The Impact of Current Tobacco Product Use Definitions on Estimates of Transitions Between Cigarette and ENDS Use

Abstract

Definitions of current tobacco and nicotine delivery product use vary and depend on frequency of use, established-use criteria, and the product type. Previous research has not considered how transition rates between current use of different products depend on the current use definition. We applied a multistate transition model to data on U.S. adults from waves 1-4 (2013-2017) of the Population Assessment of Tobacco and Health (PATH) study. We estimated transition rates between never, non-current, cigarette, electronic nicotine delivery systems (ENDS), and dual use states with and without established-use criteria (has smoked 100+ cigarettes in their lifetime; ever fairly regularly used ENDS) and different frequency thresholds (1+, 10+, 20+, and 30 days of the past 30 days). We considered use below a frequency threshold as either non-current use or a distinct, infrequent use category. When treating use below a frequency threshold as non-current use, transition probability estimates were largely robust to the choice of use frequency threshold, although sole ENDS users were more likely to transition to non-current use or dual use as the current use threshold increased. Removing the established-use criterion for ENDS reduced the estimates of sole ENDS and dual users staying in their use state. When treating infrequent use as a separate category, transition probability estimates were dependent on the use frequency threshold, particularly transitions among the dual use states. Product use definitions have important implications for assessing product use transitions and thus the public health implications of cigarette and ENDS control strategies. How we define "current use" of tobacco and nicotine delivery products changes our estimates of how individuals transition to, between, and from different patterns of use. We show that the robustness of transition estimates to whether or not non-established users are included as current users and to different frequency-of-use threshold depends in part on whether low-frequency users are categorized as non-current users or as a distinct category. Our results emphasize the importance of intentional definitions of product use that reflect the larger goals of public health and tobacco control.