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Objective: This study utilized a socioecological approach to prospectively identify intrapersonal, familial, and environmental factors associated with single nicotine product use (NPU) and multiple NPU among U.S. youth., Methods: Participants were 10,029 youths (ages 12-17 years) who had completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments and data on past 30-day nicotine product use. Multinomial logistic regression was fit for the 3-level outcome (no use, single NPU, multiple NPU) to estimate adjusted associations between the predictors and the outcome., Results: The current study found that intrapersonal (sex, age, race/ethnicity, internalizing symptoms, sensation seeking, harm perceptions, lifetime history of using two or more tobacco products), familial (parental discussion about not using tobacco and living with someone who uses tobacco products) and environmental factors (exposure to tobacco advertising) commonly associated with tobacco use differentiated between individuals who later reported past 30-day NPU (either multiple or single NPU) from those who did not report past 30-day NPU. One familial factor only differentiated between lifetime users who were single NPUs from those who reported no NPU: non-combustible tobacco product use allowed anywhere in the home. Intrapersonal factors differentiated multiple NPU from single NPU: older age, being male, lifetime history of using nicotine product and less harm perceptions., Conclusions: This study identified factors that may be studied to prevent any NPU, along with factors that may be studied to promote harm reduction by preventing escalation of single NPU to problematic patterns of multiple NPU., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This study examines the demographic factors associated with youths' first product tried (i.e., cigarettes, e-cigarettes, cigars, hookah, or smokeless tobacco). This study also evaluates whether the first product tried is associated with future nicotine product use (i.e., no use, single product use, and multiple product use) and nicotine dependence. Participants were 1999 youths (ages 12-17 years) who had ever tried a nicotine product and completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments. Two separate multinomial logistic regression models examined the association between 1) demographic factors and the first product tried at Wave 1 and 2) the first product tried at Wave 1 and past-30-day product use status at Wave 4. A two-part multivariable model examined the association between the first product tried and nicotine dependence, with part 1 modeling the presence (or absence) of any symptom of dependence and part 2 modeling the degree of dependence among those with any symptom of dependence. The first product tried was associated with sex, race, urbanicity, and parent education. First trying smokeless tobacco (vs. e-cigarettes) was associated with a greater likelihood of multiple product use (vs. no use and vs. single product use). Regarding the degree of nicotine dependence (n = 713), first trying smokeless tobacco (vs. e-cigarettes) was associated with higher nicotine dependence scores among those with any symptom of dependence. Youths who first try smokeless tobacco (vs. e-cigarettes) may be at higher risk for future multiple product use and more symptoms nicotine dependence. Research should explore tailored interventions for smokeless tobacco users., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Use of flavored tobacco has been associated with lower likelihood of short-term abstinence from tobacco. It is unknown whether longer-term associations exist, particularly for a variety of products and specific flavor categories. This study used adult survey data from the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). We tested associations of past 30-day tobacco product use at wave 2 using both a 2-category any flavor versus unflavored variable and 4-category specific flavor (menthol/mint, sweet, and both menthol/mint and sweet) versus unflavored variable with past 12-month cessation from the same product two years later at wave 4. Separate models were run for each product (combustible cigarettes, cigars, hookah, e-cigarettes, and smokeless), adjusting for wave 1 sociodemographic characteristics. For all five products, past 30-day use of any flavored (versus unflavored) product at wave 2 was associated with reduced likelihood of same-product cessation at wave 4. Most specific flavor categories were associated with reduced odds of same-product cessation across all products. Any flavor use was also associated with reduced likelihood of longer-term cessation (i.e., past 24-months at both waves 3 and 4) and cessation from all five tobacco products in several analyses. Exploratory moderation results indicated that the association between e-cigarette flavor use and lower likelihood of cessation was stronger for young adults (18-24) versus older adults (25+). Current use of flavored tobacco products is associated with lower likelihood of product cessation. Flavored tobacco products warrant