Pathways of Nicotine Product Use: A Qualitative Study of Youth and Young Adults in California.

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Existing research on youth's adoption of alternative nicotine delivery systems (ANDS) has focused on identifying pathways of nicotine product use, specifically examining whether vaping encourages progression to smoking. Few studies have considered other pathways of initiation. Qualitative studies suggest that meanings of vaping vary significantly, suggestive of the need for a more nuanced understanding of the role of vaping for youth with different pathways into vaping and smoking. We conducted in-depth qualitative interviews with 49 Californian youth between 15 and 25 years old who reported ever vaping nicotine to gain a deeper understanding of their initiation pathways of vaping and smoking, paying special attention to youth's experiences and reasons for ANDS initiation and use. Categorizing participants into initiation pathways by self-reported use and age of initiation of ANDS and cigarettes, we then compared the meaning and role of vaping across three distinct pathways of use: (1) smoking to vaping, (2) vaping to smoking, and (3) vaping only. The most common pathway reported was smoking to vaping (74%), eight participants began vaping before smoking, and five participants reported only vaping but never smoking. Analysis of participants' narratives emphasized that youth in our study, regardless of initiation pathway, were generally aware of the health consequences of smoking and negotiated their use of nicotine products considering relative risks. Findings from this study suggest that ANDS serve as a transitional tool for youth who are keenly aware of the health consequences of smoking, thus challenging conventional discourses about ANDS as a threat to youth's health. This qualitative study queries concerns about the potential of alternative nicotine delivery systems (ANDS) to serve as a gateway into cigarette smoking for youth and young adults. Findings suggest that most of the youth participants discussed and considered relative risks in their pathways of initiation, highlighting the need to acknowledge harm reduction in constructing public health messaging and policies for smoking cessation.