Dual and poly-nicotine and tobacco use among adolescents in the United States from 2011 to 2022

BACKGROUND

Adolescent nicotine and tobacco product use remains common despite declining smoking rates in the United States, likely due to the emergence of novel products. Concurrent use of multiple products may increase the risk of nicotine dependency and subsequent substance use.

AIM

To identify patterns and trends of dual and poly nicotine and tobacco use among adolescents in the US and explore associations of dual and poly nicotine and tobacco use with sociodemographic factors.

METHODS

12 years of annual National Youth Tobacco Survey data (2011-2022) from 242,637 respondents were used to examine prevalence trends of different combinations of nicotine or tobacco product use among adolescents in the US using weighted point estimates for each year. Poisson regression models examined sociodemographic factors associated with different patterns of dual and poly-product use from 2011 to 2022.

RESULTS

Overall, the prevalence of dual (i.e. at least two products) and poly (i.e. at least three products) use decreased between 2011 and 2021 (from 9.5 % to 2.8 % and from 5.1 % to 1.1 %, respectively), but showed signs of increase between 2021 and 2022 (3.7 % for dual and 1.7 % for poly use). The most common combinations included a combustible product with either a novel or noncombustible product. The risk for dual and poly-product use was higher among non-Hispanic Whites, males, and high school students.

CONCLUSIONS

Previously declining trends in the prevalence of tobacco/nicotine dual and poly use may have been reversed. Close monitoring and targeted tobacco control policies are essential to tackle multiple product use among adolescents.

Patterns of tobacco use and nicotine dependence among youth, United States, 2017-2018

This study examined patterns of tobacco product use and their association with nicotine dependence among U.S. youth. Combined data from the 2017-2018 National Youth Tobacco Surveys were analyzed for students that reported current (past-30-day) use of e-cigarettes, cigarettes, cigars, smokeless tobacco, or hookah (n = 6106). Analyses assessed multiple product use (≥2 tobacco products) overall and by sex, school level, race/ethnicity, current use, and frequent use (use of a product for ≥20 of the preceding 30 days). Multivariable logistic regression was used to identify correlates of nicotine dependence. During 2017-2018, 40.8% of tobacco product users reported use of multiple products. Multiple product use ranged from 47.0% among e-cigarette users to 80.7% among cigarette smokers. Among frequent users of each respective product, 80.0% of cigarette smokers, 74.9% of cigar smokers, 73.6% of smokeless tobacco users, 70.7% of hookah smokers, and 40.3% of e-cigarette users reported use of multiple products. Most youth who reported nicotine dependence (64.0%) were multiple product users. E-cigarettes were the most common single product used (36.3%) and the product most commonly used in combination with other products; e-cigarettes plus cigarettes (6.7%) was the most common product combination. Combustible product use, smokeless tobacco use, multiple product use and frequent use were associated with greater odds of nicotine dependence. Nicotine dependence among youth is especially influenced by cigarette use, smokeless tobacco use, frequent use of any tobacco product, and multiple product use. Proven tobacco control interventions in coordination with regulatory efforts can reduce youth tobacco product use.

Longitudinal associations between use and co-use of cigars and cigarettes: A pooled analysis of three adolescent cohorts

INTRODUCTION

Patterns of adolescent tobacco product use are evolving rapidly and need examination. We assessed whether ever use of cigars (i.e., lifetime use) was related to an increased risk of subsequent cigarette initiation and dual use of cigars and cigarettes.

METHODS

Leveraging data from three prospective cohort studies of adolescents (n = 6258), we assessed the odds of initiating cigarettes at one-year follow-up among ever cigar users at baseline, relative to never cigar users, after adjusting for demographics and e-cigarette use. We also assessed patterns of transition between exclusive use of cigars, exclusive use of cigarettes, and dual use of both cigars and cigarettes between baseline and follow-up and whether these associations differed by e-cigarette use.

RESULTS

Among never cigarette smokers (n = 4876; 79.3% of the total sample), 3.4% reported ever cigar use by baseline. Ever cigar use by baseline was associated with higher likelihood of initiating cigarettes by follow-up (31.3%) relative to never cigar use at baseline (8.4%; adjusted odds ratio = 2.26, 95% confidence interval: 1.52, 3.35). Effect estimates were stronger if e-cigarette was used by baseline. Furthermore, exclusive ever cigar use by baseline was associated with a 2-4-fold increase in the odds of transition to exclusive cigar, exclusive cigarette, and dual use at follow-up relative to non-users of either product by baseline.

CONCLUSIONS

Comprehensive tobacco regulations and early prevention efforts focused on reducing youth appeal of cigars may be warranted, as cigar use may place youth at risk for subsequent cigarette use as well as dual use of cigars and cigarettes.

