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Binge drinking and marijuana use among menthol and non-menthol adolescent smokers: Findings from the Youth Smoking Survey
Addictive Behaviors 39 (2014) 740–743
Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
Binge drinking and marijuana use among menthol and non-menthol adolescent smokers: Findings from the Youth Smoking Survey Sunday Azagba a,b,⁎, Mesbah F. Sharaf c a b c
Propel Centre for Population Health Impact, University of Waterloo, Canada School of Public Health and Health Systems, University of Waterloo, Canada Department of Economics, Faculty of Commerce, Damanhour University, Egypt
a r t i c l e
i n f o
Keywords: Menthol cigarette smoking Binge drinking Marijuana use Adolescents Bivariate probit Canada
a b s t r a c t Introduction: Research has shown that smoking menthol cigarettes induces smoking initiation and hinders cessation efforts especially among youth. The objective of this paper is to examine the association between menthol cigarette smoking and substance use among adolescent students in Canada. Methods: A nationally representative cross-sectional sample of 4466 Canadian students in grades 7 to 12 from the 2010–2011 Youth Smoking Survey is analyzed. A bivariate probit model is used jointly to examine the association of menthol smoking status with binge drinking and marijuana use. Results: 32% of the current smokers in grades 7 to 12 smoke mentholated cigarettes, 73% are binge drinkers and 79% use marijuana. Results of the bivariate probit regression analysis, controlling for other covariates, show statistically significant differences in the likelihood of binge drinking and marijuana use between menthol and non-menthol smokers. Menthol cigarette smokers are 6% (ME = 0.06, 95% CI = 0.03–0.09) more likely to binge drink and 7% (ME = 0.07, 95% CI = 0.05–0.10) more likely to use marijuana. Conclusion: Smoking menthol cigarettes is associated with a higher likelihood of binge drinking and marijuana use among Canadian adolescents. Banning menthol in cigarettes may be beneficial to public health. © 2013 Elsevier Ltd. All rights reserved.
1. Introduction Substantial evidence exists on the adverse health effects of substance use (Centers for Disease Control and Prevention, 2008; Hall & Degenhardt, 2009; Stickley, Koyanagi, Koposov, Razvodovsky, & Ruchkin, 2013; Yanbaeva, Dentener, Creutzberg, Wesseling, & Wouters, 2007). Smoking is the leading cause of premature and preventable mortality with more than six million deaths every year (WHO, 2011). Studies have shown that binge drinking is positively associated with several health-risk behaviors among adolescents such as engaging in violence, sexual risk behaviors, and illicit drug use (Stickley et al., 2013). In addition, binge drinking is positively associated with the three major causes of death among youth: suicide, homicide and unintentional injury (National Center for Injury Prevention and Control, 2007). Similarly, it is well documented that marijuana use is associated with several adverse outcomes such as cardiovascular disease, impaired respiratory function, development of a dependence syndrome, increased risk of motor vehicle accidents, and the
⁎ Corresponding author at: Propel Centre for Population Health Impact, Faculty of Applied Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada. E-mail address: [email protected] (S. Azagba). 0306-4603/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.addbeh.2013.12.005
negative effects of regular use on adolescent mental health (Hall & Degenhardt, 2009). There is a growing concern that menthol smoking may stimulate other health risk behavior (Kong, Singh, Camenga, Cavallo, & KrishnanSarin, 2013; Winhusen et al., 2013). Tobacco companies have continually exploited the sensory characteristics of menthol cigarettes in order to reinforce smoking behavior and addiction among youth and beginning smokers (Anderson, 2011; Lee & Glantz, 2011). Studies have shown that menthol cigarettes may attract beginning smokers and young people because of a preference for lighter taste (Connolly, Behm, Osaki, & Wayne, 2010). There is also evidence that the association between menthol cigarette smoking and difficulty with quitting is stronger among younger smokers, and that smoking menthol cigarettes is significantly associated with indicators of nicotine dependence (Hersey et al., 2006; Wayne & Connolly, 2004). While marijuana use and binge drinking are strongly related to smoking among youth (e.g., Choquet, Morin, Hassler, & Ledoux, 2004; Höhne et al., 2013; Weitzman & Chen, 2005), little is known as to whether menthol smokers are more likely to use marijuana and to binge drink compared to non-menthol smokers. A recent systematic review (Ramo, Liu, & Prochaska, 2012) on the co-use of tobacco and marijuana among adolescents and young adults finds a statistically significant association in 85% of the covered studies. Similar strong evidence exists on the co-occurrence of smoking and binge drinking in
S. Azagba, M.F. Sharaf / Addictive Behaviors 39 (2014) 740–743
adolescence and young adults (Chung & Chun, 2010; Johnson, Boles, Vaughan, & Kleber, 2000; Weitzman & Chen, 2005). Several studies have examined the clustering of smoking with other health-risk behaviors, but few studies have examined the association between smoking menthol cigarettes, marijuana use and binge drinking among youth. For example, in a recent study of 837 high school students from the U.S. State of Connecticut, Kong et al. (2013) find that smoking menthol cigarettes is associated with life-time marijuana use. Thus, the objective of this paper is to examine the association between menthol cigarette smoking and two public health risk factors; binge drinking and marijuana use among adolescent students in Canada. To the best of our knowledge, no previous study has examined the dual association of menthol smoking and binge drinking among adolescents. Using a nationally representative sample of adolescent students in Canada, this paper adds to the sparse literature on the use of menthol cigarette with either marijuana or binge drinking.
