Abstract
Cigarettes are still a commonly used tobacco product among youth despite recent declines in cigarette use. The aim of this study was to prospectively estimate the age of cigarette use initiation among youth (aged 12-17 years) overall, by sex, and by race/ethnicity. This cohort study used data from waves 1 through 4 of the nationally representative Population Assessment of Tobacco and Health (PATH) study, conducted from September 12, 2013, to January 3, 2018. Two subpopulations of youth were assessed: (1) those nonsusceptible to cigarette use and (2) never users of cigarettes at their first wave of PATH participation. Weighted interval-censoring survival analyses were used to prospectively estimate the age of initiation of cigarette use outcomes. Weighted interval-censoring Cox proportional hazard models were used to estimate differences in the age of initiation by sex and by race/ethnicity. Statistical analyses were performed from October 7, 2019, to May 1, 2020. Differences in the age of initiation by sex and race/ethnicity. Age of initiation of susceptibility to cigarette use, ever use, past 30-day use, and fairly regular cigarette use overall, by sex, and by race/ethnicity. A total of 15 776 youth never users and, among them, 11 022 youth who were nonsusceptible to cigarette use, were included in this study (weighted mean [SE] age, 13.5 [0.01] years; 58.6% [SE, 0.46%] non-Hispanic White; and 51.0% [SE, 0.32%] boys) and 15 776 were never users of cigarettes at their first wave of PATH participation (weighted mean [SE] age, 13.7 [0.01] years; 55.0% [SE, 0.29%] non-Hispanic White; and 51.0% [SE, 0.15%] boys). By age 18 years, among those who were nonsusceptible, 46.2% (95% CI, 44.3%-48.2%) became susceptible to cigarette use. Among never users, 24.4% (95% CI, 22.9%-25.9%) initiated ever cigarette use, 16.4% (95% CI, 15.2%-17.6%) initiated past 30-day cigarette use, and 4.3% (95% CI, 3.9%-4.8%) initiated fairly regular cigarette use. Boys had a higher risk of initiating ever (hazard ratio [HR], 1.21; 95% CI, 1.08-1.36) and past 30-day cigarette use (HR, 1.27; 95% CI, 1.10-1.47) at earlier ages compared with girls. Non-Hispanic White youth had a higher risk of an earlier age of initiation of susceptibility to cigarette use (HR, 0.77; 95% CI, 0.68-0.88), ever use (HR, 0.59; 95% CI, 0.49-0.71), past 30-day use (HR, 0.64; 95% CI, 0.52-0.77), and fairly regular cigarette use (HR, 0.25; 95% CI, 0.14-0.43) compared with non-Hispanic Black youth. The results of this cohort study suggest that, despite current interventions and existing laws, a large number of youth initiated cigarette use before the legal age to purchase tobacco products.
Highlights
Identifying the age of initiation of tobacco use has been pivotal to achieving reductions in tobacco use nationwide, as tobacco use remains one of the leading causes of preventable diseases and death in the US.[1,2] According to the 2012 Surgeon General’s report, 88.2% of adult daily smokers aged 30 to 39 years recall initiating cigarette use at or before age 18 years.[3]
Boys had a higher risk of initiating ever and past 30-day cigarette use (HR, 1.27; 95% CI, 1.10-1.47) at earlier ages compared with girls
Non-Hispanic White youth had a higher risk of an earlier age of initiation of susceptibility to cigarette use (HR, 0.77; 95% CI, 0.68-0.88), ever use (HR, 0.59; 95% CI, 0.49-0.71), past 30-day use (HR, 0.64; 95% CI, 0.52-0.77), and fairly regular cigarette use (HR, 0.25; 95% CI, 0.14-0.43) compared with non-Hispanic Black youth
Summary
Identifying the age of initiation of tobacco use has been pivotal to achieving reductions in tobacco use nationwide, as tobacco use remains one of the leading causes of preventable diseases and death in the US.[1,2] According to the 2012 Surgeon General’s report, 88.2% of adult daily smokers aged 30 to 39 years recall initiating cigarette use at or before age 18 years.[3]. Susceptibility to cigarette smoking has been identified as a risk factor for smoking initiation before youth start using cigarettes.[4,5] A previous publication of the Population Assessment of Tobacco and Health (PATH) study, conducted from September 12, 2013, to December 14, 2014, reported the prevalence of susceptibility to cigarette use among youth (aged 12-17 years) overall (28.6%)[6] and by race/ethnicity (for Hispanic youth, 31.3%; for non-Hispanic Black youth, 30.5%; and for non-Hispanic White youth, 26.9%).[6] The 2019 National Youth Tobacco Survey (NYTS) reported cigarette susceptibility by sex (boys, 46.4%; girls, 45.5%).[7] In addition, previous reports of PATH among youth have reported initiation of ever (3.8%)[8] and past 30-day (1.6%)[8] cigarette use after 1 or 2 years of follow-up,[9] as well as differences by sex and race/ethnicity. Middle and high school students from the 2014-2016 NYTS reported their median recalled age of cigarette initiation as 13 years, but this finding is prone to recall bias.[10,11,12]
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