Correlates of poly-tobacco use among youth and young adults: Findings from the Population Assessment of Tobacco and Health study, 2013-2014

INTRODUCTION

Poly-tobacco use is common among youth and young adults. This study examined sociodemographic, tobacco-related, and substance use characteristics of poly-tobacco use compared to mono-tobacco use among youth and young adults (12-34 years) in the United States.

METHODS

We conducted a descriptive analysis by age-group of 12898 youth (12-17 years), 8843 younger young adults (18-24 years), and 6081 older young adults (24-34 years) from the 2013-2014 Population Assessment of Tobacco and Health study. Multiple logistic regression modeling was conducted to assess the sociodemographic, tobacco-related, and substance use associations with current (past 30 days) tobacco use on a binary scale (poly- versus mono-tobacco use) among tobacco users.

RESULTS

Between 2013 and 2014, 3.6% of youth, 21.7% of younger young adults, and 15.8% of older young adults were current poly-tobacco users in the general population. In the regression analyses, among youth tobacco users, heavy drinking was the only factor associated with higher odds of poly-tobacco use. Factors associated with higher odds of poly-tobacco use among younger young adults included being male, having less than high school diploma or GED, residing in the South, having 2 and ≥3 quit attempts, heavy drinking, and marijuana use. Residing in the South, older ages of exposure to tobacco use, and marijuana use were associated with higher odds of poly-tobacco use among older young adults.

CONCLUSIONS

Regardless of tobacco product type, poly-tobacco use was common among youth and young adults. Interventions designed to address factors associated with poly-tobacco use among youth and young adults are warranted.

Exclusive e-cigarette use predicts cigarette initiation among college students

INTRODUCTION

An increasing body of research indicates that use of electronic nicotine delivery systems (ENDS) predicts cigarette initiation. However, no studies examine if risk for cigarette initiation varies for exclusive ENDS users versus users of ENDS and other tobacco products. This study examined if: a) cigarette-naïve young adults (i.e., never cigarette users) who ever used ENDS had a greater odds of initiating cigarettes than non-ENDS users over a 1.5year period and b) the odds of cigarette initiation was consistent across exclusive ENDS users and users of ENDS and at least one tobacco product.

METHODS

Participants were 2558 cigarette-naïve 18-25year old (M=19.71; SD=1.61) students from 24 Texas colleges who participated in a four-wave study, with six months between each wave.

RESULTS

Overall, 11% of students reported cigarette initiation by wave 4. Of those, 20.1% were wave 1 ENDS users and 8.4% were non-ENDS users. Multivariable, multilevel discrete-time hazard models indicated that wave 1 ENDS use predicted subsequent cigarette initiation, over and above the significant effects of cigarette use susceptibility, family-of-origin tobacco use, friend cigarette use, and other tobacco use. Additional findings indicated that exclusive ENDS users had a greater odds than non-users of subsequent cigarette initiation. Among users of alternative tobacco products, ENDS users did not have a greater odds of initiation than non-ENDS users.

CONCLUSION

Findings extend existing research by showing that ENDS use by young adults is a specific risk factor for later cigarette initiation and not an extension of a constellation of existing tobacco use behaviors.

Hookah tobacco smoking in a large urban sample of adult cigarette smokers: Links with alcohol and poly-tobacco use

Hookah tobacco smoking (HTS) has been increasing, particularly among young adults and has similar health effects compared to cigarette smoking. The link between HTS and poly-tobacco use is well documented, but fewer show an association between HTS and alcohol use. It is essential to identify factors that increase the risk for or addictiveness and consequences of HTS, given its growing prevalence. This study examined whether the association between HTS and poly-tobacco use differed as a function of age and alcohol consumption within in a sample of 1223 adult cigarette smokers. Approximately 20% of participants reported HTS. Compared to non-users, hookah users were more likely to be male, highly educated, and to report drug and alcohol use, binge drinking, and poly-tobacco use but were less likely to be heavy smokers (≥10 cigarettes per day). Regression analyses predicting number of tobacco products used (excluding cigarettes and HTS) indicated a three-way interaction of HTS, frequency of alcohol use, and age such that the association between HTS and number of tobacco products used was strongest for younger respondents who consumed alcohol more frequently. As observed in previous studies, alcohol is an important risk factor in the relationship between HTS and poly-tobacco use, particularly among younger cigarette smokers. The links between alcohol, HTS, and poly-tobacco use should be considered when developing HTS education and prevention materials directed toward younger cigarette smokers. Findings provide information relevant to FDA's interest in the addiction potential of HTS and its link to poly-tobacco use.