2. Materials and methods 2.1. Data To achieve the objective of this paper, a nationally representative sample of adolescent Canadian students in grades 7 to 12 from the 2010–2011 Youth Smoking Survey (YSS) is used. Briefly, the YSS is a cross-sectional, biennial, classroom-based survey that focuses on the attitudes and behavior of Canadian youth in grades 6 to 12, with respect to tobacco use and substance abuse. The total response rate for the 2010–2011 YSS at the school-board level is 82%, 56% of schools and 73% of students. All ethical approvals related to the survey are granted from the University of Waterloo (the principal coordinator of the YSS) and Health Canada. A more detailed description of the YSS can be found elsewhere (University of Waterloo, 2011).
2.2. Outcome variables The outcome variables of interest in this paper are binge drinking and marijuana use. Binge drinking is defined as having five or more drinks on one occasion at least once a month in the past year and marijuana use is defined by students who reported using marijuana in the last 12 months.
2.3. Independent variables The primary predictor of interest, menthol cigarette smoking status, is determined by a student's response to the following question “In the last 30 days, did you use any of the following flavored tobacco products? Menthol cigarette”. Students who reported smoking menthol cigarette in the last 30 days prior to the interview of the survey are classified as menthol cigarette smokers; otherwise they are classified as non-menthol smokers. The multivariate analysis also controls for other covariates such as school grade level (12, 11, 10, 9 and 8 with grade 7 as the reference category); gender (1 = male, 0 = female); peer effect, a dichotomous measure (1 = student has at least a friend that smokes, 0 = no friends that smoke); skipping class (1 = if the student skip classes, 0 otherwise) and province of residence (Alberta, Ontario, Quebec, British Columbia, Manitoba Saskatchewan, Prince Edward Island, Nova Scotia, with Newfoundland & Labrador as the reference category). Smoking status of friends is determined by response to the following question: “Your closest friends are the friends you like to spend the most time with. How many of your closest friends smoke cigarettes?” The response to this question is dichotomized to indicate either having at least one friend that smokes or no friends that smoke.
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2.4. Statistical analysis A bivariate probit model is used to examine whether a statistically significant difference in binge drinking and marijuana use exist between menthol and non-menthol adolescent smokers. A bivariate probit model of the following form is specified: yj = 1 is binary indicator of whether an individual binge drinks (j = 1) or uses marijuana (j = 2), otherwise non-binge drinkers or no marijuana use is represented as yj = 0. The bivariate model can be expressed in terms of latent variables that represent an unobserved tendency to binge drink or to use marijuana: y⁎j = αjMenthol + βjx + μj, because y⁎j is latent, we only observe yj = 1 if y⁎j N 0, zero otherwise. Menthol cigarette use is represented as, Menthol and other predictors or control variables included in the analysis are captured by, x. The estimation methodology takes into account that there may be unobserved characteristics which jointly influence the decision to binge drink and to use marijuana and therefore may be correlated. The estimated coefficient of correlation (ρ) between the two error terms (μ1, μ2) captures the unobserved influences on the probability of having a binge drink and the probability of using marijuana. It is possible to expect a positive correlation between binge drinking and marijuana use due to clustering of health-risk behaviors among adolescents. All regression results and the descriptive analysis are population weighted using the survey weights to produce population estimates and adjust for unequal probabilities of selection. All analyses are carried out using Stata version 13.