consideration in regulatory policy to reduce the adverse public health impact of tobacco use., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Menthol cigarette use contributes to disproportionate tobacco-related health disparities amongst minoritized race/ethnic groups. E-cigarettes are available in flavors such as menthol and may be a less harmful substitute among adults who smoke. Yet little is known about e-cigarette flavor preference and reasons for use by race/ethnicity among adults who smoke menthol cigarettes., Methods: Nationally representative PATH wave 4 adult data (Dec. 2016-Jan. 2018) were used to examine how menthol cigarette status and race/ethnicity were associated with past 30-day e-cigarette use, flavors used, and reasons for use with adjusted logistic regression models., Results: Menthol (vs. non-menthol) cigarette use was associated with higher odds of e-cigarette use (AOR=1.33, 95%CI=1.16-1.52). However, non-Hispanic (NH) Black and Hispanic individuals (vs. NH White) had lower odds of e-cigarette use (p's ≤ 0.004). In terms of flavor used, adults smoking menthol cigarettes and NH Black and Hispanic individuals had greater odds of using menthol/mint-flavored e-cigarettes (p's ≤ 0.02), and older adults (vs. 18-24-year-olds) had lower odds of using sweet-flavored e-cigarettes (p's < 0.0001). Regarding reasons for use, adults smoking menthol cigarettes had higher odds of reporting using e-cigarettes due to liking flavors (AOR=1.63, 95%CI=1.30-2.04), while NH Black adults had lower odds of liking flavors (AOR=0.64, 95%CI=0.43-0.96), and Hispanic adults had lower odds of using e-cigarettes to cut down on cigarette smoking (AOR=0.59, 95%CI=0.42-0.83)., Conclusions: Findings suggest menthol flavored e-cigarettes may be important for adults who smoke menthol cigarettes, although racial disparities in current e-cigarette use and reasons for use may exacerbate tobacco-related health disparities., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Importance: Multiple nicotine product use (MNPU) among youths is a significant public health concern. Much remains unknown about the patterns of MNPU in youths, including how socioecological factors influence trajectories of MNPU, which may inform targeted prevention., Objective: To identify longitudinal trajectories of MNPU and characterize them according to socioecological factors associated with tobacco use., Design, Setting, and Participants: This US-based longitudinal survey study used data from waves 1 (September 12, 2013, to December 14, 2014) through 4 (December 1, 2016, to January 3, 2018) of the Population Assessment of Tobacco and Health (PATH) study. Participants included 10 086 youths (aged 12-17 years) at wave 1, with follow-up data at waves 2 to 4 (assessed approximately 1 year apart) in the youth or adult data sets. Data were analyzed from January 15, 2020, to December 22, 2021., Exposures: Socioecological factors at wave 1., Main Outcomes and Measures: Outcome variables were days of use in the past 30 days of 4 products: cigarettes, e-cigarettes, cigars, and smokeless tobacco. Factors associated with use of the nicotine products that were collected at wave 1 included sociodemographic factors, internalizing and externalizing symptoms, living with a tobacco user, rules about tobacco use at home, conversations with parents about not using tobacco, tobacco accessibility, and exposure to advertising. Multitrajectory latent class growth analysis was used to identify distinct subgroups with similar patterns of use over time. Multinomial logistic regression models were used to investigate factors associated with class membership. Weights were applied to all data except frequencies to account for the complex survey design., Results: Of the 10 086 youths included in the analysis, 5142 (51.2%) self-identified as male; 4792 (54.7%) were non-Hispanic White; and 5315 (50.6%) were aged 12 to 14 years. Six latent trajectory classes were identified: nonuse (8056 [78.2%]), experimentation (908 [9.8%]), increasing e-cigarette/cigarette use (359 [4.0%]), increasing cigarette/cigar use (320 [3.3%]), decreasing cigarette/e-cigarette/cigar use (302 [3.2%]), and stable smokeless tobacco/cigarette use (141 [1.6%]). Compared with the nonuse class, being older (odds ratio [OR] range, 2.54 [95% CI, 1.94-3.32] to 9.49 [95% CI, 6.03-14.93]), being female (OR range, 0.06 [95% CI, 0.03-0.14] to 0.71 [95% CI, 0.53-0.94]), living with a tobacco user (OR range, 1.43 [95% CI, 1.11-1.83] to 4.94 [95% CI, 3.43-7.13]), and having relaxed rules about noncombustible tobacco product use at home (OR range, 1.41 [95% CI, 1.02-1.94] to 3.42 [95% CI, 1.74-6.75]) were associated with classification in all the use classes. A high degree of difficulty accessing tobacco was associated with lower odds of membership in the increasing cigarette/cigar use vs nonuse classes (OR, 0.62 [95% CI, 0.40-0.98])., Conclusions and Relevance: These survey results highlight the heterogeneity of longitudinal pathways of MNPU in US youths and suggest directions for future prevention and regulatory efforts directed at tobacco use behaviors in this population.

