Initiation of any tobacco and five tobacco products across 3 years among youth, young adults and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

National longitudinal tobacco product discontinuation rates among US youth from the PATH Study: 2013-2019 (waves 1-5)

OBJECTIVE

Determine longitudinal tobacco product discontinuation rates among youth (ages 12-17 years) in the USA between 2013 and 2019.

METHODS

The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study, was used to determine annual/biennial rates of tobacco product discontinuation behaviours among youth across 2013-2019: (1) discontinuing product use (transition from past 30-day use to no past 30-day use), (2) attempting to quit product use and (3) discontinuing product use among those who attempted to quit. Discontinuing use was evaluated separately for cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah, smokeless tobacco and any tobacco. Attempting to quit and discontinuing use among those who attempted were each evaluated for cigarettes and ENDS. Generalised estimating equations were used to evaluate linear and non-linear trends in rates across the study period.

RESULTS

Between 2013 and 2019, biennial rates of discontinuing tobacco product use among youth increased for cigarettes from 29% to 40%, increased for smokeless tobacco from 39% to 60%, and decreased for ENDS from 53% to 27%. By 2018/2019, rates of discontinuing use among attempters were 30% for those who used ENDS and 30% for those who smoked cigarettes.

CONCLUSIONS

Findings show decreasing rates of discontinuing ENDS use among youth in the USA alongside the changing ENDS marketplace and increasing rates of discontinuing cigarette smoking and smokeless tobacco use. Findings will serve as benchmarks against which future tobacco product discontinuation rates can be compared with evaluating impacts of subsequent tobacco regulatory policies, ENDS product development and public education campaigns.

Using Eye tracking to Examine Young Adults' Visual Attention to E-cigarette Advertising Features and Associated Positive E-cigarette Perceptions

BACKGROUND

Little is known about the influence of e-cigarette marketing features on the antecedents of e-cigarette use.

PURPOSE

Using an eye-tracking experiment, we examined visual attention to common features in e-cigarette ads and its associations with positive e-cigarette perceptions among young adults.

METHODS

Young adults (ages 18-29) who smoke cigarettes (n = 40) or do not use tobacco (n = 71) viewed 30 e-cigarette ads on a computer screen. Eye-tracking technology measured dwell time (fixation duration) and entry time (time to first fixation) for 14 pre-defined ad features. Participants then completed a survey about perceptions of e-cigarettes shown in the ads. We used regression models to examine the associations between ad features and standardized attention metrics among all participants and by tobacco-use status and person-aggregated standardized attention for each ad feature and positive e-cigarette perceptions.

RESULTS

Dwell time was the longest for smoker-targeted claims, positive experience claims, and price promotions. Entry time was the shortest for multiple flavor descriptions, nicotine warnings, and people. Those who do not use tobacco had a longer dwell time for minor sales restrictions and longer entry time for purchasing information than those who smoke. Longer dwell time for multiple flavor descriptions was associated with e-cigarette appeal. A shorter entry time for fruit flavor description was associated with positive e-cigarette-use expectancies.

CONCLUSIONS

Young adults allocated attention differently to various e-cigarette ad features, and such viewing patterns were largely similar by tobacco-use statuses. Multiple or fruit flavors may be the features that contribute to the positive influence of e-cigarette marketing among young adults.

Understanding American Indian tribal college student knowledge, attitudes, beliefs, and behaviors surrounding alternative tobacco products

OBJECTIVES

To examine knowledge, attitudes, beliefs, and behaviors about alternative tobacco products among American Indian tribal college students.

PARTICIPANTS

One hundred and five tribal college students.

METHODS

Focus groups, one interview, and demographic surveys.

RESULTS

Tobacco use varied across the sample with 35.2% of the participants being users of ENDS products and 29.5% were cigarette smokers. Overall, participants viewed electronic nicotine delivery systems and chewing tobacco as primary examples of alternative tobacco products and described a generational divide between alternative and conventional tobacco product use. Alternative tobacco products were not considered suitable for use in traditional contexts.

CONCLUSIONS

Previously successful cessation programs in this population have relied on cultural tailoring related to traditional tobacco use in American Indian communities. Our findings suggest that this strategy may be less effective for addressing alternative tobacco use. Reliance on the importance of family relationships may prove more impactful in future programming.

National longitudinal tobacco product cessation rates among US adults from the PATH Study: 2013-2019 (waves 1-5)

OBJECTIVE

To report on longitudinal tobacco product cessation rates, by product type, among adults (ages 18+ years) in the USA between 2013 and 2019.

METHODS

The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study was used to report on annual and biennial rates of the following three cessation behaviours across 2013-2019: (1) discontinuing tobacco product use (ie, transition from past 30-day use to no past 30-day use), (2) attempting to quit tobacco product use and (3) quitting tobacco product use among those who attempted to quit. Each cessation behaviour was evaluated separately for cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco. Generalised estimating equations were used to evaluate linear and nonlinear trends in cessation rates across the study period.

RESULTS

Between 2013 and 2019, rates of discontinuing cigarette smoking among adults in the USA statistically increased from 16% to 18%, though these were consistently lower than rates of discontinuing use of other tobacco products. Similarly, quit attempt rates and rates of quitting among attempters increased for cigarette smokers. However, rates of discontinuing ENDS use sharply declined across the study period, from 62% to 44%.

CONCLUSIONS

Findings show that tobacco product cessation rates have been changing in recent years in the USA alongside the changing tobacco product marketplace and regulatory environment, though rates of discontinuing cigarette smoking remain relatively low. Findings can serve as a benchmark against which future cessation rates can be compared to evaluate the impacts of future tobacco regulatory policies.

Noticing people, discounts and non-tobacco flavours in e-cigarette ads may increase e-cigarette product appeal among non-tobacco-using young adults

INTRODUCTION

Young adults new to tobacco (including e-cigarettes) are at an increased risk of e-cigarette use after e-cigarette exposure. This study examined the association between noticing e-cigarette advertising features and perceived product appeal among non-tobacco-using young adults.

METHODS

A sample of non-tobacco-using young adults (ages 18-29 years; n=1993) completed an online survey in 2021. We content analysed visible features from 12 e-cigarette ads that represented commonly used e-cigarette brands. Participants viewed the ads and clicked on the areas of the ads that drew their attention. Participants reported e-cigarette product appeal for each ad, including ad liking, product curiosity and use interest. We used generalised estimating equations to examine within-person associations between noticing specific ad features and reporting each and any type of product appeal, adjusting for noticing other features and participant characteristics.

RESULTS

Noticing people, discounts, non-tobacco (menthol and mint/fruit) flavours, positive experience claims or product images was positively associated with having any e-cigarette product appeal. Noticing discounts or mint/fruit flavours was also positively associated with e-cigarette use interest. In contrast, noticing nicotine warnings or smoking cessation claims was negatively associated with ad liking and product curiosity.

CONCLUSIONS

Attention to several e-cigarette ad features (eg, people, discounts, non-tobacco flavours) was associated with increased e-cigarette product appeal, whereas attention to nicotine warnings and smoking cessation claims was associated with reduced appeal among non-tobacco-using young adults. Restricting appeal-promoting features while strengthening the effects of nicotine warnings and smoker-targeted claims in e-cigarette ads may potentially reduce e-cigarettes' overall appeal among this priority population.

Trends in age of tobacco use initiation over time in Bangladesh, India and Pakistan: analysis of cross-sectional nationally representative surveys

OBJECTIVE

Tobacco use begins at an early age and typically leads to a long-term addiction. The age of initiation for tobacco use is not well studied in South Asia, where 22% of tobacco smokers and 81% of smokeless tobacco (SLT) users reside.

METHODS

Data from the nationally representative Global Adult Tobacco Surveys in India, Bangladesh and Pakistan were analysed to examine patterns of initiation among smokers and smokeless tobacco users.

RESULTS

Data on 94 651 individuals were analysed, of which 13 396 reported were ever daily smokers and 17 684 were ever SLT users. The proportion of individuals initiating tobacco use before the age of 15 years has increased over time. The rates of SLT initiation among those aged 15-24 years increased markedly in Bangladesh (by 7.8%) and Pakistan (by 37.7%) between 1983 and 1999-2000. Among males, the increase in SLT initiation was higher in individuals aged below 15 years compared with other age groups in India and Bangladesh. Smoking initiation among females aged below 15 years has also significantly increased in India over time. Compared with the initiation of tobacco smoking before the age of 15 years, a greater increase in the proportion of SLT users was observed in urban areas.

CONCLUSION

Our findings indicate that the proportion of youth initiating tobacco (both smoking and smokeless) before the age of 15 years has increased over time in all three countries. Moreover, variations in age at initiation for different types of tobacco products across countries, and by rurality, were noticeable. Younger youths (aged up to 15 years) should therefore be a priority population for tobacco control interventions. Strategies such as raising the legal age of tobacco sale and use to 21 years, and, other measures under WHO Framework Convention on Tobacco Control (FCTC), may prevent underage use and avert lifelong addiction to tobacco products.