3. Results The weighted sample characteristics, reported in Table 1, show that 32% of the current smokers in grades 7 to 12 smoke mentholated cigarettes, 73% are binge drinkers and 79% use marijuana.
Table 1 Weighted sample characteristics (%). Binge drinking
Marijuana use
Total
Total
(n = 220,633a)
(n = 248,039a)
Menthol smoking status Menthol smoking Non-menthol smoking
32 68
31 69
Binge drinking status Binge drink No binge drink
73 27
Marijuana use status Marijuana use No marijuana use
79 21
Gender Female Male
45 55
44 56
Grade level 12 11 10 9 8 7
30.1 26.4 19.3 15 7 2
30 24 19 15 9 3
School truancy Class skip No class skip
63 37
60 40
Peer effect Friend smokes No friend smokes
92 8
92 8
a
Population estimates.
742
S. Azagba, M.F. Sharaf / Addictive Behaviors 39 (2014) 740–743
Table 2 Bivariate probit marginal effects for binge drinking and marijuana use among smokers in grades 7 to 12.
Menthol smoking status Menthol smoking Non-menthol smoking Gender Male Female School grade level Grade 12 Grade 11 Grade 10 Grade 9 Grade 8 Grade 7 Other covariates Friend that smokes No friend that smokes Class skipping No class skipping ρ Observations
Binge drinking
Marijuana use
ME (95% CI)
ME (95% CI)
0.06⁎⁎⁎ (0.03–0.09) Ref
0.07⁎⁎⁎ (0.05–0.10) Ref
0.07⁎⁎⁎ (0.04–0.09) Ref
0.03⁎⁎⁎ (0.02–0.05) Ref
0.20⁎⁎⁎ (0.00–0.40) 0.15⁎⁎
0.16⁎⁎⁎ (0.09–0.22) 0.11⁎⁎⁎
(−0.01–0.31) 0.09 (−0.13–0.31) 0.08 (−0.16–0.32) 0.05 (−0.10–0.19) Ref
(0.03–0.18) 0.13⁎⁎⁎ (0.07–0.20) 0.10⁎⁎⁎ (0.00–0.19) 0.07⁎⁎ (0.03–0.12) Ref
0.07 (−0.06–0.21) Ref 0.14⁎⁎⁎
0.02 (−0.04–0.08) Ref 0.10⁎⁎⁎
(0.08–0.21) Ref 0.36 (0.32–0.40) 4466
(0.04–0.17) Ref
4466
The analyses controlled for the province of residence. ME is average marginal effect. 95% confidence intervals (CI) are in parentheses. ⁎⁎ p b 0.05. ⁎⁎⁎ p b 0.01
To facilitate ease of interpretation of the estimated coefficients from the bivariate probit model, the average marginal effect (ME) of each predictor is provided, given that the untransformed coefficients can only be interpreted qualitatively. The bivariate probit regression analysis (Table 2), controlling for other covariates, shows statistically significant differences in the likelihood of binge drinking and marijuana use between menthol and non-menthol smokers. Specifically, compared with non-menthol smokers, menthol cigarette smokers are 6% (ME = 0.06, 95% CI = 0.03–0.09) and 7% (ME = 0.07, 95% CI = 0.05–0.10) more likely to binge drink and use marijuana, respectively. The expected signs on the coefficients of included covariates were obtained. An increased likelihood of binge drinking is found for males (ME = 0.07, 95% CI = 0.04–0.09) and those that skipped classes (ME = 0.14, 95% CI = 0.08–0.21). Similarly, being male, of higher grade level, and truancy (skipping classes) are significantly associated with an increased likelihood of marijuana use. The bivariate probit model reveals that ρ is positive (ρ = 0.3, 95% CI = 0.32–0.40) indicating that unobservable factors that are positively related to binge drinking are positively related to marijuana use.