Characterizing variations in the timing of alcohol, cigarette, and cannabis use onset both among and between Black and White youth can inform targeted prevention. The current study aimed to capture cross-substance initiation patterns in Black and White girls and characterize these patterns with respect to substance use related socioeconomic, neighborhood, family, community, and individual level factors. Data were drawn from interviews conducted at ages 8 through 17 in an urban sample of girls (n = 2172; 56.86% Black, 43.14% White). Discrete-time multiple event process survival mixture modeling was used to identify patterns (i.e., classes) representing timing of alcohol, cigarette, and cannabis use initiation, separately by race. Class characteristics were compared using multinomial logistic regression. Among both Black and White girls, four classes, including abstainer and cross-substance early onset classes, emerged. Two classes characterized by mid-adolescence onset (Black girls) and variation in onset by substance (White girls) were also observed. Class differences centered around cannabis for Black girls (e.g., preceding or following cigarette use) and alcohol for White girls (e.g., (in)consistency over time in greater likelihood of initiation relative to cigarette and cannabis use). Several factors distinguishing the classes were common across race (e.g., externalizing behaviors, friends' cannabis use); some were specific to Black girls (e.g., intentions to smoke cigarettes) or White girls (e.g., primary caregiver problem drinking). Findings underscore the need to recognize a more complex picture than a high-risk/low-risk dichotomy for substance use initiation and to attend to nuanced differences in markers of risky onset pathways between Black and White girls., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The purpose of this study is to evaluate the association of electronic nicotine product (ENP) use and its respiratory manifestations in a nationally representative sample of adolescents in the US. Cross-sectional evidence from 9750 adolescents in wave 3 (October 2015-October 2016) of the Population Assessment of Tobacco and Health (PATH) survey was used. Adjusting for demographics, lifetime number of cigarettes and cigars used, home rules about tobacco use, and tobacco used by other household members, we used logistic regression models to examine associations between ENP use and its respiratory manifestations in the past year. Among 9750 adolescents, 12% ( n = 1105) used ENP in the past year. Compared to non-users, past-year ENP-users had 37% higher odds of wheezing in general (Adjusted Odds Ratio (AOR) = 1.37, 95% Confidence interval (CI): 1.11-1.71, p = 0.005) and higher odds of wheezing 4-12 times or >12 times per year versus no wheezing (AOR = 1.57, 95% CI: 1.01-2.46, p = 0.05 and AOR = 2.58, 95% CI: 1.04-6.41, p = 0.04, respectively). Additionally, odds of dry cough at night were 23% higher among ENP-users than among non-users (AOR = 1.23, 95% CI: 1.04-1.46, p = 0.02). There was no association between past-year ENP use and exercise-induced wheezing or asthma diagnosis. Among those with asthma, there was no evidence of an association between ENP use and long-acting inhaler or quick-relief inhaler use. ENP use among adolescents is associated with increased frequency of wheezing and dry cough. Early recognition of pulmonary clinical manifestations among young ENP users should be critical considerations in regulatory and prevention efforts to protect public health, and clinical efforts to prevent progression to serious pulmonary complications.

In recent years, the tobacco use landscape among youth has changed greatly, underscoring a need to understand current tobacco product initiation patterns. This study aimed to examine if adolescents' first tobacco product tried differs by race/ethnicity and socioeconomic status (SES). Cross-sectional survey data were collected from 6 Connecticut high schools in Spring 2019 (N = 4875). The analytic sample comprised ever users of tobacco products who reported on the first tobacco product they tried (N = 2530; 53.6% female). Of ever tobacco product users, 64.6% reported that their first tobacco product tried was an e-cigarette, 24.4% reported blunts, 6.5% reported another tobacco product, and 4.5% reported cigarettes. A multinomial logistic regression model examined race/ethnicity and SES as predictors of the first tobacco product tried with cigarettes as the reference group. Compared to Non-Hispanic (NH) White students, NH Black students (OR = 0.38, 95%CI = 0.17-0.82), Hispanic students (OR = 0.44, 95%CI = 0.27-0.71), and students of other NH races (OR = 0.30, 95%CI = 0.18-0.52) were less likely to report initiating tobacco product use with e-cigarettes. Additionally, compared to NH White students, NH Black students were more likely to report using blunts as their first tobacco product (OR = 3.01, 95%CI = 1.38-6.56). Compared to low SES, middle SES (OR = 1.62, 95%CI = 1.04-2.52) was associated with greater odds of reporting e-cigarettes as the first tobacco product. These findings suggest that youth of different backgrounds initiate tobacco use with different tobacco products and tailored prevention strategies are needed., (Copyright © 2020. Published by Elsevier Ltd.)

