Adolescent Electronic Cigarette Use

Adolescent Electronic Cigarette Use

Adolescent Electronic Cigarette Use Associations With Conventional Cigarette and Hookah Smoking Tracey E. Barnett, PhD, Eric K. Soule, PhD, MPH, Jamie...

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Adolescent Electronic Cigarette Use Associations With Conventional Cigarette and Hookah Smoking Tracey E. Barnett, PhD, Eric K. Soule, PhD, MPH, Jamie R. Forrest, MS, Lauren Porter, PhD, MPH, Scott L. Tomar, DMD, MPH, DrPH Introduction: The emerging trends and rapid growth of electronic cigarettes (e-cigarettes) among adolescents are being monitored closely. The trends are critical as policy to prevent uptake among adolescents is considered. The purpose of this study is to describe the prevalence of e-cigarette use and potential correlates for use. Associations between e-cigarettes, cigarettes, and hookah are assessed. Methods: This study used data from the 2013 Florida Youth Tobacco Survey. Prevalence estimates were calculated in 2014 and differences were determined based on CIs. Adjusted logistic regression models were used to identify correlates of e-cigarette use among participants based on demographic and other tobacco products used. Results: There were no sex differences in middle school, whereas male high school students reported higher use than their female counterparts. Cigarette smoking and hookah use were significantly associated with ever and current e-cigarette use among both middle and high school students. Conclusions: Although e-cigarettes are being assessed as a potential replacement product for traditional tobacco, evidence from this study indicates the possibility of multiple product use among adolescents. E-cigarettes are not only associated with traditional cigarettes, but also with hookahs, a similar emerging product that offer tobacco flavors that may appeal to adolescents. Notably, many e-cigarette users also reported no cigarette or hookah use. (Am J Prev Med 2015;](]):]]]–]]]) & 2015 American Journal of Preventive Medicine

Introduction

F

indings from the 2012 National Youth Tobacco Survey (NYTS) were recently released in a special issue of this journal.1 For the non-conventional tobacco products, ever electronic cigarette (e-cigarette) use (6.8%) was less prevalent compared to hookah use (8.9%), but more youth were aware of e-cigarettes (50.3%) compared to hookahs (41.2%).2 Corey et al.3 reported that the percentage of high school students who had tried e-cigarettes rose from 4.7% in 2011 to 10.0% in From the Department of Behavioral Science and Community Health (Barnett, Soule), College of Public Health and Health Professions, Department of Community Dentistry and Behavioral Science (Tomar), College of Dentistry, University of Florida, Gainesville, Florida; Bureau of Chronic Disease Prevention (Forrest) and the Bureau of Tobacco Free Florida (Porter), Florida Department of Health, Tallahassee, Florida Address correspondence to: Tracey E. Barnett, PhD, Department of Behavioral Science and Community Health, College of Public Health and Health Professions, University of Florida, P.O. Box 100175, Gainesville FL 32610-0175. E-mail: [email protected]fl.edu. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.02.013

& 2015 American Journal of Preventive Medicine

2012.3 Similarly, current use of e-cigarettes rose from 1.5% in 2011 to 2.8% in 2012.3 Although national rates are imperative in understanding the current state of tobacco use, state surveys are also important given the differences in policies, enforcement, and general culture of tobacco use among youth populations. In 2012, the Florida Youth Tobacco Survey (FYTS)4 reported that 8.4% of high school students had tried e-cigarettes, which represents a 40% increase since 2011 (6.0%). Similarly, current use of e-cigarettes by high school students was 3.5%, an increase from 3.1% in 2011,4 which was higher than the national level. The prevalence of e-cigarette use among middle school students is lower than that among high school students; however, the increasing trend is the same. According to the NYTS, ever use of e-cigarettes among middle school students increased from 1.4% in 2011 to 2.7% in 2012,3 and current e-cigarette use increased from 0.6% in 2011 to 1.1% in 2012. In Florida, middle school students’ ever use of e-cigarettes increased from 3.0% in 2011 to 3.9% in 2012, representing a 30% increase, whereas current

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Am J Prev Med 2015;](]):]]]–]]] 1

