Alternative combusted tobacco product and multiple tobacco product use among individuals with serious mental illness enrolled in a large pragmatic randomized controlled trial

Objective: Use of combustible alternative tobacco products (ATPs; e.g., little cigars, loose tobacco, multiple tobacco product types [TPTs]) is increasingly common. Inexpensive, combusted ATPs (e.g little cigars) are predominantly marketed to lower-income communities. Prevalence of combusted ATP use among those with serious mental illness (SMI) is unknown.Methods: We examined rates and correlates of combusted ATP use and association with tobacco abstinence in a secondary analysis of a single-cohort (N = 1007) trial of tobacco-smoking adults with SMI and severe SMI-related functional impairment. The parent study aimed to test a community-health worker-delivered intervention for promoting smoking cessation among adults with SMI. Participants were surveyed at baseline on demographic and smoking characteristics including combusted TPT (cigarettes, cigars/little cigars, loose tobacco), and breath carbon-monoxide (CO). CO-verified 7-day point-prevalence tobacco abstinence was assessed at Year 2.Results: At baseline, 59% of participants reported using cigarettes only, 25% multiple (>1) combusted TPTs, 12% cigars/little cigars only, and 4% loose tobacco (e.g., "rollies", pipes) only. Those reporting any ATP use at baseline had higher expired CO concentration and reported using more tobacco products per day than exclusive cigarette users (p's < 0.05). ATP use was not associated with abstinence in adjusted logistic regression models (p's > 0.05).Conclusions: Use of ATPs was associated with use of more tobacco products per day and greater tobacco toxicant exposure than exclusive cigarette use in this population. Future policy efforts work to change preferential taxation policies (e.g., lower taxation for cigar products) and disproportionate marketing of ATPs to lower income communities.