Systematic Review and Critical Analysis of Longitudinal Studies Assessing Effect of E-Cigarettes on Cigarette Initiation among Adolescent Never-Smokers

Prospective longitudinal studies mainly conclude on a causal role of e-cigarettes in the initiation of cigarettes in flagrant contradiction with conclusions drawn from epidemiology and other studies showing a sharp decline in cigarette use in parallel with the spread of e-cigarette use. This systematic review explores the reasons for this discrepancy.

METHODS

Among 84 publications on e-cigarette/cigarette association in adolescents identified in the Medline database from 2011 to 2022, 23 concern 22 never-smoker longitudinal sub-cohorts.

RESULTS

A link between e-cigarette experimentation at T1 and cigarette initiation at T2 is reported in sub-cohort analyses of never-smokers (AOR: 1.41 to 8.30). However, studies exclude 64.3% of T1 e-cigarette experimenters (because of dual-use) and 74.1% of T2 cigarette experimenters. With this study design, e-cigarettes contribute only to 5.3% of T2 cigarette experimentation, casting major doubt on the external validity of results and authors' conclusions that e-cigarettes have a significant effect on the initiation of cigarettes (Gateway effect) at the population level. This sub-cohort design prohibits highlighting any Diversion effect, which is the most likely mechanism accounting for the competition between these two products.

CONCLUSIONS

While nicotine abstinence remains the best medical option, over-regulation of e-cigarettes because of misinterpretation of longitudinal study results may be detrimental to public health and tobacco control.

Associations of daily alcohol, cannabis, combustible tobacco, and e-cigarette use with same-day co-use and poly-use of the other substances

BACKGROUND

Young adults frequently use alcohol, cannabis, and tobacco together. Given the increased prevalence of e-cigarette use and recreational cannabis use, we investigated daily patterns of alcohol, cannabis, and tobacco use and distinguished combustible tobacco from e-cigarettes.

METHODS

Young adult college students (N=341) reporting past-month alcohol and cannabis use "at the same time so that their effects overlapped" completed two 28-day bursts of repeated daily surveys. Exposures were day- and person-level use of each substance. Outcomes were (1) same-day co-use of each remaining substance or (2) poly-use of the other substances.

RESULTS

Daily use of alcohol, cannabis, combustible cigarettes, and e-cigarettes increased the odds of same-day co-use of the other substances (except combustible tobacco with e-cigarettes) and each poly-use outcome. The influence of person-level substance use on daily substance use was less consistent. Only e-cigarette use increased the odds of daily alcohol use. Use of either tobacco product but not alcohol increased the odds of daily cannabis use. Person-level alcohol and cannabis use increased the odds of daily use of either tobacco product but use of one tobacco product was not associated with daily use of the other product.

CONCLUSIONS

These findings increase our understanding of emerging daily patterns of alcohol, cannabis, and tobacco co-use, and the impact of different tobacco products. Future work is needed to extend this research into non-college samples and people who use tobacco but do not use alcohol and cannabis simultaneously, and examine daily chronologies of multiple substances that could serve as dynamic markers of risk.

Prescription Psychotherapeutic Drug Use and Nicotine Use among Young People in the United States

Background: While prescription psychotherapeutic drug use (PPDU) and nicotine use pose substantial problems in isolation, they pose an increased risk in combination. This study aimed to estimate the prevalence of PPDU for young people, stratified by nicotine use status. A trend analysis was used to examine changes in PPDU and nicotine use over time. Methods: We used a cross-sectional population-based sample of young people aged 16-25 years (n = 10,454) from the National Health and Nutrition Examination Survey (NHANES, 2003-2018). For each data cycle, the prevalence of self-reported PPDU and nicotine including pain relievers, sedatives, stimulants, and tranquilizers was estimated. Using Joinpoint regression, we tested for significant changes in trends using a log-linear model and permutation test approach and produced the average data cycle percentage change (ADCPC). Results: From 2003 to 2018, 6.7% of young people had PPDU and 27.3% used nicotine. The prevalence of cigarette smoking decreased while other nicotine product use increased (p's < 0.001). Those who used nicotine were more likely to have PPDU (8.2%; 95% CI = 6.5%, 9.8%) vs. non-nicotine use (6.1%; 95% CI = 5.1%, 7.0%; p = 0.01). Results indicated a decreasing trend for nicotine use (ADCPC = -3.8, 95% CI = -7.2, -0.3; p = 0.04), but not for PPDU (ADCPC = 1.3; 95% CI = -4.7, 7.8; p = 0.61). On further examination, opioid use decreased, sedative use remained stable, and stimulant and tranquilizer use increased over time. Conclusions: From 2003 to 2018, young people who used nicotine had a higher prevalence of PPDU than those who did not. Clinicians should communicate the association between nicotine use and prescription drugs when prescribing or managing young patients' medications.

Longitudinal transitions in e-cigarette and cigarette use among US adults: prospective cohort study

Background

To support tobacco control efforts, this study sought to characterize longitudinal transitions in use of electronic nicotine delivery systems (ENDS) and cigarettes.

Methods

Participants were nationally representative samples of 53,729 US adults from Waves 3-5 (2015-2019) of the Population Assessment of Tobacco and Health Study. We examined behavioral transitions (initiation, relapse, progression, and cessation) in ENDS and cigarette use across waves. Weighted generalized estimating equation models adjusted for sociodemographic variables.

Findings

Of never ENDS users at baseline, an estimated 1.7% reported initiating ENDS use by follow-up. Of former ENDS users, an estimated 12.1% relapsed into ENDS use. Of periodic ENDS users at baseline, 13% progressed to established ENDS use. Of baseline current ENDS users, 46.3% discontinued ENDS use. The corresponding transitions for cigarette smoking were 1.6% (initiation), 4.8% (relapse), 21.1% (progression), and 14% (discontinuation). Adults aged 18-24 (vs. older age), Hispanics (vs. non-Hispanic white), and past 12-month cannabis users were more likely to initiate ENDS or cigarettes (all p < 0.05). Having any internalizing mental health symptoms increased the odds of ENDS initiation, while externalizing symptoms increased the odds of cigarette initiation. Those who perceived nicotine as very harmful (vs. none/low harm) were more likely to discontinue ENDS. Current cigarette users (vs. non-users) at baseline were more likely to initiate, relapse, or discontinue ENDS (all p < 0.05) and vice versa.

Interpretation

We observed high changeability in ENDS and cigarette use among US adults over time. In absolute terms, ENDS use grew, while smoking fell. Tobacco control programs should focus on priority populations, including young adults and people with internalizing and externalizing mental health symptoms.

Funding

National Institutes of Health, R01-CA246606-01A1, R01-DA048390.

Longitudinal transitions in adolescent polytobacco use across waves 1-4 of the Population Assessment of Tobacco and Health study

AIMS

This study aims to identify adolescent patterns of polytobacco use and measure transitions between patterns over time.

DESIGN

Longitudinal analysis using data derived from waves 1-4 (2013-18) of the Population Assessment of Tobacco and Health (PATH) study. Transitions in tobacco use patterns were examined via latent transition analysis, and then, socio-demographic characteristics were used to predict transitions via logistic regression.

SETTING

United States.

PARTICIPANTS

Participants included 975 adolescents who used at least one tobacco product at any wave (W1 mean age = 13.29, standard deviation = 0.86; W4 54.2% male; 54.5% white, 25.9% Hispanic).

MEASUREMENTS

Measurements included past 30-day use of cigarettes, electronic cigarettes (e-cigs), traditional cigars, cigarillos, filtered cigars, snus, smokeless tobacco (SLT) or hookah.

FINDINGS

Six latent classes were identified. Cigarette users (43.5-58.8%) and SLT users (50.8-79.6%) tended to persist in their use over time. E-cig users began to probably transition to non-users (80.0%), but became more likely to persist in this use over time (31.1%). Non-users at a given wave were most likely to transition to e-cig users (8.5-43.7%) or cigarette users (6.7-28.6%). Cigarillo/poly-users and hookah/poly-users displayed more variable transition patterns. Adolescents were more likely to transition to non-use (versus become/remain e-cig users) if they were older (cigarette users, SLT users), younger (e-cig users), other race (SLT users), male (SLT users) or had less-educated parents (SLT users) compared with their counterparts. Hispanic (versus white) cigarette users were more likely to transition to non-users than to persist in this use.

CONCLUSIONS

Among adolescents in the United States, patterns of tobacco use characterized by the use, mainly, of single, specific products appear to be stable, particularly by late adolescence. In contrast, patterns characterized by polytobacco use appear to be more variable and may represent experimentation without specialization.

