Adolescent Alternative Tobacco Users More Likely to Try Conventional Cigarettes

Dentistry Today


Nonsmoking adolescents who use electronic cigarettes, smokeless tobacco, or tobacco water pipes are more likely to start smoking conventional cigarettes within a year, according to a national study of more than 10,000 adolescents between the ages of 12 and 17 years by the University of California San Francisco (UCSF). 

The researchers reported that any form or tobacco, including e-cigarettes, was associated with future smoking, especially when adolescents used more than one product. As a result, novel tobacco products have the potential to undermine public health gains in combatting smoking, the researchers said. Dentists should be particularly concerned, as smoking’s effects on the oral cavity include stained teeth, plaque, gum disease, lost teeth, and oral cancer.

“We found that teens who experimented with tobacco in any form were at greater risk of future smoking,” said Benjamin W. Chaffee, DDS, PhD, an assistant professor at the UCSF School of Dentistry and senior author of the study.

“In the last few years, research has focused on the potential of e-cigarettes to engage never-smoking adolescents in tobacco use,” said Chaffee. “Our findings confirm that the use of the full range of tobacco products, including e-cigarettes, cigars, tobacco water pipes, and smokeless tobacco, is associated with greater odds of future cigarette smoking.”

Approximately 90% of adult smokers smoked their first cigarette by the time they were 18 years old, the researchers report. Earlier studies have shown that smoking a single cigarette per month during adolescence is tied to daily smoking during adulthood. 

Also, as non-cigarette tobacco products have become more popular among youth, e-cigarettes have become the most common form of tobacco used by adolescents. In 2016, nearly 4 million middle and high school students used at least one tobacco product, and 1.8 million reported using two or more products, studies have shown.

The new study was based on 10,384 subjects in the Population Assessment of Tobacco and Health (PATH) study who had said that they had never tried a cigarette. The PATH study is a collaboration between the Food and Drug Administration and the National Institutes of Health. The never-smoking youth were first interviewed from September 2013 to December 2014.

The questionnaires looked at eight types of combustible and noncombustible tobacco and nicotine products: bidis, cigarettes, cigars (traditional, filtered, and cigarillos), e-cigarettes, hookah (tobacco water pipes), kreteks, pipes, and smokeless tobacco (chewing tobacco, dissolvable tobacco, moist snuff, and snus). All of the subjects had parental consent.

“This finding is particularly important because products like cigarillos and smokeless tobacco are often used by young people of vulnerable populations. A focus solely on e-cigarettes ignores health risks for those youth,” said first author Shannon Lea Watkins, PhD, a postdoctoral fellow at the UCSF Center for Tobacco Control Research and Education.

The mean age of the subjects was 14.3 years. The estimated effects of non-cigarette tobacco products on subsequent cigarette smoking were adjusted for sociodemographic, environmental, and behavioral smoking risk factors. 

A year later, 469 subjects (4.6%) said they had tried a cigarette, and 219 (2.1%) had smoked a cigarette within the previous 30 days. Smoking was higher among adolescents who used e-cigarettes (19.1%), hookah (18.3%), non-cigarette combustible tobacco (19.2%), or smokeless tobacco (18.8%). 

After adjusting for smoking risk factors, the odds of smoking the previous month were about twice as high among e-cigarette users and more than three times as high for those who used multiple products, an increasingly common use pattern in adolescents, the researchers reported.

Various factors could explain the findings, the researchers said. For example, the use of non-cigarette tobacco products might induce nicotine dependence. Also, adolescents might find that such products are more convenient and effective in satisfying nicotine cravings. And, use of the products could change how adolescents perceive cigarettes.

The researchers further noted that any tobacco use is harmful, even if adolescents don’t progress to smoking cigarettes. Policies such as restricting flavors in e-cigarettes and raising the age of tobacco purchasing could divert youth from becoming smokers, the researchers said.

Additionally, the researchers said that the study provides support for legislation to ban flavored tobacco products on the grounds that flavors are used to attract youth to the non-cigarette tobacco products that were studied. In San Francisco, a measure seeking to repeal the ban is heading to voters this year. 

“San Francisco and Oakland have both acted to ban the sale of flavored tobacco. These are measures that the tobacco industry is attempting to overturn. Any policy designed to keep kids from smoking needs to account for alternative products,” Watkins said. 

“Our findings suggest that flavor restrictions, raising the minimum purchase age to 21, and higher excise taxes on non-cigarette products not only make these non-cigarette products less appealing to youth, but have the benefit of fewer kids being led to cigarette smoking as well,” Watkins said.  

The study, “Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015,” was published by JAMA.

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