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Adolescent e-cigarette users are more likely than never-users to progress to cigarette smoking, even among those who had no intention to start smoking

Olusegun Owotomo, Haley Stritzel, Sean Esteban McCabe, Carol J Boyd, Julie Maslowsky

Introduction

E-cigarette use is a relatively new risk factor for nicotine use disorder among U.S. adolescents. In 2019, 28% of high school students and 11% of middle school students were current e-cigarette users. With the emergence of newer and potentially highly addictive e-cigarette products, adolescents who use e-cigarettes are at increased risk of developing nicotine use disorder and progressing to smoke conventional cigarettes. However, what remains unclear is which e-cigarette users progress to cigarette smoking, and why?

One hypothesis is that adolescent e-cigarette users who progress to cigarette smoking are simply those who would have smoked cigarettes anyway even without exposure to e-cigarettes. 

This brief reports on a study that challenges that hypothesis by using a theory-guided approach to isolate the effect of e-cigarette use on cigarette smoking. The authors investigate whether the progression to cigarette smoking is truly dependent on prior predisposition to smoke cigarettes. In other words, the authors ask whether e-cigarette users who have no intention to smoke cigarettes are protected from making that transition.

The authors use data on adolescents aged 12-17 from two rounds of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative household cohort study of tobacco use among civilian, non-institutionalized U.S. population. In the survey conducted in 2014-2015, adolescents were asked if they had ever used e-cigarettes and whether they had an intention to start smoking cigarettes. In the 2015-2016 survey conducted one year later, the same adolescents were asked if they had progressed to smoking cigarettes.

Key Findings

  • Among adolescent never-smokers who had no intention to smoke cigarettes, 9.7% of e-cigarette users progressed to cigarette smoking after one year, compared to 1.5% of never e-cigarette users. E-cigarette users were also over four times more likely than never e-cigarette users to have progressed to smoke cigarettes one year later. See Figure, below.
  • E-cigarette use predicted cigarette smoking only among adolescent never-smokers who had no prior intentions to smoke cigarettes.
    • This finding debunks the hypothesis that e-cigarette users who progress to cigarette smoking are simply those who are already predisposed to cigarette smoking and would have progressed to cigarette smoking even without exposure to e-cigarettes.
    • Indeed, e-cigarette use was associated with higher risk of cigarette smoking among adolescents who had no prior smoking intention but not among those who had previously expressed intention to smoke cigarettes.

Policy Implications

These findings inform future adolescent smoking prevention efforts. With the proliferation of e-cigarettes among adolescents, adolescents who have no intention to smoke conventional cigarettes still may progress to cigarette smoking if they use e-cigarettes. On the other hand, abstinence from e-cigarette use can protect adolescents from starting cigarette smoking.

It is essential that pediatricians, other health care providers, and education campaigns emphasize the dangers associated with e-cigarette use. These education efforts should include the risk of progressing to cigarette smoking even among adolescents who have no intention to smoke cigarettes.

Tailored interventions that emphasize abstinence from e-cigarette use may be effective in preventing cigarette smoking among adolescents. Indeed, abstinence from e-cigarette use should be framed as an adolescent smoking prevention strategy.

Finally, tobacco control policies that discourage e-cigarette use among adolescents, including a ban on all flavors and age-restriction on sales, should be enforced in all U.S. states.

Reference

Owotomo, O., Stritzel, H., McCabe, S.E., Boyd, C.J. & Maslowsky, J. (2020). Smoking intention and progression from e-cigarette use to cigarette smoking. Pediatrics. Published online ahead of print.

Suggested Citation

Owotomo, O., Stritzel, H., McCabe, S.E., Boyd, C.J. & Maslowsky, J. (2020). Adolescent e-cigarette users are more likely than never-users to progress to cigarette smoking, even among those who had no intention to start smoking. PRC Research Brief 5(9). DOI: 10.26153/tsw/10604. 

About the Authors

Olusegun Owotomo (segunowotomo@gmail.com), a pediatric resident physician at Children’s National Hospital, Washington D.C., graduated with a PhD in Health Behavior and Health Education from The University of Texas at Austin; Haley Stritzel is a PhD student in sociology and a graduate research trainee in the Population Research Center, UT Austin; Sean Esteban McCabe is a professor in the Department of Health Behavior and Biological Sciences and director of the Center for the Study of Drugs, Alcohol, Smoking and Health at the University of Michigan, Ann Arbor; Carol J. Boyd is a professor emerita in the Department of Health Behavior and Biological Sciences and co-director of the Center for the Study of Drugs, Alcohol, Smoking and Health at the University of Michigan, Ann Arbor; and Julie Maslowsky (maslowsky@austin.utexas.edu) is an associate professor in the Department of Kinesiology & Health Education and in the Department of Population Health, Dell Medical School and a faculty research associate at the PRC, UT Austin.

Acknowledgements

This research was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K01HD091416 and P2CHD042849), National Cancer Institute (R01CA203809), National Institute on Drug Abuse (R01DA44157), and from the William T. Grant Foundation Scholars Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.


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