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

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

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

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


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.

Berry KM, Fetterman JL, Benjamin EJ, et al. Association of Electronic Cigarette Use With Subsequent Initiation of Tobacco Cigarettes in US Youths. JAMA Netw Open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794
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United States