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

December 2020
Preventive Medicine 141(7):106284

December 2020
141(7):106284

DOI:10.1016/j.ypmed.2020.106284

Authors:

Yessica Gomez

U.S. Department of Health and Human Services

MeLisa Creamer

National Institute on Drug Abuse

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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.

Proportion of single and multiple tobacco product use combinations † among current youth tobacco users, National Youth Tobacco Survey, 2017-2018. *Smokeless tobacco includes chewing tobacco/snuff/dip. †

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Preventive Medicine 141 (2020) 106284

Available online 14 October 2020

0091-7435/Published by Elsevier Inc.

Patterns of tobacco use and nicotine dependence among youth, United

States, 2017–2018

Yessica Gomez

, MeLisa Creamer

, Katrina F. Trivers

, Gabriella Anic

, Aura Lee Morse

Chad Reissig

, Israel Agaku

Ofce on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA

Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA

ARTICLE INFO

Keywords:

Youth

Tobacco

Nicotine

Dependence

Poly-tobacco use

Multiple product use

ABSTRACT

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 inuenced

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.

1. Introduction

Nicotine is the key compound in tobacco products that causes

dependence (USDHHS, 2012; USDHHS, 2014). Nicotine dependence

during adolescence is a predictor of sustained tobacco product use in

adulthood (USDHHS, 2014). About 9 in 10 daily adult cigarette smokers

report having tried their rst cigarette before age 18 years (USDHHS,

2014). Youth are especially vulnerable to the addictive and harmful

effects of nicotine (USDHHS, 2012). Nicotine exposure during adoles-

cence can harm the developing brain, impacting learning, memory and

attention, and increases the risk of tobacco-related diseases in adulthood

(USDHHS, 2012; USDHHS, 2018). Consequently, surveillance of tobacco

product use patterns and their association with nicotine dependence are

important to inform interventions to prevent and reduce tobacco prod-

uct use among youth.

While considerable progress has been made in reducing youth ciga-

rette smoking in the U.S. over the past two decades, the tobacco product

landscape has diversied, and youth tobacco product use patterns are

becoming increasingly complex. For example, while combustible to-

bacco product use has declined, the use of electronic cigarettes (e-cig-

arettes) among youth has signicantly increased (Gentzke et al., 2019;

Cullen et al., 2018). During 2017–2018, current use of any tobacco

product increased from 19.6% to 27.1% among U.S. high school stu-

dents (Gentzke et al., 2019). This increase was predominately driven by

a 78% increase in e-cigarette use; youth use of other tobacco products

remained unchanged (Gentzke et al., 2019). During the same period,

multiple tobacco product use (≥2 products) among high school students

increased from 9.2% to 11.3% (Gentzke et al., 2019). In 2019, 31.2%

and 10.8% of high school students reported current use of any tobacco

product and multiple product use, respectively (Wang et al., 2019).

* Corresponding author at: Ofce on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and

Prevention, 4770 Buford Highway, MS S107-7, Atlanta, Georgia 30341, United States.

E-mail address: ygomez@cdc.gov (Y. Gomez).

Contents lists available at ScienceDirect

Preventive Medicine

journal homepage: www.elsevier.com/locate/ypmed

https://doi.org/10.1016/j.ypmed.2020.106284

Received 14 February 2020; Received in revised form 26 August 2020; Accepted 10 October 2020

Preventive Medicine 141 (2020) 106284

A 2014–2015 study found that among youth, cigarettes were the

most commonly used tobacco product among single product users,

cigarettes plus e-cigarettes were the most common combination among

multiple product users, and cigarettes were the most commonly used

product in combination with other products; to our knowledge, this is

the most recent study that conducted an in-depth assessment of multiple

product use, including combinations of products used among youth

(Kasza et al., 2017). Recent work by Gentzke et al. (2019) reported on

the most common combinations of products used by youth and found

that e-cigarettes plus cigars and e-cigarettes plus cigarettes were the

most common product combinations used (Gentzke et al., 2019).

Research on patterns of tobacco use has shown that the type, number,

and frequency of tobacco products used can have an effect on nicotine

dependence in youth (USDHHS, 2012; Apelberg et al., 2014; Liu et al.,

2017; Azagba et al., 2019). For example, using more than one tobacco

product can increase exposure to nicotine which increases the likelihood

of nicotine dependence (USDHHS, 2012). Recent studies on youth to-

bacco use and nicotine dependence have focused on e-cigarette use and

dual use of e-cigarettes and cigarettes (Liu et al., 2017; Azagba et al.,

2019; Vogel et al., 2018; Vogel et al., 2019a; Veliz et al., 2019; Vogel

et al., 2019b). These studies found that most e-cigarette users were

exclusive users and experienced less dependence compared to cigarette

users (Liu et al., 2017; Azagba et al., 2019; Veliz et al., 2019).

Monitoring patterns of tobacco product use and their inuence on

nicotine dependence is important because nicotine levels, ingredients,

and toxins vary across products (USDHHS, 2012; USDHHS, 2016). For

example, cigarettes are designed to deliver nicotine to the brain within

seconds, making it easier to become dependent on nicotine (USDHHS

(USDHHS), 2004). Additionally, in recent years, a variety of new and

different forms of tobacco products have emerged, some of which have

high nicotine content. Certain e-cigarettes, like JUUL, use nicotine salts,

which allow higher levels of nicotine to be used more easily and with

less irritation than previous generations of e-cigarettes and conventional

tobacco products that have used free-base forms of nicotine (JUUL,

2019; Jackler and Ramamurthi, 2019). Self-reported data suggest JUUL

is a commonly reported brand among U.S. youth (Cullen et al., 2019).

In this study, we provide an in-depth assessment of patterns of to-

bacco product use, including types of products used, number of products

used, combinations of products used, and frequency of use, in a national

probability sample of youth. We further examine whether different to-

bacco use patterns are associated with nicotine dependence.

2. Methods

2.1. Data source

This study used data from the National Youth Tobacco Survey

(NYTS), an annual, school-based, cross-sectional survey. The NYTS

employs a three-stage cluster sampling procedure to generate a na-

tionally representative sample of U.S. public and private school students

in grades 6–12 in 50 states and the District of Columbia. We combined

data from the 2017 and 2018 surveys to obtain stable estimates. The

sample sizes and response rates were 17,872 (68.1%) in 2017 and

20,189 (68.2%) in 2018; the total analytic sample was 38,061. The study

was exempt from IRB review because it was a secondary analysis of de-

identied data.

2.2. Measures

We analyzed data for respondents who reported current use of cig-

arettes, e-cigarettes, cigars (cigars, little cigars, and cigarillos), smoke-

less tobacco (chewing tobacco/snuff/dip), or hookah (hookah or

waterpipe). Current tobacco product use was assessed using the

following question: “During the past 30 days, on how many days did you

smoke/use [tobacco product]?” Current use of each product was dened

as use on one or more days during the past 30 days. Combustible product

use was a composite variable dened as current use of one or more of the

following products: cigarettes, cigars, and hookah. Frequent versus less

frequent use was examined; frequent use was dened as use of a product

on 20–30 days, and less frequent use was dened as use of a product on

1–19 days of the past 30 days; this is a standard threshold that is used for

the NYTS (Wang et al., 2019; Anic et al., 2018). We excluded use of pipe

tobacco, bidis, snus, and dissolvable products from this study because

respondents were not asked about frequency of use for these products in

the 2017 and 2018 surveys. Multiple product use was dened as current

use of two or more tobacco products.

