Abstract
The purpose of this study is to understand differences in demographics, frequency of tobacco use, and tobacco-related attitudes between youth/young adults who carry tobacco products and those who do not. Carrying tobacco is hypothesized to affect individuals’ smoker identity and thereby their tobacco-related attitudes. Carriers are an influential peer group, often serving as social sources of tobacco for others, setting tobacco-related social norms, and advertising tobacco via the packs they carry. Thus, understanding their characteristics and attitudes can aid in the targeting and tailoring of cessation messaging. In this study, 3,927 attendees ages 13 to 24 years at the Vans Warped Tour were surveyed using iPads and asked to photograph any tobacco products they were currently carrying. Current tobacco users were classified as proven carriers (n = 363), unproven carriers (n = 182), or noncarriers (n = 1,426). Carriers (N = 545) were older, were more often White, and used tobacco over twice as often as noncarriers. Results indicated carriers and noncarriers differed significantly on most antitobacco attitudes, with carriers feeling less strongly antitobacco.
Whether smokers physically carry tobacco products with them is an underexplored smoking behavior that may have important implications for smoking cessation interventions (Shu-Hong, 2012). A qualitative study in Norway demonstrated that cigarette package design is an integrated aspect of young smokers’ construction of their smoker identities (Scheffels, 2008). Similarly, if carrying tobacco is an integrated part of smokers’ construction of their smoker identities, it may influence formation of tobacco-related attitudes and receptivity to different kinds of smoking cessation messages. Not carrying tobacco could also play a role in constructing an identity whereby someone smokes yet does not consider himself or herself an actual smoker because he or she does not purchase and physically carry around tobacco products. In this case, those not carrying tobacco may need cessation messages and interventions that address social smoking; traditional cessation approaches targeted at smokers may not resonate with this group.
Beyond their own smoking patterns and identities, those carrying tobacco (i.e., carriers) may influence others’ smoking patterns and perceptions, particularly among youth and young adults, in three main capacities. First, young carriers likely serve as social sources of tobacco for other young people that do not carry tobacco. Research indicates U.S. youth rely heavily on social sources of cigarettes (Jones, Sharp, Husten, & Crossett, 2002), with 28% of current cigarette users younger than 18 years reporting borrowing cigarettes (Jones & Caraballo, 2014). Second, young carriers probably contribute to protobacco social norms among their peers. Social influence has consistently been associated with adolescent smoking (Simons-Morton & Farhat, 2010), and youth report feeling pressure to smoke when with other peers who are smoking (Nichter, Vuckovic, Quintero, & Ritenbaugh, 1997). Additionally, identification with certain peer crowds, including those that listen to a particular type of music, has been associated with smoking norms, behavior, and antitobacco attitudes (Lee, Jordan, Djakaria, & Ling, 2014). So carriers who smoke more heavily and consider smoking a part of their identity may perpetuate group norms around the acceptability and desirability of smoking.
Third, young carriers may serve as “silent salespersons,” exposing peers to tobacco brands and imagery via the tobacco packs they carry (Wakefield et al., 2013). Tobacco industry research indicates that strategic variations in cigarette packaging influence brand appeal and risk perceptions and increase cigarette sales (Kotnowski & Hammond, 2013). Additionally, research indicates that pack structure and color are associated with adolescent susceptibility to smoke (Ford, MacKintosh, Moodie, Richardson, & Hastings, 2013).
All of these roles that carriers play are especially salient in social venues popular among youth, such as music festivals. Thus, this study uses data from a survey of youth attending a popular music festival to understand the differences in demographics, tobacco use frequency, and tobacco-related attitudes between youth/young adult carriers versus noncarriers. Understanding these differences could aid in targeting and tailoring cessation messaging for carriers, who may be receptive to different kinds of smoking cessation messages than noncarriers if they are different in terms of their demographics, tobacco use, or tobacco-related attitudes.
