Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US Youths

Question: Is electronic cigarette (e-cigarette) use among tobacco-naive youths associated with subsequent risk of cigarette initiation?

Findings: In this cohort study using data from the Population Assessment of Tobacco and Health Study (2013-2016), youths whose first tobacco product was an e-cigarette were more likely to initiate cigarettes over 2 years of follow-up. At the population level, approximately 180 000 new ever smokers and 45 000 current smokers in the United States over 2 years may have started smoking combustible cigarettes after initiating e-cigarette use.

Meaning: Tobacco-naive youths who initiate e-cigarettes may be at greater risk of subsequently initiating cigarette smoking.

Abstract

Importance: The use of electronic cigarettes (e-cigarettes) and other noncigarette tobacco products may increase the odds of cigarette initiation, even among low-risk youths.

Objective: To evaluate the associations of prior e-cigarette use and other tobacco product use with subsequent cigarette initiation within 2 years of follow-up.

Design, Setting, and Participants: In this prospective cohort study, data from waves 1 through 3 of the Population Assessment of Tobacco and Health Study (2013-2016) were used to assess youths aged 12 to 15 years who had never used cigarettes, e-cigarettes, or other tobacco products at wave 1. This was a nationally representative study of the US population. Data analysis was conducted in 2018.

Exposures: First noncigarette tobacco product used (none, e-cigarette, or other tobacco product) between wave 1 and wave 3.

Main Outcomes and Measures: Ever cigarette use and current cigarette use at wave 3.

Results: In the sample (N = 6123), respondents were 49.5% female; 54.1% non-Hispanic, white; and the mean (SD) age was 13.4 (1.2) years. Of these, 8.6% reported e-cigarettes as their first tobacco product, while 5.0% reported using another noncigarette product first; 3.3% reported using cigarettes first. Cigarette use at wave 3 was higher among prior e-cigarette users (20.5%) compared with youths with no prior tobacco use (3.8%). Prior e-cigarette use was associated with more than 4 times the odds of ever cigarette use (odds ratio, 4.09; 95% CI, 2.97-5.63) and nearly 3 times the odds of current cigarette use (odds ratio, 2.75; 95% CI, 1.60-4.73) compared with no prior tobacco use. Prior use of other tobacco products was similarly associated with subsequent ever cigarette use (OR, 3.84; 95% CI, 2.63-5.63) and current cigarette use (OR, 3.43; 95% CI, 1.88-6.26) compared with no prior tobacco use. The association of prior e-cigarette use with cigarette initiation was stronger among low-risk youths (OR, 8.57; 95% CI, 3.87-18.97), a pattern not seen for prior other product use. Over the 2 years between 2013 and 2014 and 2015 and 2016, 21.8% of new cigarette ever use (178 850 youths) and 15.3% of current cigarette use (43 446 youths) among US youths aged 12 to 15 years may be attributable to prior e-cigarette use.

Conclusions and Relevance: This study’s findings support the notion that e-cigarette use is associated with increased risk for cigarette initiation and use, particularly among low-risk youths. At the population level, the use of e-cigarettes may be a contributor to the initiation of cigarette smoking among youths.