E-Cigarette Use and Subsequent Smoking Frequency Among Adolescents
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E-cigarette Use and Subsequent Jessica L. Barrington-Trimis, PhD, a Grace Kong, PhD, b Adam M. Leventhal, PhD, a Feifei Liu, MS, a SmokingMargaret Mayer, MPH, b Tess FrequencyBoley Cruz, PhD, a Suchitra Krishnan-Sarin, PhD, b Rob McConnell, MDa Among Adolescents BACKGROUND AND OBJECTIVES: abstract Electronic cigarette (e-cigarette) use is associated with cigarette initiation among adolescents. However, it is unclear whether e-cigarette use is associated with more frequent cigarette use after initiation. Also, the extent to which cigarette or dual cigarette and e-cigarette users transition to exclusive e-cigarette use or to the nonuse of METHODS: either product is not yet known. – – N Data were pooled from 3 prospective cohort studies in California and Connecticut (baseline: 2013 2014; follow-up: 2014 2016; = 6258). Polytomous regression models were used to evaluate the association of baseline e-cigarette use (never or ever) with – – cigarette use frequency at follow-up (experimental: initiation but no past-30-day use; infrequent: 1 2 of the past 30 days; frequent: 3 5 or more of the past 30 days). Polytomous regression models were also used to evaluate transitions between baseline ever or past-30- RESULTS: day single or dual product use and past-30-day single or dual product use at follow-up. – Among baseline never smokers, e-cigarette users had greater odds of subsequent – – experimental (odds ratio [OR] = 4.58; 95% confidence interval [CI]: 3.56 5.88), infrequent (OR = 4.27; 95% CI: 2.75 6.62) or frequent (OR = 3.51; 95% CI: 1.97 6.24) cigarette use; the 3 OR estimates were not significantly different. Baseline past-30-day exclusive cigarette use was associated with higher odds at follow-up of exclusive cigarette or dual product use than CONCLUSIONS: of exclusive e-cigarette use. Tobacco control policy to reduce adolescent use of both e-cigarettes and cigarettes is needed to prevent progression to more frequent tobacco use patterns and reduce combustible cigarette use (with or without concurrent e-cigarette use) to lessen the NIH adverse public health impact of e-cigarettes. WHAT’S KNOWN ON THIS SUBJECT: Electronic cigarette (e-cigarette) use is associated with cigarette initiation. a b Department of Preventive Medicine, University of Southern California, Los Angeles, California; and Department However, it is unclear whether e-cigarette use is of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut associated with more frequent cigarette use after Dr Barrington-Trimis formulated the research question, interpreted the results, wrote and edited initiation or whether adolescent cigarette or dual the manuscript, and is the guarantor; Ms Liu and Ms Mayer contributed to formulating the product users transition to exclusive e-cigarette use or research question, conducted the analyses, interpreted the results, and edited the manuscript; nonuse. Drs Kong and Cruz contributed to formulating the research question, the interpretation of results, WHAT THIS STUDY ADDS: Adolescent e-cigarette and the editing of the manuscript; Drs Leventhal, Krishnan-Sarin, and McConnell designed the study (each cohort), collected data, contributed to formulating the research question and the users appear to follow similar trajectories of cigarette interpretation of the results, and critically reviewed the manuscript; and all authors approved the smoking frequency as nonusers. Exclusive cigarette or final manuscript as submitted. dual product users are more likely to continue using cigarettes than to transition away from smoking to DOI: https:// doi. org/ 10. 1542/ peds. 2018- 0486 exclusive e-cigarette use or to nonuse. Accepted for publication Sep 11, 2018 To cite: Barrington-Trimis JL, Kong G, Leventhal AM, et al. E-cigarette Use and Subsequent Smoking Frequency Among Adolescents. Pediatrics. 2018;142(6):e20180486 Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018:e20180486 ARTICLE – 29 31 Recent studies of population trends adults, there has been little In the current study, we aimed to in tobacco and alternative tobacco study of transitions from cigarette assess 2 critical questions that are use prevalence among youth in or multiple tobacco product use to central to the evaluation of the the United States have revealed an the exclusive use of e-cigarettes (or public health impact of e-cigarettes indication that electronic cigarettes transition to the nonuse of cigarettes on youth. First, among baseline (e-cigarettes) are used by at least or e-cigarettes) among youth. We never smokers, we assessed the some youth who are unlikely to reported in an earlier publication association of e-cigarette use have started using– tobacco products– 1, 2 that ever cigarette use was with the frequency of smoking in if e-cigarettes 3were6 unavailable7 20. the past 30 days at follow-up in associated with a subsequent onset3 Moreover, we and others have of e-cigarette use in