Method
Data used in this analysis are from a survey of 3,926 attendees at the Vans Warped Tour (VWT) conducted to evaluate presence of the truth® campaign at VWT. VWT is a traveling music festival that reaches over 600,000 fans each summer in the United States and Canada (VWT, 2012). The truth® campaign (Allen, Vallone, Vargyas, & Healton, 2009), one of the largest national youth smoking prevention mass media campaigns, has maintained a presence at VWT since the early 2000s, giving teens the opportunity to experience truth’s message firsthand and engage with the brand on a peer-to-peer level. At the VWT, truth’s presence is in the form of the “truth zone,” with a number of hands-on activities and apparel giveaways referencing tobacco-related facts.
Data Collection
Approximately one hundred 13- to 24-year old concert attendees were surveyed per day in 39 of the 41 VWT stops between June 15 and August 5, 2012 (two stops in Canada were excluded because truth does not operate outside the United States; Yancey, 2012). Participants were surveyed immediately on entry into the truth zone or as they were completing their experience and leaving the zone. The survey was programmed onto iPads using the Survey on Demand Application, a mobile survey application developed by Confirmit. At each stop, participants were approached by the same data collector who asked if they would be interested in taking a short survey on an iPad in exchange for a free bottle of cold water. Water bottles cost $3 to $4 in each venue, and most venues were outside in extreme heat. Participants were provided with written information about survey participation and provided consent. Those outside the 13 to 24 age range or who had previously been to the truth zone earlier that day or at another event were excluded. This study was approved by Independent Investigational Review Board, Inc.
Measures
Participants were asked to select from a list all tobacco products they had used in the past 30 days, and those indicating use of any product in the past 30 days were classified as current tobacco users. Frequency of use was determined by asking respondents, “During the past 30 days, on how many days did you use tobacco?” Current tobacco users were classified as proven carriers (responded yes to “Are you carrying any tobacco products on you today?” and using the iPad, took photographs of one or more tobacco products they were carrying), unproven carriers (responded yes to “Are you carrying any tobacco products on you today?” but did not take a photograph or took a photograph of something other than a tobacco product/package), or noncarriers (responded no to “Are you carrying any tobacco products on you today?”). Comparing carrier status among only current tobacco users provided insight into how carrying tobacco, beyond using tobacco, might be associated with different characteristics and attitudes. Standard demographic items (see Table 1) and tobacco-related attitudes (see Table 2 for measures and response categories) were also assessed. Region of the United States in which one resides was determined using respondents’ zip codes.
Demographics of Noncarriers Versus Unproven Carriers Versus Proven Carriers.
Note. df = degrees of freedom.
Chi-square tests compare three groups (noncarriers, unproven carriers, and proven carriers). Response categories used in the chi-square analyses are as follows: for gender, male and female; for age, 13-24; for race/ethnicity, White, African American, Hispanic, Asian, other; for education, <high school, high school/GED, some college, college, or more. bSurvey item response options: Open-ended response (13-24). cSurvey item response options: (a) male, (b) female. dSurvey item response options: (a) White, (b) Black, (c) African American, (d) Asian or Pacific Islander, (e) Native American or Alaskan native, (f) mixed racial background, (g) other race, (h) Hispanic or Latino, (i) decline to answer. eSurvey item response options: (a) have not graduated from high school, (b) high school diploma/GED, (c) some college, (d) college degree, (e) some graduate, (f) graduate degree, (g) Doctoral/PHD.
Differences in Antitobacco Attitudes Among Carriers and Noncarriers.
All analyses are logistic regression models and control for age, gender, race/ethnicity, education, and region of the United States where one resides. Differences in sample size are due to the fact that not all respondents were asked all questions in an effort to limit the survey to 5 minutes for this concert-attending audience. bResponse options: (1) definitely yes, (2) probably yes, (3) probably not, (4) definitely not, (5) not sure; dichotomized for analysis as definitely or probably yes versus probably not, definitely not, or not sure. cResponse options: (1) strongly disagree, (2) somewhat disagree, (3) neither disagree/agree, (4) somewhat agree, (5) strongly agree; dichotomized for analysis as strongly agree or somewhat agree versus neither disagree/agree, somewhat disagree, or strongly disagree. dIndicates item was reverse-coded. eResponse options: (1) extremely negative, (2) very negative, (3) somewhat negative, (4) neutral, (5) somewhat positive, (6) very positive, (7) extremely positive; dichotomized for analysis as extremely, very, or somewhat negative versus neutral or somewhat, very, or extremely positive.
p < .05. **p < .01. ***p < .001.