Introduction: Most tobacco use is initiated during adolescence and susceptibility is an important predictor of initiation. Research is needed to understand susceptibility across tobacco products among youth to inform prevention efforts., Aims and Methods: We surveyed 2945 students from four Southeastern Connecticut high schools in 2017. We assessed susceptibility to future use of seven different tobacco products (ie, cigarettes, e-cigarettes, hookah, cigars, cigarillos, blunts, and smokeless tobacco) among youth who had never used a tobacco product. Susceptibility was coded as any response other than "definitely not" to three items assessing (1) curiosity, (2) willingness to experiment with the product in the future, and (3) willingness to try if offered by a friend. Latent class analysis was used to identify patterns of susceptibility across multiple tobacco products and sociodemographic predictors of these classes., Results: Among n = 1246 youth who had never tried a tobacco product, 51.2% (n = 638) were susceptible to at least one product and 29.1% (n = 363) were susceptible to two or more products (average among susceptible youth: M = 2.4 products, SD = 1.7, range 1-7). Latent class analysis identified three classes: youth who were: (1) susceptible to all products (5.6%), (2) susceptible to e-cigarettes, hookah, and blunts (23.6%), and (3) mostly non-susceptible to all products (70.8%). In a multivariable model, demographic variables and peer tobacco use predicted class membership., Conclusions: We observed high rates of susceptibility to non-traditional tobacco products among youth, and many youth were susceptible to more than one product. Targeting susceptibility across multiple tobacco products may be important for reducing youth tobacco use., Implications: Patterns of polytobacco use susceptibility were identified among youth who had never previously used tobacco products. Many youth were susceptible to more than one product and we observed three distinct classes of susceptibility among youth: those who were mostly non-susceptible, those who were susceptible to alternative or non-traditional tobacco products (e-cigarettes, hookah, and blunts), and those who were susceptible to all tobacco products. These findings suggest the importance of addressing susceptibility across multiple tobacco products., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: E-cigarettes appeal to adolescents because of alternative uses, such as dripping (i.e., applying e-liquid directly on the atomizer) and conducting vape tricks (i.e., creating shapes from exhaled aerosol). However, little is known about these behaviors and adolescents who engage in these behaviors., Methods: Using cross-sectional surveys from 4 high schools in Connecticut in 2017 (N = 2945), we assessed the frequency of dripping and conducting vape tricks, product characteristics (e.g., nicotine, flavor) used for these behaviors, and where adolescents learn about these behaviors. We also conducted multinomial logistic regression analysis to assess whether demographics, age of e-cigarette use onset, past-month-use of e-cigarettes, and lifetime use of other tobacco products were associated with dripping and/or vape tricks., Results: Among ever e-cigarette users (N = 1047), 20.5% ever dripped and 54.9% ever conducted vape tricks. The most frequently endorsed 1) flavors used for both behaviors were fruit, candy, and mint, 2) nicotine concentrations used for dripping was 3 mg and for vape tricks was 0 mg, and 3) the top source for learning these behaviors were friends. The multinomial model showed that earlier age of e-cigarette use onset, past-month-use of e-cigarettes, and lifetime use of other tobacco products were associated with dripping and vape tricks., Discussion: Engaging in dripping and vape tricks was associated with risky tobacco use behaviors (e.g., earlier age of onset, other tobacco use), and involved exposure to nicotine and flavors. Reducing appeal of dripping and vape tricks and preventing product characteristics that facilitate these behaviors may reduce harm to adolescents., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Prevalence estimates of electronic cigarette (e-cigarette) use may underestimate actual use in youth. Confusion resulting from the fact that a multitude of devices (eg, vape pens, JUULs) fall under the umbrella term "e-cigarettes," the use of different names to refer to e-cigarettes (eg, vapes, electronic vaping devices), and the use of different terminology to refer to e-cigarette use (eg, "vaping," "JUULing"), may lead some young e-cigarette users to incorrectly indicate nonuse. Therefore, we compared rates of endorsing lifetime e-cigarette use when adolescents were asked about lifetime e-cigarette use in two different ways., Methods: In May to June 2018, a total of 1960 students from two high schools in Connecticut completed a computerized, school-based survey. Participants first reported on lifetime "e-cigarette" use and, subsequently, on lifetime use of five different e-cigarette devices: disposables, cig-a-likes, or E-hookahs; vape pens or Egos; JUULs; pod systems other than JUULs such as PHIX or Suorin; and advanced personal vaporizers or mods., Results: In total, 35.8% of students endorsed lifetime "e-cigarette" use, whereas 51.3% endorsed lifetime use of at least one e-cigarette device. The kappa statistic indicated only 66.6% agreement between the methods of assessing e-cigarette use. Overall, 31.5% of adolescents who endorsed lifetime device use did not endorse lifetime "e-cigarette" use, although rates of discordant responding varied across subgroups of interest (eg, sex, race)., Conclusions: Assessing adolescents' use of specific e-cigarette devices likely yields more accurate results than assessing the use of "e-cigarettes." If these findings are replicated in a nationally representative sample, regulatory efforts requiring all e-cigarette devices to be clearly labeled as "e-cigarettes" may help to reduce confusion., Implications: Different prevalence estimates of lifetime e-cigarette use were obtained depending on the way that prevalence was assessed. Specifically, fewer adolescents (35.8%) endorsed lifetime e-cigarette use when they were asked "Have you ever tried an e-cigarette, even one or two puffs?" than when they were queried about lifetime use of five different e-cigarette devices (51.3%). Among those who endorsed lifetime use of at least one specific e-cigarette device, 31.5% did not endorse lifetime "e-cigarette" use. These findings suggest that when assessing