To describe patterns of multiple product use, the following three

mutually exclusive categories were examined: current use of only one

tobacco product, current use of only two tobacco products; and current

use of three or more tobacco products. The following product combi-

nations were examined: exclusive use of e-cigarettes, cigars, cigarettes,

smokeless tobacco, or hookah, and combinations of two products, three

products, four products, and ve products. Combinations with estimates

of less than 1% were pooled into an “other” category. Additionally, for

combinations of more than three products, we did not examine indi-

vidual combinations due to the small sample size.

We created one measure of nicotine dependence. Participants were

considered to have reported nicotine dependence if they answered

either “yes” to the question “During the past 30 days, have you had a

strong craving or felt like you really needed to use a tobacco product of

any kind (such as smoking a cigarette or cigar, or using chewing to-

bacco?)” or answering “within 5 minutes” or “from 6 to 30 minutes” to

the question “How soon after you wake up do you want to use a tobacco

product?” Both of these measures have been shown to be reliable and

valid constructs of dependence in youth (O’Loughlin et al., 2002; Non-

nemaker et al., 2004). Assessment of the measures separately did not

demonstrate signicant differences that would warrant keeping them

separate.

Demographic correlates included sex (male, female), school type

(middle school [grades 6–8], high school [grades 9–12]), and race/

ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and non-

Hispanic other [non-Hispanic American Indian, non-Hispanic Asian,

and non-Hispanic Native Hawaiian or other Pacic Islander]).

2.3. Analysis

All analyses were conducted in SAS 9.4 (Cary, NC) and SAS-callable

SUDAAN, and accounted for the complex survey design (e.g., clustering,

weighting, stratication). Analyses were limited to those reporting

current use of at least one product (n =6106). Descriptive analyses were

conducted for demographic and tobacco use characteristics by the

number of products used. Weighted prevalence and 95% condence

intervals were estimated for the outcomes “one product only,” “two

tobacco products,” “three or more tobacco products,” and “multiple

tobacco product use” by sex, school type, race/ethnicity, tobacco

product currently used, frequent use, and nicotine dependence. Results

where the relative standard error was higher than 30% or an unweighted

denominator less than 50 were considered to be statistically unstable

and were not reported.

To examine the association between nicotine dependence and to-

bacco use patterns, 18 adjusted logistic regression models were con-

ducted for the following independent variables: current use of each

product, exclusive use of each product, frequent use of each product (use

of a product on 20–30 days), multiple product use (≥2 tobacco prod-

ucts), and combustible use. The outcome variable of interest was nico-

tine dependence (dependent versus not dependent). All models

controlled for grade, sex, race/ethnicity, and survey year; models

assessing the association between frequency of use and dependence also

controlled for use of other tobacco products that were not part of the

independent variable of interest (e.g., the model for frequent versus less

frequent cigarette use controlled for use of cigars, smokeless tobacco,

hookah, and e-cigarettes). Estimates were statistically signicant if the

Y. Gomez et al.

Preventive Medicine 141 (2020) 106284

p-value was <0.05.

3. Results

3.1. Descriptive statistics

During 2017–2018, 59.2% of youth current tobacco users reported

use of a single product, 22.4% reported use of two products, and 18.4%

reported use of three or more tobacco products; 40.8% reported use of

two or more products (Table 1). Most females (64.0%) and males

(55.8%) reported single product use. Single product use, followed by use

of two products were the most common patterns reported among non-

Hispanic whites (58.6%; 23.4%), non-Hispanic Blacks (70.3%; 17.8%),

and Hispanics (55.5%; 22.5%), respectively. Among those of non-

Hispanic other race/ethnicity, single product use was the most com-

mon pattern reported (67.0%), followed by use of three or more prod-

ucts (17.7%).

Use of three or more products was the most common tobacco use

pattern reported among current cigarette smokers (46.6%), cigar

smokers (47.7%), smokeless tobacco users (50.1%), and hookah

smokers (52.0%); single product use was the most common tobacco use

pattern among e-cigarette users (53.0%). Over one-third of combustible

tobacco product users reported use of two products (34.9%), followed by

use of three or more products (32.7%). Most frequent users of cigarettes

(43.2%), cigars (44.7%), smokeless tobacco (46.9%), and hookah

(46.5%) reported using three or more products. Most frequent users of e-

cigarettes (59.7%) reported using one product. Use of three or more

products was the common tobacco product use pattern among current

tobacco users that reported nicotine dependence (37.2%), while single

product use was the most common tobacco use pattern among those who

did not report nicotine dependence (70.6%).

3.2. Tobacco product use combinations

Among current tobacco product users, exclusive use of e-cigarettes

(36.3%) and cigars (7.5%) were the two most commonly reported single

products used by youth (Fig. 1). Cigarettes plus e-cigarettes (6.7%),

followed by e-cigarettes plus cigars (4.5%) were the most common two

product combinations reported. The most common three product com-

binations reported were e-cigarettes plus cigarettes plus cigars (4.6%)

and e-cigarettes plus cigarettes plus smokeless tobacco (1.7%). About

7% of current tobacco users reported use of a combination of four or

more products: 4.6% four products and 2.5% ve products.

3.3. Tobacco product use patterns associated with nicotine dependence

Among current tobacco product users, 55.5% (95% CI: 52.8%,

58.2%) of cigarette smokers, 43.1% (95% CI: 39.2%, 47.1%) of cigar

smokers, 58.0% (95% CI: 55.2%, 60.7%) of smokeless tobacco users,

51.0% (95% CI: 44.0, 58.0) of hookah smokers, and 32.3% (95% CI:

29.4%, 35.4%) of e-cigarette users reported nicotine dependence (data

not shown).

The odds of reporting nicotine dependence were increased among

those who reported current use of cigarettes (adjusted odds ratio [aOR]:

7.52; 95% CI: 6.31, 8.97), cigars (aOR: 2.06; 95% CI: 1.73, 2.44),

smokeless tobacco (aOR: 4.17; 95% CI: 3.29, 5.28), and hookah (aOR:

2.86; 95% CI: 2.38, 3.44) as compared to current use of any other to-

bacco product than the respective tobacco product of interest in the

adjusted models for each individual product (Table 2). For example,

current cigarette smoking had increased odds of nicotine dependence as

compared to current use of cigars, smokeless tobacco, hookah, and/or e-

cigarettes. The odds of reporting nicotine dependence were increased

among exclusive cigarette smokers (aOR: 3.72; 95% CI: 2.66, 5.19) and

exclusive smokeless tobacco users (aOR: 2.68 (95% CI: 1.84, 3.90) and

were decreased among exclusive cigar smokers (aOR: 0.57; 95% CI:

0.41, 0.80) and exclusive e-cigarette users (aOR: 0.45, 95% CI: 0.34,

Table 1

Proportion of single and multiple tobacco product use by demographic charac-

teristics and product use characteristics among current youth tobacco users,

National Youth Tobacco Survey, United States, 2017–2018

Sample

size (n)

One

product

only

Two

products

only

Three or

products

Multiple

product use

(≥2

products)