E-cigarette Marketing Expenditures in the United States From 2016 to 2021: Targeted Media Outlets Geared Toward People Who Are at Increased Risk for Tobacco Use

INTRODUCTION

E-cigarette advertising exposure is linked to e-cigarette initiation and use. Thus, monitoring trends in e-cigarette advertising practices is important to understand e-cigarette use patterns observed over recent years.

AIMS AND METHODS

E-cigarette advertising expenditures (January 2016-July 2021; Numerator Ad Intel) for 154 U.S. market areas were harmonized with U.S. Census sociodemographic data through Nielsen zip code designations by market area. Descriptive statistics and multivariable linear regressions were used to examine trends in e-cigarette advertising expenditures across media outlets and associations between sociodemographic characteristics and e-cigarette advertising over time.

RESULTS

E-cigarette advertising expenditures peaked in 2018/2019, followed by a sharp decline in 2020. Expenditures were concentrated primarily on print (58.9%), TV (20.6%), and radio (14.4%). Major print outlets were Sports Illustrated, Rolling Stone, and Star magazines. Top TV channels were AMC, Investigation Discovery, and TBS. TV advertisements were purchased commonly during popular movies and TV series (eg King of Queens, Everybody Loves Raymond, The Walking Dead). Higher expenditures were associated with U.S. market areas that had (1) a larger percentage of non-rural zip codes (radio), (2) smaller male populations (radio), and (3) larger White or Caucasian, Black or African American, American Indian or Alaska Native, Asian, and Other or Multiracial populations (radio, print, online display, and online video).

CONCLUSIONS

E-cigarette companies advertised in print magazines geared toward males and youth and young adults, radio commercials focused in urban areas with smaller male populations, and nationwide TV commercials. Declines in e-cigarette advertising expenditures in 2020 demonstrate the potential impact that federal policies may have on protecting populations who are at higher risk for tobacco use from predatory advertising practices.

IMPLICATIONS

E-cigarette advertising exposure is associated with the initiation and use of e-cigarettes. This study shows how e-cigarette marketing expenditures in the United States may have targeted specific consumers (eg youth and young adults) between 2016 and 2021. The precipitous drop in advertising expenditures across all outlets during early 2020 corresponds with the implementation of the Tobacco 21 federal policy, the federal enforcement policy to remove most unauthorized flavored e-cigarette cartridges from the U.S. market, preparations for FDA's premarket review of e-cigarette products, and the decision by several TV broadcast companies to stop showing e-cigarette ads. The potential impact of federal policies may have far-reaching implications for protecting populations who are at high risk for tobacco use and its health consequences.

Predictors of E-cigarette and Cigarette Use Trajectory Classes from Early Adolescence to Emerging Adulthood Across Four Years (2013-2017) of the PATH Study

INTRODUCTION

This study examines predictors of trajectories of cigarette and e-cigarette use among a cohort of US adolescents transitioning into young adulthood. Comparing trajectories of each tobacco product is important to determine if different intervention targets are needed to prevent progression to daily use.

METHODS

Latent trajectory class analyses identified cigarette and e-cigarette use (never, ever excluding past 12-month, past 12-month (excluding past 30-day (P30D)), P30D 1-5 days, P30D 6+ days) trajectory classes, separately, among US youth (12-17; N = 10,086) using the first 4 waves (2013-2017) of data from the nationally representative PATH Study. Weighted descriptive analyses described the class characteristics. Weighted multinomial logistic regression analyses examined demographic, psychosocial, and behavioral predictors of class membership.

RESULTS

Younger adolescents 12-15 years had lower tobacco use compared to 16-17 year olds and less stable classes. In the 16-17 year group, there were five unique trajectories of cigarette smoking, including a Persistent High Frequency class. Four e-cigarette use trajectories were identified; but not a persistent use class. Shared predictors of class membership for cigarettes and e-cigarettes included mental health problems, other tobacco use, marijuana use, and poorer academic achievement. Male sex and household tobacco use were unique e-cigarette trajectory class predictors.

CONCLUSIONS

There was no evidence that initiation with e-cigarettes as the first product tried was associated with cigarette progression (nor cigarettes as first product and e-cigarette progression). Interventions should focus on well-established risk factors such as mental health and other substance use to prevent progression of use for both tobacco products.

IMPLICATIONS

Using nationally representative data and definitions of use that take into account frequency and recency of use, longitudinal 4-year trajectories of e-cigarette and cigarette use among US adolescents transitioning into young adulthood were identified. Results among 16-17-year olds revealed a class of persistent high frequency cigarette smoking that was not identified for e-cigarette use. Cigarette use progression was not associated with e-cigarettes as the first product tried. Risk factors for progression of use of both products included mental health and other substance use, which are important prevention targets for both tobacco products.

Longitudinal Transition Patterns of Tobacco Use Among Youth and Young Adults Never Tobacco Product Users: Findings From the Population Assessment of Tobacco and Health Study, 2014-2019

Aims

To identify, visualize, and describe the prevalence of within-product patterns of tobacco use behaviors for e-cigarettes, cigarettes, and hookah (TP) by 3 age groups (ie, 12-14-year-old, 15-17-year-old, and 18-20-year-old) with U.S. nationally representative data.

Methods

In 2014-2015, never users of each (TP) and age group were followed-up longitudinally between 2015-2019 using five transition states: non-susceptible to (TP) use, susceptible to (TP) use, ever (TP) use, past 30-day (TP) use, and discontinued past 30-day (TP) use. Sankey diagrams were used to graphically visualize patterns in tobacco use behaviors across time.

Results

Among 12-14-year-old who were never users and susceptible to each TP from 2014-2017, 7% initiated ever e-cigarette use and 9.4% first reported past 30-day use by 2018-2019; 5.8% initiated ever cigarette use and 3% first reported past 30-day cigarette use by 2018-2019; and, 4.5% initiated ever hookah use and 1.0% first reported past 30-day hookah use by 2018-2019. Among 15-17-year-old who were never users and susceptible to each TP from 2014-2017, 4.2% initiated ever e-cigarette use and 9.0% first reported past 30-day use by 2018-2019; 4.5% initiated ever cigarette use and 3% first reported past 30-day cigarette use by 2018-2019; and, 4.5% initiated ever hookah use and 2.4% first reported past 30-day hookah use by 2018-2019. Among 18-20-year-old who were never users and susceptible to each TP from 2014-2017, 3.2% initiated ever e-cigarette use and 3.6% first reported past 30-day e-cigarette use by 2018-2019; 3.0% initiated ever cigarette use and 2.3% first reported past 30-day cigarette use; and, 2.8% initiated ever hookah use and 1.0% first reported past 30-day hookah use by 2018-2019.

Conclusions

From 2014 to 2019, onset and progression of e-cigarette, cigarette, and hookah use occurred more frequently in 12-14 and 15-17-year-old than in young adults 18-20-year-old.

Youth E-Cigarette Use and Functionally Important Respiratory Symptoms: The Population Assessment of Tobacco and Health (PATH) Study Waves 3 and 4

Respiratory effects of e-cigarette use among youth are not fully understood. This study investigated the longitudinal association between e-cigarette use and a validated index of functionally important respiratory symptoms among US youth. Data from Waves 3-4 of the Population Assessment of Tobacco and Health Study were analyzed. The sample included youth (aged 12-17) without asthma at baseline (Wave 3), who completed a follow-up survey (Wave 4), and were not missing data for analytic variables (n = 3899). Exposure was e-cigarette use status (never, former, or current) at baseline. The outcome was a respiratory symptom index based on responses for seven wheezing items at Wave 4. An index of ≥2 was defined as having functionally important respiratory symptoms. Lagged logistic regression models examined the association between baseline e-cigarette use and functionally important respiratory symptoms at follow-up by combustible tobacco use status (never or ever), and controlling for baseline covariates. At baseline, 13.7% of participants reported former e-cigarette use, and 4.3% reported current use. Baseline e-cigarette use did not increase the odds of having functionally important respiratory symptoms at follow-up regardless of combustible tobacco use status. Future research on larger populations of e-cigarette users with longer follow-up periods will improve our understanding of the respiratory risks associated with e-cigarette use among youth.

Correlates of tobacco product initiation among youth and young adults between waves 1-4 of the population assessment of tobacco and Health (PATH) study (2013-2018)

INTRODUCTION

While risk factors for cigarette smoking among youth and young adults are well-documented, less is known about the correlates of initiation of other tobacco products. This study aims to provide estimates and correlates of initiation among U.S. youth and young adults.

METHODS

Data on youth aged 12-17 (n = 10,072) and young adults aged 18-24 (N = 5,727) who provided information on cigarettes, electronic nicotine delivery systems (ENDS), cigars, pipe, hookah and smokeless tobacco use in Wave 1 (W1: 2013-2014)-Wave 4 (W4: 2016-2018) of the nationally-representative PATH Study were used to calculate ever use initiation and correlates of initiation by W4.