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e-cigarette prevalence increased from 1.5% to 1.8%,4 representing a 20% increase, both higher than national rates. Concerns with increasing e-cigarette use among youth are not only the risk for nicotine addiction, but also the potential initiation of other tobacco products, including but not limited to conventional cigarettes and hookahs. Dutra and Glantz5 reported from the 2011 and 2012 NYTS that ever e-cigarette use was positively associated with ever and current conventional cigarette use. Not only was e-cigarette use associated with experimental cigarette use, but e-cigarette users also had higher odds of established smoking and lower odds of smoking abstinence. Given this finding, it appears that e-cigarettes may be used in conjunction with other tobacco products, establishing a pattern of dual product use among youth rather than product substitution. The purpose of this study is to estimate the 2013 prevalence of e-cigarette use and associated factors among Florida youth. Demographic correlates of e-cigarette use are assessed, as well as the relationship between e-cigarette and cigarette or hookah use. Hookah use is important to assess because it is an alternative tobacco product, currently less regulated than cigarettes in the U.S., and appealing to youth for its flavors, all similarities with e-cigarettes. Hookah use has been shown to be increasing in the state of Florida6 and e-cigarette use prevalence needs to be monitored to assess whether it is following the same pattern.

Methods Study Sample This study used data from the 2013 FYTS.7 The FYTS is a statewide, anonymous, self-completed, school-based paper survey that has been administered annually to a random sample of Florida public middle and high school students since 1998. The FYTS used a twostage cluster probability sample design. First, a random sample of public middle schools and high schools (grades 6–12) was selected for participation in the survey. Second, within each selected school, a random sample of classrooms was selected and students in those classrooms were invited to participate in the survey. Larger schools were sampled with greater probabilities of selection than smaller schools to ensure that every public middle school and high school student in the state had the same probability of selection. Parental consent was mostly obtained through passive permission forms which require a parent to return the form to “opt-out” their child from participation. In a few counties, active permission was required. The Florida Department of Health considered this survey ongoing public health surveillance, and the University of Florida IRB approved the de-identified data as exempt. In 2013, students in 172 middle and high school schools participated in the FYTS (6,440 middle school students and 6,175 high school students). For middle school, the overall response rate was 83%; for high school, the survey response rate was 75%.

Measures Sociodemographic variables examined in this study included sex, grade, and race/ethnicity. Race/ethnicity was established from two questions. The first question asked if the student was Hispanic or Latino, and the second asked: How do you best describe yourself? (Select only one response) with the following options: (1) American Indian or Alaska Native; (2) Asian; (3) black or African American; (4) Native Hawaiian or Other Pacific Islander; (5) white; or (6) Other. The two questions were combined so students who responded that they were Hispanic or Latino were coded as Hispanic/Latino for their race/ethnicity, regardless of their response to the second question. For analytic purposes, students who responded that they were not Hispanic or Latino were categorized as: (1) Non-Hispanic white; (2) Non-Hispanic black; or (3) Other. Tobacco use was queried through a series of questions that led with the statement: Have you ever tried, even once…, and the response options included items such as bidis, kreteks, flavored cigarettes, and cigars. The response options of interest for this study were smoking tobacco out of a water pipe (also called a “hookah”) and using an electronic cigarette. If the respondent indicated yes to either question, they were categorized as “ever e-cigarette user” or “ever hookah user.” The next question assessed current use, also with a dichotomous response option and the same list of tobacco products. Again, the items of interest following the opening stem: During the past 30 days, have you… were smoked tobacco out of a water pipe (also called a “hookah”) and used an electronic cigarette. A respondent who answered in the affirmative was categorized a “current hookah user” or “current e-cigarette user.” “Ever cigarette use” was determined using the following question: Have you ever tried cigarette smoking, even one or two puffs? If the respondents answered yes they were categorized as an “ever cigarette user.” “Current cigarette use” was determined using the following question: During the past 30 days, on how many days did you smoke cigarettes? If the respondents answered 1 or more, they were categorized as a “current cigarette user.”

Statistical Analysis The FYTS data were statistically weighted to be representative of all Florida public middle and high school students. In 2014, SAS, version 9.3 was used to calculate the prevalence of ever use and current use of e-cigarettes, cigarettes, and hookahs, analyzed separately by high school and middle school student status. SAS survey procedures were applied to account for the complex sample design. To indicate the level of precision for each prevalence estimate, 95% CIs were calculated for prevalence estimates. Two groups whose CIs do not overlap can be interpreted as having a statistically significant difference at the po0.05 level. Finally, hierarchical logistic regression modeling was used to estimate the odds of e-cigarette use associated first with participants’ demographic characteristics, and then ever or current cigarette or hookah use. Bonferroni correction was applied to calculate the p-value based on the number of comparisons per model in order minimize the probability of Type I error.8