% (95%

CI)

% (95%

CI)

% (95%

CI)

% (95% CI)

Overall 6,106 59.2

(56.2,

62.2)

22.4

(20.8,

24.1)

18.4

(16.5,

20.2)

40.8 (37.8,

43.8)

Sex

Male 3,321 55.8

(52.3,

59.3)

22.6

(20.5,

24.7)

21.6

(19.3,

23.9)

44.2 (40.7-

47.7)

Female 2,704 64.0

(60.4,

67.5)

22.2

(19.6,

24.8)

13.9

(11.7,

16.0)

36.0 (32.5-

39.6)

School type

Middle

(grades 6-8)

1,134 65.4

(62.1,

68.8)

16.8

(14.2,

19.4)

17.8

(14.8,

20.7)

34.6 (31.2,

37.9)

High (grades

9-12)

4,907 58.2

(54.7,

61.8)

23.5

(21.6,

25.5)

18.3

(16.1,

20.5)

41.8 (38.2,

45.3)

Race/ethnicity

Non-Hispanic

White

3,429 58.6

(55.2,

62.0)

23.4

(21.6,

25.3)

17.9

(15.6,

20.3)

41.4 (38.0,

44.8)

Non-Hispanic

Black

626 70.3

(65.2,

75.4)

17.8

(13.8,

21.8)

12.0 (9.3,

14.6)

29.7 (24.6,

34.8)

Hispanic 1,556 55.5

(50.8,

60.2)

22.5

(19.6,

25.4)

22.0

(18.5,

25.5)

44.5 (39.8,

49.2)

Non-Hispanic

other race

254 67.0

(58.0,

76.0)

17.7

(11.6,

23.8)

33.0 (24.0-

42.0)

Current product used

Cigarette 2,072 19.3

(15.6,

23.0)

34.1

(31.6,

36.6)

46.6

(42.7,

50.5)

80.7 (77.0,

84.4)

Cigar 2,038 23.9

(19.6,

28.2)

28.5

(26.2,

30.7)

47.7

(43.6,

51.8)

76.1 (71.8,

80.4)

Smokeless

tobacco

1,133 24.3

(20.4,

28.2)

25.5

(22.7,

28.4)

50.1

(46.2,

54.1)

75.7 (71.8,

79.6)

Hookah 1,072 26.0

(19.6,

32.5)

22.0

(18.8,

25.2)

52.0

(45.0,

58.9)

74.0 (67.5,

80.4)

E-cigarette 4,063 53.0

(48.8,

57.2)

23.4

(21.1,

25.8)

23.6

(20.7,

26.5)

47.0 (42.8,

51.2)

Combustible

3,566 32.5

(28.5,

36.4)

34.9

(32.6,

37.1)

32.7

(29.8,

35.5)

67.5 (63.6,

71.5)

Frequent product use

Cigarette 1,593 20.0

(16.7,

23.4)

36.8

(33.7,

39.9)

43.2

(39.2,

47.2)

80.0 (76.6,

83.3)

Cigar 1,686 25.1

(20.2,

30.1)

30.2

(27.5,

32.9)

44.7

(39.6,

49.7)

74.9 (69.9,

79.8)

Smokeless

tobacco

724 26.3

(21.7,

30.9)

26.7

(22.8,

30.7)

46.9

(42.3,

51.6)

73.7 (69.1,

78.3)

Hookah 862 29.3

(21.8,

36.8)

24.2

(20.1,

28.3)

46.5

(38.9,

54.2)

70.7 (63.2,

78.2)

E-cigarette 3,081 40.3 (35.8,

44.9)

(continued on next page)

Y. Gomez et al.

Preventive Medicine 141 (2020) 106284

0.59) as compared to exclusive users of any other product than the

product of interest.

The odds of reporting nicotine dependence were increased among

frequent users of cigarettes (aOR 15.16; 95% CI: 8.42, 27.31), cigars

(aOR: 2.28; 95% CI: 1.40, 3.71), smokeless tobacco (aOR: 5.98; 95% CI:

3.15, 11.33), hookah (aOR: 2.46 95% CI: 1.11, 5.44), and e-cigarettes

(aOR: 6.24; 95% CI: 4.54, 8.57) as compared to less frequent users of

these products. Additionally, use of two products (aOR: 2.69; 95% CI:

2.25, 3.21) and use of three or more products (aOR: 7.91; 95% CI: 6.52,

9.58) were both associated with higher odds of reporting nicotine

dependence as compared to single product use. Finally, use of

combustible tobacco products (aOR: 3.45; 95% CI: 2.86, 4.17) was

associated with increased odds of reporting nicotine dependence as

compared to use of other tobacco products (e.g., smokeless tobacco and/

or e-cigarettes).

4. Discussion

This study estimates that during 2017–2018, the majority of youth

tobacco product users were single product users (59.2%), and close to

half were multiple product users (40.8%). Multiple product use was high

regardless of the type of tobacco product used; however, multiple

product use was more common (67.5%) among those who reported

current and frequent use of a combustible product as compared to users

of other types of products. Moreover, most youth who reported nicotine

dependence were multiple product users (64.0%). Multiple product use

raises concerns that youth are exposing themselves to higher levels of

nicotine and carcinogens from different tobacco products, and thus

increasing their risk of nicotine dependence and adverse health effects

(USDHHS, 2012; USDHHS, 2014).

While past studies have reported e-cigarettes and cigarettes to be the

most common products used among youth tobacco product users

(Gentzke et al., 2019; Kasza et al., 2017), e-cigarettes and cigars were

the most commonly used products among single tobacco product users

in our study; similar ndings were reported by Wang et al. (2019). This

may be attributed to the shifts in youth tobacco product use that has

occurred in recent years, including the signicant increase in e-cigarette

use, the decline in cigarettes, and the use of cigars, including avored

cigars (Gentzke et al., 2019; King et al., 2014). Use of other substances

(e.g., marijuana) in these products may also be contributing to their

reported use (Audrain-McGovern et al., 2019; Trivers et al., 2018).

Among multiple product users, e-cigarettes were also the product

most commonly used in combination with other products - predomi-

nately combustible tobacco products. These ndings differ from prior

studies which have found that cigarettes were the most common product

used in combination with other tobacco products (Kasza et al., 2017; Lee

et al., 2015). Specically, our results found that e-cigarettes plus ciga-

rettes, e-cigarettes plus cigars, and e-cigarettes plus cigarettes plus cigars

are the most common tobacco product combinations. These ndings

suggest that e-cigarettes have replaced cigarettes as the most commonly

used product in combination with other products, and underscore that

Table 1 (continued )

Sample

size (n)

One

product

only

Two

products

only

Three or

products

Multiple

product use

(≥2

products)

% (95%

CI)

% (95%

CI)

% (95%

CI)

% (95% CI)

59.7

(55.1,

64.2)

22.3

(20.3,

24.2)

18.0

(14.6,

21.5)

Nicotine dependence

Yes 1,920 36.0

(31.9,

40.2)

26.8

(23.5,

30.1)

37.2

(34.0,

40.3)

64.0 (59.8,

68.1)

No 4,014 70.6

(67.9,

73.2)

20.0

(18.6,

21.5)

9.4 (7.9,

11.0)

29.1 (26.8,

32.1)

n =unweighted number of current tobacco users.