adolescents' lifetime e-cigarette use, using of terms referring to specific devices likely produces more accurate prevalence estimates than using the term "e-cigarettes.", (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: We conducted a systematic review of the literature on cigar research on youth to identify potential future research agenda to generate evidence to inform cigar regulations to prevent cigar use among youth., Methods: We searched articles on Medline, EMBASE, and PsycINFO in April 2017 to identify articles relevant to cigars and adolescents. Two independent coders examined 48 articles to determine eligibility: (1) published between 2000-April 2017; (2) published in English; (3) conducted in the United States; (4) published in a peer-review journal; (5) examined cigars, cigarillos, or little cigars; (6) included youth (12-18 years old); and (7) included empirical data. Three independent coders reviewed the included articles (n = 48) to identify whether the studies addressed FDA's Research Priorities., Results: The studies addressed FDA's Research Priorities of "behavior" (n = 48), "communications" (n = 4), "marketing influences" (n = 1), and "impact analysis" (n = 1). Studies on "behavior" underscored the need for improvements in measurement, such as using brand names and distinguishing cigar products. The review revealed the need for restrictions on cigar flavors, development of media campaigns and interventions, increasing the cost (via taxation), and evaluating the impact of cigar policies., Conclusions: The studies mostly focused on surveillance of behaviors and use patterns, which revealed cigar specific issues to address in policies to decrease cigar use among youth. The lack of studies addressing other FDA's research priorities highlighted the critical need for future studies that inform prevention of youth cigar use., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Many e-cigarette users find the variety of e-cigarette flavors appealing. We examined whether preferences for e-liquid flavors and the total number of flavors preferred differed between samples of adolescent and adult e-cigarette users. We also examined whether these preferences were associated with e-cigarette use frequency for adolescents or adults, respectively., Materials and Methods: The analytic samples comprised 1) 396 adolescent, past-month e-cigarette users from 5 Connecticut high schools who completed an anonymous, school-based survey in Fall 2014 (56.1% male; 16.18 [1.18] years; 42.2% past-month smokers), and 2) 590 adult, past-month e-cigarette users who completed an anonymous, MTurk survey in Fall 2014 (53.7% male; 34.25 [9.89] years; 51.2% past-month smokers)., Results: Compared to adults, a larger proportion of adolescents preferred fruit, alcohol, and "other"-flavored e-liquids, whereas adults disproportionately preferred tobacco, menthol, mint, coffee, and spice-flavored e-liquids (p-values < .05). Adults also preferred a greater total number of flavors compared to adolescents and used e-cigarettes more frequently (p-values < .001). Flavor preferences uniquely were associated with frequency of e-cigarette use within the adolescent sample; the total number of flavors preferred was associated with more days of e-cigarette use (ηp2 = 0.04), as were preferences for fruit (ηp2 = 0.02), dessert (ηp2 = 0.02), and alcohol-flavored (ηp2 = 0.02) e-liquids., Conclusions: Flavor preferences differed between adolescent and adult samples. While youth reported less frequent e-cigarette use overall, their preferences for specific flavors and the total number of flavors preferred were associated with more days of e-cigarette use, indicating that flavor preferences may play an important role in adolescent e-cigarette use.

Background: Electronic cigarette (e-cigarette) use is common among youth, and there are concerns that e-cigarette use leads to future conventional cigarette use. We examined longitudinal associations between past-month cigarette and e-cigarette use to characterize the stability and directionality of these tobacco use trajectories over time., Methods: High school students ( N = 808, 53% female) completed surveys across 3 waves (2013, 2014, and 2015) in 3 public schools in Connecticut. Using autoregressive cross-lagged models, we examined bidirectional relationships between past-month cigarette and e-cigarette use over time. Models were adjusted for covariates related to tobacco use (ie, sex, race/ethnicity, socioeconomic status, and use of other tobacco products)., Results: Past-month e-cigarette use predicted future cigarette use (wave 1-2: odds ratio [OR] = 7.08, 95% confidence interval [CI] = 2.34-21.42; wave 2-3: OR = 3.87, 95% CI = 1.86-8.06). However, past-month cigarette use did not predict future e-cigarette use (wave 1-2: OR = 2.02, 95% CI = 0.67-6.08; wave 2-3: OR = 1.90, 95% CI = 0.77-4.71). Additionally, frequency of cigarette and e-cigarette use increased over time. By wave 3, 26% of cigarette users and 20.5% of e-cigarette users reported using 21-30 days out of the past month., Conclusions: E-cigarette use was associated with future cigarette use across 3 longitudinal waves, yet cigarette use was not associated with future e-cigarette use. Future research needs to examine mechanisms through which e-cigarette use leads to cigarette use. E-cigarette regulation and prevention programs may help prevent future use of cigarettes among youth., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objective: There is limited research on adolescents' use of e-cigarettes and other substances., Materials and Methods: 2241 Connecticut high school students completed anonymous, cross-sectional surveys assessing e-cigarette and other substance use. We used latent class analysis (LCA) to: (1) classify students based on their past-month use of e-cigarettes, cigarettes, cigars, smokeless tobacco, hookah, blunts, marijuana, and alcohol, and (2) determine if age, sex, or race predicted class membership., Results: Past-month e-cigarette use was 11.6%, and use rates for the remaining substances ranged from 2.8% (smokeless tobacco) to 20.7% (alcohol). The optimal latent class solution comprised four classes: (1) primarily abstainers (81.6%; abstainers), (2) primarily e-cigarette and alcohol users (4.6%; E-cigarette-Alcohol), (3) primarily marijuana and alcohol users (6.9%; Marijuana-Alcohol), and (4) primarily users of all products (6.9%; All Products). Compared to abstainers, (1) all substance-using classes comprised older students, (2) the All Products and E-cigarette-Alcohol classes were more likely to comprise males and less likely to comprise Blacks, and (3) the Marijuana-Alcohol class was more likely to comprise Blacks and Latinos. Relative to the All Products and E-cigarette-Alcohol classes, the Marijuana-Alcohol class was more likely to comprise females, Blacks, and Latinos., Conclusions: LCA identified four substance use classes, two of which included elevated e-cigarette use. Class membership differed by age, sex, and race. Additional research should evaluate characteristics that may explain the different product use profiles identified in the current study including cultural differences, peer group norms, and differing perceptions of the harmfulness of each substance., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Evaluations of multiple tobacco product use and temporal changes in patterns of use are complicated by a large number of combinations and transitions. Visualization tools could easily identify most common patterns and transitions.Methods: Set intersection bar plots describe ever use of five tobacco products among 12-17 years old youth in wave 1 of the Population Assessment of Tobacco and Health (PATH) study (N = 11 497). Heat maps visualize unweighted frequencies of transitions from ever use at wave 1 (2013-2014) to past 12-month use at wave 2 (2014-2015). Weighted calibrated heat maps assess differences in relative frequencies of transitions by pattern at wave 1 and identify differences in transitions by sex.Results: The most common tobacco product ever use patterns in wave 1 were of cigarettes only, e-cigarettes only or hookah only, followed by ever use of both cigarettes and e-cigarettes. Initiation of use between waves was uncommon. The most frequent transition among those who reported use at wave 2 but not at wave 1 (N = 971) was to e-cigarette use (N = 301). However, among e-cigarette-only ever users at wave 1 (N = 260), about half did not report any product use at wave 2. Use of three or more products remained stable. Adolescent girls compared to boys appeared more likely to report hookah use at both waves.Conclusion: Set intersection bar plots and heat maps are useful for visualizing tobacco product use patterns and transitions, especially for multiple products. Both techniques could identify common problematic tobacco use patterns across and within populations.Implications: Given the growing complexity of the youth tobacco use landscape, approaches to efficiently communicate patterns of multiple tobacco product use should be used more often. This study introduces set intersection bar plots and modified versions of heat maps to the tobacco product literature and illustrates their use in the PATH youth sample. These techniques are useful for visualizing absolute and relative frequencies of multiple possible patterns and transitions. They also suggest targets for subsequent statistical inference such as sex differences in hookah use. The methods can be applied more generally for data visualization wherever large number of combinations occurs. [ABSTRACT FROM AUTHOR]

Background and Aims: To estimate progression to polytobacco use (PTU) over 1 year among a sample of US youth. Design Prospective survey with two waves 1 year apart: wave 1 (2013–14) and wave 2 (2014–15). We conducted latent transition analysis (LTA) to identify latent class transitions and examine socio‐demographic predictors of transition types. Setting: United States. Participants: A total of 11, 996 people who were aged 12–17 years at wave 1. Measurements Publicly available data were used from the Population Assessment of Tobacco and Health (PATH) study, a nationally representative sample of US civilian, non‐institutionalized population aged 12 years and older. Tobacco use status was assessed and classified in terms of: never use, non‐current (not in the past 30 days) and current (past 30‐day) use of cigarettes, cigars, e‐cigarettes, hookah and smokeless tobacco. Other nicotine products were excluded because rates of use were either too low to model (e.g. pipe) or the product was not assessed in the PATH youth sample (e.g. nicotine replacement products). Findings We identified three distinct patterns: class 1, non‐use (wave 1 prevalence = 86%; wave 2 prevalence = 78%); class 2, ever use of cigarettes and e‐cigarettes (wave 1 prevalence = 11%; wave 2 prevalence = 14%); and class 3, current PTU (wave 1 prevalence = 4%; wave 2 prevalence = 7%). Probability of progression from non‐use to ever use of cigarettes and e‐cigarettes was 0.06 and ever use of cigarettes and e‐cigarettes to current PTU was 0.32. Non‐users were more likely to transition to ever use of cigarettes and e‐cigarettes if they were older (versus younger), white (versus non‐white) or if their parental education level was high school or less (versus more than high school); and ever users of cigarettes and e‐cigarettes to current PTU if they were older, male or white. Conclusions: US youth who had previously tried e‐cigarettes and cigarettes at wave 1 (2013–14) had a 32% chance of transitioning to current use of two or more tobacco products within 1 year. [ABSTRACT FROM AUTHOR]