Results Weighted to represent the Florida public school student population, slightly more than half (51.0%) of the sample www.ajpmonline.org

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included male students; 48.9% of students were in middle school and 51.1% were in high school. Overall, in terms of race/ethnicity, the sample was weighted to represent 27.6% Hispanics, 44.0% non-Hispanic whites, 22.7% non-Hispanic blacks, and 5.8% from other racial/ethnic backgrounds. The total ever cigarette smoking prevalence was 20.9%; more than one fourth (27.6%) of high school students and 12.0% of middle school students reported ever smoking cigarettes. Hookah tobacco smoking followed with 11.2% of the overall sample, and 16.7% of high school students and 4.0% of middle school students reported ever smoking a hookah. Current cigarette smoking was reported by 7.1% overall: 10.0% of high school students and 3.4% of middle school students. Current hookah use was reported by 5.6% of students overall, 8.2% of high school students, and 2.0% of middle school students. Overall, 4.3% of Florida middle school students reported ever using e-cigarettes and 1.8% reported current use (Table 1). Neither lifetime nor current use among middle school students differed significantly by sex. Non-Hispanic black middle school students had a significantly lower prevalence of lifetime use compared with non-Hispanic white students (po0.05). In 2013, 12.1% of Florida public high school students had ever smoked e-cigarettes and 5.4% currently smoked them. The prevalence of lifetime or current e-cigarette use was higher among male than female high school students. Non-Hispanic white students reported the highest prevalence of ever e-cigarette use. For those who reported ever smoking a hookah, 43.3% reported also ever using e-cigarettes, whereas of those who ever smoked cigarettes, 35.7% reported ever using e-cigarettes. About one fifth (21.9%) of those who reported ever smoking a hookah reported current e-cigarette use, whereas 15.7% of those who reported ever smoking cigarettes reported current e-cigarette use. More than half (58.9%) of high school students who reported current cigarette smoking also reported ever e-cigarette use. Hierarchical logistic regression modeling was conducted first to assess demographic correlates of e-cigarette use, and then the association of other tobacco (cigarette or hookah) use with e-cigarette use (Table 2). Among middle schoolers, there were no sex differences in e-cigarette use in any of the models. After adjusting for demographics and ever cigarette and hookah use, nonHispanic black middle school students were 0.4 times as likely as non-Hispanic white students to ever use e-cigarettes. Compared with students in sixth grade, when demographic variables were used only for association, eighth graders were more likely to report ] 2015

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e-cigarette use; this was also true when associating ever e-cigarette use and ever hookah use, but the remaining grade differences were non-significant. For ever use of e-cigarettes, ever use of cigarettes (Table 2, Model 2) and ever use of hookahs (Model 3) had the strongest associations. For those who ever used cigarettes, the AOR for ever e-cigarette use was 19.3 (95% CI¼14.1, 26.5). Similarly, middle school students who reported ever using a hookah were 13.9 times as likely (95% CI¼9.7, 19.8) to have ever used e-cigarettes. Middle school students who reported current cigarette smoking were 35.6 times as likely (95% CI¼22.3, 56.9) to report current e-cigarette use. Too few middle school students currently used e-cigarettes (1.8%) or hookahs (2.0%) to examine their association with demographic characteristics or use of hookahs. In hierarchical logistic regression modeling for e-cigarette use among high school students, male students were approximately 1.5 times as likely to ever use ecigarettes across the models and 1.8 times as likely to currently use e-cigarettes compared with female students (Table 3). Ever use of e-cigarettes was consistently least likely among non-Hispanic black high school students (AOR¼0.2–0.3) compared with non-Hispanic white students, when both demographic correlates and ever use of cigarettes or hookahs were assessed. For high school students, grade level generally was not significantly associated with e-cigarette use; only 12th graders were more likely to ever use e-cigarettes compared to ninth graders with only demographic variables in the model. Similar to middle school students, the strongest correlates of e-cigarette use among high school students were use of cigarettes or hookahs. For high school students who had ever used cigarettes, the AOR for ever using e-cigarettes was 18.0 (95% CI¼14.2, 22.7) relative to those who had never smoked. Those who had ever used hookahs were 11.4 times as likely (95% CI¼9.3, 13.9) to have ever used e-cigarettes. Current cigarette smokers were 23.4 times as likely (95% CI¼17.6, 31.0) also to report current e-cigarette use. Similarly, current hookah users were 21.7 times as likely (95% CI¼16.2, 29.2) to also report current e-cigarette use compared with non-current hookah users.

