• Andrew C Stokes, Anna E Wilson, Dielle J Lundberg, Wubin Xie, Kaitlyn M Berry, Jessica L Fetterman, Alyssa F Harlow, Yvette C Cozier, Jessica L Barrington-Trimis, Kymberle L Sterling, Emelia J Benjamin, Michael J Blaha, Naomi M Hamburg, Aruni Bhatnagar, and Rose Marie Robertson.
• American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX.
• Nicotine Tob. Res. 2021 May 24; 23 (6): 900-908.

IntroductionUnderstanding which non-cigarette tobacco products precede smoking in youth across different racial/ethnic groups can inform policies that consider tobacco-related health disparities.MethodsWe used nationally representative, longitudinal data from the Population Assessment of Tobacco and Health Study waves 1-4. The sample was a dynamic cohort of cigarette-naïve youth aged 12-17 years. Mixed-effects models were used to assess non-cigarette product (e-cigarette, cigar product, or other product) use with cigarette use over 1-year intervals.ResultsOf the 28 788 observations pooled across waves 1-4, respondents were 48.7% non-Hispanic white, 13.9% non-Hispanic black, and 23.1% Hispanic. Odds of cigarette initiation over 1-year follow-up were higher among youth with prior use of e-cigarettes (odds ratio [OR], 2.76; 95% confidence interval [CI], 2.21-3.45), cigars (OR, 2.00; 95% CI, 1.42-2.80), or other products (OR, 1.66; 95% CI, 1.28-2.14) compared to never users. At the population level, 20.6% of cigarette initiation was attributable to e-cigarette use among white youth and 21.6% among Hispanic youth, while only 3.5% of cigarette initiation was attributable to e-cigarette use among black youth. In contrast, 9.1% of cigarette initiation for black youth was attributable to cigar use compared to only 3.9% for both white and Hispanic youth.ConclusionsPrior use of e-cigarettes, cigars, and other non-cigarette products were all associated with subsequent cigarette initiation. However, white and Hispanic youth were more likely to initiate cigarettes through e-cigarette use (vs. cigar or other product use), while black youth were more likely to initiate cigarettes through cigar use (vs. e-cigarette or other product use).ImplicationsOur findings suggest that previous studies on effects of non-cigarette tobacco products may overlook the critical role of cigar products as a pathway into cigarette smoking among US youth, particularly black youth. While our data support the importance of e-cigarette use as a pathway into smoking, regulatory actions aimed at addressing youth e-cigarette use alone may contribute to disparities in black versus white tobacco use and further exacerbate inequities in tobacco-related disease. Thus, contemporary policy development and discourse about the effects of non-cigarette tobacco products on cigarette initiation should consider cigar and other non-cigarette products as well as e-cigarettes.© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.

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