4. Discussion A clustered pattern of health risk behaviors are normally established during adolescence (Alamian & Paradis, 2009). National survey data show a high prevalence rate, and an upward trend, in the use of menthol cigarettes among adolescents. For example data from the National Survey on Drug Use and Health (NSDUH) show that in 2010 there are about 20.7 million menthol cigarette smokers in the United
States, out of which about one million are between the ages of 12 to 17 (Center for Behavioral Health Statistics and Quality, 2011). Data drawn from the 2010–2011 Canadian National Youth Survey show that around 32% of the adolescent students in grades 7 to 12 reported smoking menthol cigarette in the last 30 days prior to the survey (Manske, Rynard, & Minaker, 2013). Studies have shown that menthol cigarettes have an appeal to youth because of its cool minty, refreshing, and smooth taste, sensory effects and an ability to mask irritation, in addition to a perception of being less harmful, all of which reinforce smoking and nicotine dependence among youth and young adults (Hersey et al., 2006; Lee & Glantz, 2011; Yerger & McCandless, 2011). Using a nationally representative sample of Canadian adolescents, this paper finds that smoking menthol cigarettes is associated with higher rate of marijuana use and binge drinking. Only one study to our knowledge has examined the dual use of menthol smoking and marijuana use among adolescent smokers (Kong et al., 2013). Our results are in keeping with Kong et al. (2013) which find that menthol cigarette smoking is associated with having ever used marijuana. One limitation of the current study is the cross-sectional design of the YSS data set which limits the ability to infer a causal relationship between menthol smoking, binge drinking and marijuana use. Also the selfreported nature of the data on substance-related variables may entail measurement error; although the use of self-reported data is standard in the literature. Despite these limitations, the findings of this study support the concern that menthol cigarette may cluster with other adverse health risk behaviors among youth. 5. Conclusion Smoking menthol cigarettes is associated with a higher likelihood of binge drinking and marijuana use among Canadian adolescents. The findings of this paper provide supporting evidence that banning menthol in cigarettes may be beneficial to public health. Given that the literature on dual use of menthol cigarettes and other substance use is emerging, more research is needed, particularly among adolescents. Role of funding sources None.
Conflict of interest None.
References Alamian, A., & Paradis, G. (2009). Clustering of chronic disease behavioral risk factors in Canadian children and adolescents. Preventive Medicine, 48(5), 493–499. Anderson, S. J. (2011). Marketing of menthol cigarettes and consumer perceptions: A review of tobacco industry documents. Tobacco Control, 20(Suppl. 2), ii20–ii28. Center for Behavioral Health Statistics and Quality (2011). The NSDUH report: Recent trends in menthol cigarette use. (Rockville, MD. http://www.samhsa.gov/data/2k11/ WEB_SR_088/WEB_SR_088.pdf) Centers for Disease Control and Prevention (2008). Smoking-attributable mortality, years of potential life lost, and productivity losses-United States, 2000–2004. Morbidity and Mortality Weekly Report, 57, 1226–1228. Choquet, M., Morin, D., Hassler, C., & Ledoux, S. (2004). Is alcohol, tobacco, and cannabis use as well as polydrug use increasing in France? Addictive Behaviors, 29(3), 607–614. Chung, I. J., & Chun, J. (2010). Co-occurring patterns of smoking and alcohol consumption among Korean adolescents. The American Journal on Addictions, 19(3), 252–256. Connolly, G. N., Behm, I., Osaki, Y., & Wayne, G. F. (2010). The impact of menthol cigarettes on smoking initiation among non-smoking young females in Japan. International Journal of Environmental Research and Public Health, 8(1), 1–14. Hall, W., & Degenhardt, L. (2009). Adverse health effects of non-medical cannabis use. The Lancet, 374(9698), 1383–1391. Hersey, J. C., Ng, S. W., Nonnemaker, J. M., Mowery, P., Thomas, K. Y., Vilsaint, M. C., et al. (2006). Are menthol cigarettes a starter product for youth? Nicotine & Tobacco Research, 8(3), 403–413. Höhne, B., Pabst, A., Hannemann, T. V., & Kraus, L. (2013). Patterns of concurrent alcohol, tobacco, and cannabis use in Germany: Prevalence and correlates. Drugs: Education, Prevention and Policy, 1–8.
