Correlates of tobacco product reuptake and relapse among youth and adults in the USA: findings from the PATH Study Waves 1–3 (2013–2016)

Abstract

OBJECTIVE:

This study examines sociodemographic and tobacco use correlates of reuptake and relapse to tobacco use across a variety of tobacco products (cigarettes, electronic nicotine delivery systems, cigars, hookah, and smokeless tobacco) among the U.S. population.

DESIGN:

Data were drawn from the first three waves (2013–2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (ages 12–17) and adults (ages 18+). Reuptake (past 30-day use among previous tobacco users) and relapse (current use among former established users; adults only) were examined among previous users of at least one type of tobacco product at Wave 1 (W1) or Wave 2 (W2) (N = 19,120 adults, N = 3,039 youth). Generalized estimating equations were used to evaluate the association between demographic and tobacco use characteristics at baseline, with reuptake/relapse at follow-up, over two 1-year periods (W1-W2 and W2-W3).

RESULTS:

Any tobacco product reuptake occurred in 7.8% of adult previous users and 30.3% of youth previous users. Correlates of any tobacco reuptake included being male, non-Hispanic black, and bisexual in adults, but race and sexual orientation were not consistent findings in youth. Among recent former users, relapse rates were greater (32.9%). Shorter time since last use and greater levels of tobacco dependence showed the strongest association with any tobacco relapse.

DISCUSSION:

Continued clinical and public health efforts to provide adults with tools to cope with tobacco dependence symptoms, especially within the first year or two after quitting, could help prevent relapse.

INTRODUCTION

The majority of cigarette smokers who make at least one serious quit attempt relapse back to cigarette smoking, usually within the first week of quitting.^1–3 This relapse could be due to the addictive nature of nicotine and negative nicotine withdrawal symptoms when stopping use,⁴ exposure to conditioned cues associated with the automated behavior of tobacco product use,⁵ a desire to reinforce the subjective satisfaction derived from the product,⁶ and/or other social influences or stressors.^6,7 Relapse among cigarette smokers has been studied extensively.^3,8–13 The cycle between use, discontinued use, and relapse can repeat multiple times throughout a tobacco user’s lifetime. Despite great progress in psychosocial and pharmacotherapy interventions, long-term abstinence rates for cigarette smokers tend to be 30% or less, making relapse the most likely outcome for addicted smokers who make a cessation attempt.³ Clinical data on relapse among cigarette smokers have revealed numerous factors associated with relapse, including sociodemographic characteristics (e.g., age, race, socioeconomic status^8,9), cognitive and behavioral factors (e.g., lack of self-efficacy¹⁴), nicotine dependence/withdrawal,¹⁵ experiencing a smoking lapse,¹⁶ and other comorbidities (e.g., psychiatric illness, other substance use¹⁷).

Epidemiological studies of smoking relapse are less common and limited due to the cross-sectional nature of most population-based studies. Caraballo et al.⁸ used 25 years of data from a community-based cohort study to assess cigarette smoking relapse. They found that 39% of former smokers (at baseline) relapsed at least once, but of those, 70% had quit again by the end of the study. Using data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS), Yi and colleagues⁹ investigated sociodemographic factors related to cigarette smoking relapse and found that at least 15% of young adults, ages 18–29, experience smoking relapse (or move from being a former smoker to a current smoker) compared to 3–8% of older adults, age 30 or older, who relapse to smoking. Researchers have also examined the role of other tobacco product use on cigarette relapse and found that e-cigarette and smokeless tobacco users were more likely to relapse to cigarette smoking than non-users of these products.^18–20 Yet less is known about relapse with other tobacco products in the current tobacco marketplace. Non-cigarette tobacco product users exhibit different patterns of use²¹ and different levels of nicotine dependence.^22,23 The lack of data on relapse for tobacco products other than cigarettes is a significant limitation of the current literature, since use of non-cigarette tobacco products has increased in recent years.^24–27

Understanding the sociodemographic and tobacco use factors associated with reuptake and relapse to different tobacco products fills a large gap in the primarily cigarette-focused literature. Few studies have assessed the transition from any previous use back to past 30-day use (hereafter referred to as product reuptake) or from former established use back to current use (i.e., using every day or some days; hereafter referred to as product relapse).^8,9,18 We have chosen to differentiate reuptake from relapse to allow exploration of behavior changes that may or may not be indicative of a persistent pattern of use, especially among youth who may be experimenting with tobacco products. Using longitudinal data of the Population Assessment of Tobacco and Health (PATH) Study to assess within-person changes over time, this study evaluates the sociodemographic and tobacco use correlates of tobacco product reuptake among youth (ages 12–17) and adults (ages 18+), and tobacco product relapse among adults across several tobacco products available in the U.S. (cigarettes, electronic nicotine delivery systems [ENDS], cigars, hookah, and smokeless tobacco). Knowing which sociodemographic and other tobacco use characteristics contribute to reuptake and relapse across a spectrum of tobacco products will enhance a targeted public health approach to preventing tobacco use relapse.

METHODS

Data Source and Participants

The PATH Study is an ongoing, nationally representative, longitudinal cohort study of youth and adults in the U.S. to gather information on tobacco use patterns and associated health behaviors. Data were collected from September 12, 2013, through December 14, 2014 (Wave 1 [W1]); from October 23, 2014, through October 30, 2015 (Wave 2 [W2]); and from October 19, 2015, through October 23, 2016 (Wave 3 [W3]). Further details regarding the PATH Study design and W1 methods are published elsewhere.²⁸ The overall weighted response rate was 78.4% for youth and 74.0% for adults at W1, 87.3% for youth and 83.2% for adults at W2, and 83.3% for youth and 78.4% for adults at W3. Details on interview procedures, questionnaires, sampling, weighting, response rates, and accessing the data are described in the PATH Study Restricted Use Files User Guide at https://doi.org/10.3886/Series606. The study was conducted by Westat and approved by the Westat Institutional Review Board. All respondents ages 18 or older provided informed consent, with youth respondents ages 12 to 17 providing assent while each one’s parent/legal guardian provided consent. Data in this paper were drawn from respondents in W1, W2, and W3 of the PATH Study (25,384 adults at W1 or W2 and 12,993 youth at W1 or W2^*). See Supplemental Table 1 for additional details.

The analytic sample is subset to respondents who had ever used a tobacco product but are not past 30-day (P30D) users of at least one type of tobacco product at baseline (N = 18,988 adults; N = 2,983 youth). W1 is considered as the baseline to W2 and W2 is the baseline to W3. The weighted estimates represent the civilian, noninstitutionalized population of the U.S. at the time of W3 who were ages 9 or older at W1, through application of population and replicate weights that adjust for the complex study design characteristics (e.g., oversampling at W1) and nonresponse at W1, W2, and W3.

Measures

Tobacco product use

Tobacco products were grouped into five types: cigarettes, ENDS (e-cigarettes at W1 and e-cigarettes, e-cigars, e-pipes, and e-hookah at W2 and W3), cigars (traditional cigars, cigarillos, and filtered cigars), hookah, and smokeless tobacco (loose snus, moist snuff, dip, spit, chewing tobacco, and snus pouches). Previous use, former established use (adults only), and recent former established use (adults only) are defined (see Table 1) for each type of product and any tobacco use.

Table 1:

Definitions.

