Abstract
Purpose
To determine whether use of alternative tobacco products (i.e., cigars, blunts, hookah, smokeless tobacco), alcohol and marijuana use differs between adolescents who currently use 1) e-cigarettes; 2) cigarettes only; and 3) never-smokers.
Methods
Analysis of a self-reported survey from 4 high schools in 2010–2011 (n=3,102) with a subsample (n=1,556) surveyed on alcohol and marijuana. Analyses were conducted with multinomial logistic regression models accounting for clustering by schools.
Results
The sample contained 2.4% (n=76) e-cigarette users, 12.4% (n=386) cigarette smokers, and 85.1% (n=3,197) never-smokers. E-cigarette users were more likely than cigarette-only smokers to report blunt (Adjusted odds ratio (AOR) 1.81 (95% Confidence Interval (CI) 1.21–2.71) and hookah use (AOR 3.12 (CI 1.90–5.13), but not cigar, smokeless tobacco, alcohol, or marijuana use.
Conclusions
E-cigarette users are more likely than cigarette smokers to use hookah and blunts.
Keywords: Tobacco Products, Adolescent, Alcohol, Marijuana
Introduction
Electronic cigarettes (e-cigarettes) are battery-operated devices that deliver vapor through inhalation. There is concern that use of e-cigarettes among youth may be linked to the initiation or continuation of tobacco products. Existing research suggests that adolescent cigarette smokers are more likely than non-smokers to use e-cigarettes,[1] however the patterns of alternative tobacco product use (i.e., cigars, blunts [marijuana rolled in tobacco], hookah, smokeless tobacco [chew/dip]) are unknown.
There is a well-documented increased likelihood of alcohol and marijuana use in adolescent cigarette smokers.[2] This may be due to the desire to seek novel or intense experiences (i.e. “sensation-seeking),[3] the “gateway hypothesis”, wherein individuals may start using one tobacco product and then proceed to use other substances,[4] or the social milieu of adolescence which supports the adoption of multiple risky behaviors.[5] Given these findings, adolescents who use e-cigarettes may arguably also be at increased risk for adopting alternative tobacco product, alcohol, or marijuana use; however it is unknown whether this risk is higher than that of cigarette smokers who do not use e-cigarettes.
The objective of this study is to determine whether alternative tobacco product, alcohol and marijuana use differs between adolescent 1) current e-cigarette users; 2) current cigarette smokers; and 3) never-smokers.
Methods
This is a data analysis of cross-sectional, self-report surveys assessing tobacco behaviors conducted in 4 suburban high schools in Connecticut and New York in October 2010 (NY) and January 2011 (CT). A subsample of schools (n=2) agreed to survey students about alcohol and drug use. Full methods have been published elsewhere.[6] This study was approved by the Yale School of Medicine and Roswell Park Cancer Institute Institutional Review Boards. We obtained passive parental permission through letters mailed home to parents, and students were informed that the survey was voluntary and anonymous.
Sample
The full sample consisted of 3,912, students (response rate = 80.1%). Students who did not use e-cigarettes and were former smokers were excluded (n=605). Of the remaining students (n=3307), 3102 (93.8%) were included in the analysis with complete demographic and tobacco use data. The subsample examining alcohol and marijuana use consisted of 1,957 students attending 2 high schools in Connecticut of which 293 were excluded due to former smoking status. Of the remaining 1,849 students, 1556 (84.1%) were included in the analysis with complete data. Students with missing data did not differ from the included sample or subsample in grade, sex, or race/ethnicity.
Measures
Current e-cigarette and alternative tobacco use was assessed with the question, “In the past 30 days have you used any of the following tobacco products?” Choices included: cigars, blunts [marijuana with tobacco], bidis/kreteks, hookahs, smokeless tobacco [chew/dip], and e-cigarettes[An electronic cigarette that is filled with liquid nicotine and emits “smoke” vapor]). Bidi/kretek use was not included in the analysis due to the low prevalence of use (n=24; 0.7%). Current cigarette, alcohol (drinking one or more drinks of an alcoholic beverage), binge drinking (drinking more than 5 drinks in a row on one occasion), and marijuana use were defined as reporting the behavior ≥ 1 day in the past month.