Indicates that the estimate is unstable (relative standard error >0.3 or un-

weighted denominator <50).

Smokeless tobacco includes chewing tobacco/snuff/dip.

Combustible tobacco includes cigarettes, hookah, and cigars.

Frequent use of each product is dened as use on 20 or more days of the

preceding 30 days.

36.3

7.5

6.4

6.7

Fig. 1. Proportion of single and multiple tobacco product use combinations

†

among current youth tobacco users, National Youth Tobacco Survey, 2017–2018.

*Smokeless tobacco includes chewing tobacco/snuff/dip.

†

Product combinations with estimates less than 1% were pooled in an “other” product combination category.

Y. Gomez et al.

Preventive Medicine 141 (2020) 106284

many youth who use tobacco products use e-cigarettes in addition to

other tobacco products. This is likely due to the marked increase in e-

cigarette use among youth in recent years, including concurrent use with

other products (Gentzke et al., 2019; Cullen et al., 2018; King et al.,

2018). While research shows that many youth e-cigarette users remain

exclusive users, studies have also shown that many users transition to

using other tobacco products, including cigarettes, and among those

who initiate with e-cigarettes, persistent and frequent use over time is

common (Vogel et al., 2019a; Dunbar et al., 2018; Berry et al., 2019;

Huh and Leventhal, 2016).

Current use of combustible tobacco products, including cigarettes,

cigars, and hookah, and smokeless tobacco was associated with higher

levels of nicotine dependence. This may be due, in part, to the nicotine

levels in these products and, as reported in this study, multiple product

use among frequent users of these products (USDHHS, 2012; Apelberg

et al., 2014; Anic et al., 2018). However, among exclusive users, only

exclusive cigarette smoking and smokeless tobacco use were associated

with increased odds of nicotine dependence, while exclusive cigar and e-

cigarette use were associated with decreased odds of dependence as

compared to exclusive users of other tobacco products. These ndings

are consistent with existing research that shows that the use of certain

tobacco products may increase risk of nicotine dependence (Apelberg

et al., 2014; Liu et al., 2017; Vogel et al., 2018; Veliz et al., 2019; Morean

and Krishnan-Sarin, 2018). This may be attributed, in part, to the vari-

ation in nicotine content and the efciency of nicotine delivery to the

user within and between different types of tobacco products (USDHHS

(USDHHS), 2004; Lawler et al., 2017), as well as differences in behaviors

related to use, such as multiple product use and frequency of use

(Apelberg et al., 2014; Azagba et al., 2019). For example, frequent use is

higher among smokeless tobacco and cigarette users than cigar and e-

cigarette users (Anic et al., 2018). Furthermore, for all tobacco products

assessed, a signicant proportion of youth reported nicotine dependence

and any level of nicotine dependence among youth is concerning. No

form of tobacco use among youth is safe, irrespective of whether it’s

combustible, non-combustible, or electronic (USDHHS, 2012; USDHHS,

2016).

Frequent tobacco product use and multiple product use were asso-

ciated with increased odds of nicotine dependence as compared to less

frequent users and single product users, respectively. Across all tobacco

products, frequent use increased the odds of nicotine dependence and

this effect was most pronounced among cigarette smokers. Notably,

while exclusive cigar and e-cigarette users experienced lower odds of

nicotine dependence, when frequency of use was considered, there was

an association between frequent use of each product and nicotine

dependence. These ndings reinforce the importance of examining be-

haviors related to use, as they can affect and/or exacerbate the risk of

nicotine dependence. Moreover, given the sustained use of cigars and

the increase in e-cigarette use among youth, including the frequency of

use (Gentzke et al., 2019; Vogel et al., 2019a), it will be important to

continue to monitor use behaviors and their relationship with nicotine

dependence.

As expected based on prior studies, differences in demographic fac-

tors among single and multiple product users were observed (Gentzke

et al., 2019; Kasza et al., 2017; Apelberg et al., 2014). Males and high

school students reported higher multiple product use as compared to

females and middle school students, respectively. Non-Hispanic Blacks

reported higher single product use, while Hispanics reported higher

multiple product use. Of note, our ndings document similar estimates

by sex, school type, and among some racial/ethnic groups for some

patterns of multiple product use. Further research can demonstrate

whether any shifts may be occurring in multiple product use by de-

mographic factors.

Evidence suggests that several factors may contribute to tobacco

product use among youth, including misperceptions of harm, social in-

uences, tobacco industry marketing tactics and availability of avored

tobacco products (USDHHS, 2012; USDHHS, 2016; Lee et al., 2015; Tsai

et al., 2018). Research has shown that heavy marketing exposure and

tobacco product use among social contacts are associated with increased

risk of frequent tobacco use and multiple product use (USDHHS, 2012;

USDHHS, 2016; Lee et al., 2015; Tsai et al., 2018; Ali et al., 2016; Stanton

and Halenar, 2018). Our study ndings highlight the importance of sus-

tained, coordinated, and comprehensive efforts to prevent and reduce all

forms of tobacco product use among youth. Evidence-based tobacco

control strategies, including increasing the price of tobacco, restricting

the sale of avored tobacco products, implementing advertising and

promotion restrictions, and tobacco counter marketing media campaigns,

coupled with regulatory efforts from the U.S. Food and Drug Adminis-

tration (FDA) can reduce and prevent tobacco product use among youth

(USDHHS, 2012; USDHHS, 2014; USDHHS, 2018; USDHHS, 2016; Cen-

ters for Disease Control and Prevention, 2014). On December 20, 2019,

the federal minimum age of sale of tobacco products in the U.S. was

changed from 18 to 21 years (U.S. Food and Drug Administration, 2020).

Additionally, on January 2, 2020, the FDA announced an enforcement

policy effective February 7, 2020 on any avored cartridge-based e-

cigarette product other than tobacco- or menthol-avored cartridge-

based products in an effort to curb youth tobacco use (U.S. Food and Drug

Administration, n.d.). These efforts can help reduce tobacco product use

among youth by reducing access to tobacco products, including avored

tobacco products (USDHHS, 2012; USDHHS, 2016).

This study is subject to limitations. First, ndings might not be

generalizable to all U.S. youth, including those who do not attend public

or private schools (e.g., home-schooled, institutionalized) and those

who have dropped out of school. Second, this analysis used two mea-

sures of nicotine dependence; however, other validated scales exist, and

it is unclear the extent to which these ndings would be consistent with

Table 2

Association between patterns of tobacco use and nicotine dependence, National

Youth Tobacco Survey, 2017–2018.