Relapse Behaviors	Baseline Tobacco Use Group (W1 or W2)	Follow-up Outcome (W2 or W3)
Reuptake1 (Table 2 and Supplemental Table 2)	Adults and Youth, Previous Use: For any tobacco and each tobacco product category4, had ever used the product (even once or twice) but not in the past 30 days.	Adults and Youth, Reuptake: Past 30-day use of the given tobacco product
Relapse2 (Table 3)	Adults only, Former Established Use: For cigarettes, had previously smoked at least 100 cigarettes in their lifetime, but had not smoked cigarettes in the past 30 days and not currently smoking every day or some days. For the other tobacco product categories, had previously used the product “fairly regularly” but not in the past 30 days, and not currently using every day or some days.	Adults only, Relapse: Current (every day/ some days) use of the given tobacco product
Relapse3 (Supplemental Table 3)	Adults only, Recent Former Established Use: For cigarettes, had previously smoked at least 100 cigarettes in their lifetime, had quit smoking in the past 12 months, had not smoked cigarettes in the past 30 days and not currently smoking every day or some days. For the other tobacco product categories, had previously used the product “fairly regularly,” had quit in the last 12 months, and had not used the product in the past 30 days, and not currently using every day or some days.	Adults only, Relapse: Current (every day/ some days) use of the given tobacco product

Notes:

Abbreviations: W1 = Wave 1; W2 = Wave 2; W3 = Wave 3

¹The respondent could have been a previous user for varied amounts of time prior to reuptake, ranging from 31 days to 70+ years.

²The respondent could have been a former established user for varied amounts of time prior to relapse, ranging from 31 days to 70+ years.

³The respondent could only have become a former established user within the past 12 months, with previous use ranging from 31 days to 12 months.

⁴Tobacco product categories include cigarettes, ENDS (e-cigarettes at W1 and e-cigarettes, e-cigars, e-pipes, and e-hookah at W2 and W3), cigars (traditional cigars, cigarillos, and filtered cigars), hookah, and smokeless tobacco (loose snus, moist snuff, dip, spit, chewing tobacco, and snus pouches)

Outcomes

Reuptake was defined as the transition from previous use at baseline (W1 or W2) to P30D use at follow-up (W2 or W3). Relapse was defined as the transition from former established use^† at baseline (W1 or W2) to current every day or some day use at follow-up (W2 or W3). See Table 1 for definitions. For a visual depiction of how the reuptake definition compares to the relapse definition, see Supplemental Figure 1.

Demographic characteristics

Demographic characteristics were assessed at the baseline wave and categorized as shown in the tables. Missing data on age, sex, race, and Hispanic ethnicity were imputed at W1 as described in the PATH Study Restricted Use Files User Guide.^29‡

Tobacco use characteristics

Time since last use for each tobacco product among adult former established users was categorized as: between 30 days and 1 year, between more than 1 year up to 2 years, or more than 2 years. Among adult recent former established users only, tobacco dependence was also assessed (using a 16 item measure validated across multiple types of tobacco use, see Strong et al.²³ for more details).

Statistical Analyses

Generalized estimating equations (GEE) were used to evaluate the association between correlates assessed at baseline and reuptake/relapse to tobacco product use at follow-up, over two 1-year periods (W1-W2 and W2-W3). This statistical method allows for the inclusion of transitions from both periods in a single analysis while statistically controlling for interdependence among observations contributed by the same individuals.^30,31 GEE logistic regression models specified unstructured covariance, within-person correlation matrices and the binomial distribution of the dependent variable using the logit link function. Analyses were weighted using the W3 “all-wave” weights to produce nationally representative estimates, and variances were computed using the balanced repeated replication (BRR) method³² with Fay’s adjustment set to 0.3 to increase estimate stability.³³ All analyses were conducted using SAS 9.4 software (SAS Institute, Inc., Cary, NC). See Supplemental Material for the SAS macro code created to run weighted GEE analyses and calculate adjusted odds ratios (aORs) and confidence intervals (CIs). Analyses were run on the W1-W3 Restricted Use Files to allow for exploration of more race/ethnicity categories and sexual orientation (https://doi.org/10.3886/ICPSR36231.v18). Demographic and tobacco use correlates were included in each model, adjusting for all correlates including wave among adults and youth separately.

RESULTS

Reuptake Among Previous Users

Adults

Among adult previous users, the rate of P30D reuptake of any tobacco product use was 7.8% (95% CI: 7.4–8.3; Table 2) at one-year follow-up. Rates of P30D reuptake for each type of tobacco product at follow-up were 5.2% (95% CI: 4.9–5.6) for cigarettes, 16.0% (95% CI: 15.2–16.8) for ENDS, 7.3% (95% CI: 6.9–7.8) for cigars, 6.1% (95% CI: 5.7–6.6) for hookah, and 4.4% (95% CI: 3.9–5.0) for smokeless tobacco.

Table 2:

Correlates of Reuptake Among Previous Users at Baseline (Adults 18+).