S. Azagba, M.F. Sharaf / Addictive Behaviors 39 (2014) 740–743 Johnson, P. B., Boles, S. M., Vaughan, R., & Kleber, H. D. (2000). The co-occurrence of smoking and binge drinking in adolescence. Addictive Behaviors, 25(5), 779–783. Kong, G., Singh, N., Camenga, D., Cavallo, D., & Krishnan-Sarin, S. (2013). Menthol cigarette and marijuana use among adolescents. Nicotine & Tobacco Research, ntt102. Lee, Y. O., & Glantz, S. A. (2011). Menthol: Putting the pieces together. Tobacco Control, 20(Suppl. 2), ii1–ii7. Manske, S. R., Rynard, V., & Minaker, L. (2013). Flavoured tobacco use among Canadian youth: Evidence from Canada's 2010/2011 Youth Smoking Survey. Waterloo: Propel Centre for Population Health Impact, 1–2 (www.yss.uwaterloo.ca/index.cfm? section=5&page=288) National Center for Injury Prevention and Control (2007). 10 leading causes of death, United States, 2007, all races, both sexes. WISQARS Leading Causes of Death Reports, 1999–2007 (Available at: http://webapp.cdc.gov/sasweb/ncipc/leadcaus10.html) Ramo, D. E., Liu, H., & Prochaska, J. J. (2012). Tobacco and marijuana use among adolescents and young adults: A systematic review of their co-use. Clinical Psychology Review, 32(2), 105–121. Stickley, A., Koyanagi, A., Koposov, R., Razvodovsky, Y., & Ruchkin, V. (2013). Adolescent binge drinking and risky health behaviours: Findings from northern Russia. Drug and Alcohol Dependence, 133(3), 838–844.
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University of Waterloo (2011). Youth Smoking Survey (YSS): 2010/2011 YSS Microdata User Guide. Waterloo: Propel Centre for Population Health Impact, 1–50 (http://www.yss. uwaterloo.ca/results/yss10_user_guide.pdf) Wayne, G. F., & Connolly, G. N. (2004). Application, function, and effects of menthol in cigarettes: A survey of tobacco industry documents. Nicotine & Tobacco Research, 6(Suppl. 1), S43–S54. Weitzman, E. R., & Chen, Y. Y. (2005). The co-occurrence of smoking and drinking among young adults in college: National survey results from the United States. Drug and Alcohol Dependence, 80(3), 377–386. Winhusen, T. M., Adinoff, B., Lewis, D. F., Brigham, G. S., Ii, J. G. G., Sonne, S.C., et al. (2013). A tale of two stimulants: Mentholated cigarettes may play a role in cocaine, but not methamphetamine, dependence. Drug and Alcohol Dependence, 133(3), 845–851. World Health Organization (2011). WHO report on the global tobacco epidemic, 2011, warning about the dangers of tobacco. Geneva, Switzerland: WHO Press (http:// www.who.int/tobacco/global_report/2011/en/ index.html) Yanbaeva, D.G., Dentener, M.A., Creutzberg, E. C., Wesseling, G., & Wouters, E. F. (2007). Systemic effects of smoking. CHEST Journal, 131(5), 1557–1566. Yerger, V. B., & McCandless, P.M. (2011). Menthol sensory qualities and smoking topography: A review of tobacco industry documents. Tobacco Control, 20(Suppl. 2), ii37–ii43.
Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
Binge drinking and marijuana use among menthol and non-menthol adolescent smokers: Findings from the Youth Smoking Survey Sunday Azagba a,b,⁎, Mesbah F. Sharaf c a b c
Propel Centre for Population Health Impact, University of Waterloo, Canada School of Public Health and Health Systems, University of Waterloo, Canada Department of Economics, Faculty of Commerce, Damanhour University, Egypt
a r t i c l e
i n f o
Keywords: Menthol cigarette smoking Binge drinking Marijuana use Adolescents Bivariate probit Canada
a b s t r a c t Introduction: Research has shown that smoking menthol cigarettes induces smoking initiation and hinders cessation efforts especially among youth. The objective of this paper is to examine the association between menthol cigarette smoking and substance use among adolescent students in Canada. Methods: A nationally representative cross-sectional sample of 4466 Canadian students in grades 7 to 12 from the 2010–2011 Youth Smoking Survey is analyzed. A bivariate probit model is used jointly to examine the association of menthol smoking status with binge drinking and marijuana use. Results: 32% of the current smokers in grades 7 to 12 smoke mentholated cigarettes, 73% are binge drinkers and 79% use marijuana. Results of the bivariate probit regression analysis, controlling for other covariates, show statistically significant differences in the likelihood of binge drinking and marijuana use between menthol and non-menthol smokers. Menthol cigarette smokers are 6% (ME = 0.06, 95% CI = 0.03–0.09) more likely to binge drink and 7% (ME = 0.07, 95% CI = 0.05–0.10) more likely to use marijuana. Conclusion: Smoking menthol cigarettes is associated with a higher likelihood of binge drinking and marijuana use among Canadian adolescents. Banning menthol in cigarettes may be beneficial to public health. © 2013 Elsevier Ltd. All rights reserved.
