January 2, 2018

Stanton A. Glantz, PhD

Youth Using Alternative Tobacco Products Are More Likely to Smoke 1 Year Later, including E-cigarettes and Smokeless Tobacco

Shannon Watkins, Ben Chaffee, and I just published “Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015” in JAMA Pediatrics.  This paper shows that use of any non-cigarette tobacco product, including but not just e-cigarettes, predicts smoking cigarettes a year later.  Importantly, the effects of these different products in stimulating future cigarette smoking are independent of each other, which means that dual and poly-product increases the odds of progressing to smoking more than using one product alone.  This is very concerning because poly-product use is becoming the norm among young people.
Here is the UCSF press release on the paper:
Nonsmoking adolescents who use e-cigarettes, smokeless tobacco or tobacco water pipes are more likely to start smoking conventional cigarettes within a year, according to new research by UC San Francisco.
The study analyzed data from a nationally-representative sample of more than 10,000 adolescents, ages 12 to 17. It is the largest study to date to estimate the impact between alternative tobacco use and the subsequent start of conventional cigarette smoking in youth.
Any form of tobacco, including e-cigarettes, was associated with future smoking, the authors reported, especially when adolescents used more than one product. As a result, novel tobacco products have the potential to undermine public health gains in combatting smoking, the researchers said.
The study will be published at 11 a.m. ET on Jan. 2, 2018, in JAMA Pediatrics.
“We found that teens who experimented with tobacco in any form were at greater risk of future smoking,” said senior author Benjamin W. Chaffee, DDS, PhD, an assistant professor at the UCSF School of Dentistry.
“In the last few years, research has focused on the potential of e-cigarettes to engage never-smoking adolescents in tobacco use,” Chaffee said. “Our findings confirm that the use of the full range of tobacco products, including e-cigarettes, cigars, tobacco water pipes, and smokeless tobacco, is associated with greater odds of future cigarette smoking.”
Approximately 90 percent of adult smokers smoked their first cigarette by the time they were 18. Earlier studies have shown that smoking a single cigarette per month during adolescence is tied to daily smoking during adulthood.
In recent years, non-cigarette tobacco products have become increasingly popular among youth, especially e-cigarettes, the most common form of tobacco used by youth. In 2016, nearly 4 million middle and high school students used at least one tobacco product, and 1.8 million of the students reported using two or more products, studies have shown.
The new UCSF study was based on some 10,384 respondents in the Population Assessment of Tobacco and Health (PATH) study, who said they’d never tried a cigarette. The PATH Study is a collaboration between the FDA and the National Institutes of Health. Never-smoking youth were first interviewed from September 2013 to December 2014.
Questionnaires looked at eight types of combustible and noncombustible tobacco and nicotine products: bidis, cigarettes, cigars (traditional, filtered, and cigarillos), e-cigarettes, hookah (tobacco water pipes), kreteks, pipes, and smokeless tobacco (chewing tobacco, dissolvable tobacco, moist snuff, and snus). All youth participants had parental consent.
“This finding is particularly important because products like cigarillos and smokeless tobacco are often used by young people of vulnerable populations. A focus solely on e-cigarettes ignores health risks for those youth,” said first author Shannon Lea Watkins, PhD, a postdoctoral fellow at the UCSF Center for Tobacco Control Research and Education.
The mean age for adolescents participating in the study was 14.3 years. The estimated effects of non-cigarette tobacco products on subsequent cigarette smoking were adjusted for sociodemographic, environmental and behavioral smoking risk factors.
A year later, 469 adolescents (4.6 percent) said they’d tried a cigarette; and 219 (2.1 percent) had smoked a cigarette within the past 30 days. Smoking was higher among adolescents who used e-cigarettes (19.1 percent); hookah (18.3 percent); non-cigarette combustible tobacco (19.2 percent); or smokeless tobacco (18.8 percent).
After adjusting for smoking risk factors, the odds of smoking the previous month were approximately twice as high among e-cigarette users and more than three times as high for those who used multiple products, an increasingly common use pattern in adolescents.
Various factors could explain the findings, the authors said: Using non-cigarette tobacco products might induce nicotine dependence; adolescents might find that such products are more convenient and effective in satisfying nicotine cravings; and use of the products could change how adolescents perceive cigarettes.