	P30D use at follow-up
	Any Tobacco					Cigarettes					ENDS					Cigars					Hookah					Smokeless
Correlates at baseline	%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI
Overall	7.8	(7.4–8.3)	N/A	N/A		5.2	(4.9–5.6)	N/A	N/A		16.0	(15.2–16.8)	N/A	N/A		7.3	(6.9–7.8)	N/A	N/A		6.1	(5.7–6.6)	N/A	N/A		4.4	(3.9–5.0)	N/A	N/A
DEMOGRAPHIC CHARACTERISTICS
Age group
18–24	25.5	(23.5–27.6)	--	--		19.4	(17.9–21.1)	--	--		21.3	(20.0–22.7)	--	--		16.5	(15.4–17.7)	--	--		11.3	(10.3–12.4)	--	--		10.0	(8.3–11.9)	--	--
25–39	12.0	(10.8–13.3)	0.5	(0.4–0.6)***		8.4	(7.7–9.3)	0.5	(0.5–0.6)***		15.9	(14.7–17.2)	0.7	(0.6–0.8)***		9.2	(8.3–10.2)	0.6	(0.5–0.7)***		4.7	(4.0–5.4)	0.4	(0.4–0.5)***		6.4	(5.4–7.4)	0.7	(0.5–1.0)*
40–54	6.0	(5.1–7.0)	0.2	(0.2–0.3)***		3.8	(3.2–4.6)	0.3	(0.2–0.3)***		14.1	(12.5–15.8)	0.6	(0.5–0.7)***		5.8	(5.1–6.5)	0.4	(0.3–0.5)***		3.0	(2.3–4.0)	0.3	(0.2–0.4)***		2.8	(2.0–3.8)	0.3	(0.2–0.5)***
55+	3.9	(3.2–4.7)	0.1	(0.1–0.2)***		2.4	(2.0–2.9)	0.2	(0.1–0.2)***		10.0	(8.3–11.9)	0.4	(0.3–0.5)***		3.4	(2.9–4.1)	0.3	(0.2–0.3)***		2.2	(1.3–3.5)	0.3	(0.1–0.4)***		2.0	(1.3–3.3)	0.2	(0.1–0.4)***
Sex
Female	6.7	(6.1–7.4)	--	--		4.9	(4.4–5.5)	--	--		15.5	(14.5–16.6)	--	--		6.3	(5.7–6.9)	--	--		5.8	(5.2–6.5)	--	--		2.4	(1.8–3.2)	--	--
Male	9.1	(8.3–9.9)	1.5	(1.3–1.8)***		5.5	(5.1–6.0)	1.0	(0.8–1.2)		16.5	(15.5–17.6)	1.0	(0.9–1.1)		7.8	(7.3–8.4)	1.6	(1.4–1.8)***		6.4	(5.7–7.0)	1.2	(1.0–1.4)		4.9	(4.3–5.6)	2.5	(1.8–3.5)***
Race/ethnicity
Non-Hispanic White	6.6	(6.0–7.1)	--	--		4.1	(3.7–4.5)	--	--		16.8	(15.8–17.8)	--	--		6.3	(5.8–6.8)	--	--		4.2	(3.7–4.8)	--	--		4.6	(4.0–5.2)	--	--
Non-Hispanic Black	11.9	(10.3–13.6)	1.4	(1.1–1.7)**		8.1	(6.9–9.4)	1.5	(12–1.9)***		14.1	(12.2–16.3)	0.7	(0.6–0.9)**		13.5	(11.8–15.3)	1.9	(1.5–2.3)***		12.9	(11.0–15.2)	2.7	(2.1–3.5)***		3.1	(1.9–5.0)	0.6	(0.4–1.1)
Non-Hispanic Other (includes two or more races)	8.7	(6.7–11.2)	1.0	(0.8–1.4)		6.4	(4.9–8.5)	1.2	(0.9–1.7)		14.1	(11.5–17.3)	0.8	(0.6–1.1)		6.9	(5.4–8.7)	0.9	(0.7–1.2)		7.3	(5.8–9.1)	1.9	(1.5–2.6)***		4.5	(2.9–6.9)	0.8	(0.5–1.4)
Hispanic	12.5	(11.1–14.1)	1.2	(0.9–1.4)		9.5	(8.1–11.0)	1.5	(12–1.9)***		15.5	(13.6–17.6)	0.9	(0.7–1.0)		10.4	(9.2–11.8)	1.3	(1.1–1.5)**		8.7	(7.7–9.9)	1.8	(1.4–2.2)***		4.5	(3.2–6.3)	0.7	(0.5–1.1)
Sexual orientation
Straight/Heterosexual	7.8	(7.3–8.3)	--	--		5.1	(4.7–5.5)	--	--		15.7	(14.9–16.6)	--	--		7.2	(6.8–7.6)	--	--		5.8	(5.3–6.3)	--	--		4.4	(3.8–5.0)	--	--
Gay or Lesbian	9.8	(6.7–14.1)	0.9	(0.6–1.4)		8.2	(5.6–11.8)	1.3	(0.9–1.9)		21.7	(16.8–27.6)	1.4	(1.0–2.0)*		8.1	(5.6–11.5)	0.9	(0.7–1.4)		10.6	(7.7–14.4)	1.6	(1.1–2.3)*		#	#	#	#
Bisexual	14.4	(10.6–19.2)	1.5	(1.0–2.0)*		13.7	(10.1–18.1)	1.6	(1.1–2.2)**		20.6	(17.0–24.8)	1.1	(0.8–1.5)		12.8	(10.0–16.2)	1.5	(1.1–2.0)**		10.5	(8.4–13.1)	1.7	(1.2–2.2)**		#	#	#	#
Something else	12.2	(7.7–18.7)	1.0	(0.6–1.8)		7.7	(4.6–12.7)	0.9	(0.5–1.6)		18.6	(12.5–26.8)	1.2	(0.7–1.9)		10.0	(6.3–15.7)	1.1	(0.6–1.8)		8.3	(5.2–12.9)	1.4	(0.9–2.2)		#	#	#	#
Educational attainment
Less than high school or some high school (no diploma) or GED	9.7	(8.1–11.5)	--	--		7.1	(6.0–8.3)	--	--		17.6	(15.8–19.6)	--	--		11.1	(10.0–12.4)	--	--		8.4	(7.0–10.1)	--	--		6.1	(4.8–7.8)	--	--
High school graduate— diploma	9.1	(7.8–10.5)	1.0	(0.8–1.3)		6.6	(5.7–7.6)	1.0	(0.8–1.3)		17.4	(15.8–19.1)	1.0	(0.9–1.2)		9.5	(8.3–10.8)	1.0	(0.8–1.2)		9.2	(8.1–10.4)	1.1	(0.9–1.4)		5.6	(4.4–7.1)	0.9	(0.6–1.3)
Some college (no degree) or associate degree	8.7	(7.9–9.5)	0.9	(0.7–1.1)		5.6	(5.0–6.2)	0.8	(0.6–1.0)		15.9	(14.8–17.0)	1.0	(0.8–1.1)		7.1	(6.5–7.7)	0.8	(0.7–0.9)**		6.7	(5.9–7.5)	0.9	(0.7–1.2)		4.6	(3.7–5.6)	0.8	(0.5–1.2)
Bachelor’s degree or more	5.9	(5.3–6.6)	0.7	(0.5–0.9)*		3.4	(2.9–3.9)	0.7	(0.5–0.9)**		12.7	(11.0–14.6)	0.9	(0.7–1.1)		4.8	(4.2–5.5)	0.8	(0.7–1.1)		3.0	(2.5–3.7)	0.7	(0.5–0.9)**		2.6	(2.0–3.5)	0.5	(0.3–0.9)*
Annual household income
< $25,000	12.2	(10.8–13.7)	--	--		9.0	(8.0–10.2)	--	--		17.3	(16.1–18.5)	--	--		11.9	(11.0–12.9)	--	--		9.1	(8.1–10.3)	--	--		6.0	(5.1–7.1)	--	--
$25,000- $74,999	7.2	(6.5–8.1)	0.7	(0.6–0.9)**		4.7	(4.1–5.3)	0.7	(0.6–0.9)***		16.1	(14.8–17.4)	1.1	(1.0–1.2)		6.4	(5.8–7.1)	0.7	(0.6–0.8)***		5.4	(4.7–6.1)	0.9	(0.7–1.1)		3.7	(3.0–4.6)	0.8	(0.6–1.1)
≥ $75,000	6.2	(5.4–7.0)	0.7	(0.5–0.8)***		3.4	(2.9–4.1)	0.6	(0.5–0.8)**		12.7	(11.0–14.6)	0.9	(0.8–1.1)		4.8	(4.2–5.4)	0.7	(0.6–0.8)***		3.3	(2.7–4.0)	0.7	(0.5–0.8)**		3.8	(2.9–5.1)	1.1	(0.8–1.6)
Not reported	6.4	(4.9–8.3)	0.7	(0.5–1.0)*		4.6	(3.5–6.1)	0.8	(0.6–1.1)		17.5	(14.7–20.7)	1.1	(0.9–1.5)		8.0	(6.3–10.0)	0.9	(0.7–1.3)		7.1	(5.5–9.1)	0.9	(0.7–1.2)		5.2	(3.5–7.7)	1.2	(0.8–1.9)
TOBACCO USE CORRELATES
Use of cigarettes
No P30D use	N/A	N/A	N/A	N/A		N/A	N/A	N/A	N/A		10.5	(9.4–11.7)	--	--		5.0	(4.6–5.4)	--	--		4.7	(4.2–5.3)	--	--		3.2	(2.5–3.9)	--	--
P30D use	N/A	N/A	N/A	N/A		N/A	N/A	N/A	N/A		19.6	(18.5–20.7)	2.1	(1.8–2.5)***		12.6	(11.8–13.4)	1.9	(1.7–2.2)***		8.1	(7.4–8.9)	1.4	(1.2–1.6)***		6.5	(5.7–7.3)	1.3	(1.0–1.7)
Use of ENDS
No P30D use	N/A	N/A	N/A	N/A		4.6	(4.2–5.0)	--	--		N/A	N/A	N/A	N/A		6.7	(6.2–7.1)	--	--		5.7	(5.2–6.2)	--	--		3.9	(3.4–4.5)	--	--
P30D use	N/A	N/A	N/A	N/A		24.2	(21.2–27.5)	3.6	(2.9–4.5)***		N/A	N/A	N/A	N/A		13.4	(12.2–14.7)	1.2	(1.1–1.4)**		8.5	(7.2–10.0)	1.1	(0.9–1.4)		7.7	(6.3–9.4)	1.2	(0.9–1.6)
Use of cigars
No P30D use	N/A	N/A	N/A	N/A		4.8	(4.4–5.2)	--	--		14.7	(13.8–15.6)	--	--		N/A	N/A	N/A	N/A		5.1	(4.6–5.6)	--	--		3.7	(3.2–4.4)	--	--
P30D use	N/A	N/A	N/A	N/A		15.5	(13.7–17.5)	2.1	(1.8–2.5)***		22.4	(20.5–24.3)	1.3	(1.2–1.6)***		N/A	N/A	N/A	N/A		11.1	(9.8–12.4)	1.5	(1.2–18)***		8.4	(6.9–10.2)	1.5	(1.1–2.1)*
Use of hookah
No P30D use	N/A	N/A	N/A	N/A		4.9	(4.6–5.3)	--	--		15.0	(14.2–15.8)	--	--		7.0	(6.5–7.4)	--	--		N/A	N/A	N/A	N/A		4.3	(3.7–4.9)	--	--
P30D use	N/A	N/A	N/A	N/A		22.7	(19.2–26.7)	1.2	(1.0–1.6)		27.8	(25.3–30.4)	1.8	(1.5–2.2)***		20.0	(17.3–23.0)	1.5	(12–1.9)***		N/A	N/A	N/A	N/A		10.9	(7.8–14.9)	1.2	(0.8–1.9)
Use of smokeless
No P30D use	N/A	N/A	N/A	N/A		5.1	(4.7–5.5)	--	--		15.8	(15.0–16.6)	--	--		7.0	(6.6–7.5)	--	--		6.1	(5.6–6.6)	--	--		N/A	N/A	N/A	N/A
P30D use	N/A	N/A	N/A	N/A		9.0	(7.3–11.1)	1.5	(1.1–2.0)**		20.1	(17.1–23.5)	1.0	(0.8–1.3)		11.9	(10.2–13.8)	1.4	(1.1–1.8)**		6.5	(4.9–8.5)	0.9	(0.7–1.3)		N/A	N/A	N/A	N/A

