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The Population Assessment of Tobacco and Health (PATH) Study is a nationally representative study of the US population on tobacco use and its effects on health, with four waves of data collection between 2013 and 2017. Prior work described the methods of the first three waves. In this paper, we describe the methods of Wave 4, during which a replenishment sample was added to the ongoing cohort. We describe the design and estimation methods of the continuing Wave 1 cohort (with four waves of data) and the Wave 4 cohort (the new cohort created at Wave 4). We provide survey quality metrics, including response rates for both cohorts and a panel conditioning analysis, and guidance on understanding the target populations for both cohorts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In guidance published in February 2020, the FDA described their intent to prioritize enforcement against the sale of flavored cartridge-based Electronic Nicotine Delivery Systems (ENDS) except tobacco and menthol flavors. This guidance was specific to cartridge-based ENDS and did not apply to other ENDS types or e-liquids sold in the U.S.. It remains unknown if use of certain types of ENDS devices and flavors changed following the publication of this guidance., Methods: This analysis includes PATH Study data from Wave 5 (W5, 2018-2019) and Wave 6 (W6, 2021) and examines cross-sectional estimates of (1) use of flavored ENDS and (2) use of different device types. All analyses in this study were stratified by self-reported age (youth-aged 12-17 years at W5 and aged 14-17 years at W6, and adults-aged 18-20, 21-24, and 25+ years). Analyses were conducted in 2023-2024., Results: Among adults aged 21 years and over, there were significant increases in the use of menthol or mint flavored ENDS. There were no substantial changes in flavors of ENDS used among youth or adults aged 18-20 years. Among all age groups, the use of cartridge-based ENDS was lower in 2021 than 2018-2019, with a notable shift to disposable-style ENDS., Conclusions: Federal-level tobacco control actions taken in the U.S. in early 2020 prioritized enforcement against "any flavored, cartridge-based ENDS product (other than a tobacco- or menthol-flavored ENDS product)." Based on this analysis, there was a shift following the policy to menthol or mint-flavored ENDS and disposable-style ENDS., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

In the 50 years since its establishment, the National Institute on Drug Abuse has made significant investment and strides toward improving individual and public health. Epidemiology serves as the foundation for understanding the how many, why, how, where, and who of drug use and its consequences, and effective epidemiology research and training are geared toward actionable findings that can inform real-world responses. Epidemiologic findings enhance clinicians' ability to provide ongoing care by incorporating information about the patterns and outcomes of drug use that their patients may experience. The goal of this article is to provide a context for epidemiology of substance use as a foundation for prevention, with examples of how epidemiology can provide targets for prevention, and to set the stage for addressing the importance of prevention in clinical settings., Competing Interests: Dr. Parker reports investment holdings in Putnam Global Health Care Fund Class A (PHSTX). The other authors report no financial relationships with commercial interests., (Copyright © 2024 by the American Psychiatric Association.)

Introduction: Tobacco harm perceptions are associated with tobacco use for both youth and adults, but it is unknown how these harm perceptions have changed over time in a changing tobacco product landscape., Methods: Data from Waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study were analyzed to examine perceptions of harm of eight non-cigarette tobacco products compared to cigarettes. Perceptions of harm were assessed with the questions, "Is smoking/using [product] less harmful, about the same, or more harmful than smoking cigarettes?"., Results: The share of participants who perceived non-cigarette combustible products as posing similar harm to cigarettes increased over time, while the share of participants who perceived non-combustible products as less harmful than cigarettes decreased over time., Conclusions: Tobacco harm perceptions are changing over time, along with the tobacco product marketplace and regulatory environment., 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. Published by Elsevier Ltd.)

