There was a high (49.3%) prevalence of polytobacco use among African-American adult cigarette smokers that held for men (57.3%) and women (40.6%). Substantial smoking of non-cigarette products was also found among non-cigarette smokers, with 19.5% of men and 12.1% of women non-smokers smoking at least one non-cigarette product in the past 30 days. The odds of smoking most non-cigarette products were generally higher for men than women (ORs=2.5 to 3.0), and for cigarette smokers than non-smokers (ORs=3.2 to 5.3); however, gender did not contribute to smoking bidis or kreteks, and cigarette smoking did not contribute to smoking bidis, kreteks or blunts. Smoking of any non-cigarette product and of each specific product was generally highest among adults aged 18–24 years (ORs=3 to 15.9) as in prior studies,13–16 and decreased as age increased. The exception was smoking kreteks/cloves; for these, older adults were more likely to be users. Moreover, unlike the well-known relationship between cigarette smoking and low SES,1 3–5 for these non-cigarette products, SES was related only to smoking blunts, with higher incomes a predictor. The type of cigarette smoked contributed to smoking non-cigarette products in general, and to smoking Phillies/Blacks specifically, with higher odds for those who smoked menthol and non-menthol cigarettes, rather than one or the other; menthol smoking generally did not predict the use of other products.

These findings suggest a problematically high prevalence of polytobacco use among African-American smokers that is strongly associated with gender and young adulthood but not associated with low income, low education or menthol smoking. Polytobacco users were mostly young men of varied SES who smoked all types of cigarettes along with non-cigarette products–that is, a possible pattern of smoking whatever was available. Given that low SES was not a risk factor for this, polytobacco use might perhaps instead be related to the social risk factors for cigarette smoking among African-Americans that have been identified in prior studies–that is, racial segregation27–29 and racial discrimination.30–32 High levels of residential segregation (with high exposure to targeted tobacco advertising and easy access to single cigarettes in black neighbourhoods), and high levels of (the stress of) racial discrimination might be associated with smoking any cigarette and non-cigarette product available. Studies of the possible role of these factors in polytobacco use among African-Americans are needed.

The 14.9% prevalence of the past 30-day smoking of non-cigarette products by non-cigarette smokers also is a concern. Smoking blunts and bidis was not associated with cigarette smoking but was strongly associated with youth. This suggests that smoking blunts and bidis might reflect youthful experimentation,13 15 17 and raises questions about whether young African-Americans try these before they try cigarettes.13 Studies of age of initiating smoking of cigarettes versus blunts and cigarillos among African-Americans are needed to clarify this.

This study also found a substantial prevalence of smoking products that are not assessed in most population smoking surveys of adults (eg, marijuana, cigarillos, blunts). Hence, it would be beneficial for surveillance studies to assess smoking of blunts, bidis and (in particular) cigarillos such as Phillies, Black & Mild and Swisher Sweets. Smoking of cigarillos may need to be assessed by brand name because young African-Americans often do not categorise them as cigars,18 and hence their reports of cigar use increase significantly when these brand names are included.18 That these cigarillos are sold individually and come in a variety of flavours (eg, chocolate, apple, cherry) may contribute to their not being categorised as cigars or as cigarettes. Such an assessment will provide a more comprehensive picture of smoking among African-American adults, and would match the complexity of recent (2011) assessments of youth smoking that included bidis, kreteks and cigarillos.33

This study has several limitations, including the use of self-reports that may be lower than biologically validated data,25 lack of assessment of some forms of tobacco use (eg, pipes) and a Californian sample whose data might not generalise to other states. In addition, we treated age as a categorical variable rather than as a continuous variable, and this may have limited the sensitivity of analyses. We note, however, that the age categories used here are similar to those used in prior studies of polytobacco use in which the highest prevalence found was for 18–24 year olds.13–16 Moreover, to decrease the number of consecutive significance tests, potentially interesting interaction effects (eg, gender × age, gender × income) were not examined; such effects, however, are generally not examined in basic epidemiological studies of product use (33), and this is a limitation of this study and of similar studies. Likewise, because more than 90% of these African-American cigarette-smokers consumed 10 or fewer cigarettes per day, the potential relationships between the number of cigarettes smoked and smoking of other products were not examined. In addition, the prevalence of smoking the products may have changed since this study. This is particularly the case for kreteks (clove cigarettes) that were banned by the 2009 Family Smoking Prevention and Tobacco Control Act.34 The Center for Disease Control's 2011 study of youth33 revealed that youth still smoke kreteks despite the ban, and this suggests that adults also might still smoke them. How youth and adults acquire banned and illegal products is worthy of investigation.

Despite these limitations, this study is the first to highlight the magnitude and complexity of smoking among a random community sample of African-American adults, and the first to underscore the need to improve its assessment in research and practice. More comprehensive, population-level assessment of multiple-substance smoking might yield data that in part explain African-American smokers’ difficulty in quitting tobacco despite smoking only a few cigarettes per day5 6 and likewise might yield findings that in part explain the puzzling high incidence of smoking-related cancers at young ages among African-American men.7 35 Similarly, it would be beneficial for healthcare providers to include non-cigarette products such as bidis and blunts in 5A (ask, advise, assess, assist and arrange) assessment of smoking36 among cigarette smokers and non-smokers alike, young adults in particular. Smoking cessation interventions also might be enhanced by assessing and addressing cessation of smoking such products. However, whether evidence-based smoking cessation interventions and nicotine replacement therapy are effective with polytobacco users remain unknown. Studies are needed to assess the possibility that hidden polytobacco use might contribute to the relative failure of standard smoking cessation programmes with black smokers,5 6 and research on the possible need for new cessation interventions for polytobacco users is needed as well.