Discussion The findings of this study demonstrate the continued increase in popularity of e-cigarettes. Consistent with previous research on e-cigarette use among youth in the U.S.,3 the prevalence of either lifetime or current use of e-cigarettes found in this study are the highest levels reported to date. This trend is consistent for both ever and current use of e-cigarettes. Given the uncertainty of

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Table 1. Prevalence of Ever or Current Use of E-Cigarettes Among Florida Middle and High School Students Total (n¼12,615)

Middle School (n¼6,175)

High School (n¼6,440)

Ever used e-cigarettes % (95% CI)

Currently use e-cigarettes % (95% CI)

Ever used e-cigarettes % (95% CI)

Currently use e-cigarettes % (95% CI)

Ever used e-cigarettes % (95% CI)

Currently use e-cigarettes % (95% CI)

10.0 (9.1, 11.0)

4.7 (4.0, 5.3)

4.5 (3.7, 5.4)

1.8 (1.3, 2.3)

14.2 (12.7, 15.7)

6.8 (5.7, 7.9)

7.2 (6.5, 8.0)

3.0 (2.5, 3.5)

4.0 (3.2, 4.7)

1.7 (1.2, 2.2)

9.7 (8.6, 10.8)

3.9 (3.2, 4.7)

Hispanic

8.2 (7.2, 9.2)

4.1 (3.4, 4.9)

4.5 (3.5, 5.4)

2.1 (1.4, 2.9)

11.1 (9.6, 12.6)

5.7 (4.5, 6.9)

Non-Hispanic black

3.2 (2.4, 4.0)

1.7 (1.1, 2.3)

2.0 (1.1, 2.8)

0.8 (0.2, 1.3)

4.1 (2.9, 5.4)

2.4 (1.4, 3.4)

11.7 (10.6, 12.8)

4.7 (4.0, 5.4)

5.3 (4.3, 6.3)

2.1 (1.5, 2.8)

16.4 (14.7, 18.0)

6.6 (5.5, 7.7)

8.9 (7.2, 10.7)

4.0 (2.8, 5.2)

4.4 (2.7, 6.2)

1.5 (0.5, 2.6)

12.6 (9.8, 15.4)

6.0 (4.1, 8.0)

6





2.2 (1.5, 2.9)

0.7 (0.3, 1.0)





7





4.1 (3.1, 5.1)

2.0 (1.3, 2.7)





8





6.2 (5.0, 7.5)

2.4 (1.6, 3.1)





9









10.4 (8.6, 12.2)

5.1 (3.7, 6.4)

10









10.4 (8.7, 12.2)

4.6 (3.4, 5.7)

11









11.9 (10.1, 13.8)

5.1 (3.9, 6.4)

12









15.7 (13.5, 17.9)

6.4 (4.9, 7.9)

Ever smoked cigarettes

33.0 (30.9, 35.2)

14.5 (12.9, 16.1)

24.6 (21.1, 28.0)

10.6 (8.3, 13.0)

35.7 (33.2, 38.3)

15.7 (13.7, 17.7)

Currently smoke cigarettes

54.9 (51.2, 58.7)

34.5 (30.9, 38.2)

39.1 (32.0, 46.3)

28.1 (21.5, 34.7)

58.9 (54.7, 63.1)

36.1 (31.9, 40.4)

Ever smoked hookah

41.9 (39.0, 44.8)

22.0 (19.5, 24.5)

33.5 (27.2, 39.8)

22.5 (16.8, 28.3)

43.3 (40.1, 46.6)

21.9 (19.2, 24.7)

Currently smoke hookah

46.2 (42.0, 50.4)

37.0 (32.9, 41.1)

43.9 (34.6, 53.3)

38.0 (28.9, 47.1)

46.6 (42.0, 51.2)

36.8 (32.2, 41.4)

8.7 (8.1, 9.4)

3.9 (3.5, 4.3)

4.3 (3.7, 4.9)

1.8 (1.4, 2.2)

12.1 (11.1, 13.0)

5.4 (4.8, 6.1)

Characteristic Sex Male Female Race / Ethnicity

Other Grade level

Other tobacco use

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TOTAL e-cigarette

Note: Boldface indicates statistical significance (po0.05).