1. Introduction Substantial evidence exists on the adverse health effects of substance use (Centers for Disease Control and Prevention, 2008; Hall & Degenhardt, 2009; Stickley, Koyanagi, Koposov, Razvodovsky, & Ruchkin, 2013; Yanbaeva, Dentener, Creutzberg, Wesseling, & Wouters, 2007). Smoking is the leading cause of premature and preventable mortality with more than six million deaths every year (WHO, 2011). Studies have shown that binge drinking is positively associated with several health-risk behaviors among adolescents such as engaging in violence, sexual risk behaviors, and illicit drug use (Stickley et al., 2013). In addition, binge drinking is positively associated with the three major causes of death among youth: suicide, homicide and unintentional injury (National Center for Injury Prevention and Control, 2007). Similarly, it is well documented that marijuana use is associated with several adverse outcomes such as cardiovascular disease, impaired respiratory function, development of a dependence syndrome, increased risk of motor vehicle accidents, and the
⁎ Corresponding author at: Propel Centre for Population Health Impact, Faculty of Applied Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada. E-mail address: [email protected] (S. Azagba). 0306-4603/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.addbeh.2013.12.005
negative effects of regular use on adolescent mental health (Hall & Degenhardt, 2009). There is a growing concern that menthol smoking may stimulate other health risk behavior (Kong, Singh, Camenga, Cavallo, & KrishnanSarin, 2013; Winhusen et al., 2013). Tobacco companies have continually exploited the sensory characteristics of menthol cigarettes in order to reinforce smoking behavior and addiction among youth and beginning smokers (Anderson, 2011; Lee & Glantz, 2011). Studies have shown that menthol cigarettes may attract beginning smokers and young people because of a preference for lighter taste (Connolly, Behm, Osaki, & Wayne, 2010). There is also evidence that the association between menthol cigarette smoking and difficulty with quitting is stronger among younger smokers, and that smoking menthol cigarettes is significantly associated with indicators of nicotine dependence (Hersey et al., 2006; Wayne & Connolly, 2004). While marijuana use and binge drinking are strongly related to smoking among youth (e.g., Choquet, Morin, Hassler, & Ledoux, 2004; Höhne et al., 2013; Weitzman & Chen, 2005), little is known as to whether menthol smokers are more likely to use marijuana and to binge drink compared to non-menthol smokers. A recent systematic review (Ramo, Liu, & Prochaska, 2012) on the co-use of tobacco and marijuana among adolescents and young adults finds a statistically significant association in 85% of the covered studies. Similar strong evidence exists on the co-occurrence of smoking and binge drinking in
S. Azagba, M.F. Sharaf / Addictive Behaviors 39 (2014) 740–743
adolescence and young adults (Chung & Chun, 2010; Johnson, Boles, Vaughan, & Kleber, 2000; Weitzman & Chen, 2005). Several studies have examined the clustering of smoking with other health-risk behaviors, but few studies have examined the association between smoking menthol cigarettes, marijuana use and binge drinking among youth. For example, in a recent study of 837 high school students from the U.S. State of Connecticut, Kong et al. (2013) find that smoking menthol cigarettes is associated with life-time marijuana use. Thus, the objective of this paper is to examine the association between menthol cigarette smoking and two public health risk factors; binge drinking and marijuana use among adolescent students in Canada. To the best of our knowledge, no previous study has examined the dual association of menthol smoking and binge drinking among adolescents. Using a nationally representative sample of adolescent students in Canada, this paper adds to the sparse literature on the use of menthol cigarette with either marijuana or binge drinking.
2. Materials and methods 2.1. Data To achieve the objective of this paper, a nationally representative sample of adolescent Canadian students in grades 7 to 12 from the 2010–2011 Youth Smoking Survey (YSS) is used. Briefly, the YSS is a cross-sectional, biennial, classroom-based survey that focuses on the attitudes and behavior of Canadian youth in grades 6 to 12, with respect to tobacco use and substance abuse. The total response rate for the 2010–2011 YSS at the school-board level is 82%, 56% of schools and 73% of students. All ethical approvals related to the survey are granted from the University of Waterloo (the principal coordinator of the YSS) and Health Canada. A more detailed description of the YSS can be found elsewhere (University of Waterloo, 2011).