Notes.

Abbreviations: P30D = past 30-day; ENDS = electronic nicotine delivery system; aOR = adjusted odds ratio; CI = confidence interval; N/A = not applicable

The percentages and odds ratios in the table are based on weighted data.

Denominator N (unweighted number of observations) for aOR in “Any tobacco” = 14,707 Denominator N (unweighted number of observations) for aOR in “Cigarettes” = 16,356 Denominator N (unweighted number of observations) for aOR in “ENDS” = 12,124 Denominator N (unweighted number of observations) for aOR in “Cigars” = 18,606 Denominator N (unweighted number of observations) for aOR in “Hookah” = 12,946 Denominator N (unweighted number of observations) for aOR in “Smokeless” = 7,612

Tobacco product types were categorized into five groups: cigarettes, ENDS (e-cigarettes at Wave 1, and e-cigarettes, e-cigars, e-pipes, and e-hookah at Waves 2 & 3), cigars (traditional cigars, cigarillos, filtered cigars), hookah, and smokeless tobacco (loose snus, moist snuff, dip, spit, chewing tobacco, and snus pouches).

For each of the five tobacco products, and for any tobacco product, use is defined with respect to the given tobacco product/any tobacco product: Previous use is defined as ever use, with no P30D use (or ever using the product, even 1 or 2 times, but not in the past 30 days);

P30D use is defined as using the product at least once in the past 30 days.

The outcome ‘reuptake’ is defined as P30D use at follow-up (vs. no P30D use at follow-up) among previous users at baseline. Since no P30D use at baseline is defined with respect to each tobacco product, P30D of ‘other’ tobacco products at baseline are considered as correlates of ‘reuptake’ of the given tobacco product at follow-up.

GEE logistic regression analyses were used to assess correlates of ‘reuptake’ of P30D use at follow-up among previous users at baseline over a one-year period of time (i.e., Wave 1-Wave 2 and Wave 2-Wave 3), including up to two change data points per individual and statistically controlling for the correlation among observations from the same individuals. All correlates reflect baseline measurement for each wave pair (e.g., when evaluating change between Wave 1 and Wave 2, the age correlate reflects a person’s age at Wave 1, and when evaluating change between Wave 2 and Wave 3, the age correlate reflects a person’s age at Wave 2).

¹Analyses adjusted for age group, sex, race/ethnicity, sexual orientation, educational attainment, annual household income, each tobacco use correlate, and wave.

^#Estimates with either a relative standard error greater than 30 or a corresponding denominator less than 50 have been suppressed.

^*p <0.05

^**p <0.01

^***p <0.001

Any tobacco.

Adults ages 25–39, 40–54, or 55+ (adjusted odds ratio [aOR] range: 0.1–0.5), those with a bachelor’s degree or higher (aOR = 0.7, 95% CI: 0.5–0.9), and household income of $25,000-$74,999 or ≥ $75,000 per year ($25,000-$74,999: aOR = 0.7, 95% CI: 0.6–0.9; ≥ $75,000: aOR = 0.7, 95% CI: 0.5–0.8) had lower odds of tobacco use reuptake than those ages 18–24, those without a high school diploma, and to those with household income less than $25,000 per year, respectively. Male sex (aOR = 1.5, 95% CI: 1.3–1.8), non-Hispanic black race/ethnicity (aOR = 1.4, 95% CI: 1.1–1.7), and identifying as bisexual (aOR = 1.5, 95% CI: 1.0–2.0) all had higher odds of tobacco use reuptake than females, non-Hispanic white race/ethnicity, and those who identified as straight/heterosexual, respectively as shown in Table 2.

Cigarettes.

Older adults (ages 25 or older; aOR range = 0.2–0.5) and those with a bachelor’s degree or higher (aOR = 0.7, 95% CI: 0.5–0.9) had lower odds of cigarette use reuptake compared to those ages 18–24 and those without a high school diploma, respectively. Non-Hispanic black (aOR = 1.5, 95% CI: 1.2–1.9) and Hispanic (aOR = 1.5, 95% CI: 1.2–1.9) race/ethnicities and identifying as bisexual (aOR = 1.6, 95% CI: 1.1–2.2) had higher odds of cigarette use reuptake compared to those who are non-Hispanic or identified as straight/heterosexual. Those who were P30D users of cigars (aOR = 2.1, 95% CI: 1.8–2.5), ENDS (aOR = 3.6, 95% CI: 2.9–4.5), or smokeless tobacco products (aOR = 1.5, 95% CI: 1.1–2.0) at baseline had higher odds of cigarette use reuptake compared to those who were not P30D users of these products, as shown in Table 2.