Data Analysis
Descriptive statistics were reported for : 1) current e-cigarette users, which included both current cigarette and non-cigarette users; 2) current cigarette users who did not report current e-cigarette use and 3) never-smokers. Bivariate comparisons were conducted with chi-square and fisher’s exact text for categorical variables and the t-test for continuous variables. Separate multinomial logistic regression models were constructed for each alternative tobacco product, current alcohol use, current binge drinking and current marijuana use to compare the associations between e-cigarette users and never-smokers, cigarette smokers and never-smokers, and e-cigarette users vs. cigarette smokers. We reported unadjusted associations and models adjusted for demographic variables (grade, sex, and race/ethnicity). Proc surveylogistic procedures were conducted with SAS v.9.3 (Cary, NC) to account for clustering by school. Bonferroni correction for multiple comparisons was applied and p<0.0008 was considered statistically significant.
Results
The sample consisted of 2.5% (n=76) current e-cigarette users, 12.4% (n=386) current cigarette smokers and 85.1% (n=2,640) never-smokers (Table 1). Most current e-cigarette users reported occasional (44.7%) or daily smoking (30.3%), 15.7% had ever tried a cigarette, but were not current smokers, and 9.2% were never-smokers. Current e-cigarette users used a higher mean number of alternative tobacco products (i.e. cigars, blunts, hookah, smokeless tobacco) (1.75; Standard Deviation (SD=1.32) than current cigarette smokers (1.15; SD=1.03) or never-smokers (0.06; SD=0.3) (p<0.0001). The prevalence of all types of alternative tobacco products was higher among current e-cigarette users and cigarette smokers than never-smokers (p<0.001). In addition, a larger proportion of current e-cigarette users reported hookah use (42.1% vs. 18.9%; p<0.0001) than current cigarette smokers. Among the subsample (n=1,556), the prevalence of current alcohol, binge drinking and marijuana use did not differ between current e-cigarette users and current cigarette smokers, although these groups had a higher prevalence than never-smokers (p<0.0001).
Table 1.
Demographic Characteristics, Tobacco Use Patterns, and Other Drug Use Patterns of Three Different Tobacco Use Groups
| Current e-cigarette users
|
No current e-cigarette use
|
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Total (n=3,102) | Current e-cigarette users (n= 76) | Current cigarette smokers (n=386) | Never-Smokers (n=2,640) | E-cigarette vs. cigarette vs. never-smoker p valuea | E-cigarette vs. Cigarette p valuea | ||||||
| Demographics | |||||||||||
| Grade (n,%) | <0.0001 | 0.3 | |||||||||
| 9 | 843 | (27.2) | 10 | (13.2) | 74 | (19.2) | 759 | (28.8) | |||
| 10 | 777 | (25.0) | 24 | (31.6) | 88 | (22.8) | 665 | (25.2) | |||
| 11 | 778 | (25.1) | 18 | (23.7) | 104 | (26.9) | 656 | (24.8) | |||
| 12 | 704 | (22.7) | 24 | (31.6) | 120 | (31.1) | 560 | (21.2) | |||
| Gender (n,%) | 0.01 | 0.07 | |||||||||
| Male | 0 | 1467 | (47.3) | 47 | (61.8) | 195 | (50.5) | 1225 | (46.4) | ||
| Female | 1 | 1635 | (52.7) | 29 | (38.2) | 191 | (49.5) | 1415 | (53.6) | ||
| Race/Ethnicity (n,%) | <0.001 | 0.9 | |||||||||