adolescents. a prospective study with a large demonstrated that youth and young A separate study revealed that pooled sample in which 3 cohorts of adults who have used e-cigarettes youth in California and Connecticut past-30-day cigarette use was not are more likely than those who have were combined. We aimed to associated with subsequent past-30- not used e-cigarettes to subsequently evaluate whether e-cigarette users day e-cigarette use across 3 annual initiate combustible cigarette use, 16 who initiate cigarette smoking are waves of data in adolescents. with a meta-analytic estimate of disproportionately represented Researchers in each of these studies more than a threefold increase in by young people who are only have evaluated the use of cigarettes the risk of21 subsequent cigarette temporarily experimenting, resulting initiation. and e-cigarettes as separate in a reduced risk of progression to “ variables, which cannot be used to higher levels of smoking in contrast Based in part on this evidence, in ” distinguish whether the association to nonusers of e-cigarettes, or a 2016 report E-cigarette Use of combustible cigarette use with whether the progression to more among Youth and Young Adults, subsequent e-cigarette use reflects frequent cigarette use equals or the Surgeon General concluded that – youth who quit smoking and have exceeds the typical probability of e-cigarette use in this population 22 completely transitioned to exclusive transitioning observed among non e- is a public health concern. – – e-cigarette use or youth who are now cigarette users, which would suggest However, others have suggested dual product users of both cigarettes that the e-cigarette to cigarette that this conclusion may be and e-cigarettes. Most youth do not use transition is a significant public premature if e-cigarette users are use e-cigarettes to quit smoking; data health concern. Second, we examined disproportionately more likely to be from the National Youth Tobacco the rates of transition from cigarette merely experimenting temporarily use or the dual use of e-cigarettes with cigarettes and are unlikely to Survey (2016) revealed that only 23 – and cigarettes to the exclusive use of progress to more frequent smoking. 7.8% (95% confidence interval [CI]: e-cigarettes or no tobacco product Because e-cigarettes have gained 6.5% 9.5%) of youth cited cessation32 use. Appreciable rates of transition popularity only recently and the as a reason for e-cigarette use. In 1 away from cigarette use (to progression from cigarette initiation of our cohort studies (unpublished – exclusive e-cigarette use or complete to regular use typically transpires data), we also observed that few 24 28 abstention) that are substantially over several years, it could be young adults (12.8%) cited cessation 33 lower than the likelihood of argued that researchers in studies as a reason for using e-cigarettes. 34 continued cigarette use, with or to date showing a risk of subsequent Although many youth (52.8%) 35 without concurrent e-cigarette use, cigarette experimentation among and young adult (62.3%) smokers may benefit the public health of the e-cigarette users may not have are interested in quitting using population of youth and young adult followed e-cigarette users long cigarettes, it is not clear that these cigarette smokers. enough or in sample sizes large populations are using e-cigarettes METHODS enough to assess the risk of to do so or whether e-cigarettes are progression to regular smoking. an effective aid in these populations. Participants Another key question regarding With no published evidence of Southern California Children’s Health the public health impact of the the likelihood that adolescent and Study high e-cigarette use prevalence young adult smokers transition to ’ among youth and young adults the exclusive use of e-cigarettes or is whether e-cigarettes facilitate to complete abstention from both The Southern California Children s smoking cessation. Although there tobacco products, this possible Health Study (CHS) is a population- has been considerable study of the positive public health impact of based prospective cohort study of potential for e-cigarettes to be a e-cigarettes in youth and young youth in 12 communities36, 37 across cigarette smoking cessation aid in adults remain uninvestigated. Southern California. The use Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 BARRINGTON-TRIMIS et al “ ” – “ of e-cigarettes was first assessed completed a follow-up questionnaire days), infrequent users (use on ” – when participants were in 11th or andN were successfully matched with 1 2 of the past 30 days), or frequent 12th grade between January 2014 their baseline data at follow-up users (use on 3 5 or more of the and June 2014 by using a paper- Ethics( = 1404; Statement match rate = 60.0%). past 30 days). Participants who and-pencil questionnaire completed reported using e-cigarettes, but under study staff supervision36,37 in not cigarettes, in the past 30 days school classrooms.