Patterns of tobacco product use AOR 95% CI

Current tobacco use

Cigarette vs. another product 7.52 (6.31, 8.97)

Cigar vs. another product 2.06 (1.73, 2.44)

Smokeless tobacco

vs. another product 4.17 (3.29, 5.28)

Hookah vs. another product 2.86 (2.38, 3.44)

E-cigarette vs. another product 0.96 (0.80, 1.15)

Exclusive tobacco use

Cigarette vs. exclusive use of another product 3.72 (2.66, 5.19)

Cigar vs. exclusive use of another product 0.57 (0.41, 0.80)

Smokeless tobacco

vs. exclusive use of another product 2.68 (1.84, 3.90)

Hookah vs. exclusive use of another product 1.24 (0.78, 1.96)

E-cigarette vs. exclusive use of another product 0.45 (0.34, 0.59)

Frequency

of tobacco use

Frequent vs. less frequent cigarette use 15.16 (8.42, 27.31)

Frequent vs. less frequent cigar use 2.28 (1.40, 3.71)

Frequent vs. less frequent smokeless tobacco

use 5.98 (3.15, 11.33)

Frequent vs. less frequent hookah use 2.46 (1.11, 5.44)

Frequent vs. less frequent e-cigarette use 6.24 (4.54, 8.57)

Number of tobacco products

Two products vs. one product 2.69 (2.25, 3.21)

Three or more products vs. one product 7.91 (6.52, 9.58)

Type of tobacco product

Combustible vs. another type of product 3.45 (2.86, 4.17)

AOR: Adjusted odds ratio; adjusted models controlled for grade, sex, and race/

ethnicity; models assessing frequency of tobacco use and nicotine dependence

also controlled for use of other tobacco products.

Smokeless tobacco includes chewing tobacco/snuff/dip.

Current tobacco use is dened as past 30-day use on at least one day; current

tobacco use does not exclude use of other tobacco products.

Combustible tobacco includes cigarettes, hookah, and cigars; another type of

product includes smokeless tobacco products and/or e-cigarettes.

Frequent use was dened as use of a tobacco product on 20 days or more; less

frequent use was dened as use of a tobacco product on fewer than 20 days of the

preceding 30 days.

Y. Gomez et al.

Preventive Medicine 141 (2020) 106284

other validated dependence scales. Third, the exclusion of pipe tobacco,

bidis, snus, and dissolvable products may have affected ndings,

although we do not expect it had a signicant impact given their low

prevalence among youth (Gentzke et al., 2019). Fourth, because this is a

cross-sectional survey, it is not possible to assess temporal and causal

relationships between patterns of tobacco product use and dependence.

Finally, the data are self-reported and subject to recall and reporting

biases. Despite these limitations, our study documents important nd-

ings on patterns of tobacco product use and dependence.

5. Conclusions

Multiple product use among current and frequent tobacco product

users is common. About 4 in 10 U.S. youth tobacco product users are

using two or more products, and 1 in 5 are using three or more products.

Use of multiple products among combustible tobacco product users is

high; more than two-thirds of combustible tobacco product users report

using two or more products. E-cigarettes are the product most

commonly used tobacco product in combination with other products,

and predominately with combustible tobacco products. Combustible

tobacco product use, smokeless tobacco use, frequent use of tobacco

products, and use of more than one product are associated with greater

odds of nicotine dependence among youth. FDA regulatory efforts,

coupled with sustained, comprehensive tobacco control efforts, can

prevent and reduce all forms of tobacco product use among youth.

Funding

This research did not receive any specic grant from funding

agencies in the public, commercial, or not-for-prot sectors.

Disclaimers

The ndings and conclusions in this report are those of the authors

and do not necessarily represent the ofcial position of the USDHHS or

any of its afliated institutions or agencies.

Acknowledgments

We thank Elyse Phillips, MPH, for her contributions to this study.

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Article

Jul 2023

Purpose: Limited information exists on multiple tobacco product use, particularly among youth. This study assessed the prevalence of current youth use of e-cigarettes with other tobacco products and their associated characteristics using 2020 National Youth Tobacco Survey data. Methods: Prevalence estimates were calculated for current e-cigarette users, by multiple tobacco product use status and product combination. Demographic characteristics, e-cigarette use behaviors, age at first combustible tobacco use, and tobacco dependence symptoms were compared between current users of both e-cigarettes and combustible tobacco (dual users) and current exclusive e-cigarette users. Results: In 2020, 61.1% of all current e-cigarette users reported exclusive e-cigarette use, and 38.9% used e-cigarettes with other tobacco products. Among those who used e-cigarettes with other tobacco products, 85.0% used combustible tobacco, with cigarettes being the most commonly used other tobacco product. Compared with current exclusive e-cigarette users, higher proportions of dual users reported the following: frequent e-cigarette use; obtaining e-cigarettes from gas stations, persons other than a family member/friend, vape shops, or the internet; and having any tobacco dependence symptoms. Among dual users, 31.2% reported first combustible product use after e-cigarette initiation, and 34.3% reported first combustible product use prior to e-cigarette initiation. Discussion: Approximately four in 10 youth current e-cigarette users reported using multiple tobacco products, with a majority using combustible tobacco. Frequent e-cigarette use and tobacco dependence symptoms were more prevalent among dual users of e-cigarettes and combustible tobacco.

Prevalence of and Factors Associated With Tobacco Dependence Among Adolescents Aged 12-16 Years Who Were Currently Smoking Tobacco in 125 Countries or Territories, 2012-2019

Article

May 2023
AM J PUBLIC HEALTH

Objectives. To examine the global prevalence of and factors associated with tobacco dependence among adolescents who are currently smoking. Methods. We obtained 2012 to 2019 Global Youth Tobacco Survey data on 67 406 adolescents aged 12 to 16 years from 125 countries or territories (hereafter countries). Those with tobacco dependence were defined as current smokers who felt a strong desire to smoke again within 24 hours after smoking or who had ever smoked or felt like smoking first thing in the morning. Results. The global prevalence of tobacco dependence among adolescents who were currently smoking was 38.4% (95% confidence interval [CI] = 34.0, 42.7). The prevalence was highest in high-income countries (49.8%; 95% CI = 47.0, 52.6) and lowest in lower-middle-income countries (31.2%; 95% CI = 26.9, 35.4). Secondhand smoke exposure, parental smoking, smoking among closest friends, tobacco advertisement exposure, and offers of free tobacco products were positively associated with tobacco dependence. Conclusions. Nearly 40% of adolescents who are currently smoking have tobacco dependence worldwide. Public Health Implications. Our findings emphasize the need to develop tobacco control interventions to prevent experimentation from progressing to regular smoking among adolescents who are currently smoking tobacco. (Am J Public Health. 2023;113(8):861–869. https://doi.org/10.2105/AJPH.2023.307283 )

Individual and Combined Association between Unhealthy Lifestyle Behaviors and Body Weight Dissatisfaction in a Sample of Adolescents from Southern Brazil

Article

Full-text available

Apr 2023

The individual and combined association between unhealthy lifestyle behaviors and body weight dissatisfaction in adolescents was investigated. This cross-sectional research used data from 676 students (348 female), aged between 14 and 19 years old (mean of 14.6 years old) from southern Brazil. Unhealthy lifestyle behaviors and body weight dissatisfaction were assessed through a questionnaire. Unhealthy lifestyle behaviors included smoking, excessive alcohol consumption, sedentary lifestyle, and poor diet, and were analyzed as individual factors and as combinations of behaviors. For males, smoking (OR: 2.6; 95% CI: 1.6–4.0) and the combination of smoking/excessive consumption of alcoholic beverages (OR: 2.5; 95% CI: 1.1–5.8) were directly associated with the desire to reduce body weight, whereas the combination of smoking/inadequate diet (OR: 1.3; 95% CI: 1.0–1.6) was associated with the desire to increase body weight. For females, the combinations of inadequate diet/physical inactivity (OR: 1.6; 95% CI: 1.0–2.5) and of smoking/excessive consumption of alcoholic beverages (OR: 1.9; 95% CI: 1.4–2.8) were directly associated with the desire to reduce body weight. The presence of simultaneous unhealthy lifestyle behaviors is associated with bodyweight dissatisfaction in adolescents.