Data Analysis
Photographs of tobacco products were coded by two independent coders, with high interrater reliability (.97-.99) for coding of whether there were tobacco products present, product type, brand, flavor, and if the product was a menthol product. In the event of disagreement, a third coder made the final determination.
Demographic differences between proven carriers, unproven carriers, and noncarriers were assessed using chi square tests, and differences in tobacco use were determined using Poisson regression. Logistic regression analyses were used to assess whether carrier status predicted antitobacco attitudes while controlling for demographic characteristics. All analyses were conducted using Stata 13.
Results
Of the 3,927 total respondents, 1,971 were self-reported current tobacco users; these users were proven carriers (n = 363), unproven carriers (n = 182), or noncarriers (n = 1,426), as defined above. Among the proven carriers, as determined by the photographs, 91.5% were carrying only one product, such as one pack of cigarettes. Overall, 95.9% of proven carriers were carrying cigarettes, 5.2% were carrying smokeless products, and fewer than 2% were carrying other tobacco products, such as cigars. By brand, 47.4% of proven carriers were carrying a Marlboro product, 23.4% were carrying a Camel product, 9.4% were carrying a Newport product, and 24.5% were carrying another brand. Additionally, 39.7% of proven carriers were carrying a menthol product, and 5.0% were carrying another flavored product.
Demographics
Significant demographic differences between proven carriers, unproven carriers, and noncarriers (Table 1) included age, χ2(22, N = 1,971) = 80.53, p < .001; education, χ2(6, N = 1,941) = 15.12, p < .05; and race/ethnicity, χ2(8, N = 1,941) = 27.15, p < .01. On average, proven carriers were older than unproven carriers, and both were older than noncarriers. Of proven carriers, 72.9% were White, compared with 67.0% of unproven carriers and only 63.5% of noncarriers. Overall, there were no significant differences by gender (Table 1).
Frequency of Tobacco Use
Controlling for age, gender, race/ethnicity, education, and region of the United States where one resides, Poisson regression analyses indicated that proven carriers used tobacco on 2.8 times more days than noncarriers (Poisson regression incident rate ratio [IRR], p < .001), and unproven carriers used tobacco on 2.4 times more days than noncarriers (IRR, p < .001). Unproven carriers used tobacco on 0.83 times fewer days than proven carriers (IRR, p < .001).
Antitobacco Attitudes
Logistic regression analyses (controlling for age, gender, race/ethnicity, education, and region of the United States where one resides) indicated there were no significant differences between unproven and proven carriers across any attitudes assessed; thus, these groups were combined into one group (i.e., carriers) for multivariable logistic regression analyses and compared with noncarriers (Table 2). Items are grouped together based on category in Table 2, but each attitude item was analyzed separately as an outcome variable in regression analyses, not as part of a scale. Not all respondents were asked all attitude items, so chi-square tests were conducted to ensure groups asked different sets of items were equivalent across demographic characteristics. Tests indicated there were no significant differences across any of the demographic variables assessed (age, gender, race/ethnicity, education, and region of the United States).
Overall, a number of antitobacco attitudes were predicted by carrier status. Carriers were less likely to believe in the negative health effects of tobacco (e.g., less likely to agree using tobacco is dangerous; odds ratio [OR] = 0.48, p < .001) and less likely to harbor negative attitudes toward tobacco products (e.g., less likely to feel negatively about tobacco products; OR = 0.36, p < .001). Carriers were also less likely to agree tobacco use is a huge problem for society (OR = .44, p < .001) and less likely to feel negatively about tobacco companies (OR = 0.42, p < .001). Carriers had well over 3 times the odds as noncarriers of saying they would likely use tobacco in the next year (OR = 3.82, p < .001).