| White, non-Hispanic | 4 | 2509 | (80.9) | 55 | (72.4) | 281 | (72.8) | 2173 | (82.3) | ||
| Black, non-Hispanic | 3 | 152 | (4.9) | 4 | (5.3) | 25 | (6.5) | 123 | (4.7) | ||
| Hispanic | 2 | 188 | (6.1) | 10 | (13.2) | 39 | (10.1) | 139 | (5.3) | ||
| Other | 1 | 253 | (8.2) | 7 | (9.2) | 41 | (10.6) | 205 | (7.8) | ||
| Tobacco Use Behaviors | |||||||||||
| Status of Cigarette Useb (n,%) | |||||||||||
| Never Smokers | 2659 | (85.7) | 7 | (9.2) | 0 | (0.0) | 2640 | (100.0) | <0.001 | <0.0001 | |
| Ever Tried Cigarettes, but not current | 12 | (0.4) | 12 | (15.8) | 0 | (0.0) | 0 | (0.0) | |||
| Current occasional Smoker | 289 | (9.3) | 34 | (44.7) | 255 | (66.1) | 0 | (0.0) | |||
| Current Daily Smoker | 154 | (5.0) | 23 | (30.3) | 131 | (33.9) | 0 | (0.0) | |||
| Age First Smoked Whole Cig. (mean, SD) | (0.0) | (0.0) | |||||||||
| 13.3 (2.4)c | 12.8 (2.6) | 13.4 (2.3) | NA | NA | 0.07 | ||||||
| Cigarette per day (n,%) | NA | 0.002 | |||||||||
| less than 1 | 1 | 241 | (7.8) | 39 | (51.3) | 202 | (52.3) | NA | |||
| 1 to 5 | 2-Jan | 122 | (3.9) | 18 | (23.7) | 104 | (26.9) | NA | |||
| 6 to 1/2 pack | 3 | 57 | (1.8) | 11 | (14.5) | 46 | (11.9) | NA | |||
| 1 pack or more | 4 | 35 | (1.1) | 6 | (7.9) | 30 | (7.8) | NA | |||
| Missing | 6 | (0.2) | 2 | (2.6) | 4 | (1.0) | NA | ||||
| Number of Alternative Tobacco Products Used,d (n, %) | <0.001 | <0.0001 | |||||||||
| 0 | 2647 | (85.3) | 14 | (18.4) | 114 | (29.5) | 2519 | (95.4) | |||
| 1 | 279 | (9.0) | 25 | (32.9) | 157 | (40.7) | 97 | (3.7) | |||
| 2 | 104 | (3.4) | 14 | (18.4) | 72 | (18.7) | 18 | (0.7) | |||
| 3 | 47 | (1.5) | 12 | (15.8) | 31 | (8.0) | 4 | (0.2) | |||
| 4 | 25 | (0.8) | 11 | (14.5) | 12 | (3.1) | 2 | (0.1) | |||
| Mean (SD) | 0.23 (0.70) | 1.75 (1.32) | 1.15 (1.03) | 0.06 (0.3) | <0.0001 | 0.0003 | |||||
| Type of Other Tobacco Product Used (n,%) | (0.0) | (0.0) | |||||||||
| Cigars | 173 | (5.6) | 31 | (40.8) | 109 | (28.2) | 33 | (1.3) | <0.0001 | 0.03 | |
| Blunts | 331 | (10.7) | 51 | (67.1) | 207 | (53.6) | 73 | (2.8) | <0.0001 | 0.04 | |
| Hookahs | 131 | (4.2) | 32 | (42.1) | 73 | (18.9) | 26 | (1.0) | <0.0001 | <0.0001 | |
| Smokeless Tobacco | 93 | (3.0) | 19 | (25.0) | 53 | (13.7) | 21 | (0.8) | <0.0001 | 0.01 | |
| Total (n=1556) | Current e- cigarette users (n= 52) | Current cigarette smokers (n=145) | Never-smokers (n=1,359) | ||||||||
| Other Substance Use Behaviors (n,%) | |||||||||||
| Ever Alcohol Use | 844 | (54.2) | 49 | (94.2) | 131 | (90.3) | 664 | (48.9) | <0.0001 | 0.6 | |
| Current Alcohol Use | 503 | (32.3) | 45 | (86.5) | 113 | (77.9) | 345 | (25.4) | <0.0001 | 0.2 | |
| Current Binge Drinking | 306 | (19.7) | 35 | (67.3) | 86 | (59.3) | 185 | (13.6) | <0.0001 | 0.3 | |
| Ever Marijuana Use | 355 | (22.8) | 41 | (78.8) | 120 | (82.8) | 194 | (14.3) | <0.0001 | 0.5 | |
| Current Marijuana Use | 229 | (14.7) | 37 | (71.2) | 99 | (68.3) | 93 | (6.8) | <0.0001 | 0.7 | |
Compared using chi-square test and Fisher’s exact test for categorical variables and students t-tests for anova for continuous variables.
Ever tried cigarettes was defined as having tried a cigarette, even 1 or 2 puffs, but not being a current smoker, occasional smoker smoked 1–29 days in past 30 days and regular smoker smoked every day in past 30 days.
