotine delivery products in college freshmen • Importance of topic Policy application Educational and prevention strategies

25. Contact Information: Stephanie Smith stsmith@jhsph.edu JHUFreshmanNicotineStudy@yahoo.com

26. References • Johnston, L.D., O’Malley, P.M., Bachman, J.G. 2002. Monitoring the Future National Survey Results on Drug Use, 1975-2001. Volume II: College Students and Adults Ages 19-40. (NIH Publication No. 02-5107). Bethesda, MD National Institute on Drug Abuse • Johnston, L.D., O’Malley, P.M., Bachman, J.G. 2002. Monitoring the Future National Survey Results on Drug Use, 1975-2001. Volume I: College Secondary School Students. (NIH Publication No. 02-5106). Bethesda, MD National Institute on Drug Abuse • First Annual Tobacco Study, Sept. 2002, MD Department of Health and Mental Hygiene • Hughes, J.R. 1998. “Harm Reduction Approaches to Smoking: The Need for Data.” American Journal of Preventive Medicine 15(1):78-79 • IOM (Institute of Medicine). 2001. Clearing the Smoke. K. Stratton, P. Shetty, R. Wallace, and S. Bondurant, eds. Washington, D.C.: National Academy Press • Pierce, J.P., Choi, W.S., and Gilpin, E.A. 1998. “Tobacco Industry Promotion of Cigarettes and Adolescent Smoking.” Journal of the American Medical Association 279:511-515

27. Phase I Procedures Qualitative Focus Groups • Recruitment • Flyers • Consent • Timeframe • Compensation • 4 Focus Groups • Gender • Smoking Status