Conversely, some antitobacco attitudes were not predicted by carrier status in logistic regression analyses. Based on tallying responses to these attitude items, both carriers and noncarriers agreed that tobacco companies add flavors to make it more appealing; tobacco companies lie so they can make more money and that tobacco marketing is designed to manipulate young people. Both groups also agreed that using tobacco is a social thing to do; however, they disagreed that using tobacco is part of socializing with friends.
Discussion
Overall, results from this study indicate that carrier status is associated with feeling less strongly antitobacco across most tobacco-related attitude items assessed. It is possible that carrier status influences antitobacco attitudes via the creation of a particular smoker identity, though further research is needed to demonstrate such a causal path.
The large proportion of smokers (50.3%) in this sample may be a result of unique characteristics of a young outdoor-concert–attending population. Interestingly, there were no major differences across antitobacco attitudes between proven versus unproven carriers, suggesting that self-report of carrier status may be an adequate indicator, without the need for objective proof (i.e., photo). However, this additional step provides information on product type and brand that may not be available or reliable when collected via self-report. The top three brands found in this study (Marlboro, Camel, Newport) align with the three most popular cigarette brands in the United States (Maxwell, 2013).
Notably, though carrier status was associated with feeling less strongly antitobacco across most attitudes assessed, carriers and noncarriers did not differ in social smoking attitudes, which may be partially due to noncarriers crafting an identity as “social smokers.” The heightened acceptability of social smoking as compared to other protobacco attitudes among noncarriers may be driven by their own social smoking or by youth/young adult behavior more broadly. National surveys indicate high young adult social smoking prevalence, ranging from 51% to 62% (Moran, Wechsler, & Rigotti, 2004; Song & Ling, 2011).
There are a number of limitations to this study, including its cross-sectional nature, which makes it impossible to demonstrate that carrier status precedes tobacco-related attitudes (as opposed to attitudes influencing carrier status). Due to the fact that not all survey respondents were asked all questions, it was not possible to create attitudinal scales, and the resultant assessment of separate models for each attitude of interest increases Type I error. However, each of these attitudes individually are of interest, and 62% of the assessed models demonstrated significance, which is substantially more than likely to occur by chance, even with the number of models considered in this analysis. The measurement of carrier status in this study is a novel approach, and further research is needed to understand its reliability. Carrier status was assessed only once, and motivations for carrying tobacco products were not assessed. Additionally, it is possible that underage smokers are more likely to conceal the fact that they are carrying tobacco products. Relatedly, carriers in this sample were older than noncarriers (likely a result of policies prohibiting minors from accessing tobacco products); it is possible that this imbalance is so strong that adjusting for age in analyses is not adequate to achieve reliable results.
However, this study also exhibits numerous strengths, including in-the-moment data collection via iPads, which provides important insights into the tobacco-carrying behaviors of young people in an outdoor concert setting. Additionally, those who self-reported carrying a product were asked to take a photograph, which provided objective proof of carrier status. This is also the first study to our knowledge to compare tobacco-related attitudes and behaviors among carriers and noncarriers.
The differences found between carriers and noncarriers, namely, carrier status being associated with feeling less strongly antitobacco, have implications for tobacco control in that these results suggest that an understanding of carrier status may aid in targeting and tailoring cessation messaging for young smokers. If carriers are crafting certain distinct smoker identities that lead to them exhibiting stronger protobacco attitudes than noncarriers, interventions targeting these groups may need to avoid strongly anti-industry messages, as these may cause heightened psychological reactance among this proindustry group of smokers, leading them to ignore or counter such messages. To prevent this, antismoking messages for carriers could employ strategies to reduce reactance such as using tactics to increase positive feelings like enthusiasm (Rains & Turner, 2007). Additionally, given that carriers will be directly exposed to tobacco product packaging by virtue of carrying tobacco products, warning labels on cigarette packages could be a key channel through which to reach this group of smokers with tailored cessation messages. Ensuring carriers are reached and influenced by antismoking messages is critical because of their own heavier smoking patterns and smoker identities, as well as the impact they have on peers’ tobacco brand exposure and social norms.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded entirely with internal funds of Truth Initiative (formerly American Legacy Foundation).