Represents mean age for current e-cigarette users (n=76) and current cigarette smokers (n=386) only.
Alternative tobacco products included cigars, blunts, hookah or smokeless tobacco. This was coded as an ordinal variable, as well as a continous variable to calculate the mean.
bolded values indicate significance at p<0.0008
Adjusted models demonstrated alternative tobacco product, alcohol and marijuana use were more likely in current e-cigarette users and current cigarette smokers compared to never-smokers (Table 2). Current e-cigarette users were more likely than current cigarette smokers to report blunt (Adjusted odds ratio (AOR) 1.81 (95% Confidence Interval (CI) 1.21–2.71) and hookah use (AOR 3.12 (CI 1.90–5.13) use, but not cigar, smokeless tobacco, alcohol, or marijuana use.
Table 2.
Odds Ratios for Alternatie Tobacco Product and Drug Use among E-cigarette Users, Cigarette Smokers, and Never-Smokers
| Current E-Cigarette Users vs. Never-Smokers
|
Current Cigarette Smokers vs. Never-Smokers
|
E-cigarette users vs. Cigarette Smokers
|
||||
|---|---|---|---|---|---|---|
| Crude OR | Adjusted OR | Crude OR | Adjusted OR | Crude OR | Adjusted OR | |
|
|
|
|
||||
| Alternative Tobacco Product Use (n=3,659) | ||||||
| Cigars | 54.41 (11.51–257.17) | 47.54 (7.28–310.36) | 31.09 (15.84–61.01) | 29.70 (15.48–56.96) | 1.75 (0.36–8.51) | 1.62 (0.26–10.21) |
| Blunts | 71.74 (54.61–94.24) | 67.22 (53.52–84.43) | 40.67 (21.30–77.65) | 38.20 (20.73–70.37) | 1.76 (1.05–2.96) | 1.81 (1.22–2.71) |
| Hookahs | 73.12 (34.60–154.50) | 63.79 (27.49–148.05) | 23.45 (9.31–59.06) | 20.76 (8.99–47.95) | 3.12 (1.67–5.83) | 3.12 (1.90–5.13) |
| Smokeless Tobacco | 41.57 (16.05–107.65) | 36.21 (12.60–104.05) | 19.85 (5.22–75.42) | 19.55 (5.43–70.43) | 2.09 (0.93–4.70) | 1.86 (0.62–5.57) |
| Other Drug Use (n=1,556) | ||||||
| Current Alcohol | 18.89 (11.60–30.75) | 17.88 (10.25–31.18) | 10.38 (7.37–14.62) | 10.00 (5.42–18.45) | 1.82 (0.79–4.18) | 1.81 (0.87–3.74) |
| Current Binge Drinking | 13.07 (6.61–25.81) | 11.62 (4.85–27.80) | 9.25 (7.39–11.59) | 8.52 (8.49–8.55) | 1.41 (0.90–2.23) | 1.47 (0.66–3.27) |
| Current Marijuana | 33.58 (14.87–75.84) | 29.14 (12.12–70.05) | 29.30 (9.60–89.41) | 28.02 (9.83–79.83) | 1.15 (0.85–1.55) | 1.07 (1.01–1.13) |
adjusted for grade, sex, and white/other race
bolded values indicate significance at p<0.008
Discussion
A large proportion of current e-cigarette users concurrently used cigarettes. E-cigarette users were more likely than both current cigarette smokers and never-smokers to use certain alternative tobacco products (blunts, and hookah). Similar to findings from young adults,[7] current e-cigarette users did not have an elevated risk of also using alcohol or marijuana as compared to current cigarette smokers. Adolescents who use e-cigarettes may use hookah and blunts because they perceive that all of these products are less harmful than traditional tobacco products.[8–10] Future studies are needed to examine these and other possibilities.
Limitations of this study include self-reported data and limited generalizability due to predominantly White (80.9%) northeast suburban schools. As the study was cross-sectional, we cannot make causal inferences. The e-cigarette users mostly included adolescents who concurrently smoked cigarettes. The sample size of the e-cigarette users who did not use cigarettes was small, making it impossible to separate out the effects of only using e-cigarettes. We were only able to ascertain alcohol and marijuana use in a subsample of schools. Lastly, given the overall low prevalence of e-cigarette use (especially within the subsample), our estimates have wide confidence intervals and further larger studies are needed to provide more precise effect estimates. As this data is cross-sectional, future longitudinal studies are needed to understand the potential consequences of dual e-cigarette and alternative tobacco product use when trying to estimate the net population health impact of these novel products in youth.