Introduction: Given the US Food and Drug Administration (FDA)'s authority to regulate hookah, more research is needed to inform regulations intended to prevent youth from using hookah. This systematic review summarizes and assesses the literature related to hookah use among adolescents (11 to ≤18 years of age) in the United States from 2009 to 2017.Methods: Database searches yielded 867 peer-reviewed articles. After duplicates were removed, authors reviewed 461 articles for inclusion. Included articles (n = 55) were coded for study themes, study quality, and their relevance to FDA's research priorities. A qualitative synthesis is presented.Results: The following themes were identified: (1) prevalence of hookah use (n = 42), (2) tobacco use transitions (n = 7), (3) sociodemographic correlates (n = 35), (4) psychosocial risk factors (n = 21), (5) concurrent use of other tobacco products (n = 31), (6) concurrent use of other substances (n = 9), and (7) other (n = 15)-which includes low prevalence themes. The qualitative synthesis showed increasing rates of hookah use. Older age, male gender, positive social normative beliefs, higher peer use, as well as lower perceived risk were associated with hookah use. Longitudinal studies of youth hookah use showed bidirectional relationships between use of hookah and other tobacco products. All articles fell within FDA's research priority related to "behavior," and three priorities ("impact analysis," "health effects," and "toxicity") have not been explored for hookah use among US youth since 2009.Conclusions: The prevalence of hookah use among youth in the United States is increasing, thus more research is needed to inform policies targeted to protect this vulnerable population.Implications: This study represents a novel contribution to our understanding of hookah use among youth in the United States from 2009-the year that the Family Smoking Prevention and Tobacco Control Act was passed-to 2017. In recent years, hookah has become a more popular tobacco product among US youth; however, to date, no systematic reviews of hookah use among this population exist. Results highlight implications for future US FDA regulatory policy and identify gaps in research to be addressed in future studies. [ABSTRACT FROM AUTHOR]

Objectives: In this study, we identified groups of adolescents who share similar awareness and perceptions of harm regarding e-cigarettes, cigars, hookah, and smokeless tobacco. Methods: We used latent class analyses (LCA) with the data from Wave 1 (2013-14) of the Population Assessment of Tobacco and Health youth and parent survey (PATH; N = 13,650) to address the research goal. Multinomial logistic regression analysis assessed the associations between identified classes with demographic characteristics and tobacco use. Results: LCA identified 5 classes: (1) perceived harm across all alternative tobacco products (36.6%); (2) perceived harm for ecigarettes and smokeless tobacco but never heard of cigars and hookah (48.2%); (3) never heard of alternative tobacco products (8.6%); (4) mix of no harm and harm across alternative tobacco products (5.2%); and (5) "don't know" the harm across alternative tobacco products (1.4%). Relative to the class who perceived harm across all alternative tobacco products, classes of adolescents who were unaware of the products or did not know the harms were more likely to be non-white, younger, have lower parental education, and less likely to have tried an alternative tobacco product. Conclusions: Tobacco prevention should target vulnerable youth, such as adolescents who are non-white, young, and have low parental education. [ABSTRACT FROM AUTHOR]

Objectives: We evaluated the appeal and use of e-cigarette product features in a sample of high school students in Connecticut. Methods: In 2015, we conducted school-wide surveys in 8 high schools and analyzed data from 1765 students (877 susceptible tobacco-naïve never-e-cigarette users, 315 susceptible tobacco-exposed never-e-cigarette users, and 656 current e-cigarette users). Students were asked: "What is cool about e-cigarettes?" Response options included e-liquid ingredients (eg, flavors, nicotine content, propylene glycol/vegetable glycerin ratio [ie, PG/VG), the heating source (eg, battery), and physical design (eg, color, shape, appearance). Students were asked: "How do you customize your e-cigarette?" (Change flavors, voltage, PG/VG levels, temperature, skin/tank color, other) and use of nicotine in the e-liquid (yes/no). Multivariable regression assessed associations between current e-cigarette users' customization and e-cigarette use frequency (#days/month). Results: Flavors were the most appealing product feature among all groups. Among current users, using nicotine e-liquid was more prevalent than changing flavors (44.2% vs 29.6%). Using nicotine e-liquids and changing PG/VG ratios were associated with more frequent e-cigarette use among current users. Conclusions: These findings can inform tobacco regulatory actions that put forth evidence-based recommendations to manufacture eliquid flavors, nicotine concentrations and PG/VG ratios that prevent e-cigarette initiation and escalation of use. [ABSTRACT FROM AUTHOR]

Background E-cigarette use rates are high among youth, but there is limited information on the types of e-cigarette devices that are used by youth. Methods During Spring 2017, students from 4 high schools completed surveys on use of e-cigarette devices (cig-a-like, vape/hookah pen, modified devices or mods, and JUUL). Among youth who endorsed ever (lifetime) use of an e-cigarette and of at least one device (n = 875), we assessed 1) prevalence rates of ever and current (past-month) use of each device, 2) use of nicotine in each device, and 3) predictors [age, sex, race, socioeconomic status (SES), other tobacco use] of ever use of each device and of use of single versus multiple devices. Results Cig-a-likes were used least frequently (Ever use: cig-a-likes: 25.4%; vape/hookah pens: 60.6%; JUUL: 64.2%; mods: 71.2%; Current use: cig-a-likes: 7.3%; vape/hookah pens; 18.7%; mods: 33.1%; JUUL: 47.1%;). Nicotine use was highest for JUUL (JUUL: 80.3%; mods: 56.3%; cig-a-likes: 51.4%; vape/hookah pens: 46.8%). Among ever users of single devices, use of JUUL was highest (JUUL: 43%; mods: 32%; vape/hookah pens: 21%; cig-a-likes: 4%). Ever use of all devices, except JUUL, was associated with other tobacco product use. Ever use of JUUL was associated with higher SES. Ever use of multiple devices (two: 34.7%; three: 25.8%; four: 11.7%) compared with a single device (27.8%) was associated with other tobacco product use. Conclusions Targeted regulatory and prevention efforts that consider the use of multiple e-cigarette devices are needed to lower youth e-cigarette use rates. [ABSTRACT FROM AUTHOR]