The Population Assessment of Tobacco and Health (PATH) Study is a nationally representative, longitudinal study of the US population on tobacco use and its effects on health, collecting data annually since 2013. The COVID-19 pandemic interrupted in-person survey data collections around the world. In the USA, this included a PATH Study data collection focused on youth (13-17) and young adults (18-19) as well as other US surveys on tobacco use. Given that it was necessary to pause data collection and considering that tobacco-use behaviours could be expected to change along with pandemic-related changes in the social environment, the original design for the 2020 PATH Study data collection for youth and young adults was modified. Also, the PATH Study Adult Telephone Survey was developed to address the need for adult tobacco use monitoring in this unprecedented time. This article describes the modifications made to the 2020 PATH Study design and protocol to provide nationally representative data for youth and adults after the onset of the COVID-19 pandemic as well as the implications of these modifications for researchers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: We compare real-world trends in population-level cigarette discontinuation rates among adults (ages ≥21) who smoked cigarettes, by electronic nicotine delivery systems (ENDS) use., Aims and Methods: U.S nationally representative data from adults in the Population Assessment of Tobacco and Health (PATH) Study (2013/14-2021, Waves 1-6) who smoked cigarettes in the past 30 days (P30D) were analyzed (n = 13 640). The exposure was P30D ENDS use. The outcome was P30D cigarette discontinuation at biennial follow-up. Weighted trend analyses were conducted to test for differences in cigarette discontinuation trends by ENDS use., Results: Between 2013/14 and 2015/16, cigarette discontinuation rates were both 16% for those who used ENDS and for those who did not; between 2018/19 and 2021, rates were ~30% for those who used ENDS and ~20% for those who did not; the time by ENDS use interaction was significant., Conclusions: The relationship between adults' ENDS use and cigarette discontinuation in the context of an expanded ENDS marketplace, new tobacco regulatory actions, and COVID-19 differs from the relationship in earlier years., Implications: It is important for public health decisions to be informed by research based on the contemporary ENDS marketplace and circumstances., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: Understanding the characteristics of premium cigar use patterns is essential for minimizing public health harms. Typically, premium cigars are handmade, larger, more expensive, and without the characterizing flavors that are present in other cigar types: Nonpremium traditional cigars, cigarillos, and filtered cigars., Aims and Methods: Self-reported brand and price data were used from Wave 6 of the Population Assessment of Tobacco and Health (PATH) Study to define and estimate premium versus nonpremium cigar use among U.S. adults, as well as to explore cigar smoking patterns, purchasing behavior, and reasons for use by cigar type., Results: In 2021, 0.9% (95% CI = 0.7-1.0) of adults were premium cigar users, compared to 0.4% of nonpremium traditional cigar users (95% CI = 0.3-0.5), 1.1% of cigarillo users (95% CI = 1.0-1.2), and 0.6% filtered cigar users (95% CI = 0.5-0.7). Premium cigar users were overwhelmingly male (97.7%), and 35.8% were aged ≥55 years. The average premium cigar price/stick was $8.67, $5.50-7.00 more than other cigar types. Compared to other cigar types, significantly fewer premium cigar users had a regular brand with a flavor other than tobacco (~15% vs. 38%-53%). Though flavors remained the top reason for premium cigar use, they were less likely to endorse flavors as a reason for use than other cigar users (~40% vs. 68-74%). Premium cigar users had a lower prevalence (aRR: 0.37, 95% CI = 0.25-0.55) of dual use of cigars and cigarettes., Conclusions: Although <1% of U.S. adults use premium cigars, their use and purchasing characteristics continue to differ from other cigar types, highlighting the importance of capturing data specific to premium cigar use., Implications: This manuscript extends previous research from the National Academies of Science, Engineering, and Medicine report, "Premium cigars: Patterns of use, marketing, and health effects" by utilizing the most recent PATH Study data (Wave 6) to examine patterns of cigar use, including purchasing behavior and reasons for use, by cigar type (eg, premium traditional cigars, nonpremium traditional cigars, cigarillos, and filtered cigars). The findings support continued research on patterns of premium cigar use, which differ from use patterns of other cigar types., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Importance: Information about national substance use trends among youths and adults after mid-March 2020 is limited due to constraints on surveillance during the COVID-19 pandemic., Objective: To evaluate whether substance use prevalence in the early part of the pandemic (2020) differed from the prepandemic periods of 2018 to 2019 and 2016 to 2018., Design, Setting, and Participants: This cross-sectional study was a repeated analysis of 2016 to 2020 data from a nationally representative sample of youths and adults in the Population Assessment of Tobacco and Health (PATH) Study. Participants were representative of the US civilian noninstitutionalized population. Household residents age 13 years or older were interviewed in person from 2016 to 2019 and via telephone in 2020., Exposures: Age, calendar year., Main Outcomes and Measures: Past 30-day self-reported use of any tobacco, any alcohol, binge drinking, cannabis, and any other illegal or misused prescription drugs., Results: The overall nationally representative 2020 sample included 7129 youths (ages 13-17 years), 3628 young adults (ages 18-20 years), and 8874 adults (ages ≥21 years). Comparing 2018 to 2019 with 2020 among youths, prevalence of all substances used declined (eg, cannabis use declined in those aged 16-17 years from 14.9% to 7.6%; absolute difference, -7.3 percentage points [95% CI -8.8 to -5.8 percentage points]). Among young adults, prevalence of all substances other than any alcohol decreased significantly (eg, tobacco use declined from 37.8% to 22.8%; absolute difference, -15.1 percentage points [95% CI -16.8 to -13.3 percentage points]). In adults ages 21 to 24 years, any tobacco use declined from 39.0% to 30.9% (absolute difference, -8.2 percentage points [95% CI, -10.6 to -5.7 percentage points]), and alcohol use increased from 60.2% to 65.2% (absolute difference, 5.0 percentage points [95% CI, 2.3 to 7.7 percentage points]). Among adults aged 25 years or older, any tobacco use declined from 39.0% to 30.9% (absolute difference, -8.2 percentage points [95% CI, -10.6 to -5.7 percentage points]), cannabis use increased from 11.3% to 12.4% (absolute difference, 1.2 percentage points [95% CI, 0.3 to 2.0 percentage points]), and other substance use declined from 5.8% to 3.7% (absolute difference, -2.1 percentage points [95% CI, -2.9 to -1.4 percentage points])., Conclusions and Relevance: In this cross-sectional study, substance use decreased between 2019 and 2020 among those aged 13 to 20 years; consistent declines were not seen in older persons other than tobacco use reductions, and cannabis use increased among adults ages 25 years and older. While social changes during the COVID-19 pandemic could have affected substance use, findings should be interpreted with caution due to differences in data collection methods in 2016 to 2019 and 2020.

Introduction: Much of the population-based e-cigarette use and cigarette cessation literature is restricted to smokers who have expressed intention to quit smoking, though experimental studies suggest e-cigarette use might motivate some smokers to change their quit intentions. We used U.S. nationally representative data to evaluate whether e-cigarette use by smokers initially not planning to ever quit is associated with change in plans to quit., Methods: Longitudinal Population Assessment of Tobacco and Health (PATH) Study data collected between 2014 and 2019 were analyzed. Main analyses were conducted among adult daily cigarette smokers not currently using e-cigarettes with no plans to ever quit smoking (n = 2366 observations from n = 1532 individuals). Generalized estimating equations were used to evaluate the association between change in e-cigarette use and change in plans to quit smoking within the next six months, over three assessment pairs., Results: Daily cigarette smokers with no plans to quit had a higher rate of change to plan to quit if at follow-up they used e-cigarettes daily (41.4%, 95% CI: 27.1-57.3%) versus not at all (12.4%, 95% CI: 10.6-14.5%; aOR = 5.7, 95% CI: 2.9-11.2). Rate of change to plan to quit did not statistically differ between those who at follow-up used e-cigarettes some days versus not at all., Conclusions: Among adult daily cigarette smokers initially not planning to ever quit, subsequent daily e-cigarette use is associated with subsequent plans to quit smoking. Population-level research on e-cigarette use that is focused on smokers already motivated to quit may limit a complete evaluation of the smoker population., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The purpose of this qualitative study was to gain a deeper understanding of how adult e-cigarette users describe quantity of e-cigarettes used. Data for this analysis came from a qualitative study of U.S. adult dual e-cigarette and cigarette users and former cigarette smokers aged 18 years and older. Eligible respondents from Wave 4 (2016-2017) of the Population Assessment of Tobacco and Health (PATH) Study responded to a brief web questionnaire and participated in an in-depth telephone interview (n = 112) between March and August 2018. Using the respondent's native terminology for their e-cigarette device, interviewers asked respondents to describe in their own words the quantity of e-cigarettes used. Using NVivo software, interview transcripts were coded and analyzed to identify themes and patterns. Respondents described quantity used in three different ways: number of times and/or puffs; device-specific terms (i.e., replacement of disposable devices, cartridges/pods; use of e-liquid); and perceived equivalence to a quantity of traditional cigarettes. The most commonly reported approach across all device types and levels of device proficiency, although with varying ease and specificity, was the number of times and/or puffs taken in a day. Several respondents used multiple approaches to describe quantity. E-cigarette users use a variety of approaches to describe quantity of e-cigarette used, contributing to challenges developing standardized survey measures. The variety of approaches should be taken into consideration along with device type and other contextual factors such as device proficiency when developing survey questions., Competing Interests: 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., (© 2021 Published by Elsevier Inc.)

