Combustible cigarette smoking and alternative tobacco use in a sample of youth transitioning from foster care

Highlights

• Assessment of tobacco use by youth in foster care is scarce in both child welfare settings and the research literature.

• To date, studies of alternative tobacco product use in this population have been limited in scope.

• We assessed combustible and alternative tobacco use, as well as nicotine dependence and preferred cessation methods.

• Youth exiting foster care are at high risk for tobacco product use, yet are rarely screened for use or advised to quit.

• These results underscore a missed opportunity to promote public health in a vulnerable population.

Abstract

Among the struggles faced by youth currently in or recently exiting foster care, tobacco use remains a low priority for practitioners and researchers, alike. Indeed, despite the dramatically altered landscape of tobacco products on the market, there have been no studies evaluating the use of alternative tobacco products among this vulnerable population. The current study aimed to determine the prevalence of lifetime and current combustible and non-combustible tobacco use among youth exiting foster care, and report on the prevalence of nicotine dependence, motivation to quit, and preferred methods of tobacco cessation. Youth aged 18–24 (M = 20.13, SD = 1.16) who were transitioning from foster care (N = 154) completed a survey of tobacco product use adapted from the Population Assessment of Tobacco and Health Baseline Survey. Most participants (76%) reported lifetime use of combustible cigarettes, while almost half (42%) were current combustible cigarette smokers. Current use of electronic cigarettes was comparable to general population rates. Many participants (76%) reported interest in quitting and willingness to try through patches/gum (56%) and technology-based (61%) approaches. Youth exiting foster care are at high risk for smoking and other tobacco product use, as well as dependence, yet are rarely screened for use or advised to quit. As tobacco use remains among the most preventable causes of mortality and morbidity, future work should involve implementation of screening within child welfare and tailoring interventions to the unique needs of this population. The current results underscore a missed opportunity to promote public health in a vulnerable population.

Introduction

Cigarette smoking remains the most preventable cause of disease and death in the United States, as it accounts for >480,000 annual deaths and over 16 million Americans who suffer with a smoking-related disease (U.S. Department of Health and Human Services, 2014). Recently, however, combustible cigarette use has declined across the population (Centers for Disease Control and Prevention, 2018) and particularly among youth and young adults (Center for Behavioral Health Statistics and Quality, 2016; Miech et al., 2017). While these decreases are certainly welcome, they have been offset by substantial increases in the use of alternative tobacco products including combustible products such as small cigars, cigarillos and hookah, and non-combustible products, most notably, electronic nicotine delivery devices (ENDS, or electronic cigarettes [“e-cigarettes”]). Indeed, e-cigarette use surpassed combustible cigarette use among youth and young adults for the first time in 2014 national data (Arrazola et al., 2015), a trend that has continued to the present, making e-cigarette prevalence rates lag only behind marijuana and alcohol (Miech et al., 2017). Moreover, a cumulative body of work is beginning to show strong evidence that use of e-cigarettes is related to the initiation of combustible cigarettes (National Academies of Sciences, 2018), even prompting youth who may not have otherwise began smoking (Barrington-Trimis et al., 2016).

Many vulnerable and underserved groups have not fully shared in the recent national decline in combustible cigarette use. Homeless youth (Tucker, Shadel, Golinelli, & Ewing, 2014; Wenzel, Tucker, Golinelli, Green Jr, & Zhou, 2010), sexual minorities (Lee, Griffin, & Melvin, 2009), individuals with mental illness (Schroeder & Morris, 2010), and foster youth (Braciszewski & Colby, 2015) are among those groups facing substantial tobacco-related health disparities. Indeed, among homeless youth – a group that substantially overlaps with youth in foster care (Fowler, Toro, & Miles, 2009) – rates of current cigarette use have ranged from 40% to 70% (Thompson & Hasin, 2011; Wenzel et al., 2010), while use of alternative tobacco products in this population have also exceeded 70% (Tucker et al., 2014), though the latter were lifetime cigarette smokers. Like youth experiencing homelessness, youth in foster care are exposed to a unique set of risk factors (e.g., maltreatment, neglect, substance use in the home, and marital conflict), which have been shown to be predictive of tobacco use above and beyond other well-established tobacco-related risk factors (Ford et al., 2011; Mills, Alati, Strathearn, & Najman, 2014). As such, cigarette smoking among youth in foster care remains extraordinarily high, with lifetime rates ranging from 40% to 62% and current/recent rates from 15% to 46% (Braciszewski & Colby, 2015; Scott Jr, Munson, McMillen, & Ollie, 2006; Shpiegel, Sussman, Sherman, & El Shahawy, 2017; Siegel, Benbenishty, & Astor, 2016; Snyder & Medeiros, 2013; U.S. Department of Health and Human Services, 2005; Zhan, Smith, Warner, North, & Wilhelm, 2016). A national study recently found that youth with a foster care history were twice as likely as their general population peers to smoke cigarettes and nearly three times as likely to expect they will be smokers as adults (McDonald, Mariscal, Yan, & Brook, 2014).

Although attention to cigarette smoking among youth in foster care is slowly on the rise, only two studies have reported on use of alternative tobacco products, both of which were limited to self-reported rates of smokeless tobacco use (Kim, Buchanan, & Price, 2017; McDonald et al., 2014). As the use of e-cigarettes and other products is increasing, creating risk for progression to and maintenance of more harmful tobacco use patterns such as dual use and multiple tobacco product (MTP) use, investigation of alternative product use among foster youth is imperative. The current study fills a significant gap in the literature by reporting, for the first time, a full range of alternative tobacco product use in a sample of youth who are transitioning out of the foster care system. We also report on the prevalence of nicotine dependence, motivation to quit, and preferred methods of tobacco cessation for youth who have been emancipated from foster care.