The authors note that even if young people don’t progress to smoking cigarettes, “any tobacco use is harmful.” They suggest that policies such as restricting flavors in e-cigarettes and raising the age of tobacco purchasing could divert youth from becoming smokers. They also said that the paper provides support for legislation to ban flavored tobacco products on the grounds that flavors are used to attract youth to the non-cigarette tobacco products studied here. In San Francisco, a measure seeking to repeal the ban is heading to voters this year.
“San Francisco and Oakland have both acted to ban the sale of flavored tobacco,” Watkins said. “These are measures that the tobacco industry is attempting to overturn. Any policy designed to keep kids from smoking needs to account for alternative products. Our findings suggest that flavor restrictions, raising the minimum purchase age to 21, and higher excise taxes on non-cigarette products not only make these non-cigarette products less appealing to youth, but have the benefit of fewer kids being led to cigarette smoking as well.”
The paper was co-authored by Stanton Glantz, PhD, professor of medicine and director of the UCSF Center for Tobacco Control Research and Education. The research was supported in part by grant P50 CA180890 from the U.S. National Cancer Institute and Food and Drug Administration Center for Tobacco Products; grant R01DA043950 from the National Institute on Drug Abuse; grant KL2TR000143 from the U.S. National Center for Advancing Translational Sciences; and grant T32CA113710-11 from the National Cancer Institute.
UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, transitional and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children's Hospitals in San Francisco and Oakland, and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.
Here is the abstract from the paper:
Question  Does noncigarette tobacco use among never-smoking youth determine subsequent cigarette smoking initiation?
Findings  In this cohort study of the Population Assessment of Tobacco and Health, ever and past 30-day use of electronic cigarettes, hookah (tobacco waterpipe), noncigarette combustible tobacco, or smokeless tobacco was associated with cigarette initiation within 1 year.
Meaning  Youths who use any tobacco product may be at greater risk of initiating cigarette smoking.
Importance  Approximately 90% of adult smokers first tried a cigarette by 18 years of age, and even infrequent smoking in adolescence is associated with established adult smoking. Noncigarette tobacco use is increasing and could stimulate subsequent conventional cigarette smoking in youths.
Objective  To estimate the longitudinal association between noncigarette tobacco use and subsequent cigarette smoking initiation among US youth.
Design, Setting, and Participants  In this prospective cohort study of the Population Assessment of Tobacco and Health (PATH) waves 1 (September 12, 2013, to December 14, 2014) and 2 (October 23, 2014, to October 30, 2015), a nationally representative sample of youths who never smoked a conventional cigarette at baseline and completed wave 2 follow-up (N = 10 384) was studied. PATH retention at follow-up was 87.9%.
Exposures  Ever use and past 30-day use of electronic cigarettes (e-cigarettes), hookah, noncigarette combustible tobacco, or smokeless tobacco at baseline.
Main Outcomes and Measures  Ever use and past 30-day use of cigarettes at follow-up.
Results  The present analysis was based on the 10 384 PATH youth respondents who reported never having smoked a cigarette in wave 1 and whose cigarette ever or past 30-day use was reported in wave 2 (mean [SD] age, 14.3 [1.7] years; age range, 12-17 years; 5087 [49.1%] female; 4829 [52.5%] white). At 1-year follow-up, 469 (4.6%) of all baseline never-smoking youths had tried a cigarette and 219 (2.1%) had smoked a cigarette within the past 30 days. Cigarette ever use at follow-up was higher among youths who had ever used e-cigarettes (78 [19.1%]), hookah (60 [18.3%]), noncigarette combustible tobacco (45 [19.2%]), or smokeless tobacco (29 [18.8%]) at baseline. After adjusting for sociodemographic, environmental, and behavioral smoking risk factors and for baseline ever use of other tobacco products, the odds of past 30-day cigarette use at follow-up were approximately twice as high among baseline ever users of e-cigarettes (odds ratio [OR], 1.87; 95% CI, 1.15-3.05), hookah (OR, 1.92; 95% CI, 1.17-3.17), noncigarette combustible tobacco (OR, 1.78; 95% CI, 1.00-3.19), and smokeless tobacco (OR, 2.07; 95% CI, 1.10-3.87). Youths who had tried more than 1 type of tobacco product at baseline had 3.81 (95% CI, 2.22-6.54) greater adjusted odds of past 30-day cigarette smoking at follow-up than did baseline never tobacco users.
Conclusions and Relevance  Any use of e-cigarettes, hookah, noncigarette combustible tobacco, or smokeless tobacco was independently associated with cigarette smoking 1 year later. Use of more than 1 product increased the odds of progressing to cigarette use.
The full citation is  Shannon Lea Watkins, Stanton A. Glantz, Benjamin W. Chaffee. Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015. JAMA Pediatr. Published online January 02, 2018. doi:10.1001/jamapediatrics.2017.4173.  The paper is available here.