Objective: To determine if the declining trend in U.S. youth cigarette smoking changed after e-cigarettes were introduced, and if youth e-cigarette users would have been likely to smoke cigarettes based on psychosocial and demographic predictors of smoking., Methods: An interrupted time series analysis was used for cross-sectional data from the 2004 to 2018 National Youth Tobacco Surveys (NYTS) to assess changes in cigarette and e-cigarette use over time. A multivariable logistic regression model used 2004-2009 NYTS data on psychosocial risk factors to predict individual-level cigarette smoking risk from 2011 to 2018. Model-predicted and actual cigarette smoking behavior were compared., Results: The decline in current cigarette smoking slowed in 2014 (-0.75 [95% CI: -0.81, -0.68] to -0.26 [95% CI: -0.40, -0.12] percentage points per year). The decline in ever cigarette smoking accelerated after 2012 (-1.45 [95% CI: -1.59, -1.31] to -1.71 [95% CI: -1.75, -1.66]). Ever and current combined cigarette and/or e-cigarette use declined during 2011-2013 and increased during 2013-2014 with no significant change during 2014-2018 for either variable. The psychosocial model estimated that 69.0% of current cigarette smokers and 9.3% of current e-cigarette users (who did not smoke cigarettes) would smoke cigarettes in 2018., Conclusions: The introduction of e-cigarettes was followed by a slowing decline in current cigarette smoking, a stall in combined cigarette and e-cigarette use, and an accelerated decline in ever cigarette smoking. Traditional psychosocial risk factors for cigarette smoking suggest that e-cigarette users do not fit the traditional risk profile of cigarette smokers., (Published by Elsevier Inc.)

Tobacco product use is the leading cause of preventable disease, disability, and death in the United States. This report used data from the 2019 Youth Risk Behavior Survey to assess the following among U.S. high school students: ever use of cigarettes and electronic vapor products, current use (≥1 day during the 30 days before the survey) of tobacco products, frequent use (≥20 days during the 30 days before the survey) among current users of tobacco products, trends in use over time, and usual source of electronic vapor products among current electronic vapor product users. In 2019, a total of 50.1% of U.S. high school students had ever used electronic vapor products, and 24.1% had ever tried cigarette smoking. Current electronic vapor product use was 32.7%, current cigarette smoking was 6.0%, current cigar smoking was 5.7%, and current smokeless tobacco use was 3.8%. Approximately 36.5% of students were current users of any tobacco product, and 8.2% were current users of two or more tobacco products. Frequent use among users of individual products was 32.6% for electronic vapor products, 28.5% for smokeless tobacco, 22.2% for cigarettes, and 18.4% for cigars. Among current electronic vapor product users who were aged ≤17 years, the most commonly reported source was borrowing them from someone else (42.8%). Significant decreases occurred in current cigarette smoking (1991: 27.5%; 2019: 6.0%), cigar smoking (1997: 22.0%; 2019: 5.7%), and smokeless tobacco use (2017: 5.5%; 2019: 3.8%). However, significant increases occurred in current electronic vapor product use (2015: 24.1%; 2019: 32.7%) and any tobacco product use (2017: 19.5%; 2019: 36.5%). Although current cigarette smoking, cigar smoking, and smokeless tobacco use has decreased among high school students, the increased prevalence of electronic vapor product use among youths is concerning. Continued surveillance for all tobacco product use is warranted for guiding and evaluating public health policy at the local, state, tribal, and national levels., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior., Implications: The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science., (© 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.)

