Exclusive e-cigarette use predicts cigarette initiation among college students
Introduction
Use of electronic nicotine delivery systems (ENDS) has increased substantially over the past few years. Estimates from a United States (U.S.) nationally-representative survey indicate that current, or past 30-day, ENDS use among adults 18 years of age and older increased significantly from 0.3% in 2010 to 6.8% in 2013 (McMillen, Gottlieb, Shaefer, Winickoff, & Klein, 2015). The same nationally-representative survey (McMillen et al., 2015) and results from the 2014 U.S. National Health Interview Survey (Schoenborn & Gindi, 2016) indicate that among adults, 18–24 year old young adults report the highest prevalence of ENDS use. Heightened prevalence of use is concerning because the U.S. Food and Drug Administration (FDA) only recently announced ENDS regulations, many of which are not fully implemented, and the long-term health consequences of ENDS use are not known (Hess et al., 2017). There is also concern that ENDS use may lead to the use of combustible cigarettes (Barrington-Trimis et al., 2016), which have been shown to be more harmful to health than ENDS (Hecht et al., 2015).
The role of ENDS in cigarette use is a hotly debated topic. Some researchers argue that ENDS may have a public health benefit if they are used by current cigarette smokers to quit or cut down on smoking (Levy et al., 2017). Others note that the public health benefit may be diminished if ENDS use contributes to the initiation of combustible cigarettes and an increased number of new cigarette smokers (Levy et al., 2017). A growing number of prospective studies indicate that ENDS use among never cigarette smokers/cigarette-naïve participants is associated with subsequent cigarette initiation up to 16 months later, even after controlling for various socio-demographic, intrapersonal, and contextual factors (Barrington-Trimis et al., 2016; Leventhal et al., 2015; Primack, Soneji, Stoolmiller, Fine, & Sargent, 2015; Wills et al., 2016; Wills, Sargent, Gibbons, Pagano, & Schweitzer, 2016). However, most studies are limited to examination of cigarette initiation among adolescent or combined adolescent and young adult samples.
Only two prospective studies examine the role of ENDS use in cigarette initiation among young adults, the population at highest risk for ENDS use. Unger, Soto, and Leventhal (2016) reported that among 23-year-old Hispanic young adults, current use of ENDS by those who did not use cigarettes in the past month, predicted past month cigarette use one year later, even after socio-demographic, and alcohol and other tobacco use were taken into account. Similarly, Spindle et al. (2017) reported that among approximately 18.5 year old college students, current and ever use of e-cigarettes predicted cigarette initiation one year later, even after controlling for socio-demographics, other tobacco and drug use, and various intrapersonal factors. Findings from these studies extend our understanding of the potential consequences of ENDS use during young adulthood, but additional data are needed to assess the role of concurrent use of ENDS with other tobacco products (e.g., cigars and hookah) in subsequent cigarette initiation. Although existing studies control for the use of other tobacco products, none have determined if risk for cigarette initiation is consistent across exclusive ENDS users and users of ENDS and other tobacco products or multiple tobacco product users.
Multiple tobacco product use is more prevalent among young adults in the contemporary tobacco landscape than exclusive use of one product (Richardson, Williams, Rath, Villanti, & Vallone, 2014). Limited studies indicate that multiple tobacco product use is associated with elevated risk for sustaining tobacco use and for subsequently trying other products (Huh & Leventhal, 2016; Kaufman, Land, Parascandola, Augustson, & Backinger, 2015). It is possible, therefore, that cigarette-naïve young adults who use ENDS and other tobacco products, such as cigars and hookah, may be more likely than exclusive ENDS users to subsequently also try cigarettes because cigarette use is part of a constellation of tobacco use behaviors. To date, however, no studies have examined if users of ENDS and at least one tobacco product (but not cigarettes) are more likely than their exclusive ENDS user peers to subsequently initiate cigarettes. Thus, it is not clear if ENDS use is a specific risk factor for subsequent cigarette initiation or if cigarette initiation is an extension of a constellation of existing tobacco use behaviors.
The present study extended existing research by examining the role of ENDS use, both exclusive and not exclusive, in the subsequent initiation of cigarettes over a 1.5 year period among a sample of initially 18–25 year old year cigarette-naïve college students. Understanding consequences of ENDS use among college students is important because this population comprises > 40% of 18–24 year old young adults in the U.S. (U.S. Department of Education, National Center for Education Statistics) and the college years are characterized by transitions in tobacco use (Wetter et al., 2004). We used discrete-time hazard models to determine if cigarette-naïve college students who used ENDS had a greater odds of initiating cigarettes than did non-ENDS users over three subsequent waves, or 1.5 years. Similar to other studies, we controlled for other tobacco use, and various socio-demographic, intrapersonal, and interpersonal factors that have been associated with ENDS use. Consistent with existing research, we hypothesized that ENDS use among cigarette-naïve college students would be associated with increased odds of subsequent cigarette initiation, over and above the covariates. Extending existing research, we assessed if the odds of cigarette initiation was consistent across exclusive ENDS users and users of ENDS and at least one of the following tobacco products: cigars/cigarillos, little cigars, hookah, and smokeless tobacco.
Section snippets
Participants
Participants were 2558 students involved in the first four waves of the Marketing and Promotions across Colleges in Texas project (Project M-PACT). Project M-PACT is a rapid response surveillance study, collecting data every six months from a cohort of 5482 students attending one of 24 colleges in Texas. Wave 1 data were collected in November 2014–February 2015 and the three subsequent waves were collected approximately every six months thereafter with retention rates ranging from 79% (waves 2
Results
Overall, 11% (n = 282) of wave 1 cigarette-naïve participants reported cigarette initiation by wave 4. A significantly higher proportion of wave 1 ENDS users reported initiating cigarette use by wave 4 (20.1%; n = 114) compared with wave 1 non-ENDS users (8.4%; n = 168) (χ2[1] = 61.25, p < 0.001). The distribution of cigarette initiation by study period is presented in a life table (see Table 1), which also shows cumulative survival estimates (i.e., the probability that a participant did not use
Discussion
Findings from the present study on young adults contribute to a growing body of research, primarily on adolescents, indicating that ENDS use is associated with increased risk for subsequent cigarette initiation. Overall, 11% of our 18–25 year old cigarette-naïve college student sample reported initiating cigarettes over the 1.5 year study period. Moreover, more than twice as many ENDS using students initiated cigarettes during the study period compared with their non-ENDS using peers (20.1%
Role of funding source
Research reported in this publication was supported by grant number [1 P50 CA180906] from the National Cancer Institute and the Food and Drug Administration (FDA) Center for Tobacco Products. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.
Contributors
A Loukas conceptualized the study and wrote the first draft of the paper. CN Marti conducted the analyses, and contributed to writing the methods and results. M Cooper contributed to writing the method and editing the paper. KE Pasch and CL Perry edited the paper and all authors have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
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