ENDS.

Older adults (ages 25 or older; aOR range = 0.4–0.7) and identifying as non-Hispanic black race/ethnicity (aOR = 0.7, 95% CI: 0.6–0.9) had lower odds of ENDS use reuptake compared to those ages 18–24 and to those who are non-Hispanic white. Those who identify as gay or lesbian (aOR: 1.4, 95% CI: 1.0–2.0) had higher odds of ENDS use reuptake compared to heterosexuals. P30D users of cigarettes (aOR = 2.1, 95% CI: 1.8–2.5), cigars (aOR = 1.3, 95% CI: 1.2–1.6), or hookah (aOR = 1.8, 95% CI: 1.5–2.2) at baseline had higher odds of ENDS use reuptake compared to those who were not P30D users of these products, as shown in Table 2.

Cigars.

Older adults (ages 25 or older; aOR range = 0.3–0.6) had lower odds of cigar use reuptake compared to those ages 18–24. Male sex (aOR = 1.6, 95% CI: 1.4–1.8), non-Hispanic black (aOR = 1.9 95% CI = 1.5–2.3) and Hispanic (aOR = 1.3, 95% CI: 1.1–1.5) race/ethnicities, and those who identified as bisexual (aOR = 1.5, 95% CI: 1.1–2.0; had higher odds of cigar use reuptake compared to females, those who are non-Hispanic white, and those who identified as heterosexual/straight. P30D users of cigarettes (aOR = 1.9, 95% CI: 1.7–2.2), ENDS (aOR = 1.2, 95% CI: 1.1–1.4), hookah (aOR = 1.5, 95% CI: 1.2–1.9), or smokeless tobacco products (aOR = 1.4, 95% CI: 1.1–1.8) at baseline had higher odds of cigar use reuptake compared to those who were not P30D users of these products, as shown in Table 2.

Hookah.

Older adults (ages 25 or older; aOR range: 0.3–0.4) and those with a bachelor’s degree or higher (aOR = 0.7, 95% CI: 0.5–0.9) had lower odds of hookah use reuptake compared to those ages 18–24 or those without a high school diploma. Non-Hispanic black (aOR = 2.7, 95% CI: 2.1–3.5), Hispanic (aOR = 1.8, 95% CI: 1.4–2.2), and non-Hispanic other race (aOR = 1.9, 95% CI: 1.5–2.6) as well as identifying as bisexual (aOR = 1.7, 95% CI: 1.2–2.2) or gay/lesbian (aOR = 1.6, 95% CI: 1.1–2.3) all had higher odds of hookah use reuptake compared to those who are non-Hispanic white or those who identified as heterosexual/straight. P30D users of cigarettes (aOR = 1.4, 95% CI: 1.2–1.6) or cigars (aOR = 1.5, 95% CI: 1.2–1.8) at baseline had higher odds of hookah use reuptake compared to those who were not P30D users of these products, as shown in Table 2.

Smokeless tobacco.

Adults ages 25 or older (aOR range: 0.2–0.7) and those with a bachelor’s degree or higher (aOR = 0.5, 95% CI: 0.3–0.9) had lower odds of smokeless tobacco reuptake use compared to those ages 18–24 and those without a high school diploma, respectively. Male sex (aOR = 2.5, 95% CI: 1.8–3.5) and P30D use of cigars (aOR = 1.5, 95% CI: 1.1–2.1) had higher odds of smokeless tobacco use reuptake compared to females and those who were not P30D users of cigars, as shown in Table 2.

Youth

Among youth who were previous users of any tobacco product at baseline, the rate of P30D reuptake of any tobacco product use was 30.3% (Supplemental Table 2) at follow-up. Rates of P30D reuptake for each type of tobacco product at follow-up ranged from just over 15% (smokeless tobacco) to almost 25% (cigars). Being an older youth (ages 15–17) was a significant predictor of reuptake of any tobacco and of all individual tobacco products except smokeless tobacco. See Supplemental Table 2 for additional significant correlates of tobacco product reuptake in youth.

Relapse Among Former Established Users

Adults

Generally, the pattern of findings for relapse of any tobacco use among adult former established users (Table 3) was fairly consistent with reuptake among adult previous tobacco users (Table 2). Among former established users of any tobacco product at baseline, 6.5% (95% CI: 5.9–7.2; Table 3) relapsed to use of any tobacco product at follow-up. Rates of relapse for each type of tobacco product at follow-up were 4.2% (95% CI: 3.7–4.7) for cigarettes, 17.6% (95% CI: 15.4–19.9) for ENDS, 6.6% (95% CI: 5.7–7.6) for cigars, 9.1% (95% CI: 7.5–11.0) for hookah, and 6.7% (95% CI: 5.2–8.6) for smokeless tobacco.

Table 3:

Correlates of ‘Relapse’ Among Former Established Users (Adults 18+) with No P30D Tobacco Use at Baseline.

