Abstract
Alternative tobacco products are increasing in popularity. An important question is whether their use is associated with or even leads to conventional smoking, but large-scale (European) studies are scarce. In two cohorts of Dutch adolescents (Cohort I n = 6819, mean age = 13.8 SD = 1.1, 48.2% female; Cohort II n = 2758, mean age = 17.3 SD = 1.8, 61.3% female), we investigated use of electronic (e)-cigarettes with nicotine, e-cigarettes without nicotine and waterpipe. Generalized estimating equation modelling was conducted with ever conventional smoking as the dependent variable (0 = no, 1 = yes) and ever alternative tobacco use as the independent variable, correcting for clustering within schools, age, sex and education in both cohorts. In a subsample (n = 2100), the association between alternative tobacco use at baseline and conventional smoking 6 months later was tested, taking into account smoking propensity (based on personality, susceptibility to peer pressure and smoking intentions). Ever use prevalence was 13.7% for e-cigarettes with nicotine, 29.4% for e-cigarettes without nicotine and 22.1% for waterpipe in Cohort I and 12.3, 27.6 and 45.3% respectively in Cohort II. Ever smokers had tried alternative tobacco products more often than never smokers. Among never-smoking adolescents at baseline, alternative tobacco use predicted ever smoking 6 months later (e-cigarettes with nicotine OR 11.90 95% CI 3.36–42.11; e-cigarettes without nicotine OR 5.36 95% CI 2.73–10.52; waterpipe OR 5.36 95% CI 2.78–10.31). This association was strongest for adolescents with a low baseline risk of smoking. Experimenting with alternative tobacco products is common among Dutch youth. Alternative tobacco use predicts (future) smoking, especially among adolescents with a low smoking propensity.
Highlights
Electronic supplementary material The online version of this article contains supplementary material, which is available to authorized users.Alternative tobacco products are steadily increasing in popularity and are partly replacing ‘conventional’ cigarette smoking
When performing a median split on propensity to smoke and repeating GEE analyses, we found that alternative tobacco use at time point 0 (T0) predicted conventional smoking at time point 1 (T1) in both groups, but the association was much stronger for the low propensity scorers (ORs for e-cigarettes with nicotine, e-cigarettes without nicotine and waterpipe were 7.80, 6.07 and 4.22, respectively) than for the high
We showed that among adolescents who never smoked at baseline, experimentation with alternative tobacco products was associated with a higher risk of conventional smoking 6 months later
Summary
A recent study from the United States (US) demonstrated that while adolescents’ use of conventional cigarettes was on the decline between 2011 and 2014, the net use of tobacco products remained the same due to the increasing popularity of alternative forms [1]. E-cigarettes were originally intended as an aid for smoking cessation and they are considered to be less harmful than conventional cigarettes [3], they are not risk free [4, 5]. Another important concern is that for individuals who never smoked before, e-cigarettes might form a ‘stepping stone’ to conventional cigarettes [6]. Large-scale European studies among adolescents and young adults, especially those exploring different types of alternative tobacco, are scarce
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