Purpose: The purpose of this study was to compare characteristics of usual JUUL users versus other electronic nicotine delivery systems (ENDS) users, examine differences in reasons for use and perceptions across ENDS user groups, and identify significant correlates of usual JUUL use., Methods: This study used data from 510 young adult ENDS users (ages 18-29 years) from Wave 7 (Spring 2018) of the Marketing and Promotions Across Colleges in Texas Project (Project M-PACT). Chi-Square analyses, independent t-tests, and mixed-effects logistic regression analyses were conducted to identify factors associated with usual JUUL use. Four separate regression analyses were conducted based on independent variables of interest; all models included demographics and ENDS/other tobacco use behaviors as covariates., Results: Compared with other ENDS users, usual JUUL users were more likely to be male, younger, smoke cigarettes, reported a higher socioeconomic status (SES), used ENDS on more days in the past 30 days, and reported nicotine "hit" as a reason for use. Usual JUUL users had a higher prevalence of perceiving JUUL/pod vapes as addictive compared with other ENDS users, although perceived addictiveness was not significant in the multivariable models nor were the cessation and dependence measures different between ENDS user groups., Conclusions: Results highlight concerns about the dual use of JUUL and cigarettes and raise additional concerns about the high nicotine concentration of JUUL. Future longitudinal research is needed to determine if usual JUUL users are more likely to develop symptoms of nicotine dependence compared with other ENDS users., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: The prevalence of e-cigarette use among US youth increased from 2011 to 2018. Continued monitoring of the prevalence of e-cigarette and other tobacco product use among youth is important to inform public health policy, planning, and regulatory efforts., Objective: To estimate the prevalence of e-cigarette use among US high school and middle school students in 2019 including frequency of use, brands used, and use of flavored products., Design, Setting, and Participants: Cross-sectional analyses of a school-based nationally representative sample of 19 018 US students in grades 6 to 12 participating in the 2019 National Youth Tobacco Survey. The survey was conducted from February 15, 2019, to May 24, 2019., Main Outcomes and Measures: Self-reported current (past 30-day) e-cigarette use estimates among high school and middle school students; frequent use (≥20 days in the past 30 days) and usual e-cigarette brand among current e-cigarette users; and use of flavored e-cigarettes and flavor types among current exclusive e-cigarette users (no use of other tobacco products) by school level and usual brand. Prevalence estimates were weighted to account for the complex sampling design., Results: The survey included 10 097 high school students (mean [SD] age, 16.1 [3.0] years; 47.5% female) and 8837 middle school students (mean [SD] age, 12.7 [2.8] years; 48.7% female). The response rate was 66.3%. An estimated 27.5% (95% CI, 25.3%-29.7%) of high school students and 10.5% (95% CI, 9.4%-11.8%) of middle school students reported current e-cigarette use. Among current e-cigarette users, an estimated 34.2% (95% CI, 31.2%-37.3%) of high school students and 18.0% (95% CI, 15.2%-21.2%) of middle school students reported frequent use, and an estimated 63.6% (95% CI, 59.3%-67.8%) of high school students and 65.4% (95% CI, 60.6%-69.9%) of middle school students reported exclusive use of e-cigarettes. Among current e-cigarette users, an estimated 59.1% (95% CI, 54.8%-63.2%) of high school students and 54.1% (95% CI, 49.1%-59.0%) of middle school students reported JUUL as their usual e-cigarette brand in the past 30 days; among current e-cigarette users, 13.8% (95% CI, 12.0%-15.9%) of high school students and 16.8% (95% CI, 13.6%-20.7%) of middle school students reported not having a usual e-cigarette brand. Among current exclusive e-cigarette users, an estimated 72.2% (95% CI, 69.1%-75.1%) of high school students and 59.2% (95% CI, 54.8%-63.4%) of middle school students used flavored e-cigarettes, with fruit, menthol or mint, and candy, desserts, or other sweets being the most commonly reported flavors., Conclusions and Relevance: In 2019, the prevalence of self-reported e-cigarette use was high among high school and middle school students, with many current e-cigarette users reporting frequent use and most of the exclusive e-cigarette users reporting use of flavored e-cigarettes.