Here is some of the press coverage of this paper:

“Teens who try tobacco products that aren't cigarettes are twice as likely to try cigs a year later” CNBC, January 2, 2018.



“Teen use of non-cigarette tobacco products increases smoking risk - Multiple product use linked to fourfold increase in smoking risk,” MedPage Today, January 2, 2018. https://www.medpagetoday.com/pulmonology/smoking/70271


“E-cigarettes may be a gateway to smoking for teens, researchers say” CBS News, January 2, 2018.



“Teens who start vaping are more likely to end up smoking, UCSF study finds” SF Chronicle, January 2, 2018.



“Study finds teens who vape, chew tobacco more likely to later smoke cigarettes” 89.3 WFPL (NPR outlet in KY), January 2, 2018.



“Teens who smoke e-cigarettes, hookahs twice as likely to use cigarettes: Study” The Washington Times, January 2, 2018. https://www.washingtontimes.com/news/2018/jan/2/teens-who-smoke-e-cigarettes-hookahs-twice-as-like/


“E-cigarettes ARE a gateway to tobacco: Teenagers who use them are twice as likely to smoke, study reveals” The Daily Mail, January 2, 2018.



“Teens who smoke hookah, e-cigarettes are more likely to try cigarettes, study says,” The Atlanta Journal-Constitution, January 2, 2018.



“Teens who vape likely to try cigarettes, study finds,” Courthouse News, January 2, 2018.



“The talk you should have with your teen about e-cigarettes,” Deseret News, January 3, 2018.



“Adolescents who use e-cigarettes are twice as likely to smoke, new report says,” Times-Mail, January 3, 2018. https://www.tmnews.com/life/adolescents-who-use-e-cigarettes-are-twice-as-likely-to/article_7df4bafb-c203-5cb7-baa0-a93231e9bf3a.html


“Adolescents who use e-cigarettes are twice as likely to smoke, new report says,” Times-Mail, January 3, 2018.



“The truth about teen vaping is revealed in a new scientific study - And it isn't good news,” GlaucestershireLive, January 3, 2018.



“Youth use of cigarette alternatives may raise risk of trying the real thing,” TCTMD, January 3, 2018.



“VAPING DANGER: Teenagers who start using e-cigarettes are twice as likely to become regular smokers within a year, study claims,” The Sun, January 3, 2018.



“Vaping DANGER: Teens who use e-cigs are 'TWICE as likely to become regular smokers',” The Daily Star, January 3, 2018.



“Use of non-cigarette tobacco products tied to teen smoking,” Reuters, January 4, 2018.



“Use of non-cigarette tobacco products tied to teen smoking,” Business Insider, January 4, 2018.



“Non-cigarette tobacco use tied to future cigarette use in teens: E-cigarettes, hookah, non-cigarette combustible tobacco linked with cigarette smoking 1 year later,” Physician’s Briefing, January 4, 2018.



“Non-cigarette tobacco use tied to future cigarette use in teens,” MedicalXpress, January 4, 2018. https://medicalxpress.com/news/2018-01-non-cigarette-tobacco-tied-future-cigarette.html


Jongeren gaan eerder ‘echt’ roken van e-sigaretten,” NRC Handelsblad, January 4, 2018.

(“Young people are more likely to ‘really’ smoke because of e-cigarettes”)



“Noncigarette tobacco product use is associated with future cigarette smoking,” 2Minute Medicine, January 4, 2018. https://www.2minutemedicine.com/noncigarette-tobacco-product-use-is-associated-with-future-cigarette-smoking/


“Adolescents who use e-cigarettes are twice as likely to smoke, new report says,” Reporter-Times, January 4, 2018






Business Insider:



Deseret News:



HealthDay/Medical Xpress:



2Minute Medicine:



Daily Star (England):



The Sun (UK):



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