2.2. Outcome variables The outcome variables of interest in this paper are binge drinking and marijuana use. Binge drinking is defined as having five or more drinks on one occasion at least once a month in the past year and marijuana use is defined by students who reported using marijuana in the last 12 months.
2.3. Independent variables The primary predictor of interest, menthol cigarette smoking status, is determined by a student's response to the following question “In the last 30 days, did you use any of the following flavored tobacco products? Menthol cigarette”. Students who reported smoking menthol cigarette in the last 30 days prior to the interview of the survey are classified as menthol cigarette smokers; otherwise they are classified as non-menthol smokers. The multivariate analysis also controls for other covariates such as school grade level (12, 11, 10, 9 and 8 with grade 7 as the reference category); gender (1 = male, 0 = female); peer effect, a dichotomous measure (1 = student has at least a friend that smokes, 0 = no friends that smoke); skipping class (1 = if the student skip classes, 0 otherwise) and province of residence (Alberta, Ontario, Quebec, British Columbia, Manitoba Saskatchewan, Prince Edward Island, Nova Scotia, with Newfoundland & Labrador as the reference category). Smoking status of friends is determined by response to the following question: “Your closest friends are the friends you like to spend the most time with. How many of your closest friends smoke cigarettes?” The response to this question is dichotomized to indicate either having at least one friend that smokes or no friends that smoke.
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2.4. Statistical analysis A bivariate probit model is used to examine whether a statistically significant difference in binge drinking and marijuana use exist between menthol and non-menthol adolescent smokers. A bivariate probit model of the following form is specified: yj = 1 is binary indicator of whether an individual binge drinks (j = 1) or uses marijuana (j = 2), otherwise non-binge drinkers or no marijuana use is represented as yj = 0. The bivariate model can be expressed in terms of latent variables that represent an unobserved tendency to binge drink or to use marijuana: y⁎j = αjMenthol + βjx + μj, because y⁎j is latent, we only observe yj = 1 if y⁎j N 0, zero otherwise. Menthol cigarette use is represented as, Menthol and other predictors or control variables included in the analysis are captured by, x. The estimation methodology takes into account that there may be unobserved characteristics which jointly influence the decision to binge drink and to use marijuana and therefore may be correlated. The estimated coefficient of correlation (ρ) between the two error terms (μ1, μ2) captures the unobserved influences on the probability of having a binge drink and the probability of using marijuana. It is possible to expect a positive correlation between binge drinking and marijuana use due to clustering of health-risk behaviors among adolescents. All regression results and the descriptive analysis are population weighted using the survey weights to produce population estimates and adjust for unequal probabilities of selection. All analyses are carried out using Stata version 13.
3. Results The weighted sample characteristics, reported in Table 1, show that 32% of the current smokers in grades 7 to 12 smoke mentholated cigarettes, 73% are binge drinkers and 79% use marijuana.
Table 1 Weighted sample characteristics (%). Binge drinking
Marijuana use
Total
Total
(n = 220,633a)
(n = 248,039a)
Menthol smoking status Menthol smoking Non-menthol smoking
32 68
31 69
Binge drinking status Binge drink No binge drink
73 27
Marijuana use status Marijuana use No marijuana use
79 21
Gender Female Male
45 55
44 56
Grade level 12 11 10 9 8 7
30.1 26.4 19.3 15 7 2
30 24 19 15 9 3
School truancy Class skip No class skip
63 37
60 40
Peer effect Friend smokes No friend smokes
92 8
92 8
a
Population estimates.
742
S. Azagba, M.F. Sharaf / Addictive Behaviors 39 (2014) 740–743
Table 2 Bivariate probit marginal effects for binge drinking and marijuana use among smokers in grades 7 to 12.