Cigarette smoking is the leading cause of preventable disease and death in the United States (1). The prevalence of adult cigarette smoking has declined in recent years to 14.0% in 2017 (2). However, an array of new tobacco products, including e-cigarettes, has entered the U.S. market (3). To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC, the Food and Drug Administration (FDA), and the National Cancer Institute analyzed data from the 2018 National Health Interview Survey (NHIS). In 2018, an estimated 49.1 million U.S. adults (19.7%) reported currently using any tobacco product, including cigarettes (13.7%), cigars (3.9%), e-cigarettes (3.2%), smokeless tobacco (2.4%), and pipes* (1.0%). Most tobacco product users (83.8%) reported using combustible products (cigarettes, cigars, or pipes), and 18.8% reported using two or more tobacco products. The prevalence of any current tobacco product use was higher in males; adults aged ≤65 years; non-Hispanic American Indian/Alaska Natives; those with a General Educational Development certificate (GED); those with an annual household income <$35,000; lesbian, gay, or bisexual adults; uninsured adults; those with a disability or limitation; and those with serious psychological distress. The prevalence of e-cigarette and smokeless tobacco use increased during 2017-2018. During 2009-2018, there were significant increases in all three cigarette cessation indicators (quit attempts, recent cessation, and quit ratio). Implementing comprehensive population-based interventions in coordination with regulation of the manufacturing, marketing, and distribution of all tobacco products can reduce tobacco-related disease and death in the United States (1,4)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Problem/condition: Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various smoked, smokeless, and electronic products., Period Covered: 2019., Description of System: The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered survey of U.S. middle school (grades 6-8) and high school (grades 9-12) students. A three-stage cluster sampling procedure is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and associated factors. NYTS is designed to provide national data on tobacco product use and has been conducted periodically during 1999-2009 and annually since 2011. Data from NYTS are used to support the design, implementation, and evaluation of comprehensive tobacco use prevention and control programs and to inform tobacco regulatory activities. Since its inception in 1999 through 2018, NYTS had been conducted via paper and pencil questionnaires. In 2019, NYTS for the first time was administered in schools using electronic data collection methods. CDC's Office on Smoking and Health, in collaboration with the U.S. Food and Drug Administration's (FDA's) Center for Tobacco Products, analyzed data from the 2019 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 19,018 questionnaires were completed and weighted to represent approximately 27.0 million students. On the basis of self-reported grade level, this included 8,837 middle school questionnaires (11.9 million students) and 10,097 high school questionnaires (15.0 million students); 84 questionnaires with missing information on grade level were excluded from school-level analyses., Results: In 2019, an estimated 53.3% of high school students (8.0 million) and 24.3% of middle school students (2.9 million) reported having ever tried a tobacco product. Current (past 30-day) use of a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis [small brown cigarettes wrapped in a leaf]) was reported by 31.2% of high school students (4.7 million) and 12.5% of middle school students (1.5 million). E-cigarettes were the most commonly cited tobacco product currently used by 27.5% of high school students (4.1 million) and 10.5% of middle school students (1.2 million), followed in order by cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco. Tobacco product use also varied by sex and race/ethnicity. Among current users of each tobacco product, the prevalence of frequent tobacco product use (on ≥20 days of the preceding 30 days) ranged from 16.8% of cigar smokers to 34.1% of smokeless tobacco product users. Among current users of each individual tobacco product, e-cigarettes were the most commonly used flavored tobacco product (68.8% of current e-cigarette users). Among students who reported ever having tried e-cigarettes, the three most commonly selected reasons for use were "I was curious about them" (55.3%), "friend or family member used them" (30.8%), and "they are available in flavors, such as mint, candy, fruit, or chocolate" (22.4%). Among never users of each individual tobacco product, curiosity and susceptibility (a construct that can help to identify future tobacco product experimentation or use) was highest for e-cigarettes (39.1% and 45.0%, respectively) and cigarettes (37.0% and 45.9%, respectively). Overall, 86.3% of students who reported contact with an assessed potential source of tobacco product advertisements or promotions (going to a convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies; or reading newspapers or magazines) reported exposure to marketing for any tobacco product; 69.3% reported exposure to e-cigarette marketing and 81.7% reported exposure to marketing for cigarettes or other tobacco products. Among all students, perceiving no harm or little harm from intermittent tobacco product use (use on some days but not every day) was 28.2% for e-cigarettes, 16.4% for hookahs, 11.5% for smokeless tobacco products, and 9.5% for cigarettes. Among current users of any tobacco product, 24.7% reported experiencing cravings to use tobacco products during the past 30 days and 13.7% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 57.8% of current tobacco product users reported they were seriously thinking about quitting the use of all tobacco products and 57.5% reported they had stopped using all tobacco products for ≥1 day because they were trying to quit., Interpretation: In 2019, approximately one in four youths (23.0%) had used a tobacco product during the past 30 days. By school level, this represented approximately three in 10 high school students (31.2%) and approximately one in eight middle school students (12.5%). Since 2014, e-cigarettes have been the most commonly used tobacco product among youths. Importantly, more than half of current youth tobacco product users reported seriously thinking about quitting all tobacco products in 2019. However, established factors of use and initiation, including the availability of flavors, exposure to tobacco product marketing, curiosity and susceptibility, and misperceptions about harm from tobacco product use, remained prevalent in 2019 and continue to promote tobacco product use among youths., Public Health Action: The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and community levels. Everyone, including public health professionals, health care providers, policymakers, educators, parents, and others who influence youths, can help protect youths from the harms of all tobacco products. In addition, the comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with FDA's regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Diverse tobacco and nicotine products have altered the terrain of tobacco use behaviors. Limited research has examined contemporary patterns of use among young adults. This study identified tobacco and nicotine product use groups and examined changes in young adults' use patterns, across a 1.5-year period. Participants were 5,482 18-29-year-old students (M age = 20.5, SD = 2.36; 63% female) from 24 Texas colleges who completed a four-wave bi-annual online survey. Latent transition analysis was used to identify groups from 10 items (ever and current use of cigarettes, cigars, smokeless tobacco, e-cigarettes, and hookah) and to examine probabilities of transitioning between groups over four waves. Five groups were identified: Non-users (30%), Poly-experimenters (26%), Hookah experimenters (18%), E-cigarette & hookah experimenters (15%), and Poly-cigarette users (11%). Few students transitioned between groups over time. Poly-cigarette users had the highest average probability of remaining stable over time (1.00), followed by E-cigarette & hookah experimenters (.97), Non-users (.94), Poly-experimenters (.93), and Hookah experimenters (.92). All groups became more stable over time except Hookah experimenters whose members were most likely to transition to Poly-cigarette users or other experimenter groups. The greatest transition was from Poly-experimenters to Poly-cigarette users with probabilities of .10, .08, and .03 for transitioning between waves one and two, two and three, and three and four, respectively. There was substantial poly-use and experimentation, which may explain little movement between groups over the 1.5-year time period and underscores the need for prevention programs targeting multiple product use among college students.

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.)

Objective: The purpose of this study was to identify patterns of tobacco uptake and other substance use, from early to late adolescence. Methods: We used weighted latent class analysis, conducted separately for 7 th , 9 th , and 11 th graders, to assess patterns of susceptibility, ever and current use of combustible tobacco and e-cigarettes, and other substance use (ie, current alcohol, binge drinking, and marijuana). Data were from Wave 3 of the Texas Adolescent Tobacco and Marketing Surveillance System (n = 2733; N = 461,069), collected in fall 2015. Multinomial regression was used to examine differences in class membership by demographic factors. Results: Two latent classes were identified in 7 th grade, 3 classes in 9 th grade, and 4 classes in 11 th grade models. In each grade, classes included both a "no risk" and a "tobacco susceptible" class. For 9 th grade, there was an additional "tobacco ever use" class, and 11 th grade had the same additional class as well as an "all products use" class. Conclusion: Distinct patterns of polysubstance use emerged as grade level increased, supporting a stage-sequential model of onset and progression across developmental age groups. Future research can examine other factors affecting transitions across these stages.

Introduction: Hookah use is particularly prevalent among U.S. college students; however, few studies have investigated whether hookah use is a risk factor for the initiation of other tobacco products. This study examined whether hookah use predicted subsequent initiation of other combustible tobacco products (conventional cigarettes and cigar products) and Electronic Nicotine Delivery Systems (ENDS) among Texas college students during a 2.5-year study period., Methods: This study involved a longitudinal analysis of data from Waves 1-6, with 6 months between each wave, of the Marketing and Promotions Across Colleges in Texas Project (Project M-PACT). Two separate multilevel discrete-time survival analyses were used to model the associations between past 30-day hookah use and subsequent initiation of 1) other combustible tobacco products, and 2) ENDS during the 2.5 year study period, after controlling for demographic, other tobacco use, and risk-taking personality characteristics (i.e. sensation seeking and impulsivity)., Results: After controlling for covariates, past 30-day hookah use was associated with significantly higher odds of subsequent initiation of other combustible tobacco products. Past 30-day hookah use also predicted subsequent initiation of ENDS after controlling for covariates., Conclusions: This study is one of the first to demonstrate that hookah use is a predictor of subsequent initiation of other combustible tobacco products and ENDS among college students. These findings suggest that hookah may prime individuals to use other tobacco products, which has important implications for prevention programs and future research., (Copyright © 2018. Published by Elsevier Ltd.)

