Use of Tobacco Products Among Unaccompanied Youth Experiencing Homelessness

High rates of tobacco use among young people experiencing homelessness is a public health problem, though one that is largely overlooked in tobacco-control efforts. As many as 70 percent of these young people smoke cigarettes. In addition, most of these smokers use other tobacco products. Little is known about how or why they use other tobacco products or what works in helping them quit. To examine these issues, a RAND team conducted a survey among youth experiencing homelessness (YEH) in Los Angeles County about their use of various tobacco products. The survey extended an earlier study focused specifically on cigarette smoking.^[1] The goal of these studies is to develop recommendations for service providers who want to implement effective tobacco prevention programs for this group.

Most YEH Use Both Cigarettes and Other Tobacco Products

The research team surveyed 469 YEH between August 2017 and April 2018, recruited from 25 service sites (e.g., shelters, drop-in centers) and street sites (e.g., sidewalks, parks, alleys, beaches) throughout Los Angeles County. Youth were eligible for the survey if they were ages 13–25 and had used any type of tobacco or nicotine product in the past 30 days. The survey indicated that in the past 30 days

• 90 percent smoked regular cigarettes and, of these smokers, 43 percent smoked roll-your-own cigarettes that were often made at least partly from tobacco scavenged from discarded butts
• 78 percent had used at least one type of tobacco product other than regular cigarettes, most commonly cigarettes marketed as natural products (e.g., American Spirit), followed by little cigars/cigarillos (LCCs), electronic nicotine delivery systems (ENDS; these systems include e-cigarettes and personal vaporizers), cigars, hookahs, and chewing tobacco.

Use of Multiple Types of Tobacco (Polytobacco Use) Is Common

Polytobacco experimenters

35 percent

Current polytobacco users

13 percent

Current users of combustible products

27 percent

Current traditional cigarette smokers

35 percent

The research team sought to identify distinct patterns in the use of nicotine products other than cigarettes. Four main patterns of use were identified (Figure 1):

• Current traditional-cigarette smokers were likely to be currently using natural cigarettes, but not any of the other products.
• Current users of combustible products were likely to be currently using natural cigarettes, cigars, and LCCs.
• Current polytobacco users were likely to be currently using several types of products at very high rates.
• Polytobacco experimenters were likely to have tried several types of products in their lifetimes but not as likely to have used them in the past 30 days.

These results highlight the extent to which YEH use multiple tobacco products. Thus, it is important that programs to reduce tobacco use in this population focus not only on cigarette smoking but also on other tobacco products.

Motivations for Use: Similarities and Differences Across Products

The survey asked youth to indicate the reasons they used different types of tobacco products. Results indicated the following:

• There was consistency across tobacco products in endorsing certain motivations for their use. For example, across different products, most youth reported that they liked socializing while using the product (58 to 64 percent) and that the product gives them a "good buzz" (56 to 60 percent), and about one-third of youth reported that they got more nicotine for the cost compared with other tobacco products (33 to 39 percent).
• There was wider variability across tobacco products in other motivations for their use. For example, 72 percent of youth who used ENDS reported using the product because it could be used where smoking is not allowed; in contrast, only 24 to 26 percent of youth who used cigars and LCCs reported that they used these products for this reason. As another example, 67 percent of youth who used ENDS reported using this product because it smelled good; only 37 percent of youth who smoked cigarettes reported that they used that product for this reason.

These results suggest that cessation counseling efforts might benefit from some tailoring to the specific motivations associated with use of that product.

Interest in Quitting

Regular cigarettes

33 percent

ENDS

30 percent

LCCs

25 percent

Natural cigarettes

20 percent

Cigars

20 percent

The team sought to understand the extent to which youth are motivated to quit their use of different tobacco products, as well as their perceptions of the harmfulness of these products. Results indicated that

• quitting motivation was highest for regular cigarettes (Figure 2).
• perceptions of the harmfulness, relative to regular cigarettes, varied widely by product type—for example, 49 percent of youth considered natural cigarettes to be less harmful than regular cigarettes, whereas 12 percent of youth considered cigars to be less harmful than regular cigarettes
• many youth used other tobacco products to cut down on or quit their use of regular cigarettes; this ranged from 64 percent among those who used ENDS to 38 percent among those who used LCCs.

These results paint a complex picture of use and quitting motivation among YEH. They often use other tobacco products to reduce or quit smoking regular cigarettes, yet they are also interested in quitting their use of these other tobacco products. Moreover, their use of these other products to quit smoking may be partly driven by inaccurate beliefs about product harm relative to cigarettes. It is important for service providers who are discussing tobacco use with these youth to correct inaccurate beliefs about the harms of different tobacco products and to emphasize that use of other tobacco products to quit smoking will make quitting cigarettes, and all products, more difficult.

Implementing Programs to Reduce Tobacco Use in Service Settings

YEH are often exposed to others who are using tobacco products. Survey results suggest that being around others who use tobacco products strongly predicts youth tobacco use; for natural cigarettes, ENDS, LCCs, cigars, and hookah, youth who reported being often or sometimes around others who used the product were three to five times more likely (depending on product) to report using it in the past month, compared with those who were hardly ever or never around others who used the product. Service providers can counteract these social influences by making relatively small changes, including asking youth during intake about use of all tobacco products, training staff to deliver brief cessation counseling, having printed materials on tobacco use and quitting available in waiting rooms, and establishing a tobacco-free outdoor area at the service site. Health education campaigns delivered in service settings may have the added benefit of countering the potential impact of tobacco advertising on intentions to continue using tobacco products among YEH. More information for service providers on how to reduce tobacco use among YEH is available in Reducing Tobacco Use Among Young People Experiencing Homelessness: Recommendations for Service Providers, by Erika Litvin Bloom, William G. Shadel, and Joan S. Tucker, TL-A1036-1, 2021 (available at www.rand.org/t/TLA1036-1).

Notes

• [1] Joan S. Tucker, William G. Shadel, Daniela Golinelli, Brett Ewing, Leslie Mullins, and B. Lynette Staplefoote, Reducing Cigarette Smoking Among Unaccompanied Homeless Youth, Santa Monica, Calif.: RAND Corporation, RB-9828, 2015. As of December 29, 2020: https://www.rand.org/pubs/research_briefs/RB9828.html

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Topics

• Adolescents
• Homelessness
• Smoking Cessation