	Current (everyday/some day) use at follow-up
	Any Tobacco					Cigarettes					ENDS				Cigars						Hookah					Smokeless
Correlates at baseline	%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI		%	95% CI	aOR1	95% CI
Overall	6.5	(5.9–7.2)	N/A	N/A		4.2	(3.7–4.7)	N/A	N/A		17.6	(15.4–19.9)	N/A	N/A		6.6	(5.7–7.6)	N/A	N/A		9.1	(7.5–11.0)	N/A	N/A		6.7	(5.2–8.6)	N/A	N/A
DEMOGRAPHIC CHARACTERISTICS
Age group
18–24	30.2	(26.5–34.2)	--	--		24.2	(20.6–28.2)	--	--		19.3	(15.3–23.9)	--	--		12.9	(10.2–16.1)	--	--		NR	NR	NR	NR		16.9	(12.8–22.0)	--	--
25–39	14.5	(12.5–16.8)	0.4	(0.3–0.6)***		8.6	(7.3–10.0)	0.7	(0.5–1.0)		19.5	(16.1–23.5)	1.1	(0.7–1.5)		8.9	(7.0–11.4)	1.0	(0.6–1.5)		NR	NR	NR	NR		11.7	(8.7–15.4)	1.0	(0.6–1.8)
40–54	6.4	(5.2–7.9)	0.2	(0.1–0.2)***		4.0	(3.1–5.2)	0.5	(0.4–0.8)**		15.0	(11.0–20.1)	0.8	(0.5–1.4)		7.6	(5.4–10.5)	1.0	(0.5–1.7)		NR	NR	NR	NR		4.7	(3.1–7.1)	0.6	(0.3–1.2)
55+	3.1	(2.4–4.0)	0.1	(0.1–0.1)***		2.0	(1.5–2.7)	0.4	(0.2–0.6)***		13.5	(8.5–20.8)	0.7	(0.4–1.4)		2.4	(1.5–4.0)	0.5	(0.2–1.1)		NR	NR	NR	NR		#	#	#	#
Sex
Female	5.2	(4.4–6.2)	--	--		4.7	(3.9–5.5)	--	--		18.1	(15.3–21.3)	--	--		6.8	(5.0–9.1)	--	--		9.3	(6.8–12.5)	--	--		#	#	#	#
Male	7.7	(6.7–8.8)	1.7	(1.3–2.2)***		3.7	(3.2–4.4)	0.8	(0.6–1.1)		17.1	(14.0–20.7)	0.9	(0.6–1.3)		6.5	(5.4–7.9)	1.4	(0.8–2.3)		8.9	(7.0–11.3)	0.8	(0.5–1.3)		6.7	(5.1–8.7)	1.0	(0.3–3.1)
Race/ethnicity
Non-Hispanic White	5.9	(5.1–6.8)	--	--		3.6	(3.1–4.2)	--	--		17.7	(15.2–20.4)	--	--		5.4	(4.3–6.7)	--	--		8.3	(6.3–11.0)	--	--		7.0	(5.3–9.1)	--	--
Non-Hispanic Black	10.1	(7.6–13.2)	1.5	(1.1–2.2)*		6.6	(4.6–9.4)	1.4	(0.8–2.3)		17.0	(10.2–27.0)	0.9	(0.5–1.8)		13.8	(10.0–18.8)	2.5	(1.4–4.7)**		12.1	(5.6–24.3)	1.2	(0.4–3.5)		#	#	#	#
Non-Hispanic Other (includes two or more races)	6.4	(3.8–10.6)	0.8	(0.4–1.4)		4.7	(2.7–8.2)	0.9	(0.4–2.0)		14.2	(8.2–23.5)	0.9	(0.4–1.8)		4.7	(2.7–8.3)	0.9	(0.5–1.7)		9.0	(4.7–16.3)	1.0	(0.4–2.7)		#	#	#	#
Hispanic	9.6	(7.6–12.1)	0.9	(0.6–1.4)		7.1	(5.4–9.3)	1.4	(0.9–2.1)		20.1	(13.9–28.3)	1.4	(0.8–2.4)		6.6	(4.4–9.8)	0.9	(0.5–1.6)		10.6	(7.0–15.9)	1.2	(0.6–2.2)		#	#	#	#
Sexual orientation
Straight/Heterosexual	6.5	(5.9–7.2)	--	--		4.0	(3.6–4.6)	--	--		16.4	(14.1–19.0)	--	--		6.4	(5.4–7.5)	--	--		8.8	(7.1–10.9)	--	--		NR	NR	NR	NR
Gay or Lesbian	#	#	#	#		#	#	#	#		#	#	#	#		#	#	#	#		#	#	#	#		NR	NR	NR	NR
Bisexual	10.2	(6.5–15.8)	1.2	(0.8–1.9)		10.0	(6.3–15.6)	1.4	(0.8–2.4)		28.8	(19.1–40.8)	2.0	(1.0–3.9)		#	#	#	#		#	#	#	#		NR	NR	NR	NR
Something else	#	#	#	#		#	#	#	#		#	#	#	#		#	#	#	#		#	#	#	#		NR	NR	NR	NR
Educational attainment
Less than high school or some high school (no diploma) or GED	6.7	(4.9–9.2)	--	--		5.9	(4.3–8.1)	--	--		17.5	(13.3–22.8)	--	--		5.6	(3.7–8.4)	--	--		8.1	(4.6–13.7)	--	--		6.5	(4.4–9.3)	--	--
High school graduate— diploma	6.2	(4.9–7.9)	1.1	(0.6–1.8)		4.3	(3.4–5.6)	0.8	(0.5–1.3)		18.9	(13.1–26.5)	1.2	(0.7–2.2)		7.5	(5.5–10.3)	1.3	(0.8–2.3)		14.6	(9.9–21.0)	1.9	(0.9–4.3)		8.0	(5.2–12.0)	1.2	(0.6–2.3)
Some college (no degree) or associate degree	7.3	(6.2–8.7)	1.0	(0.6–1.6)		4.7	(3.9–5.5)	0.8	(0.5–1.3)		15.9	(12.9–19.5)	1.0	(0.7–1.6)		7.8	(5.9–10.2)	1.6	(0.9–2.8)		10.6	(7.7–14.4)	1.3	(0.6–2.7)		6.2	(4.1–9.3)	1.1	(0.6–2.0)
Bachelor’s degree or more	5.8	(4.8–6.9)	0.9	(0.6–1.4)		2.6	(2.0–3.4)	0.6	(0.4–1.1)		20.5	(14.2–28.7)	1.6	(0.8–3.2)		4.2	(2.7–6.5)	1.4	(0.7–2.7)		3.9	(2.3–6.7)	0.5	(0.2–1.3)		6.4	(4.2–9.8)	1.0	(0.5–1.9)
Annual household income
< $25,000	8.8	(7.3–10.5)	--	--		7.2	(6.0–8.7)	--	--		16.0	(12.9–19.6)	--	--		8.4	(6.6–10.6)	--	--		11.0	(8.5–14.2)	--	--		8.1	(5.8–11.0)	--	--
$25,000- $74,999	6.1	(5.1–7.4)	0.8	(0.6–1.0)		3.8	(3.1–4.6)	0.7	(0.5–0.9)*		18.6	(15.4–22.3)	1.3	(0.9–1.9)		5.6	(4.3–7.3)	0.9	(0.6–1.5)		8.5	(6.1–11.8)	0.8	(0.5–1.3)		5.8	(4.2–7.9)	0.8	(0.5–1.3)
≥ $75,000	6.4	(5.3–7.8)	0.7	(0.5–1.0)		2.7	(2.0–3.7)	0.6	(0.3–0.9)*		17.6	(12.8–23.6)	1.3	(0.7–2.2)		5.5	(3.5–8.6)	1.1	(0.6–2.2)		#	#	#	#		7.2	(4.5–11.4)	1.1	(0.6–2.1)
Not reported	3.1	(1.9–5.2)	0.5	(0.3–0.8)**		3.0	(1.8–4.8)	0.6	(0.4–1.0)		20.3	(12.2–31.8)	1.2	(0.6–2.5)		#	#	#	#		14.5	(7.8–25.3)	1.2	(0.5–2.8)		#	#	#	#
TOBACCO USE CORRELATES
Use of cigarettes
No P30D use	N/A	N/A	N/A	N/A		N/A	N/A	N/A	N/A		10.7	(7.8–14.3)	--	--		4.6	(3.5–5.9)	--	--		8.1	(6.2–10.6)	--	--		5.8	(3.8–8.7)	--	--
P30D use	N/A	N/A	N/A	N/A		N/A	N/A	N/A	N/A		20.6	(17.7–23.7)	2.1	(1.4–3.4)**		10.5	(8.8–12.4)	1.3	(0.9–2.1)		10.0	(7.5–13.2)	0.8	(0.5–1.3)		8.4	(6.9–10.2)	0.6	(0.4–1.0)
Use of ENDS
No P30D use	N/A	N/A	N/A	N/A		3.5	(3.1–4.0)	--	--		N/A	N/A	N/A	N/A		5.9	(5.0–7.1)	--	--		8.7	(6.9–10.8)	--	--		6.1	(4.5–8.4)	--	--
P30D use	N/A	N/A	N/A	N/A		17.9	(14.9–21.3)	1.5	(1.1–2.1)*		N/A	N/A	N/A	N/A		11.0	(7.9–15.0)	1.1	(0.7–1.8)		10.9	(7.1–16.2)	0.8	(0.4–1.7)		10.0	(6.9–14.3)	0.9	(0.5–1.7)
Use of cigars
No P30D use	N/A	N/A	N/A	N/A		4.0	(3.5–4.5)	--	--		16.8	(14.4–19.6)	--	--		N/A	N/A	N/A	N/A		8.5	(6.8–10.5)	--	--		5.9	(4.5–7.8)	--	--
P30D use	N/A	N/A	N/A	N/A		10.0	(7.8–12.6)	1.9	(1.3–2.8)***		21.4	(16.2–27.8)	1.1	(0.7–1.8)		N/A	N/A	N/A	N/A		10.7	(7.5–15.1)	1.0	(0.5–1.8)		11.7	(7.9–17.0)	1.6	(0.8–3.2)
Use of hookah
No P30D use	N/A	N/A	N/A	N/A		4.0	(3.6–4.5)	--	--		17.3	(15.2–19.7)	--	--		6.3	(5.4–7.4)	--	--		N/A	N/A	N/A	N/A		6.7	(5.2–8.6)	--	--
P30D use	N/A	N/A	N/A	N/A		20.4	(14.5–28.0)	1.2	(0.7–1.9)		20.7	(13.1–31.2)	1.1	(0.6–1.9)		13.9	(9.2–20.5)	1.1	(0.6–2.0)		N/A	N/A	N/A	N/A		#	#	#	#
Use of smokeless
No P30D use	N/A	N/A	N/A	N/A		4.0	(3.6–4.5)	--	--		17.4	(15.3–19.7)	--	--		6.2	(5.3–7.2)	--	--		8.8	(7.1–10.9)	--	--		N/A	N/A	N/A	N/A
P30D use	N/A	N/A	N/A	N/A		6.7	(4.9–9.1)	1.4	(0.9–2.2)		19.9	(12.4–30.5)	1.2	(0.6–2.5)		11.6	(7.9–16.8)	1.7	(0.9–3.2)		#	#	#	#		N/A	N/A	N/A	N/A
Time since last use
Between 30 days −1 year ago	N/A	N/A	N/A	N/A		25.7	(22.9–28.8)	13.0	(8.8–19.2)***		19.5	(17.0–22.3)	1.8	(0.8–4.3)		16.3	(13.4–19.7)	6.7	(3.7–12.3)***		14.6	(11.5–18.3)	3.5	(1.3–9.3)*		27.3	(22.5–32.8)	11.0	(5.2–23.5)***
Between 1–2 years ago	N/A	N/A	N/A	N/A		8.5	(6.5–11.0)	3.4	(2.3–5.1)***		11.3	(7.5–16.7)	1.1	(0.4–3.1)		11.3	(8.5–14.9)	5.0	(2.5–9.8)***		9.7	(6.8–13.6)	2.3	(0.9–5.9)		9.4	(6.5–13.4)	3.3	(1.3–8.1)*
More than 2 years ago	N/A	N/A	N/A	N/A		1.6	(1.2–2.0)	--	--		#	#	#	#		1.9	(1.2–3.0)	--	--		#	#	#	#		#	#	#	#