Objective : The purpose of this study is to examine differences between current and non-current cigarette users, focusing on sociodemographic factors, non-cigarette tobacco product use, parental and friend use, and alcohol and marijuana use; and to identify predictors of cigarette use sixmonths later. Participants : Participants included young adults (n = 4,296) from 24 Texas colleges, participating in a young adult cohort study, beginning in fall 2014. Methods : Mixed effects logistic regressions were conducted accounting for school-level variability. Results : Cigarette users were older, more likely to report use of non-cigarette tobacco products and peer use of cigarettes than non-current users. Wave 1 cigarette and non-cigarette tobacco product use, marijuana use and binge drinking, and peer use all uniquely predicted cigarette use at wave 2. Conclusions : Colleges need prevention programs targeting multiple tobacco products, because non-cigarette tobacco use and other risky behaviors appear to be independent risk factors for cigarette use in young adults.

Introduction: The potential of e-cigarettes to elicit symptoms of nicotine dependence has not been adequately studied, particularly in adolescent populations. The present study examined the prevalence of e-cigarette-specific symptoms of nicotine dependence ("symptoms of e-cigarette dependence") and the associations between these symptoms, e-cigarette usage group, and e-cigarette cessation-related items among Texas adolescents., Methods: This study involved a cross-sectional analysis of adolescents from Wave 4 of the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS) (n = 2891/N = 461,069). Chi-Square analyses examined differences in the prevalence of symptoms of dependence by e-cigarette usage group (exclusive versus dual users of e-cigarettes and combustible tobacco products) and demographic characteristics. Weighted multivariable logistic regression analyses examined the associations between symptoms of e-cigarette dependence, e-cigarette usage group, and e-cigarette cessation items., Results: Exclusive e-cigarette users experienced symptoms of e-cigarette dependence, although the prevalence of most of the symptoms was higher for dual users. Adolescents who reported more symptoms of dependence were less likely to report both wanting to quit e-cigarettes and a past-year quit attempt for e-cigarettes (adjusted odds ratio "AOR" = 0.61 (95% CI = 0.41, 0.92) and AOR = 0.52 (95% CI = 0.30, 0.92), respectively)., Conclusions: This study is the first to demonstrate that adolescent e-cigarette users are experiencing symptoms of dependence specific to e-cigarettes. In addition, symptoms of dependence may be barriers to e-cigarette cessation. Future research is needed to determine if characteristics of e-cigarette use (e.g. frequency and intensity) are associated with dependence., (Copyright © 2018. Published by Elsevier Ltd.)

Introduction: This study assesses the relationship between tobacco/e-cigarette marketing exposure and single, dual, and polytobacco product use, among adolescents. Given the increased use of noncigarette tobacco products (eg, cigars, e-cigarettes, hookah) among youth, it is imperative to understand if marketing exposure is associated with dual and polytobacco product use., Methods: Data were obtained from the 2014 National Youth Tobacco Survey and weighted to be representative of US middle and high school students. Multivariable multinomial logistic regression models were used to assess the relationships between product marketing (via internet, print, retail, and TV/movies) and past 30-day single, dual, and poly (three or more) tobacco product use. Three analyses were conducted using different categories as referent groups to allow for comprehensive examination of the relationships between all groups., Results: Marketing exposure was significantly correlated with a greater risk of single, dual, and polytobacco product use relative to nonusers. Relative to single product users, product marketing exposure was significantly correlated with a greater relative risk of dual and polytobacco use. There was no statistical difference in the association of marketing exposure between dual and polytobacco use, in any model., Conclusion: A positive relationship between tobacco product marketing exposure and number of tobacco products used was observed. The magnitude of the relationship grew from single product to dual/poly use. Restrictions of marketing of all tobacco products, similar to cigarettes, particularly in the retail setting, should be considered., Implications: This study has two primary public health implications. First, self-reported exposure to tobacco/e-cigarette marketing is widespread among adolescents of all tobacco product categories. Second, this widespread exposure to tobacco/e-cigarette marketing appears to not only be correlated with use of a single tobacco product (eg, cigarettes, e-cigarettes), but also multiple tobacco products. While longitudinal studies are needed to further investigate the relationships observed in this study, findings justify further study given the known relationship between tobacco marketing exposure and subsequent cigarette use.

Background: Outcome expectations are an important determinant of health behavior, according to Social Cognitive Theory; yet recent literature has not examined the relationship between outcome expectations and tobacco product use (e.g., use of cigarettes, cigars, hookah, e-cigarettes, or smokeless tobacco)., Objectives: This study examines if outcome expectations at baseline, among an adolescent cohort of never users of tobacco products, predicts tobacco product use (i.e., cigarettes, hookah, e-cigarette, cigar, or smokeless tobacco) or susceptibility to use at 6-month follow-up., Methods: Data are from the first two waves of a Texas cohort study of urban middle school and high school students, which were collected in 2014-2015. Logistic regression analyses were used; these adjusted for socio-demographic variables. Analyses were limited to never users of any tobacco product at baseline (n = 1999, N = 357,035)., Results: Outcome expectations related to stress relief predicted ever use of (AOR: 4.21, 95% CI 1.84-9.60) and susceptibility (AOR: 2.97, 95% CI 1.01-8.70) to tobacco products. Additional outcome expectations (e.g., relaxation, concentration, slimness, etc.) were not associated with ever use or susceptibility. Conclusions/Importance: This study extends the literature regarding outcome expectations among adolescents regarding tobacco products. It is important that interventions offer alternative solutions to stress relief that do not include tobacco products.