Longitudinal transitions in adolescent polytobacco use across waves 1‐4 of the Population Assessment of Tobacco and Health (PATH) study

Article

Nov 2022

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.

Association Between Adolescent Blunt Use and the Uptake of Cigars

Article

Full-text available

Dec 2019

Importance Almost two-thirds of adolescents who smoke blunts also report using cigars. Although adolescent co-use of blunts and cigars is prevalent, whether adolescent blunt use is associated with progression to current cigar use (past 30-day use) and increased frequency of use is unknown. Objective To determine whether adolescent use of blunts is associated with progression to cigar use (past 30-day use) and increased number of days used (in the past 30 days) across the subsequent 24 months compared with adolescents who have never used blunts. Design, Setting, and Participants In this prospective cohort study of adolescents from 4 public high schools outside of Philadelphia, Pennsylvania, in-classroom surveys were administered at baseline (fall 2016, beginning of 9th grade) and at 6-month intervals for the following 24 months (fall 2018, beginning of 11th grade). Data analyses were conducted in September and October 2019. Exposures Self-report of lifetime (ever) blunt use at baseline (age 14 years). Main Outcomes and Measures Progression to current cigar use (use in the past 30 days) and escalation in the frequency of use (number of days used in the past 30 days) across the subsequent 24 months. Results Of 1825 participants, 907 (49.7%) were female, 1330 (72.9%) were white, and 376 (20.6%) were Hispanic; the mean (SD) age at baseline was 14.38 (0.55) years. In all, 257 participants (14.0%) reported ever blunt use. Mixed-effects models revealed that ever blunt use at baseline vs never blunt use was associated with progression to current cigar use (past 30 days use: odds ratio, 22.66; 95% CI, 11.34-45.27) but not escalation in the number of days used across the following 24 months (β = 0.13; 95% CI, −0.17 to 0.43). Conclusions and Relevance These findings highlight the risk that blunt use may pose for subsequent cigar use among adolescents. Policies and public health campaigns addressing marijuana as well as cigars will be important to reduce adolescent blunt use and cigar use.

Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019

Article

Full-text available

Nov 2019

Problem/condition: Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various smoked, smokeless, and electronic products. Period covered: 2019. Description of system: The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered survey of U.S. middle school (grades 6-8) and high school (grades 9-12) students. A three-stage cluster sampling procedure is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and associated factors. NYTS is designed to provide national data on tobacco product use and has been conducted periodically during 1999-2009 and annually since 2011. Data from NYTS are used to support the design, implementation, and evaluation of comprehensive tobacco use prevention and control programs and to inform tobacco regulatory activities. Since its inception in 1999 through 2018, NYTS had been conducted via paper and pencil questionnaires. In 2019, NYTS for the first time was administered in schools using electronic data collection methods. CDC's Office on Smoking and Health, in collaboration with the U.S. Food and Drug Administration's (FDA's) Center for Tobacco Products, analyzed data from the 2019 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 19,018 questionnaires were completed and weighted to represent approximately 27.0 million students. On the basis of self-reported grade level, this included 8,837 middle school questionnaires (11.9 million students) and 10,097 high school questionnaires (15.0 million students); 84 questionnaires with missing information on grade level were excluded from school-level analyses. Results: In 2019, an estimated 53.3% of high school students (8.0 million) and 24.3% of middle school students (2.9 million) reported having ever tried a tobacco product. Current (past 30-day) use of a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis [small brown cigarettes wrapped in a leaf]) was reported by 31.2% of high school students (4.7 million) and 12.5% of middle school students (1.5 million). E-cigarettes were the most commonly cited tobacco product currently used by 27.5% of high school students (4.1 million) and 10.5% of middle school students (1.2 million), followed in order by cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco. Tobacco product use also varied by sex and race/ethnicity. Among current users of each tobacco product, the prevalence of frequent tobacco product use (on ≥20 days of the preceding 30 days) ranged from 16.8% of cigar smokers to 34.1% of smokeless tobacco product users. Among current users of each individual tobacco product, e-cigarettes were the most commonly used flavored tobacco product (68.8% of current e-cigarette users). Among students who reported ever having tried e-cigarettes, the three most commonly selected reasons for use were "I was curious about them" (55.3%), "friend or family member used them" (30.8%), and "they are available in flavors, such as mint, candy, fruit, or chocolate" (22.4%). Among never users of each individual tobacco product, curiosity and susceptibility (a construct that can help to identify future tobacco product experimentation or use) was highest for e-cigarettes (39.1% and 45.0%, respectively) and cigarettes (37.0% and 45.9%, respectively). Overall, 86.3% of students who reported contact with an assessed potential source of tobacco product advertisements or promotions (going to a convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies; or reading newspapers or magazines) reported exposure to marketing for any tobacco product; 69.3% reported exposure to e-cigarette marketing and 81.7% reported exposure to marketing for cigarettes or other tobacco products. Among all students, perceiving no harm or little harm from intermittent tobacco product use (use on some days but not every day) was 28.2% for e-cigarettes, 16.4% for hookahs, 11.5% for smokeless tobacco products, and 9.5% for cigarettes. Among current users of any tobacco product, 24.7% reported experiencing cravings to use tobacco products during the past 30 days and 13.7% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 57.8% of current tobacco product users reported they were seriously thinking about quitting the use of all tobacco products and 57.5% reported they had stopped using all tobacco products for ≥1 day because they were trying to quit. Interpretation: In 2019, approximately one in four youths (23.0%) had used a tobacco product during the past 30 days. By school level, this represented approximately three in 10 high school students (31.2%) and approximately one in eight middle school students (12.5%). Since 2014, e-cigarettes have been the most commonly used tobacco product among youths. Importantly, more than half of current youth tobacco product users reported seriously thinking about quitting all tobacco products in 2019. However, established factors of use and initiation, including the availability of flavors, exposure to tobacco product marketing, curiosity and susceptibility, and misperceptions about harm from tobacco product use, remained prevalent in 2019 and continue to promote tobacco product use among youths. Public health action: The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and community levels. Everyone, including public health professionals, health care providers, policymakers, educators, parents, and others who influence youths, can help protect youths from the harms of all tobacco products. In addition, the comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with FDA's regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths.