Menthol smoking status Menthol smoking Non-menthol smoking Gender Male Female School grade level Grade 12 Grade 11 Grade 10 Grade 9 Grade 8 Grade 7 Other covariates Friend that smokes No friend that smokes Class skipping No class skipping ρ Observations
Binge drinking
Marijuana use
ME (95% CI)
ME (95% CI)
0.06⁎⁎⁎ (0.03–0.09) Ref
0.07⁎⁎⁎ (0.05–0.10) Ref
0.07⁎⁎⁎ (0.04–0.09) Ref
0.03⁎⁎⁎ (0.02–0.05) Ref
0.20⁎⁎⁎ (0.00–0.40) 0.15⁎⁎
0.16⁎⁎⁎ (0.09–0.22) 0.11⁎⁎⁎
(−0.01–0.31) 0.09 (−0.13–0.31) 0.08 (−0.16–0.32) 0.05 (−0.10–0.19) Ref
(0.03–0.18) 0.13⁎⁎⁎ (0.07–0.20) 0.10⁎⁎⁎ (0.00–0.19) 0.07⁎⁎ (0.03–0.12) Ref
0.07 (−0.06–0.21) Ref 0.14⁎⁎⁎
0.02 (−0.04–0.08) Ref 0.10⁎⁎⁎
(0.08–0.21) Ref 0.36 (0.32–0.40) 4466
(0.04–0.17) Ref
4466
The analyses controlled for the province of residence. ME is average marginal effect. 95% confidence intervals (CI) are in parentheses. ⁎⁎ p b 0.05. ⁎⁎⁎ p b 0.01
To facilitate ease of interpretation of the estimated coefficients from the bivariate probit model, the average marginal effect (ME) of each predictor is provided, given that the untransformed coefficients can only be interpreted qualitatively. The bivariate probit regression analysis (Table 2), controlling for other covariates, shows statistically significant differences in the likelihood of binge drinking and marijuana use between menthol and non-menthol smokers. Specifically, compared with non-menthol smokers, menthol cigarette smokers are 6% (ME = 0.06, 95% CI = 0.03–0.09) and 7% (ME = 0.07, 95% CI = 0.05–0.10) more likely to binge drink and use marijuana, respectively. The expected signs on the coefficients of included covariates were obtained. An increased likelihood of binge drinking is found for males (ME = 0.07, 95% CI = 0.04–0.09) and those that skipped classes (ME = 0.14, 95% CI = 0.08–0.21). Similarly, being male, of higher grade level, and truancy (skipping classes) are significantly associated with an increased likelihood of marijuana use. The bivariate probit model reveals that ρ is positive (ρ = 0.3, 95% CI = 0.32–0.40) indicating that unobservable factors that are positively related to binge drinking are positively related to marijuana use.
4. Discussion A clustered pattern of health risk behaviors are normally established during adolescence (Alamian & Paradis, 2009). National survey data show a high prevalence rate, and an upward trend, in the use of menthol cigarettes among adolescents. For example data from the National Survey on Drug Use and Health (NSDUH) show that in 2010 there are about 20.7 million menthol cigarette smokers in the United
States, out of which about one million are between the ages of 12 to 17 (Center for Behavioral Health Statistics and Quality, 2011). Data drawn from the 2010–2011 Canadian National Youth Survey show that around 32% of the adolescent students in grades 7 to 12 reported smoking menthol cigarette in the last 30 days prior to the survey (Manske, Rynard, & Minaker, 2013). Studies have shown that menthol cigarettes have an appeal to youth because of its cool minty, refreshing, and smooth taste, sensory effects and an ability to mask irritation, in addition to a perception of being less harmful, all of which reinforce smoking and nicotine dependence among youth and young adults (Hersey et al., 2006; Lee & Glantz, 2011; Yerger & McCandless, 2011). Using a nationally representative sample of Canadian adolescents, this paper finds that smoking menthol cigarettes is associated with higher rate of marijuana use and binge drinking. Only one study to our knowledge has examined the dual use of menthol smoking and marijuana use among adolescent smokers (Kong et al., 2013). Our results are in keeping with Kong et al. (2013) which find that menthol cigarette smoking is associated with having ever used marijuana. One limitation of the current study is the cross-sectional design of the YSS data set which limits the ability to infer a causal relationship between menthol smoking, binge drinking and marijuana use. Also the selfreported nature of the data on substance-related variables may entail measurement error; although the use of self-reported data is standard in the literature. Despite these limitations, the findings of this study support the concern that menthol cigarette may cluster with other adverse health risk behaviors among youth. 5. Conclusion Smoking menthol cigarettes is associated with a higher likelihood of binge drinking and marijuana use among Canadian adolescents. The findings of this paper provide supporting evidence that banning menthol in cigarettes may be beneficial to public health. Given that the literature on dual use of menthol cigarettes and other substance use is emerging, more research is needed, particularly among adolescents. Role of funding sources None.
Conflict of interest None.
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