RESULTS

Nearly 6 million youth and 2.5 million young adults used tobacco for the first time between W1-W4. Approximately one quarter of youth and young adult ENDS never users initiated ENDS between W1-W4 of the PATH Study. Among youth, use of other tobacco products, ever substance use, and high externalizing problems were associated with initiation of most products. Among young adults, use of other tobacco products and ever substance use were associated with initiation of most products. In both youth and young adults, Hispanics were more likely to initiate hookah use than their non-Hispanic White counterparts. While male sex was a risk factor for most tobacco product initiation across both age groups, it was not associated with hookah initiation.

CONCLUSIONS

Cigarette and non-cigarette products shared many correlates of initiation, although there are noteworthy demographic differences. Findings can help tailor product specific interventions to reach populations at risk during preliminary stages of use.

Association between E-Cigarette Advertising Exposure and Use of E-Cigarettes among a Cohort of U.S. Youth and Young Adults

Youth and young adult (YYA) use of e-cigarettes increased rapidly between 2010 and 2019 in the United States, during which exposure to e-cigarette advertising was also increased. We aimed to examine whether exposure to e-cigarette advertising among YYAs may lead to subsequent e-cigarette use. A cohort of 3886 YYAs ages 13-24 was recruited from two survey panels in 2018 and followed up until 2019. Survey data were collected online and by telephone. The primary outcome was past 30-day use of e-cigarettes at the follow-up survey. Among 2304 YYAs who retained at the follow-up survey and were not past 30-day e-cigarette users at baseline, both youth and young adults exposed to e-cigarette advertising at baseline had elevated odds of past 30-day e-cigarette use at follow-up (Youth adjusted odds ratio (aOR): 2.77, 95% CI: 1.23, 6.24; Young adults aOR: 2.34, 95% CI: 1.08, 5.11) compared with those not reporting baseline advertising exposure. The majority of YYAs reported exposure to e-cigarette advertising at baseline (Youth: 63.7%, 95% CI: 59.8, 67.4; Young adults: 58.3%, 95% CI: 53.6, 62.8). Our findings suggest that exposure to e-cigarette advertising was associated with an increase in subsequent past 30-day use of e-cigarettes among YYAs. Restricting advertising targeted at YYAs may reduce the likelihood of e-cigarette use among YYAs.

Overall quit in triple users of conventional cigarette, e-cigarette and heated tobacco product among healthy adults: a Korea Medical Institute health check-up study

OBJECTIVE

While multiuse patterns of e-cigarettes (EC) or heated tobacco products (HTP) with conventional cigarettes (CC) have been reported, smoking cessation of multiusers is not well known. We aimed to analyse overall quit in triple users of CC, EC and HTP among healthy adults.

METHODS

A questionnaire was conducted on 89 360 adults who visited the Korea Medical Institute health check-ups in Seoul, Korea, from May 2018 to September 2019. Among 38 812 ever smokers, 9252 were ever triple users of CC, EC and HTP. Frequency and related factors of overall quit were analysed in the cross-sectional study.

RESULTS

The average age was 38.8±9.0 years, and 8458 (91.4%) were men. There were 5329 (57.6%) current triple users, 3547 (38.3%) single or dual product quitters and 376 (4.1%) overall quitters. Among the former triple users, the most common tobacco product use pattern was 'dual quit of EC and HTP (eg, current CC use)' both in men (21.3%) and women (26.3%). Age 60s or older (OR 8.5, 95% CI 5.2 to 13.8), women (OR 1.7, 95% CI 1.1 to 2.5), no hyperlipidaemia and married status were significantly related to overall quit.

CONCLUSION

The most common pathway for 'ever triple users' of the three tobacco products was 'current triple users', and the second was 'CC users'. Single or dual product quitters could continue to smoke by EC or HTP instead of quit. Further research on overall quit will be needed to develop effective regulations.

Cigar Harm Beliefs and Associations with Cigar Use among Young Adults

BACKGROUND

Cigar use, including little cigars and cigarillos (LCCs) and large traditional cigars, continues to harm young adults. Research on harm beliefs about cigars, particularly large cigars, is sparse. The current study examined cigar harm beliefs and associations with cigar use. Methods: Data are from a 2019 survey of a young adult cohort study recruited in fall 2010. Participants were asked questions about their beliefs about the harm of LCC and large cigar use. Those reporting ever use of cigars were asked how frequently they inhale the smoke into their lungs. Results: Participants (N = 1910) were 51.9% female with a mean age of 26.7 (SD = 0.6). Ever cigar use was 44.2% for large cigars and 43% for LCCs. Compared to those who have never used large cigars or LCCs, those reporting ever use of large cigars or LCCs reported lower harm beliefs about inhaling harmful chemicals and becoming addicted (ps <.0001). Those who reported higher harm beliefs also reported inhaling the smoke into their lungs more frequently for large cigars and LCCs (ps<.05). Conclusions: Cigar use harm beliefs were lower among participants reporting ever use of cigars compared to those reporting never use. Contrary to predictions, those reporting greater harm beliefs were more likely to report inhaling smoke more frequently than those with lower harm beliefs.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults

BACKGROUND

Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs).

PURPOSE

This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA).

METHODS

This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context.

RESULTS

Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined.

CONCLUSIONS

Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Changes in cigarette and e-cigarette use among US young adults from before to during the COVID-19 pandemic: News exposure and risk perceptions as potential predictors

INTRODUCTION

COVID-19 impacted cigarette and e-cigarette use behaviors among some individuals. This study examined COVID-19 factors and prior substance use as predictors of cigarette and e-cigarette cessation and initiation among US young adults from before to during the COVID-19 pandemic.

METHODS

We analyzed data from Wave 3 (Sept-Dec 2019) and Wave 5 (Sept-Dec 2020) of a 2-year, 5-wave longitudinal study of young adults across six US metropolitan areas. We examined COVID-19 news exposure, perceived smoking and e-cigarette use risk, and prior substance use, as predictors of cigarette and e-cigarette cessation and initiation, respectively.

RESULTS

Of W3 cigarette users (n=516), 37.8% (n=195) quit cigarettes at W5; predictors of cessation included younger age, fewer days of W3 past-month cigarette use, and no W3 e-cigarette use. Of W3 e-cigarette users (n=687), 38.7% (n=266) quit e-cigarettes at W5; predictors included greater COVID-19 news exposure, fewer days of W3 past-month e-cigarette use, and no W3 cigarette use. Of W3 cigarette non-users (n=1693), 5.0% (n=85) initiated cigarettes at W5; predictors of initiation included younger age, lower perceived smoking risk, lifetime cigarette and e-cigarette use, and W3 e-cigarette use. Of W3 e-cigarette non-users (n=1522), 6.3% (n=96) initiated e-cigarettes at W5; predictors included younger age, less news exposure, lifetime cigarette and e-cigarette use, and W3 cigarette use.

CONCLUSIONS

These findings underscore the need to address cigarette and e-cigarette co-use and related risk perceptions in prevention and cessation interventions.

Age of initiation of cigarillo use among young adults: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2017

SIGNIFICANCE

Young adults, especially those who identify as racial/ethnic minorities, are legal targets of the tobacco industry. Cigarillo initiation is a risk among these vulnerable groups. Estimating the age of initiation of cigarillo use among young adults may inform the timing of prevention interventions.

METHODS

Weighted interval-censored survival analyses of the Population Assessment of Tobacco and Health (PATH) young adult (ages 18-24 at their first wave of adult participation) annual datasets were conducted (2013-2017). Young adult never cigarillo users (n = 7,101; represents N = 24,023,488) at their first wave of adult participation (2013-2016) were followed-up through 2014-2017 to estimate the age of initiation of ever, past 30-day and fairly regular cigarillo use outcomes. Differences by sex and by race/ethnicity, accounting for previous use of other tobacco products and marijuana and blunt use, were assessed using weighted interval-censored Cox proportional hazards models.

RESULTS

Among PATH young adults, by age 21, 5.8% initiated ever cigarillo use, 4.1% initiated past 30-day cigarillo use, and 1.4% initiated fairly regular cigarillo use. By age 26, 15% initiated ever cigarillo use, and 10.4% initiated past 30-day cigarillo use. Males had higher risk of initiating ever (AHR: 1.63, 95% CI: 1.37-1.95) and past 30-day cigarillo use (AHR: 1.65, 95% CI: 1.32-2.06) at earlier ages than females. Non-Hispanic Blacks had higher risk of initiating ever (AHR: 2.81, 95% CI: 2.26-3.50), past 30-day (AHR: 4.88, 95% CI: 2.95-5.09) and fairly regular cigarillo use (AHR: 4.62, 95% CI: 2.70-7.93) at earlier ages than non-Hispanic Whites. Hispanics had higher risk of initiating past 30-day cigarillo use at earlier ages than non-Hispanic Whites (AHR: 1.51, 95% CI: 1.12-2.03). Non-Hispanic Other race (i.e., Asian, multiracial, etc.) had lower risk of initiating ever (AHR: 0.43, 95% CI: 0.28-0.65) and past 30-day cigarillo use (AHR: 0.40, 95% CI: 0.26-0.63) at earlier ages than Non-Hispanic Whites.