Adolescents’ E-Cigarette Use: Increases in Frequency, Dependence, and Nicotine Exposure Over 12 Months

Article

Full-text available

Jun 2019
J ADOLESCENT HEALTH

Purpose: This study examined changes in e-cigarette and dual-use frequency, levels of nicotine exposure and e-cigarette dependence, and device and e-liquid preferences over 12 months. Methods: Adolescents (N = 173, aged 13-18 years) who reported past-month e-cigarette use and at least 10 lifetime uses were recruited from the San Francisco Bay Area. The sample was 75.1% male, 54.9% non-Hispanic White, mean age 16.6 years (standard deviation = 1.2); 26.6% reported past-month cigarette smoking at baseline (i.e., dual use). At baseline, 6-month, and 12-month follow-up, participants provided saliva samples for cotinine testing and self-reported e-cigarette use frequency, dependence, past-month smoking, product preference, and flavor preference. Results: Most (80.3%) were still using e-cigarettes at 12 months, and daily use increased from 14.5% to 29.8%. Model testing indicated an overall increase from baseline to 12 months in frequency of e-cigarette use (F(2, 166) = 5.69, p = .004), dependence (F(2, 164) = 5.49, p = .005), and cotinine levels (F(2, 103) = 4.40, p = .038). Among those reporting only e-cigarette use at baseline, 28.8% reported combustible cigarette use during follow-up. Among those reporting dual use at baseline, 57.1% were still dual using at 12 months, 31.4% reported e-cigarette use only, and none abstained from both products. Higher nicotine delivering e-cigarette devices (i.e., Juul, mods) became more popular over time, whereas flavor preferences (i.e., fruit, mint/menthol, and candy) remained stable. Conclusions: Adolescents' e-cigarette use persisted over a 12-month period with significant increases in frequency of use, nicotine exposure, and e-cigarette dependence. Transitions from single to dual and dual to single nicotine product use were observed in approximately one in three users over the study period.

Measuring e-cigarette addiction among adolescents

Article

Full-text available

May 2019

Background and objectives With high rates of use and uncertain consequences, valid electronic cigarette (e-cigarette) use frequency and addiction measures for adolescents are needed. This cross-sectional study examined correlations for multiple measures of adolescent e-cigarette use with nicotine exposure quantified with salivary cotinine levels. Methods Adolescents (N=173, age 13–18) who reported past-month e-cigarette use were recruited from the San Francisco Bay Area. Participants self-reported: (1) days of e-cigarette use in a typical month, (2) number of e-cigarette sessions in a typical day (sessions per day; SPD) and the (3) E-Cigarette Addiction Severity Index (EASI). Participants also completed the 10-item Penn State Electronic Cigarette Dependence Index (ECDI), which we examined in full and as a 2-item Heaviness of Vaping Index (HVI; the sum of the ECDI items on use frequency and time to first vaping on wakening). Sessions per month (SPM) were calculated using days per month and SPD. Cotinine levels, SPD and SPM were log-transformed. Results Among frequency measures, SPM correlated most strongly with cotinine (r=0.59), followed closely by days per month (r=0.58) and SPD (r = 0.57), p<0.001. Among dependence measures, the EASI correlated most strongly with cotinine (r = 0.51), closely followed by the ECDI and HVI (r’s=0.50), all p’s<0.001. Conclusions Adolescents’ reports of frequency of e-cigarette use and degree of addiction correlated significantly with cotinine as a biomarker of nicotine exposure. We recommend the EASI and days per month as brief general measures. SPM and the ECDI are more extensive measures that may yield a more nuanced understanding of use.

Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018

Article

Full-text available

Feb 2019

Introduction: Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco product use begins during youth and young adulthood. Methods: CDC, the Food and Drug Administration, and the National Cancer Institute analyzed data from the 2011-2018 National Youth Tobacco Surveys to estimate tobacco product use among U.S. middle and high school students. Prevalence estimates of current (past 30-day) use of seven tobacco products were assessed; differences over time were analyzed using multivariable regression (2011-2018) or t-test (2017-2018). Results: In 2018, current use of any tobacco product was reported by 27.1% of high school students (4.04 million) and 7.2% of middle school students (840,000); electronic cigarettes (e-cigarettes) were the most commonly used product among high school (20.8%; 3.05 million) and middle school (4.9%; 570,000) students. Use of any tobacco product overall did not change significantly during 2011-2018 among either school level. During 2017-2018, current use of any tobacco product increased 38.3% (from 19.6% to 27.1%) among high school students and 28.6% (from 5.6% to 7.2%) among middle school students; e-cigarette use increased 77.8% (from 11.7% to 20.8%) among high school students and 48.5% (from 3.3% to 4.9%) among middle school students. Conclusions and implications for public health practice: A considerable increase in e-cigarette use among U.S. youths, coupled with no change in use of other tobacco products during 2017-2018, has erased recent progress in reducing overall tobacco product use among youths. The sustained implementation of comprehensive tobacco control strategies, in coordination with Food and Drug Administration regulation of tobacco products, can prevent and reduce the use of all forms of tobacco products among U.S. youths.

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

Article

Full-text available

Feb 2019

Importance The use of electronic cigarettes (e-cigarettes) and other noncigarette tobacco products may increase the odds of cigarette initiation, even among low-risk youths. Objective To evaluate the associations of prior e-cigarette use and other tobacco product use with subsequent cigarette initiation within 2 years of follow-up. Design, Setting, and Participants In this prospective cohort study, data from waves 1 through 3 of the Population Assessment of Tobacco and Health Study (2013-2016) were used to assess youths aged 12 to 15 years who had never used cigarettes, e-cigarettes, or other tobacco products at wave 1. This was a nationally representative study of the US population. Data analysis was conducted in 2018. Exposures First noncigarette tobacco product used (none, e-cigarette, or other tobacco product) between wave 1 and wave 3. Main Outcomes and Measures Ever cigarette use and current cigarette use at wave 3. Results In the sample (N = 6123), respondents were 49.5% female; 54.1% non-Hispanic, white; and the mean (SD) age was 13.4 (1.2) years. Of these, 8.6% reported e-cigarettes as their first tobacco product, while 5.0% reported using another noncigarette product first; 3.3% reported using cigarettes first. Cigarette use at wave 3 was higher among prior e-cigarette users (20.5%) compared with youths with no prior tobacco use (3.8%). Prior e-cigarette use was associated with more than 4 times the odds of ever cigarette use (odds ratio, 4.09; 95% CI, 2.97-5.63) and nearly 3 times the odds of current cigarette use (odds ratio, 2.75; 95% CI, 1.60-4.73) compared with no prior tobacco use. Prior use of other tobacco products was similarly associated with subsequent ever cigarette use (OR, 3.84; 95% CI, 2.63-5.63) and current cigarette use (OR, 3.43; 95% CI, 1.88-6.26) compared with no prior tobacco use. The association of prior e-cigarette use with cigarette initiation was stronger among low-risk youths (OR, 8.57; 95% CI, 3.87-18.97), a pattern not seen for prior other product use. Over the 2 years between 2013 and 2014 and 2015 and 2016, 21.8% of new cigarette ever use (178 850 youths) and 15.3% of current cigarette use (43 446 youths) among US youths aged 12 to 15 years may be attributable to prior e-cigarette use. Conclusions and Relevance This study’s findings support the notion that e-cigarette use is associated with increased risk for cigarette initiation and use, particularly among low-risk youths. At the population level, the use of e-cigarettes may be a contributor to the initiation of cigarette smoking among youths.