Non-cigarette tobacco and poly-tobacco use among persons living with HIV drawn from a nationally representative sample

INTRODUCTION

Smoking is more prevalent among persons living with HIV (PLWH) than the general population. Little is known about the prevalence of non-cigarette tobacco and poly-tobacco use (PTU; using multiple tobacco products) among this population, which, in the general population is associated with poor health and cessation outcomes. We aimed to characterize the prevalence of cigarette and non-cigarette tobacco use, PTU, and correlates of tobacco use status among a nationally-representative sample of PLWH.

METHODS

Data came from 472 HIV-positive adults from the 2005-2013 National Survey on Drug Use and Health (NSDUH).

RESULTS

The prevalence of PTU overall was 8.7% (95% CI=5.6-13.2), and 16.6% (95% CI=10.2-25.7) among past-year tobacco users. In multinomial logistic regression analyses, participants with a high school education or greater (aRRR=2.03, 95% CI=1.03-4.00) were more likely to be non-tobacco users than single product users. Past year drug users (aRRR=0.35, 95% CI=0.19-0.66) and past month binge drinkers (aRRR=0.24, 95% CI=0.12-0.50) were less likely to be non-tobacco users than single product users. Compared to 18-25 year olds, individuals age 26-34 (aRRR=0.13, 95% CI=0.03-0.65) and 35+ (aRRR=0.24, 95% CI=0.09-0.63), and with lifetime anxiety disorder(s) (aRRR=0.18, 95% CI=0.06-0.57) were less likely to be PTUs as compared to single product users. Individuals who reported liking to test themselves by doing risky things were more likely to be PTUs than single product users (aRRR=2.95, 95% CI=1.27-6.84).

CONCLUSIONS

PTU was slightly higher than in the general population, and should be taken into account when developing cessation interventions tailored to tobacco users living with HIV.

Cigarette smoking cessation attempts among current US smokers who also use smokeless tobacco

INTRODUCTION

Concurrent use of cigarettes and smokeless tobacco is common, but little is known regarding the association of smokeless tobacco use with cigarette smoking cessation. Dual users may have lower cigarette consumption levels, which may also play a role in smoking cessation.

METHODS

The 2010-2011 Tobacco Use Supplement to the Current Population Survey included 26,760 current cigarette smokers, of which 675 concurrently used smokeless tobacco. We compared characteristics of the most recent cigarette smoking quit attempt of the past year between dual users and exclusive smokers, using multivariate regression.

RESULTS

Dual users (45%) were more likely than exclusive smokers (37%) to have made a cigarette smoking quit attempt during the previous year (p<0.01), even after adjusting for demographic differences and cigarette dependence levels (ORadj 1.33, 95% CI 1.15-1.53). Half (48%) of dual users who made a quit attempt tried to quit "by switching to smokeless tobacco". However, once in a quit attempt, dual users relapsed more quickly than exclusive smokers (Cox regression HRadj 1.13, 95% CI 1.02-1.26). There was no difference in 30-day abstinence rates on the most recent quit attempt (ORadj 1.09, 95% CI 0.88-1.37). For both groups, the best predictor of past 30-day abstinence was cigarette consumption level.

CONCLUSIONS

Current cigarette smokers who also use smokeless tobacco are more likely to have tried to quit, but relapse more quickly than exclusive smokers, and are not more likely to have attained 30day smoking cessation. Prospective studies at the population level are needed.

Measurement of multiple nicotine dependence domains among cigarette, non-cigarette and poly-tobacco users: Insights from item response theory

BACKGROUND

Nicotine dependence (ND) is a key construct that organizes physiological and behavioral symptoms associated with persistent nicotine intake. Measurement of ND has focused primarily on cigarette smokers. Thus, validation of brief instruments that apply to a broad spectrum of tobacco product users is needed.

METHODS

We examined multiple domains of ND in a longitudinal national study of the United States population, the United States National Epidemiological Survey of Alcohol and Related Conditions (NESARC). We used methods based in item response theory to identify and validate increasingly brief measures of ND that included symptoms to assess ND similarly among cigarette, cigar, smokeless, and poly tobacco users.

RESULTS

Confirmatory factor analytic models supported a single, primary dimension underlying symptoms of ND across tobacco use groups. Differential Item Functioning (DIF) analysis generated little support for systematic differences in response to symptoms of ND across tobacco use groups. We established significant concurrent and predictive validity of brief 3- and 5-symptom indices for measuring ND.

CONCLUSIONS

Measuring ND across tobacco use groups with a common set of symptoms facilitates evaluation of tobacco use in an evolving marketplace of tobacco and nicotine products.