CONCLUSION

Along with those aged 21 and younger, interventions should target young adults over the age of 21, specifically males, non-Hispanic Black and Hispanic young adults, to stall initiation and progression of cigarillo use behaviors.

Prevalence and predictors of waterpipe smoking initiation and progression among adolescents and young adults in waves 1-4 (2013-18) of the Population Assessment of Tobacco and Health (PATH) study

BACKGROUND

Waterpipe tobacco (WPT) smoking has increased among the young population in the United States (US). This study assessed the extent and predictors of WPT smoking initiation and progression among US adolescents (12-17 years) and young adults (18-24 years) longitudinally.

METHODS

We analyzed data from 4 waves (2013-2018) of the Population Assessment of Tobacco and Health (PATH) study comprising 10,692 respondents (adolescents=5,428 and young adults=5,264). Kaplan-Meier survival method estimated probabilities of WPT initiation and progression. Cox proportional hazards regression models delineated predictors of the outcomes.

RESULTS

Between 2013 to 2018, 4.8% of adolescents initiated and 10.6% progressed WPT smoking. Among young adults, 18.5% initiated and 14.1% progressed WPT smoking during the same time interval. Predictors among adolescents included, WPT initiation: Hispanic ethnicity (adjusted odds ratio (aHR)=1.75, 95% confidence interval (CI)=1.23-2.49), lower harm perception (aHR=2.89, 95% CI=2.10-3.98), and other tobacco products use (aHR=3.97, 95% CI=2.73-5.78); WPT progression: illicit drug use (aHR=4.60, 95% CI=1.99-10.67). Predictors among young adults included, WPT initiation: non-Hispanic Black (aHR=2.31, 95% CI=1.78-3.00), Hispanic (aHR=1.77, 95% CI=1.34-2.33), lower harm perception (aHR=2.77, 95% CI=2.19-3.50), and other tobacco products use (aHR=3.14, 95% CI=2.25-4.38); WPT progression: non-Hispanic Black (aHR=1.51 95% CI=1.09-2.10), lower harm perception (aHR=1.80, 95% CI=1.41-2.30), and alcohol use (aHR=1.61, 95% CI=1.13-2.30).

CONCLUSIONS

Results indicate a high prevalence of WPT initiation and progression among adolescents and young adults over time, with minority racial/ethnic groups being at greater risk for both. WPT-specific risk communication interventions (e.g., educational campaigns and health warning labels) are warranted to limit WPT smoking among young people.

E-Cigarette Aerosols Promote Oral S. aureus Colonization by Delaying an Immune Response and Bacterial Clearing

E-cigarette (e-cig) vapor has been shown to play a pathological role in oral health and alter the oral microbiota, providing growth advantages for opportunistic pathogens. Enrichment of Staphylococcus aureus, a commensal resident in the oral cavity, correlates with the progression of periodontal disease, suggesting a role as an opportunistic pathogen. Environmental conditions, such as cigarette smoke, are known to increase S. aureus virulence, yet the role of S. aureus in periodontitis and oral preneoplasia is unknown. We exposed oral epithelial cells to e-cig aerosols and showed a dose-dependent cell viability reduction, regardless of nicotine content, in a possible attempt to repair DNA damage, as measured by pH2AX. S. aureus attachment to oral epithelial cells and bacterial biofilm formation were enhanced upon e-cig exposure, indicating an increased capacity for oral colonization. Mechanistically, e-cig aerosol exposure resulted in an immunosuppression, as determined by a reduction in IL8, IL6, and IL1β secretion by oral epithelial cells during co-culture with S. aureus. Consistent with this, e-cig vape reduced the oral epithelial cell clearance of S. aureus. Furthermore, we observed an increased expression of the inflammatory regulator COX2. This work suggests that e-cigs promote S. aureus colonization and modulate the oral inflammatory response, possibly promoting oral periodontitis and preneoplasia.

Cigar Use Progression Among New Cigar Initiators: A Two-Part Growth Curve Analysis Among a Youth and Young Adult Cohort

INTRODUCTION

Youth and young adults (YYAs) are at high risk of cigar use. This study's objective was to examine progression and sociodemographic differences in current cigar use and frequency among new cigar initiators.

AIMS AND METHODS

We conducted a two-part latent growth model among a nationally representative cohort of cigar initiators (aged 15-25) to examine 24-month trajectories of current cigar use and frequency (n = 1483). The cohort was recruited via address-based sampling with online data collection from 2014 to 2019 and surveyed approximately every 6 months.

RESULTS

The unconditional odds of current cigar use (ie, past 30-day use) within 6 months of initiation was 0.72 (95% confidence interval: 0.63, 0.82), corresponding to a probability of 42%. The odds of current use among recent cigar initiates declined 6 months after initiation and was followed by a stabilization in use over time. Among continued users, frequency (# days used in past 30 days) increased linearly over time but remained low (3.47 days/months at 24 months). Younger individuals, non-Hispanic African Americans, those with lower subjective financial status, and current users of cigarettes, other tobacco products and/or marijuana were at highest risk within 6 months of initiation. Males, younger users, and current cigarette smokers had the highest risk for cigar progression over time.

CONCLUSIONS

This study is the first to examine longitudinal cigar use patterns among YYA cigar initiators. Findings emphasize the need for research across the cigar use spectrum and the importance of interventions targeted by age, stage of use, cigarette, other tobacco, and marijuana use and key sociodemographics to interrupt use pathways.

IMPLICATIONS

This study is the first to examine progression of cigar use among YYAs who have newly initiated cigars. Results show a high probability of current cigar use within 6 months of initiation followed by a rapid decline and stabilization over time. Frequency increases among those who continue using cigars. Males, younger users, and current cigarette smokers had the highest risk for cigar progression over time. Findings emphasize the need for targeting interventions by age, stage of use, cigarette, other tobacco, and marijuana use and key sociodemographics to interrupt use pathways.

Age of e-cigarette initiation in USA young adults: Findings from the Population Assessment of Tobacco and Health (PATH) study (2013-2017)

INTRODUCTION

There is a lack of research prospectively estimating the age of e-cigarette initiation in U.S. young adults.

METHODS

Secondary analysis of PATH young adults across 2013-2017 (waves 1-4) were conducted. We prospectively estimated age of initiation of: ever, past 30-day, and fairly regular e-cigarette use using weighted interval-censoring survival analyses. Interval-censoring Cox proportional hazard models adjusting for sex, race/ethnicity, and previous use of six other tobacco products (cigarettes, traditional cigars, filtered cigars, cigarillos, hookah, and smokeless tobacco) were fitted for each of the three e-cigarette initiation outcomes.

RESULTS

Among never e-cigarette users, by age 21, 16.8% reported ever use, 7.2% reported past 30-day use, and 2.3% reported fairly regular e-cigarette use. Males had increased risk of initiating ever, past 30-day, and fairly regular e-cigarette use at earlier ages compared to females. Hispanic young adults had increased risk of initiating ever and past 30-day e-cigarette use at earlier ages compared to Non-Hispanic White young adults. Previous use of other tobacco products before e-cigarette initiation increased the risk of an earlier age of e-cigarette initiation.

CONCLUSION

Prevention and education campaigns should focus on young adults in order to alleviate the public health burden of initiating e-cigarette use at earlier ages.

Age of Onset of Susceptibility to Different Tobacco Products Among Non-Susceptible US Young Adults: Findings from the Population Assessment of Tobacco and Health Study Waves 2-4 (2014-2017)

INTRODUCTION

Initiation of tobacco products is increasing in young adulthood. This study prospectively estimated the age of onset of susceptibility to cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos among young adults, which is a cognitive precursor to initiation.

METHODS

Secondary data analyses of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative longitudinal cohort study of US adults. Young adults (18-24 years) who were non-susceptible to each tobacco product (cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos) at waves 2 or 3 were followed-up into waves 3-4 to prospectively estimate the age of onset of susceptibility to each tobacco product. Weighted interval-censored survival methods and interval-censored Cox regression models were implemented to estimate the age of onset of susceptibility, and to estimate differences in the hazard function by sex and by race/ethnicity, while controlling for the total number of other tobacco products ever used at their first wave of participation in PATH.

RESULTS

By age 21, 16.5%, 16.0%, 12.6%, 12.4%, and 5.9% of young adults reported onset of susceptibility to hookah, e-cigarettes, cigarillos, cigarettes, and smokeless tobacco, respectively. Among young adults who were non-susceptible to each tobacco product at waves 2 or 3, the highest increase in onset of susceptibility occurred between ages 18 and 19 for cigarettes, e-cigarettes, and hookah, while the highest increase in onset of susceptibility occurs between ages 22 and 23 for cigarillos. Young adult males had increased risk of onset of susceptibility to cigarillos and smokeless tobacco at earlier ages than young adult females. Differences in onset of susceptibility to each tobacco product were also observed by race/ethnicity among young adults.