Measuring perceptions associated with e-cigarette use can provide valuable information to help explain why youth and adults initiate and continue to use e-cigarettes. However, given the complexity of e-cigarette devices and their continuing evolution, measures of perceptions of this product have varied greatly. Our goal, as members of the working group on e-cigarette measurement within the Tobacco Centers of Regulatory Science (TCORS) network, is to provide guidance to researchers developing surveys concerning e-cigarette perceptions. We surveyed the 14 TCORS sites and received and reviewed 371 e-cigarette perception items from seven sites. We categorized the items based on types of perceptions asked, and identified measurement approaches that could enhance data validity and approaches that researchers may consider avoiding. The committee provides suggestions in four areas: (1) perceptions of benefits, (2) harm perceptions, (3) addiction perceptions, and (4) perceptions of social norms. Across these 4 areas, the most appropriate way to assess e-cigarette perceptions depends largely on study aims. The type and number of items used to examine e-cigarette perceptions will also vary depending on respondents' e-cigarette experience (i.e., user vs. non-user), level of experience (e.g., experimental vs. established), type of e-cigarette device (e.g., cig-a-like, mod), and age. Continuous formative work is critical to adequately capture perceptions in response to the rapidly changing e-cigarette landscape. Most important, it is imperative to consider the unique perceptual aspects of e-cigarettes, building on the conventional cigarette literature as appropriate, but not relying on existing conventional cigarette perception items without adjustment., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Research shows that adolescents who are overweight or obese may be at greater risk of cigarette smoking, and that this relationship may vary by gender. However, this relationship is understudied for electronic cigarettes (e-cigarettes). Given the high rate of adolescent obesity and the rise in e-cigarette use in adolescents, this relationship should be investigated., Methods: Data are from the third wave (collected October 2015-January 2016) of the Texas Adolescent Tobacco and Marketing Surveillance system. Students were in the seventh, ninth, and 11th grades (n=2,733) from five counties surrounding four major Texas metropolitan areas (Houston, Austin, San Antonio, Dallas). Weighted logistic regression was used to determine if weight status (healthy weight, overweight, or obese) was correlated with ever and past 30-day cigarette or e-cigarette use, controlling for sociodemographics. Models were stratified by gender. Data analyses were conducted in March 2017., Results: Compared with healthy-weight boys, obese boys had higher odds of past 30-day e-cigarette use (AOR=3.45, 95% CI=1.34, 8.33) and cigarette smoking (AOR=4.52, 95% CI=1.32, 15.51). There was no significant relationship between weight status and cigarette or e-cigarette use in girls., Conclusions: This study supports that there is a positive relationship between weight status and past 30-day cigarette and e-cigarette use for boys, but that there is no association for girls., (Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Sensation seeking is strongly associated with cigarette use in adolescents. However, few studies have investigated its relationship with adolescent e-cigarette use. This study examined cross-sectional and longitudinal associations between sensation seeking and a variety of e-cigarette use behaviors among Texas adolescents., Methods: This study utilized two waves of data collected 6months apart through the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS) in 2014-2015 (n=2,488/N=461,069). TATAMS employs a complex probability-sampling design and is representative of students in 6th, 8th and 10th grades from five counties surrounding the four largest cities in Texas (Houston, Dallas/Ft. Worth, San Antonio, Austin). Weighted multivariable logistic regression was used to examine the cross-sectional and longitudinal associations between sensation seeking and susceptibility to e-cigarette use, ever e-cigarette use, and current (past 30day) e-cigarette use., Results: In the cross-sectional analyses, higher mean sensation seeking scores were associated with higher odds of both susceptibility to e-cigarette use and ever e-cigarette use (AOR=1.25, 95% CI=1.07, 1.47; AOR=1.24, 95% CI=1.08, 1.43, respectively). For the longitudinal analyses, only the association between higher mean sensation seeking scores and transition to ever e-cigarette use remained statistically significant (AOR=1.45, 95% CI=1.01, 2.08). There were no significant associations between sensation seeking and current e-cigarette use in either the cross-sectional or longitudinal analyses., Conclusions: Higher sensation seeking scores were consistently and significantly related to experimentation with e-cigarette use among Texas adolescents. Future interventions (e.g., communication campaigns) should target high sensation seeking adolescents to reduce initiation of e-cigarette use among this population., (Copyright © 2017. Published by Elsevier Ltd.)

Objective: To examine the associations between sensation seeking and ever and current e-cigarette use in Texas young adults (18-29 years old). Current cigarette use was examined as a potential effect modifier of the associations., Participants: Participants included college students enrolled in four-year and two-year colleges in four metropolitan areas in Texas (n  =  5,418) who completed the survey between November 2014 and February 2015., Methods: This cross-sectional study utilized mixed effects logistic regression to determine the associations between mean sensation seeking scores and ever and current e-cigarette use after controlling for covariates., Results: After controlling for covariates, significant associations between sensation seeking and both ever and current e-cigarette use were observed; however, these associations were significant for noncurrent smokers only (adjusted odds rations [AOR]  =  1.55, 95% confidence interval (CI)  =  1.39, 1.73; AOR  =  1.82, 95% CI  =  1.54, 2.15, respectively)., Conclusions: Sensation seeking is an important factor in identifying college students who may be at increased risk for e-cigarette use behaviors.