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Non-Hispanic white

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Table 2. Hierarchical Logistic Regressions Modeling Middle School Student E-Cigarette Use by Demographics and Other Tobacco Use Model 1 Ever smoke e-cigarettes demographics AOR (CI)

Model 2 Ever smoke e-cigarettes demographics þ cigarette AOR (CI)

Model 3 Ever smoke e-cigarettes demographics þ hookah AOR (CI)

Model 4 Current smoke e-cigarettes demographics AOR (CI)

Model 5 Current smoke e-cigarettes demographics þ cigarette AOR (CI)

Ref

Ref

Ref

Ref

Ref

1.1 (0.9, 1.5)

1.1 (0.8, 1.5)

1.2 (0.9, 1.6)

1.0 (0.7, 1.6)

0.9 (0.6, 1.5)

Non-Hispanic black

0.4 (0.2, 0.6)

0.4 (0.2, 0.6)

0.4 (0.3, 0.7)

0.4 (0.2, 1.3)

0.4 (0.2, 0.9)

Non-Hispanic white

Ref

Ref

Ref

Ref

Ref

Hispanic

0.8 (0.6, 1.0)

0.9 (0.6, 1.1)

0.6 (0.5, 0.9)

0.8 (0.5, 1.3)

0.9 (0.6, 1.5)

Other

0.8 (0.5, 1.3)

0.9 (0.5, 1.5)

0.7 (0.5, 1.2)

0.6 (0.3, 1.4)

0.8 (0.3, 1.7)

6

Ref

Ref

Ref

Ref

Ref

7

1.9 (1.3, 2.9)

1.3 (0.9, 2.0)

1.7 (1.1, 2.5)

3.0 (1.6, 5.7)

2.1 (1.1, 4.1)

8

3.0 (2.1, 4.4)

1.6 (1.1, 2.5)

2.1 (1.4, 3.1)

3.6 (1.9, 6.6)

2.1 (1.1, 4.1)

Ever used cigarettes



19.3 (14.1, 26.5)







Ever used hookah





13.9 (9.7, 19.8)





Currently use cigarettes









35.6 (22.3, 56.9)

Currently use hookah











Variable Demographic characteristics Sex

Male Race/ethnicity

Grade level

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Female

Other tobacco use

Note: Boldface indicates statistical significance (po0.05). NA, e-cigarette use sample size not adequate for analysis.

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Table 3. Hierarchical Logistic Regression Modeling High School Student E-cigarette Use by Demographics and Other Tobacco Use Model 2 Ever smoke e-cigarettes demographics þ cigarettes AOR (95% CI)

Model 3 Ever smoke e-cigarettes demographics þ hookah AOR (95% CI)

Model 4 Current smoke e-cigarettes demographics AOR (95% CI)

Model 5 Current smoke e-cigarettes demographics þ cigarettes AOR (95% CI)

Model 6 Current smoke e-cigarettes demographics þ hookah AOR (95% CI)

Ref

Ref

Ref

Ref

Ref

Ref

1.5 (1.3, 1.8)

1.5 (1.2, 1.8)

1.6 (1.3, 2.0)

1.8 (1.4, 2.3)

1.7 (1.3, 2.2)

1.8 (1.3, 2.4)

Non-Hispanic black

0.2 (0.2, 0.3)

0.3 (0.2, 0.4)

0.3 (0.2, 0.4)

0.3 (0.2, 0.5)

0.5 (0.3, 0.9)

0.4 (0.2, 0.6)

Non-Hispanic white

Ref

Ref

Ref

Ref

Ref

Ref

Hispanic

0.6 (0.5, 0.7)

0.6 (0.5, 0.8)

0.6 (0.4, 0.7)

0.8 (0.6, 1.0)

1.0 (0.7, 1.4)

0.7 (0.5.1.0)

Other

0.7 (0.5, 0.9)

0.7 (0.5, 1.0)

0.6 (0.5, 0.9)

0.8 (0.5, 1.2)

1.0 (0.6, 1.5)

0.7 (0.4, 1.1)

9

Ref

Ref

Ref

Ref

Ref

Ref

10

1.0 (0.8, 1.3)

0.8 (0.6, 1.1)

0.8 (0.6, 1.0)

0.9 (0.6, 1.3)

0.7 (0.5, 1.1)

0.7 (0.5, 1.0)

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1.2 (0.9, 1.5)

0.8 (0.6, 1.1)

0.8 (0.6, 1.1)

1.0 (0.7, 1.5)

0.9 (0.6, 1.3)

0.7 (0.5, 1.1)

12

1.6 (1.3, 2.1)

1.1 (0.8, 1.4)

0.9 (0.7, 1.2)

1.3 (0.9, 1.9)

0.9 (0.6, 1.3)

0.7 (0.5, 1.0)

Ever cigarette use



18.0 (14.2, 22.7)









Ever hookah use





11.4 (9.3, 13.9)







Current cigarette use









23.4 (17.6, 31.0)



Current hookah use











21.7 (16.2, 29.2)

Variable

Model 1 Ever smoke e-cigarettes demographics AOR (95% CI)

Demographic characteristics Sex

Male Race/ethnicity

Grade level

Other tobacco use

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Note: Boldface indicates statistical significance (po0.05).