CONCLUSIONS

With the changing landscape of tobacco products, monitoring the age of onset of susceptibility of tobacco product use among non-susceptible young adults longitudinally is critical to prevent initiation. Communication and education campaigns tailored to address differences in susceptibility among young adults by tobacco product and sociodemographic factors will be useful.

Age of Initiation of Dual Tobacco Use and Binge Drinking among Youth (12-17 Years Old): Findings from the Population Assessment of Tobacco and Health (PATH) Study

Earlier exposure to binge drinking and tobacco use is associated with higher odds of substance use disorders. Using national youth data from the PATH study, we prospectively estimate the age of initiating past 30-day use of (1) cigarettes, e-cigarettes, and binge drinking, and (2) cigarettes, cigarillos, and binge drinking. Cox proportional hazard models were used to estimate differences in the age of initiation by sex, race/ethnicity, and previous use of other tobacco products. By age 21, 4.4% (95% CI: 3.7-5.2) and 2.0% (95% CI: 1.2-2.8) of youth reported initiation of past 30-day use outcomes (1) and (2), respectively. After controlling for sex and previous use of other tobacco products, statistically significant differences in the age of initiation by race/ethnicity were found for each outcome: Hispanic and non-Hispanic Black youth were less likely than non-Hispanic White youth to initiate past 30-day use of both outcomes (1) and (2) at earlier ages. Although the initiation of both outcomes remained relatively low by age 21, these incidences represent 1.56 million and 700,000 youth, respectively. This study provides the public with evidence to identify the particular ages at which education campaigns may be most effective to prevent youth from initiating these three substances. Further research is needed to estimate the age of initiation of other dual tobacco use patterns with binge drinking.

Age of initiation of hookah use among young adults: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2017

OBJECTIVE

To prospectively estimate the age of initiation of ever, past 30-day, and fairly regular hookah use among young adults (ages 18-24) overall, by sex, by race/ethnicity, and to explore the association of prior use of other tobacco products with these hookah use behaviors.

METHODS

Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US young adults. Young adult never hookah users at the first wave of adult participation in PATH waves 1-3 (2013-2016) were followed-up into waves 2-4 (2014-2017) to estimate the age of initiation of three outcomes: (i) ever use, (ii) past 30-day use, and (iii) fairly regular hookah use. Weighted interval-censoring Cox proportional hazards regression models were used to examine the differences in the estimated age of initiation by sex and by race/ethnicity while controlling for the total number of other tobacco products ever used at participants' first wave of PATH participation. In addition, to examine if prior use of other tobacco products was associated with the age of hookah initiation behaviors, six additional Cox models are reported for each hookah initiation behaviors.

RESULTS

The largest increase in hookah use occurred between ages 18 and 19: 5.8% for ever use and 2.7% for past 30-day hookah use. By age 21, 10.5%, 4.7% and 1.2% reported initiation of ever, past 30-day and fairly regular hookah use, respectively. There were statistically significance differences in the age of initiation of hookah use behaviors by race/ethnicity.

CONCLUSION

Educational interventions should target young adults before the age of 21, focusing efforts specifically on males, non-Hispanic Blacks and Hispanics, to stall initiation and progression of hookah use behaviors.

#FlavorsSaveLives: An Analysis of Twitter Posts Opposing Flavored E-cigarette Bans

BACKGROUND

Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. People took to Twitter to voice their opposition, referencing the phrase "Flavors Save Lives." This study documented the emerging themes pertaining to "Flavors Saves Lives" over a 12-month period.

METHODS

The study period was from May 1, 2019, to May 1, 2020. A stratified sampling procedure supplied 2500 tweets for analysis. Posts were classified by one or more of the following themes: (1) Political Referendum; (2) Institutional Distrust; (3) Individual Rights; (4) Misinformation; (5) THC Vaping is the Real Problem; (6) Smoking Cessation; (7) Adult Use; and (8) Not a Bot. The temporal pattern of tweets over the year was examined.

RESULTS

Political Referendum (76.5%) and Institutional Distrust (31.3%) were the most prominent themes, followed by Not a Bot (11.0%), Individual Rights (10.4%), Adult Use (8.0%), Smoking Cessation (6.6%), Misinformation (5.9%), and THC Vaping is the Real Problem (3.5%). Total tweet frequencies increased in September 2019 and peaked in November 2019 before returning to relatively low numbers. Political Referendum and Institutional Distrust were consistently the most prevalent themes over time.

CONCLUSION

Twitter posts with the phrase "Flavors Save Lives" commonly discussed voting against political incumbents and mentioned distrust of government representatives. Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans. These data may be valuable for designing tobacco control information campaigns in the future.

IMPLICATIONS

(a) Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. (b) This study content analyzed Twitter posts with the phrase "Flavors Save Lives" from a 12-month period to understand opposition to flavor restrictions. (c) Twitter posts commonly discussed voting against political incumbents and mentioned distrust of government representatives. (d) Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans, and contribute to a more comprehensive assessment of different sub-population's responses to current and proposed tobacco control information policies.

Overview of tobacco use transitions for population health

The Family Smoking Prevention and Tobacco Control Act provided the US Food and Drug Administration authority to regulate tobacco products using a population health standard. Models have been developed to estimate the population health impacts of tobacco initiation, cessation and relapse transitions. Models should be informed by high-quality, longitudinal data to estimate these constructs. Simulation studies have generated data to predict the impact of various tobacco control interventions, including the influence of regulations on tobacco use behaviours and health. The purpose of this paper is to provide a high-level conceptual overview for understanding tobacco transition behaviours and correlates of these behaviours using data from the Population Assessment of Tobacco and Health (PATH) Study, a US nationally representative longitudinal tobacco study of about 46 000 persons aged 12+ years. The papers that follow in this journal issue build and expand on this conceptual overview using data from the first three waves of the PATH Study. These papers describe use patterns of different tobacco products and their correlates, and can serve as foundations for more in-depth papers that will help the research community better understand the population health impacts and drivers of different tobacco use patterns.

Longitudinal pathways of exclusive and polytobacco cigarette use among youth, young adults and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

Cigarettes are the most harmful and most prevalent tobacco product in the USA. This study examines cross-sectional prevalence and longitudinal pathways of cigarette use among US youth (12-17 years), young adults (18-24 years) and adults 25+ (25 years and older).

DESIGN

Data were drawn from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US adults and youth. Respondents with data at all three waves (youth, N=11 046; young adults, N=6478; adults 25+, N=17 188) were included in longitudinal analyses.

RESULTS

Among Wave 1 (W1) any past 30-day (P30D) cigarette users, more than 60%, persistently used cigarettes across three waves in all age groups. Exclusive cigarette use was more common among adult 25+ W1 P30D cigarette users (62.6%), while cigarette polytobacco use was more common among youth (57.1%) and young adults (65.2%). Persistent exclusive cigarette use was the most common pathway among adults 25+ and young adults; transitioning from exclusive cigarette use to cigarette polytobacco use was most common among youth W1 exclusive cigarette users. For W1 youth and young adult cigarette polytobacco users, the most common pattern of use was persistent cigarette polytobacco use.

CONCLUSIONS

Cigarette use remains persistent across time, regardless of age, with most W1 P30D smokers continuing to smoke at all three waves. Policy efforts need to continue focusing on cigarettes, in addition to products such as electronic nicotine delivery systems that are becoming more prevalent.

Longitudinal pathways of exclusive and polytobacco cigar use among youth, young adults and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

The goal of this study is to examine the cross-sectional prevalence of use and 3-year longitudinal pathways of cigar use in US youth (12-17 years), young adults (18-24 years), and adults 25+ (25 years or older).

DESIGN

Data were drawn from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth and adults. Respondents with data at all three waves (youth, n=11 046; young adults, n=6478; adults 25+, n=17 188) were included in longitudinal analyses.

RESULTS

Weighted cross-sectional prevalence of past 30-day (P30D) use was stable for adults 25+ (~6%), but decreased in youth (Wave 1 (W1) to Wave 3 (W3)=2.5% to 1.2%) and young adults (W1 to W3=15.7% to 14.0%). Among W1 P30D cigar users, over 50% discontinued cigar use (irrespective of other tobacco use) by Wave 2 (W2) or W3. Across age groups, over 70% of W1 P30D cigar users also indicated P30D use of another tobacco product, predominantly cigar polytobacco use with cigarettes. Discontinuing all tobacco use by W2 or W3 was greater in adult exclusive P30D cigar users compared with polytobacco cigar users.

CONCLUSIONS

Although the majority of P30D cigar users discontinued use by W3, adult polytobacco users of cigars were less likely to discontinue all tobacco use than were exclusive cigar users. Tracking patterns of cigar use will allow further assessment of the population health impact of cigars.