e-Cigarette Use Among Youth in the United States, 2019

Article

Nov 2019

Importance The prevalence of e-cigarette use among US youth increased from 2011 to 2018. Continued monitoring of the prevalence of e-cigarette and other tobacco product use among youth is important to inform public health policy, planning, and regulatory efforts. Objective To estimate the prevalence of e-cigarette use among US high school and middle school students in 2019 including frequency of use, brands used, and use of flavored products. Design, Setting, and Participants Cross-sectional analyses of a school-based nationally representative sample of 19 018 US students in grades 6 to 12 participating in the 2019 National Youth Tobacco Survey. The survey was conducted from February 15, 2019, to May 24, 2019. Main Outcomes and Measures Self-reported current (past 30-day) e-cigarette use estimates among high school and middle school students; frequent use (≥20 days in the past 30 days) and usual e-cigarette brand among current e-cigarette users; and use of flavored e-cigarettes and flavor types among current exclusive e-cigarette users (no use of other tobacco products) by school level and usual brand. Prevalence estimates were weighted to account for the complex sampling design. Results The survey included 10 097 high school students (mean [SD] age, 16.1 [3.0] years; 47.5% female) and 8837 middle school students (mean [SD] age, 12.7 [2.8] years; 48.7% female). The response rate was 66.3%. An estimated 27.5% (95% CI, 25.3%-29.7%) of high school students and 10.5% (95% CI, 9.4%-11.8%) of middle school students reported current e-cigarette use. Among current e-cigarette users, an estimated 34.2% (95% CI, 31.2%-37.3%) of high school students and 18.0% (95% CI, 15.2%-21.2%) of middle school students reported frequent use, and an estimated 63.6% (95% CI, 59.3%-67.8%) of high school students and 65.4% (95% CI, 60.6%-69.9%) of middle school students reported exclusive use of e-cigarettes. Among current e-cigarette users, an estimated 59.1% (95% CI, 54.8%-63.2%) of high school students and 54.1% (95% CI, 49.1%-59.0%) of middle school students reported JUUL as their usual e-cigarette brand in the past 30 days; among current e-cigarette users, 13.8% (95% CI, 12.0%-15.9%) of high school students and 16.8% (95% CI, 13.6%-20.7%) of middle school students reported not having a usual e-cigarette brand. Among current exclusive e-cigarette users, an estimated 72.2% (95% CI, 69.1%-75.1%) of high school students and 59.2% (95% CI, 54.8%-63.4%) of middle school students used flavored e-cigarettes, with fruit, menthol or mint, and candy, desserts, or other sweets being the most commonly reported flavors. Conclusions and Relevance In 2019, the prevalence of self-reported e-cigarette use was high among high school and middle school students, with many current e-cigarette users reporting frequent use and most of the exclusive e-cigarette users reporting use of flavored e-cigarettes.

E-Cigarette Use, Polytobacco Use, and Longitudinal Changes in Tobacco and Substance Use Disorder Symptoms Among U.S. Adolescents

Article

Aug 2019
J ADOLESCENT HEALTH

Purpose: The objective of this study was to examine the combinations of e-cigarette use, cigarette use, and other tobacco use over time and the relationship these longitudinal use patterns have with symptoms of tobacco use disorder (TUD) and substance use disorders (SUDs) among a sample of adolescents. Methods: Data from U.S. adolescents (aged 12-17 years) who were surveyed for the Population Assessment of Tobacco and Health Study at baseline, first follow-up, and second follow-up (2013-2014, 2014-2015, and 2015-2016; n = 7,595) was used to analyze symptoms of TUD and SUDs based on longitudinal combinations of tobacco/nicotine use. Results: The most common combination of tobacco/nicotine use across the three waves was "no use of any tobacco/nicotine products" at baseline and first follow-up to "e-cigarette use only" at the second follow-up. Multivariable analyses found that past 30-day cigarette use and other tobacco use at the most recent follow-up was associated with an increase in both current TUD and SUD symptoms, whereas past 30-day e-cigarette use at the most recent follow-up was modestly associated with an increase in current SUD symptoms. Conclusions: Individuals who transitioned to e-cigarette use were at relatively low risk for increased TUD and SUD symptoms. However, individuals who transitioned or continually used cigarettes were typically at greater risk for indicating more TUD and SUD symptoms. Given the low risk of e-cigarette only users to indicate TUD and SUD symptoms, prevention efforts need to be made to target these youth before they transition to cigarettes and other types of tobacco use.

Adolescent Dual Use Classification and Its Association With Nicotine Dependence and Quit Intentions

Article

Jun 2019
J ADOLESCENT HEALTH

Purpose: Electronic cigarettes (e-cigarette) use is rapidly increasing in the U.S., especially among adolescents. A significant number of adolescents use both cigarettes and e-cigarettes, often referred to as dual use. We used a new classification of dual use, taking into account the frequency of use of both products. In addition, we examined the association between dual use with time to first cigarette after waking (a nicotine dependence measure) and quit intention. Methods: Data were drawn from the 2015-2018 National Youth Tobacco Survey. We grouped participants by dual use frequency. Multivariable logistic regression was used to examine the association of dual use frequency with nicotine dependence and quit intention. Results: Different categories of dual users varied in demographic characteristics and beliefs on the harms of cigarette smoking and e-cigarette use. Compared with cigarette-only smokers, significantly higher odds of nicotine dependence were found for high-frequency e-cigarette dual users (within 5 minutes of awakening, odds ratio [OR]: 1.67, 95% confidence interval [CI], 1.07-2.62; within 30 minutes, OR: 1.61, 95% CI, 1.15-2.27), high-frequency cigarette dual users (5 minutes, OR: 2.85, 95% CI, 1.76-4.63; within 30 minutes, OR: 4.14, 95% CI, 2.96-5.80), and high-frequency dual users (5 minutes, OR: 4.46, 95% CI, 2.88-6.91; 30 minutes, OR: 3.94, 95% CI, 2.43-6.42). In addition, high-frequency e-cigarette dual users had significantly lower quit intention compared with both cigarette-only smokers and low-frequency dual users. Conclusions: Findings highlight the need for a standard, granulated classification of dual user, as important characteristics may vary between different categories. Future studies on dual use should consider categorizing dual use into the four classifications described in this study.

Nicotine arms race: JUUL and the high-nicotine product market

Article

Feb 2019

Objective Until recently, purveyors of vaping products marketed e-liquids in the 1%–3% range of nicotine concentration with those at 3% described as ‘super high’ intended for two packs/day smokers. The goal of this study is to evaluate the degree to which JUUL, with its 5% nicotine and 75% US market share, has spurred other e-liquid vendors to raise the nicotine levels of their products. Methods Online search to identify brands offering e-liquid in exceptionally high nicotine concentration (≥5%) and to catalogue the appearance of devices which emulate JUUL. Results JUUL compatible pods (14) and JUUL knock off devices (39) were identified which offer equal or higher nicotine than JUUL. More than 70 e-liquid brands sell high-nicotine products (≥5%) in bulk (≥30 mL) equivalent to >40 cigarette packs. All of these products come in multiple youth appealing sweet and fruity flavours. It was noted that nicotine percentage is inconsistently reported (eg, JUUL is 5% by weight vs 5.9% by volume). Conclusions JUUL has triggered a widespread rush among aerosol purveyors to market e-liquid in unprecedentedly high nicotine concentrations. The rapidly rising popularity of high-nicotine e-liquids threatens to addict a generation of youth. When sold in large quantity bottles (eg, 30 mL) they represent a childhood poisoning risk. Labelling of nicotine concentration in e-liquids needs to be standardised to avoid consumer confusion. The addictiveness and toxicity of these products makes it imperative that regulators act swiftly to enact protective measures.

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

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