Notes:

Abbreviations: P30D = past 30-day; ENDS = electronic nicotine delivery system; aOR = adjusted odds ratio; CI = confidence interval; N/A = not applicable; NR = Not Reported-- variables in which at least one level had a numerator N < 3 were not reported

The percentages and odds ratios in the table are based on weighted data.

Denominator N (unweighted number of observations) for aOR in “Any tobacco” = 6,109 Denominator N (unweighted number of observations) for aOR in “Cigarettes” = 7,032 Denominator N (unweighted number of observations) for aOR in “ENDS” = 1,229 Denominator N (unweighted number of observations) for aOR in “Cigars” = 2,393 Denominator N (unweighted number of observations) for aOR in “Hookah” = 906 Denominator N (unweighted number of observations) for aOR in “Smokeless” = 1,836

Tobacco product types were categorized into five groups: cigarettes, ENDS (e-cigarettes at Wave 1, and e-cigarettes, e-cigars, e-pipes, and e-hookah at Waves 2 & 3), cigars (traditional cigars, cigarillos, filtered cigars), hookah, and smokeless tobacco (loose snus, moist snuff, dip, spit, chewing tobacco, and snus pouches).

For each of the five tobacco products, and for any tobacco product, use is defined with respect to the given tobacco product/any tobacco product:

Former established use is defined as having used a product fairly regularly (or smoked more than 100 cigarettes in their lifetime), and currently does not use tobacco at all and has not used the product in the past 30 days; Current (everyday/some day) use is defined as using everyday or some days;

P30D use is defined as use on at least one of the past 30 days.

The outcome ‘relapse’ is defined as current (everyday/some day) use at follow-up (vs. no use at all) among former established users at baseline.

Since no P30D use at baseline is defined with respect to each tobacco product, P30D use of ‘other’ tobacco products at baseline are considered as correlates of ‘relapse’ of the given tobacco product at follow-up.

GEE logistic regression analyses were used to assess correlates of ‘relapse’ at follow-up among former established users at baseline over a one-year period of time (i.e., Wave 1-Wave 2 and Wave 2-Wave 3), including up to two change data points per individual and statistically controlling for the correlation among observations from the same individuals.

All correlates reflect baseline measurement for each wave pair (e.g., when evaluating change between Wave 1 and Wave 2, the age correlate reflects a person’s age at Wave 1, and when evaluating change between Wave 2 and Wave 3, the age correlate reflects a person’s age at Wave 2).

¹Analyses adjusted for age group, sex, race/ethnicity, sexual orientation, educational attainment, annual household income, each tobacco use correlate, and wave.

^#Estimates with either a relative standard error greater than 30 or a corresponding denominator less than 50 have been suppressed.

^*p <0.05

^**p <0.01

^***p <0.001

Any tobacco.

Adults ages 25 or older (aOR range: 0.1–0.4) were less likely to relapse than those ages 18–24, while males (aOR = 1.7, 95% CI: 1.3–2.2) were more likely than females to relapse (see Table 3).

Cigarettes

Adults ages 40 or older (aOR range: 0.4–0.5) and those with larger income (aOR range: 0.6–0.7) were less likely to relapse than those ages 18–24 and those with a household income <$25,000, respectively. Use of cigars (aOR = 1.5, 95% CI: 1.1–2.1) or ENDS (aOR = 1.9, 95% CI: 1.3–2.8) at baseline was associated with greater odds of relapse. Time since last use of cigarettes was a significant predictor of cigarette relapse, with recent use (within the past year; aOR = 13.0, 95% CI: 8.8–19.2) as well as cigarette use 1–2 years ago (aOR = 3.4, 95% CI: 2.3–5.1) having higher odds of relapse to cigarette use compared to last use more than 2 years ago, as shown in Table 3.

Non-cigarette tobacco products.

As shown in Table 3, use of cigarettes at baseline (aOR = 2.1, 95% CI: 1.4–3.4) was associated with higher odds of relapse to ENDS use than those who did not use cigarettes at baseline. Non-Hispanic black race/ethnicity (aOR = 2.5, 95% CI: 1.4–4.7) was associated with higher odds of cigar relapse compared to non-Hispanic white race/ethnicity. For all products, other than ENDS, time since last use was a significant predictor of relapse to that product. Recent use (between 30 days-1 year) was associated with higher odds of relapse (aOR range: 3.5 [hookah] - 11.0 [smokeless]) compared to last use 2 or more years ago. Among cigar, and smokeless tobacco users, last use between 1–2 years ago was also associated with higher odds for relapse (aOR range: 3.3 [smokeless]-5.0 [cigars]).