Prospective estimation of the age of initiation of hookah use among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study waves 1-4 (2013-2017)

OBJECTIVE

This study reports the prospectively estimated age of initiation of susceptibility to, ever, past 30-day, and fairly regular hookah use.

DESIGN

Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US youth (ages 12-17).

METHODS

Youth who were never hookah users at their first wave of participation were identified (n = 16,678; N = 31,136,834). Four outcomes were analyzed, age of first report of: (i) susceptibility to use, (ii) ever use, (iii) past 30-day use, and (iv) fairly regular hookah use. The age of hookah initiation of each outcome was estimated. Weighted interval censoring survival analyses and Cox regression models were conducted to estimate the age of initiation of each hookah use outcome, and to estimate differences in age of initiation by sex and by race, respectively.

RESULTS

Around 11% of youth were classified as susceptible to hookah use by 13 years of age, 8% reported initiating ever hookah use by age 17, almost 10% reported initiating past 30-day hookah use by age 19, and 3% reported initiating fairly regular hookah use by age 20. Females and Hispanics were at higher risk of becoming susceptible to and ever hookah use at earlier ages compared to males and Non-Hispanic White youth.

CONCLUSION

Education, communication campaigns, and proven culturally targeted tobacco interventions that reach youth at ages before they first become susceptible or start using hookah use are needed to prevent the onset of hookah use among vulnerable youth.

Prospective estimation of the age of initiation of cigarettes among young adults (18-24 years old): Findings from the Population Assessment of Tobacco and Health (PATH) waves 1-4 (2013-2017)

OBJECTIVES

To prospectively estimate the age of cigarette initiation among young adults (18-24 years old) who were never cigarette users at their first wave of adult study participation overall, by sex, and by race/ethnicity given recent increases in cigarette initiation occurring in young adulthood.

METHODS

Secondary analyses were conducted using the PATH restricted-use adult datasets among young adult never users of cigarettes in waves 1-3 (2013-2016) with outcomes followed-up in waves 2-4 (2014-2017). Interval censoring survival methods were used to estimate the age of initiation of (i) ever, (ii) past 30-day, and (iii) fairly regular cigarette use. Among never cigarette users when they first entered the adult study, interval censoring Cox proportional hazard models were used to explore differences in the estimated age of initiation of the three cigarette use outcomes by sex and by race/ethnicity, controlling for the effect of previous e-cigarette use and the total number of other tobacco products ever used (0-5 products) before cigarette initiation outcomes.

RESULTS

Among the young adults who were never cigarette users at their first wave of adult participation, the highest increase in cigarette initiation occurred between 18 and 19 years old. By age 21, 10.6% (95% CI: 9.5-11.7) initiated ever cigarette use, 7.7% (95% CI: 6.1-8.1) initiated past 30-day of cigarette use, and 1.9% (95% CI: 1.4-2.5) initiated fairly regular cigarette use. After controlling for other tobacco products: (a) males were 83% more likely to initiate past 30-day cigarette use at earlier ages than females; (b) Hispanic and Non-Hispanic Black young adults had increased risk to initiate past 30-day cigarette use at earlier ages than Non-Hispanic White young adults (62% and 34%, respectively).

CONCLUSIONS

The substantial amount of cigarette initiation among young adults reinforces the need for prevention strategies among this population. Although, interventions are needed for all young adult populations, strategies should target 18-21-year-olds, with potentially differential prevention targets by sex and by race/ethnicity.

Sex Difference in the Association between Electronic Cigarette Use and Subsequent Cigarette Smoking among U.S. Adolescents: Findings from the PATH Study Waves 1-4

E-cigarettes are the most-used tobacco products among U.S. adolescents. Emerging evidence suggests that adolescents using e-cigarettes are at elevated risk for initiating cigarette smoking. However, whether this risk may differ by sex remains unknown. This study analyzed data from Wave 1 to 4 of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal survey. Generalized estimation equations (GEE) were performed to estimate the associations between baseline e-cigarette use and subsequent cigarette smoking, controlling for sociodemographic characteristics, mental health conditions, and other tobacco use. Effect modifications by sex were examined. Multivariate analyses showed that, among baseline never cigarette smokers, past-30-day e-cigarette use at baseline waves was significantly associated with past-30-day cigarette smoking at follow-up waves (aOR = 3.90, 95% CI: 2.51-6.08). This association was significantly stronger for boys (aOR = 6.17, 95% CI: 2.43-15.68) than for girls (aOR = 1.10, 95% CI: 0.14-8.33). Additionally, using other tobacco products, older age, and having severe externalizing mental health problems at baseline were significantly associated with an increased likelihood of cigarette smoking at follow-up. The prospective association between e-cigarette use and cigarette smoking differs by sex among U.S. adolescents. Sex-specific tobacco control interventions may be warranted to curb the youth tobacco use epidemic.

Age at Initiation of Cigarette Use in a Nationally Representative Sample of US Youth, 2013-2017

IMPORTANCE

Cigarettes are still a commonly used tobacco product among youth despite recent declines in cigarette use.

OBJECTIVE

The aim of this study was to prospectively estimate the age of cigarette use initiation among youth (aged 12-17 years) overall, by sex, and by race/ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from waves 1 through 4 of the nationally representative Population Assessment of Tobacco and Health (PATH) study, conducted from September 12, 2013, to January 3, 2018. Two subpopulations of youth were assessed: (1) those nonsusceptible to cigarette use and (2) never users of cigarettes at their first wave of PATH participation. Weighted interval-censoring survival analyses were used to prospectively estimate the age of initiation of cigarette use outcomes. Weighted interval-censoring Cox proportional hazard models were used to estimate differences in the age of initiation by sex and by race/ethnicity. Statistical analyses were performed from October 7, 2019, to May 1, 2020.

EXPOSURES

Differences in the age of initiation by sex and race/ethnicity.

MAIN OUTCOMES AND MEASURES

Age of initiation of susceptibility to cigarette use, ever use, past 30-day use, and fairly regular cigarette use overall, by sex, and by race/ethnicity.

RESULTS

A total of 15 776 youth never users and, among them, 11 022 youth who were nonsusceptible to cigarette use, were included in this study (weighted mean [SE] age, 13.5 [0.01] years; 58.6% [SE, 0.46%] non-Hispanic White; and 51.0% [SE, 0.32%] boys) and 15 776 were never users of cigarettes at their first wave of PATH participation (weighted mean [SE] age, 13.7 [0.01] years; 55.0% [SE, 0.29%] non-Hispanic White; and 51.0% [SE, 0.15%] boys). By age 18 years, among those who were nonsusceptible, 46.2% (95% CI, 44.3%-48.2%) became susceptible to cigarette use. Among never users, 24.4% (95% CI, 22.9%-25.9%) initiated ever cigarette use, 16.4% (95% CI, 15.2%-17.6%) initiated past 30-day cigarette use, and 4.3% (95% CI, 3.9%-4.8%) initiated fairly regular cigarette use. Boys had a higher risk of initiating ever (hazard ratio [HR], 1.21; 95% CI, 1.08-1.36) and past 30-day cigarette use (HR, 1.27; 95% CI, 1.10-1.47) at earlier ages compared with girls. Non-Hispanic White youth had a higher risk of an earlier age of initiation of susceptibility to cigarette use (HR, 0.77; 95% CI, 0.68-0.88), ever use (HR, 0.59; 95% CI, 0.49-0.71), past 30-day use (HR, 0.64; 95% CI, 0.52-0.77), and fairly regular cigarette use (HR, 0.25; 95% CI, 0.14-0.43) compared with non-Hispanic Black youth.

CONCLUSIONS AND RELEVANCE

The results of this cohort study suggest that, despite current interventions and existing laws, a large number of youth initiated cigarette use before the legal age to purchase tobacco products.

Use of E-cigarettes and Other Tobacco Products and Progression to Daily Cigarette Smoking

OBJECTIVES

To identify predictors of becoming a daily cigarette smoker over the course of 4 years.

METHODS

We identified 12- to 24-year-olds at wave 1 of the US Population Assessment of Tobacco and Health Study and determined ever use, age at first use, and daily use through wave 4 for 12 tobacco products.

RESULTS

Sixty-two percent of 12- to 24-year-olds (95% confidence interval [CI]: 60.1% to 63.2%) tried tobacco, and 30.2% (95% CI: 28.7% to 31.6%) tried ≥5 tobacco products by wave 4. At wave 4, 12% were daily tobacco users, of whom 70% were daily cigarette smokers (95% CI: 67.4% to 73.0%); daily cigarette smoking was 20.8% in 25- to 28-year-olds (95% CI: 18.9% to 22.9%), whereas daily electronic cigarette (e-cigarette) vaping was 3.3% (95% CI: 2.4% to 4.4%). Compared with single product triers, the risk of progressing to daily cigarette smoking was 15 percentage points higher (adjusted risk difference [aRD] 15%; 95% CI: 12% to 18%) among those who tried ≥5 products. In particular, e-cigarette use increased the risk of later daily cigarette smoking by threefold (3% vs 10%; aRD 7%; 95% CI: 6% to 9%). Daily smoking was 6 percentage points lower (aRD -6%; 95% CI: -8% to -4%) for those who experimented after age 18 years.