In summary, similar to previous studies, a large proportion of adolescent e-cigarette users reported using cigarettes.[1] Current e-cigarette users were more likely than current cigarette smokers to use blunts and hookah. These findings suggest that e-cigarette use is likely to be a marker of polytobacco use in adolescents.
Implications and Contribution.
This study demonstrates that adolescents who currently use electronic cigarettes are more likely than adolescents who currently smoke cigarettes only and never-smokers to use blunts and hookah. However, adolescents who currently use electronic cigarettes do not have an elevated risk of also using alcohol or marijuana as compared to adolescents who only smoke cigarettes.
Acknowledgments
Sources of Funding and Acknowledgements: This work was supported by NIDA grants R01DA026450 (To Krishnan-Sarin and Hyland) and K12DA033012 (to Camenga).
Footnotes
This study was presented in poster format at the 2013 Society for Research on Nicotine and Tobacco Annual Meeting in Boston, MA. All authors were significant contributors in preparing this manuscript.
There is no potential, perceived or real conflict of interest involved in the submission of this manuscript.
Disclosures: None
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References
- 1.Dutra LM, Glantz SA. Electronic Cigarettes and Conventional Cigarette Use among Us Adolescents: A Cross-Sectional Study. JAMA pediatrics. 2014 doi: 10.1001/jamapediatrics.2013.5488. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Camenga DR, Klein JD, Roy J. The Changing Risk Profile of the American Adolescent Smoker: Implications for Prevention Programs and Tobacco Interventions. J Adolesc Health. 2006;39:120, e121–110. doi: 10.1016/j.jadohealth.2005.10.014. [DOI] [PubMed] [Google Scholar]
- 3.Martin CA, Kelly TH, Rayens MK, et al. Sensation Seeking, Puberty, and Nicotine, Alcohol, and Marijuana Use in Adolescence. Journal of the American Academy of Child and Adolescent Psychiatry. 2002;41:1495–1502. doi: 10.1097/00004583-200212000-00022. [DOI] [PubMed] [Google Scholar]
- 4.Kandel DB, Yamaguchi K, Chen K. Stages of Progression in Drug Involvement from Adolescence to Adulthood: Further Evidence for the Gateway Theory. Journal of Studies on Alcohol. 1992;53:447–457. doi: 10.15288/jsa.1992.53.447. [DOI] [PubMed] [Google Scholar]
- 5.Jessor R. Risk Behavior in Adolescence: A Psychosocial Framework for Understanding and Action. Journal of Adolescent Health. 1991;12:597–605. doi: 10.1016/1054-139x(91)90007-k. [DOI] [PubMed] [Google Scholar]
- 6.Camenga DR, Delmerico J, Kong G, et al. Trends in Use of Electronic Nicotine Delivery Systems by Adolescents. Addict Behav. 2013 doi: 10.1016/j.addbeh.2013.09.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Sutfin EL, McCoy TP, Morrell HE, et al. Electronic Cigarette Use by College Students. Drug and alcohol dependence. 2013;131:214–221. doi: 10.1016/j.drugalcdep.2013.05.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Choi K, Forster JL. Beliefs and Experimentation with Electronic Cigarettes: A Prospective Analysis among Young Adults. Am J Public Health. 2014;46:175–178. doi: 10.1016/j.amepre.2013.10.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Sinclair CF, Foushee HR, Scarinci I, et al. Perceptions of Harm to Health from Cigarettes, Blunts, and Marijuana among Young Adult African American Men. Journal of health care for the poor and underserved. 2013;24:1266, 1275. doi: 10.1353/hpu.2013.0126. [DOI] [PubMed] [Google Scholar]
- 10.Smith JR, Novotny TE, Edland SD, et al. Determinants of Hookah Use among High School Students. Nicotine Tob Res. 2011;13:565–572. doi: 10.1093/ntr/ntr041. [DOI] [PubMed] [Google Scholar]