Relapse Among Recent Former Established Users

Adults

Among recent former users of any tobacco product, the only significant predictor of relapse was tobacco dependence, with those with higher dependence scores having higher odds of relapse to any tobacco use (aOR = 1.2, 95% CI: 1.1–1.4; Supplemental Table 3). After adjusting for correlates including tobacco dependence, those with an income ≥ $75,000 per year (aOR = 0.5, 95% CI: 0.3–0.8) had lower odds of cigarette relapse than those with an income < $25,000 per year.

DISCUSSION

Over a one-year period, less than 10% of adult users made the transition from previous product use to P30D use (reuptake) for any tobacco product (7.8%) or any individual product (reuptake ranged from 4.4% for smokeless tobacco to 7.3% for cigars) except ENDS. Among adult previous ENDS users, 16.0% were P30D ENDS users at the follow-up wave. Among youth, reuptake rates were much greater compared to adults (reuptake of any tobacco was 30.3%, with rates for individual products ranging from 15.6% for smokeless tobacco to 24.7% for cigars). This pattern is consistent with results evaluating reuptake over two waves of the PATH Study; ENDS had the highest reuptake rate of any P30D use (regardless of other products used) in youth and young adults (ages 18–24).^34–38 ENDS products have also changed substantially from first generation devices that were not efficient at nicotine delivery,³⁹ to more advanced second generation devices and pod-mods (i.e., JUUL), the latter of which increased its market share after the reporting period used for these analyses.⁴⁰ Therefore, these reuptake rates may signal continued experimentation of an evolving product or progression to regular use in youth and young adults.^41,42

The overall relapse rate reported in this study, 6.5%, is much lower than the rate found by Carabello et al.⁸ (~30%); however, it is difficult to compare findings from a 1-year period to those from a study that spanned 30 years. Our relapse definition focused on the transition back to current every day or some day use; however, using the outcome of P30D use would likely increase the number of relapse observations (i.e. from 591 observations to 818 observations among former established cigarette users who did not use cigarettes in the past 30 days at baseline). While using a different outcome would likely change the overall relapse rate, we do not believe there would be substantial impact on the correlates of relapse as they were fairly similar across our current definitions of reuptake and relapse. Future research should explore the impact of different definitions (i.e., including every day, some day, or any past 30 day use at follow-up), as well as the role of intermittent product use patterns⁴³ on relapse rates.

Many demographic correlates of tobacco product reuptake were consistent with previously published correlates of tobacco product use.^8,9,44–48 Consistent with Yi et al.,⁹ the present study found less reuptake in older adults compared to younger adults, and higher levels of education were associated with a decreased likelihood of reuptake to current use of any tobacco and cigarettes. This is consistent with literature citing continued experimentation and initiation of tobacco product use among young adults.^49–52 Furthermore, our results show that age is consistently correlated with tobacco product reuptake among youth as well, with 15- to 17-year-olds (high school students) being more likely to reuptake tobacco products than those aged 12–14 (middle school to early high school students).^53,54 In addition, this study expanded previous research findings to include sexual orientation which was a significant predictor (adults only) of tobacco reuptake, with sexual minorities (identifying as gay/lesbian or bisexual) having higher odds of reuptake to tobacco products except smokeless tobacco than those who identified as straight/heterosexual. In contrast to Yi et al.,⁹ who found no racial/ethnic differences in reuptake rates, we found a significant race/ethnicity effect in adults such that previous non-Hispanic black users were more likely to reuptake any tobacco, specifically all combusted tobacco products, than previous non-Hispanic white users were. However, among youth, racial/ethnic minorities were less likely to reuptake any tobacco use, but race/ethnicity had no significant effect across individual products.

Moreover, our findings support previous research noting that other tobacco product use is associated with reuptake of not only cigarette smoking,^18–20 but other tobacco product use as well. These findings are consistent with those in the report by Kasza et al.⁵⁵ that evaluates correlates of tobacco product initiation. Since both initiation and reuptake are behaviors that involve starting (or restarting) tobacco use, it is not surprising that the pattern of correlates, in adults,⁵⁵ is similar to those seen here. Among former established users, time since last use had the largest magnitude of effect on subsequent relapse, especially among combusted products (ranging from a four-fold increase in relapse among hookah smokers to a 13-fold increase among cigarette smokers; see Table 3).We also explored the role of tobacco dependence in relapse among recent former established users (Supplemental Table 3) and found tobacco dependence had a significant effect among any tobacco users. Tobacco dependence is a well-documented correlate of relapse to cigarette smoking,⁴ and although not statistically significant in ENDS and cigar relapse future research should continue to explore the role of dependence in other tobacco product relapse.

Limitations

The reduced sample size in models among former established and recent former established users, particularly when looking at smokeless tobacco use and sexual orientation, may have played a role in the reduced number of significant sociodemographic predictors. Additional limitations include the inability to incorporate all possible predictors of relapse in our models which we hope future research explores. Other possible predictors could include reasons for use, substance use, mental health symptoms, and parental and peer tobacco use. Furthermore, the present study focused on behavior change over two 1-year periods; additional waves of the PATH Study can assess these behavior transitions over longer periods, in which behavior change may still be occurring.^56–58 Lastly, the definition of ENDS was expanded at Wave 2 to include other electronic nicotine products (e-hookah, e-pipe) which could have impacted reuptake/relapse rates.

Summary and Implications.

The present study fills in gaps in the current literature to present correlates of tobacco product reuptake and relapse across multiple tobacco products among U.S. youth and adults. Correlates of any tobacco reuptake include being male, non-Hispanic black, and bisexual in adults, but findings for race and sexual orientation were less consistent in youth. When assessing tobacco product relapse among adult former established users, time since last use and tobacco dependence (among recent former established users) appeared to be the strongest predictors of current use at follow-up. Continued clinical and public health efforts to provide adults with tools to cope with tobacco dependence, especially within the first year or two after quitting, could help prevent relapse to both cigarette and non-cigarette tobacco products.

What this paper adds:

• Understanding the sociodemographic and tobacco use factors associated with reuptake and relapse to different tobacco products fills a large gap in the primarily cigarette-focused literature. This study evaluates the sociodemographic and tobacco use correlates of tobacco product reuptake among youth (ages 12–17) and adults (ages 18+), and tobacco product relapse among adults across any tobacco and specific classes of tobacco products available in the U.S.

• Over a one-year period, reuptake was less than 8% for all products except ENDS (16%) among adults, and higher for youth (between 15–25% across products). Correlates of any tobacco reuptake included being male, non-Hispanic black, and bisexual in adults, but race and sexual orientation were not consistent findings in youth. These correlates among adults are similar to those seen in tobacco product initiation.

• Among adults, relapse rates were similar to reuptake. Relapse rates were higher (15–28% across products) when restricting our analyses to recent (within the past 12 months) former established users. Shorter time since last use and greater levels of tobacco dependence showed the strongest association with any tobacco relapse.

• Continued clinical and public health efforts to provide adults with tools to cope with tobacco dependence, especially within the first year or two after quitting, could help prevent relapse to both cigarette and non-cigarette tobacco products.