Objective: Electronic (E-) cigarettes are one of the most popular tobacco products used by adolescents today. This study examined whether exposure to advertisements in (1) social networking sites (Facebook, Twitter, YouTube, Pinterest/Google Plus), (2) traditional media (television/radio, magazines, billboards), or (3) retail stores (convenience stores, mall kiosks, tobacco shops) was associated with subsequent e-cigarette use in a longitudinal cohort of adolescents.Methods: Data were drawn from longitudinal surveys conducted in fall 2013 (wave 1) and spring 2014 (wave 2) of a school-based cohort attending 3 high schools and 2 middle schools in Connecticut. Adolescents were asked about tobacco use behaviors and where they had recently seen e-cigarette advertising at wave 1. We used logistic regression to determine whether advertising exposure at wave 1 increased the odds of e-cigarette use by wave 2, controlling for demographics and cigarette smoking status at wave 1.Results: Among those who have never used e-cigarettes in wave 1 (n = 1742), 9.6% reported e-cigarette use at wave 2. Multivariate logistic regression demonstrated that exposure to e-cigarette advertising on Facebook (OR 2.12 = p < 0.02) at wave 1, but not other venues, significantly increased the odds of subsequent e-cigarette use wave 2. Age, white race, and cigarette smoking at wave 1 also was associated with e-cigarette use at wave 2.Conclusion: This study provides one of the first longitudinal examinations demonstrating that exposure to e-cigarette advertising on social networking sites among youth who had never used e-cigarettes increases the likelihood of subsequent e-cigarette use. [ABSTRACT FROM AUTHOR]

Introduction: Given high youth e-cigarette use, it is important to investigate how traits, like impulsivity, may be associated with youth e-cigarette use behaviors. The study aim is to determine if impulsivity is associated with trying more e-cigarette flavors and device types, and greater frequency of e-cigarette use.Method: Cross sectional survey data from CT high schoolers (n = 4875, 6 schools) were collected in 2019. Lifetime (ever) e-cigarette users (n = 2313) completed the Brief Barrett Impulsivity Scale, which contains two subscales; behavioral impulsivity and impaired self-control. Among lifetime users, associations between impulsivity subscales and number of e-cigarette flavors tried, e-cigarette devices tried, and past 30-day frequency of e-cigarette use were examined using regression models. Additionally, associations of impulsivity and use frequency were examined among only current e-cigarette users (≥1 day of use in past 30; n = 1327). School, age, race/ethnicity, vaping initiation age, other tobacco product use, and sex were included as covariates in models.Results: Higher behavioral impulsivity was associated with greater number of e-cigarette flavors tried (AOR: 1.06, 95% CI: 1.02, 1.11, p <.008) and higher frequency of past 30-day use both among ever and current e-cigarette users (AOR: 1.26, 95%CI:1.10,1.44, p <.001; AOR: 1.12, 95%CI:1.02,1.22, p <.02), but not number of e-cigarette devices tried. Impaired self-control was not associated with any outcomes.Conclusion: Youth with higher behavioral impulsivity may be more at risk for using more e-cigarette flavors and using e-cigarettes more frequently. Regulations aimed at reducing flavor availability among youth and interventions targeting impulsive behavior may be important for this population. [ABSTRACT FROM AUTHOR]

Background: Adolescent e-cigarette use has increased recently; however, little is known about trends in use of specific devices by youth. This study aims to 1) compare rates of e-cigarette device use over time, 2) examine changes in frequency of device use, and 3) identify predictors of device use.Methods: Cross-sectional surveys were distributed school-wide across 4 diverse Connecticut high-schools in 2017, 2018, 2019 and assessed current (i.e., past-30-day) use of various e-cigarette devices: disposables/cig-a-likes, vape pens, mods, JUULs, and other rechargeable pod devices (added in 2018 and 2019). Analyses compared rates of device use and frequency (i.e., number of days used in past 30) over time. Multivariable logistic regression models examined demographic and tobacco use characteristics (e.g., age first trying e-cigarettes) as predictors of current use of each device type in 2019.Results: From 2017-2019, rates of using JUUL, disposables/cig-a-likes, and vape pens increased significantly, while use of mods and other pod devices decreased (ps<.001). Over 59 % of youth reported using more than one e-cigarette device in 2019. Over time, more youth were frequent users (using ≥20 out of 30 days) of disposable/cig-a-likes (32 % to >46 %) and JUUL (28 % to >35 %) devices. In multivariable models, first trying e-cigarettes at a younger age was associated with current use of disposable/cig-a-like, vape pens, mods, and other rechargeable pod devices.Conclusions: From 2017-2019, JUUL, disposable/cig-a-like, and vape pens increased in popularity and were used frequently. Tobacco regulations designed to reduce youth use should consider various device types. [ABSTRACT FROM AUTHOR]