CONCLUSIONS

Trying e-cigarettes and multiple other tobacco products before age 18 years is strongly associated with later daily cigarette smoking. The recent large increase in e-cigarette use will likely reverse the decline in cigarette smoking among US young adults.

Age of initiation of cigarillos, filtered cigars and/or traditional cigars among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2017

SIGNIFICANCE

Early age of initiation of tobacco use is associated with sustained tobacco use and lower rates of smoking cessation. Although much is known about age of initiation of cigarette use, much less is known about the age of initiation of cigar product use among youth.

METHODS

Survival analyses of the Population Assessment of Tobacco and Health youth annual datasets (ages 12-17) from 2013 to 2017 were conducted for any cigar product use, cigarillos or filtered cigars, and traditional cigars across four cigar use outcomes, age of initiation of: susceptibility to use, ever use, past 30-day use and "fairly regular" use. An interval censoring survival method was implemented to estimate the probability of each outcome for age of initiation of each cigar product overall. Differences in age of initiation by sex and race/ethnicity were assessed using weighted Cox proportional hazards models for interval-censored data.

RESULTS

For each outcome across the three cigar products, striking increases in the probability of initiation begin before 17 years old. For cigarillo or filtered cigars, males had a higher risk of onset of susceptibility to use, initiating ever use, and initiating past 30-day use at earlier ages than females. Compared to Non-Hispanic Whites, Hispanic and Non-Hispanic Other had lower risk of initiating ever use and past 30-day use at earlier ages. Non-Hispanic Black youth had higher risk of initiating past 30-day use and "fairly regular" use than Non-Hispanic White youth at earlier ages. Similar findings are reported for any cigar use and traditional cigar use.

CONCLUSION

Developmentally and culturally appropriate cigar use interventions and communication campaigns should be provided to youth before 17 years of age to prevent the onset and progression of cigar products. Regulatory policies that reduce appeal of all cigar products should be implemented to curb cigar initiation among youth.

PROSPECTIVELY ESTIMATING THE AGE OF INITIATION OF E-CIGARETTES AMONG U.S. YOUTH: FINDINGS FROM THE POPULATION ASSESSMENT OF TOBACCO AND HEALTH (PATH) STUDY, 2013-2017

CONTEXT

There is a lack of research that prospectively estimates the age of initiation of electronic cigarette use in U.S. youth. Younger ages of initiation of tobacco product use are associated with greater exposure to nicotine, and recently e-cigarette use has been associated with subsequent cigarette initiation. This study sought to estimate the distribution of the age of first reporting of e-cigarette use outcomes among youth never e-cigarette users overall, by sex and by race/ethnicity, prospectively.

METHODS

Secondary analysis of the Population Assessment of Tobacco and Health (PATH) youth dataset (ages 12-17) across waves 1 (2013-2014), 2 (2014-2015), 3 (2015-2016), and 4 (2016-2017) were conducted. Four outcomes are presented, age of first report of: (i) susceptibility to use, (ii) ever use, (iii) past 30-day use, and (iv) "fairly regular" e-cigarette use. Each outcome was prospectively estimated using participant age when they entered the study and the number of weeks between the last report of never use and the first report of each outcome across waves. Weighted survival analyses for interval censoring accounting for the complex survey design were implemented.

RESULTS

Among youth non-susceptible to e-cigarettes, 50.2% became susceptible to e-cigarette use by age 18. There were no statistically significant differences in the age of first report of susceptibility to e-cigarette use by sex or by race/ethnicity in this nationally representative sample of U.S. youth. Among never users, 41.7%, 23.5% and 10.3% initiated ever, past 30-day and "fairly regular" e-cigarette use by the age of 18, respectively. Less than 10% initiated ever e-cigarette use between the ages of 18 and 21. Boys had a higher risk of first reporting ever, past 30-day and "fairly regular" e-cigarette use at earlier ages than girls. Non-Hispanic Blacks and Other racial/ethnic groups were less likely than Non-Hispanic Whites to initiate ever e-cigarette use at earlier ages, and there was no difference between Non-Hispanic Whites and Hispanics. Hispanic, Non-Hispanic Black and Other racial/ethnic youth were less likely to first report past 30-day use and "fairly regular" e-cigarette use at earlier ages than Non-Hispanic White youth.

CONCLUSION

This paper provides information on specific ages of the first report of e-cigarette use behaviors by sex and by race/ethnicity that can be used to culturally tailor e-cigarette interventions on specific windows of opportunity before youth begin using e-cigarettes or escalating their use.

Longitudinal transitions of exclusive and polytobacco electronic nicotine delivery systems (ENDS) use among youth, young adults and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

Electronic nicotine delivery systems (ENDS; including e-cigarettes) are rapidly evolving in the US marketplace. This study reports cross-sectional prevalence and longitudinal pathways of ENDS use across 3 years, among US youth (12-17 years), young adults (18-24 years) and adults 25+ (25 years and older).

DESIGN

Data were from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth and adults. Respondents with data at all three waves (youth, n=11 046; young adults, n=6478; adults 25+, n=17 188) were included in longitudinal analyses.

RESULTS

Weighted cross-sectional ever use of ENDS increased at each wave. Across all three waves, young adults had the highest percentages of past 12-month, past 30-day (P30D) and daily P30D ENDS use compared with youth and adults 25+. Only about a quarter of users had persistent P30D ENDS use at each wave. Most ENDS users were polytobacco users. Exclusive Wave 1 ENDS users had a higher proportion of subsequent discontinued any tobacco use compared with polytobacco ENDS users who also used cigarettes.

CONCLUSIONS

ENDS use is most common among young adults compared with youth and adults 25+. However, continued use of ENDS over 2 years is not common for any age group. Health education efforts to reduce the appeal and availability of ENDS products might focus on reducing ENDS experimentation, and on reaching the smaller subgroups of daily ENDS users to better understand their reasons for use.

Correlates of tobacco product cessation among youth and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

To report on demographic and tobacco use correlates of cessation behaviours across tobacco products (cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco) among the US population.

DESIGN

Data were drawn from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (ages 12-17) and adults (ages 18+) . Past 30-day (P30D) tobacco users at Wave 1 (W1) or Wave 2 (W2) were included (n=1374 youth; n=14 389 adults). Generalised estimating equations were used to evaluate the association between demographic and tobacco use characteristics at baseline, with cessation behaviours at follow-up (discontinuing use, attempting to quit, quitting), over two 1-year periods (W1-W2, W2-Wave 3).

RESULTS

Among adult users of each type of tobacco product, frequency of use was negatively associated with discontinuing use. Among adult cigarette smokers, non-Hispanic white smokers, those with lower educational attainment and those with lower household income were less likely to discontinue cigarette use; ENDS use was positively associated with making quit attempts but was not associated with cigarette quitting among attempters; smokeless tobacco use was positively associated with quitting among attempters; tobacco dependence was negatively associated with quitting among attempters. Among youth cigarette smokers, tobacco dependence was negatively associated with making quit attempts.

DISCUSSION

Demographic correlates of tobacco cessation behaviours underscore tobacco use disparities in the USA. Use of ENDS and use of smokeless tobacco products are positively associated with some adult cigarette cessation behaviours.

Correlates of tobacco product initiation among youth and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

To report on demographic and tobacco product use correlates of tobacco product initiation (cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco) among the US population.

DESIGN

Data were from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (aged 12-17 years) and adults (aged 18+ years). Never users of at least one type of tobacco product at Wave 1 (W1, 2013/14) or Wave 2 (W2, 2014/15) were included (n=12 987 youth; n=25 116 adults). Generalised estimating equations were used to evaluate the association between demographic and tobacco product use characteristics at baseline, and tobacco product initiation at follow-up (ever, past 30 day (P30D), frequent (use on 20 or more of thepast 30 days)) over two 1-year periods (W1-W2 and W2-Wave 3).

RESULTS

Youth aged 15-17 years were more likely than youth aged 12-14 years and adults aged 18-24 years were more likely than older adults to initiate P30D tobacco use across products; non-heterosexuals were more likely than heterosexuals to initiate P30D cigarette and ENDS use. Older adults were more likely than young adults, and males were more likely than females, to be frequent users of ENDS on initiation. Ever use of another tobacco product predicted P30D initiation of each tobacco product.

DISCUSSION

Other tobacco product use and age predict P30D tobacco initiation across products whereas associations with other demographic characteristics vary by product. Continued contemporary evaluation of initiation rates within the changing tobacco product marketplace is important.