Objectives: We assessed risk perceptions and social norms about tobacco use across adolescent non-users of tobacco, single- product users, and dual/poly-product users., Methods: Use behaviors specific to e-cigarettes, cigarettes, hookah, cigars, and smokeless tobacco were assessed among 6th, 8th and 10th grade students (sample [n] = 3907 from a population of [N] = 461,069 students). Multivariate regression was used to examine differences in these factors across use categories, adjusted for demographic factors., Results: Results highlight differences between non-users and single- or dual/poly-product users for most tobacco products. Dual/poly-product users differed from single-product users most notably in their higher perceived use of tobacco products by close friends and dating partners, and a higher proportion of single-product users reported most products were not harmful and not addictive compared to non-users. Few differences were seen between dual/poly-product users and single-product users in their perceptions of harm and addictiveness., Conclusions: Findings demonstrate the importance of proximal social influences (ie, close friends and dating partners) for adolescent dual/poly-tobacco product users. Understanding similarities and differences in risk factors between these adolescent groups can guide effective public health prevention and treatment programs., Competing Interests: Statement None of the authors has any competing interests.

Purpose: Hookah is an increasingly popular tobacco product among college students. The purpose of this study was to determine if college students are aware of tobacco and nicotine content in hookah, and examine associations between college students' knowledge and perceptions of hookah and their past 30-day hookah use., Methods: Participants were 5451 young adults attending one of 24 2- and 4-year colleges. Analyses examined if hookah knowledge was uniquely associated with current hookah use, over and above perceptions of harm and addictiveness, number of other tobacco products currently used, and socio-demographic factors. Analyses were first conducted for the entire sample and then only for current hookah users., Results: 26.9% of all students believed hookah did not contain tobacco and 38% believed that hookah did not contain nicotine. Students who believed that hookah contained tobacco were at increased odds of hookah use, and those with increased perceptions of harm were at decreased odds of hookah use. However, hookah knowledge was not associated with hookah users' intensity of use. Moreover, although increased perceptions of harm were associated with lower intensity of use among current users, increased perceptions of addictiveness were associated with higher intensity of use., Conclusions: This study shows gaps in knowledge of hookah contents, and adds to the body of literature, which provides evidence for mandating warning labels as well as tobacco interventions for college students., Competing Interests: No conflict declared, (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: We examined patterns of tobacco and electronic cigarette (e-cigarette) use among college students. Differences in sociodemographic characteristics between non-users of these products and 4 mutually exclusive groups of tobacco/e-cigarette users were assessed. Differences in cigarette cessation attempts and dependence between exclusive cigarette smokers and users of cigarettes and at least one alternative tobacco product also were examined., Methods: Participants were 5468 18-29 year-old students from 24 colleges in Texas who completed an online survey., Results: Multiple-product use was more prevalent than single-product use. All 4 current tobacco/e-cigarette-user groups were more likely than non-users to be men and older. College students who were younger when they smoked their first cigarette, and those reporting ever needing a cigarette, were more likely to be multiple-product users than cigarette-only users. There were no group differences in cigarette cessation attempts or any other variables., Conclusions: Using multiple products is associated with some indicators of dependence, but does not seem to aid or deter college students' smoking cessation attempts. Longitudinal research is needed given that transitions in tobacco/e-cigarette use continue throughout young adulthood., Competing Interests: Statement All authors of this article declare they have no conflicts of interest.

Objectives: To examine associations between current multiple tobacco product use, and current use of alcohol and marijuana, binge drinking, and lifetime use of marijuana, alcohol, and other drugs among US high school students., Methods: Using 2013 Youth Risk Behavior Survey data (N = 13,583 high school students), logistic regression analyses were conducted to determine if single tobacco product or multiple tobacco product users are more likely to engage in other risk behaviors than zero tobacco product users, controlling for demographic variables., Results: Overall, 23% of the sample used tobacco products and 10% of students reported current use of at least 2 tobacco products. Among single tobacco product users, the odds for engaging in risk behaviors ranged from 3.3 to 9.9 compared to non-tobacco users (p < .0001). Among multiple tobacco product users, the odds ranged from 1.5 to 4.7 (p < .01) compared to single tobacco product users., Conclusions: Results suggest dual users are significantly more likely to engage in risk behavior than non-users and single product users. Future interventions should consider identifying dual-users as at higher risk, and targeting multiple risk behaviors.

Objectives: We examined differences in the characteristics of youth non-users, cigarette-only, e-cigarette-only, and dual e-cigarette and cigarette users., Methods: Using weighted, representative data, logistic regression analyses were conducted to examine differences in demographic characteristics and tobacco use behaviors across tobacco usage groups. Multiple linear regression analyses were conducted to examine differences in harm perceptions of various tobacco products and perceived peer use of e-cigarettes by tobacco usage group., Results: Compared to non-users, dual users were more likely to be white, male, and high school students. Dual users had significantly higher prevalence of current use of all products (except hookah) than e-cigarette-only users, and higher prevalence of current use of snus and hookah than the cigarette-only group. Dual users had significantly lower harm perceptions for all tobacco products except for e-cigarettes and hookah as compared to e-cigarette-only users. Dual users reported higher peer use of cigarettes as compared to both exclusive user groups., Conclusion: Findings highlight dual users' higher prevalence of use of most other tobacco products, their lower harm perceptions of most tobacco products compared to e-cigarette-only users, and their higher perceived peer use of cigarettes compared to exclusive users.

Objective: The purpose of this study was to identify trends of tobacco use, among all students and current tobacco users, in a nationally representative sample of high school students from 1999 to 2013., Methods: Trends in individual and concurrent use of cigarettes, cigars, and smokeless tobacco (SLT) products were tested using 8 repeated cross-sections of the YRBS between 1999 and 2013. Tests for effect modification of race/ethnicity and sex were conducted for each trend., Results: Among all students, there were significant non-linear changes detected for the concurrent use of all 3 products, and the dual use of cigarettes and cigars. Girls significantly increased their use of SLT. Among users, significant changes were detected for each individual product and all combinations. Female users significantly increased their concurrent use of cigarettes and cigars and concurrent use of cigarettes and SLT. Male users significantly decreased their use of cigarettes and cigars., Conclusion: While the decrease in the youth prevalence of cigarette use is a public health success, there is concern about the increase in non-cigarette products, among tobacco users. These changes further drive increases in the concurrent use of tobacco products, adding to the potential health burden.