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Female

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the health risks associated with e-cigarette use, these patterns of increasing prevalence of use among young people are a cause for concern. Notably, Florida’s current cigarette smoking rate (8.6%)9 was lauded for being lower than the national rate (15.7%)10 in 2013. In the present study, cigarette smoking and hookah use were significantly associated with both ever and current e-cigarette use among both middle and high school students. These findings suggest that e-cigarettes may be correlated with use of multiple tobacco products, including traditional products such as cigarettes and other emerging products, such as hookahs. However, some adolescents also reported e-cigarette use only and did not use other tobacco products. As the greater concern for youth populations is prevention of initiation of tobacco use rather than cessation, these patterns require further examination to assess if e-cigarettes are used for tobacco cessation or uptake among adolescents. This study adds to the previous literature published by Dutra and Glantz5 that associated e-cigarettes with cigarette use and cessation attempts. For this study, similar findings were seen for both cigarette and hookah use, indicating e-cigarettes may be appealing to youth as an initiation product and not necessarily a means to quit cigarettes. Although this study did not assess the beliefs associated with use of e-cigarettes, conventional cigarettes, or hookahs, it is possible that young users may also associate e-cigarettes with alternative tobacco products such as hookahs in addition to conventional cigarettes. Hookahs and e-cigarettes both provide users with multiple flavors and are often promoted as reduced-harm products, which may be appealing. The U.S. Food and Drug Administration does not yet regulate flavorings in tobacco products other than cigarettes, and findings from this and other studies suggest that future research and regulation need to consider the role that flavorings might play in experimentation and uptake of non-cigarette tobacco products by adolescents.

Limitations This study has several limitations. The sample frame for the FYTS included only public schools; therefore, these findings cannot be generalized to private schools. Participants were considered current users of e-cigarettes, conventional cigarettes, or hookahs if they reported any use in the preceding 30 days. It is possible that users who were reporting their first ever use were classified as current users despite only reporting a single use in their lifetime. However, given the size of the sample, these occurrences were likely rare enough not to bias the current use groups and these participants were also included in the ever use group analyses. Ever use can capture one-time experimenters and inflate concerns over these products. Selfreport is a limitation of any survey project; however, this ] 2015

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remains the most common avenue to obtain prevalence of many behaviors. This study was cross-sectional in design, thus temporal relationships between e-cigarette use and any of the variables of interest cannot be determined from these findings. Finally, given these data were from a state surveillance system, other variables that could be confounders, including but not limited to attitudes and beliefs, other substance use, or environmental factors, cannot be included and may in part explain findings. The study also has many strengths. Participants were drawn from a random selection of classrooms from randomly selected schools across the state of Florida. The response rates for both middle school students (83%) and high school students (75%) were high, increasing the external validity of the findings. Participant data were also weighted based on state demographic characteristics, further increasing the generalizability to public middle and high school students. Finally, the current analysis found strong associations between e-cigarette use and other forms of tobacco use while controlling for important demographic characteristics.

Conclusions Currently, the future of e-cigarettes is uncertain. Some believe that e-cigarettes pose similar risks of addiction and negative health outcomes as do other tobacco products. Others see potential in e-cigarettes as a cessation device that may help decrease tobacco use among individuals who suffer from addiction to tobacco. Regardless of how e-cigarettes are used in the future, e-cigarette use among middle and high school students is on the rise. Although further research is needed to understand how adolescents use e-cigarettes, health professionals should be alert to the potential risks of addiction and harm that may be associated with e-cigarette use, especially if e-cigarettes play some role in introducing young users to other tobacco products. Future research should monitor use of alternative tobacco products like e-cigarettes among young populations to determine exactly how e-cigarette use is associated with use of other tobacco products. Funding for the Florida Youth Tobacco Survey is provided by the Florida Department of Health, Bureau of Tobacco Free Florida. No financial disclosures were reported by the authors of this paper.

References 1. Apelberg BJ, Backinger CL, Curry SJ, eds. Using the National Youth Tobacco Survey to inform tobacco product regulation and tobacco control. Am J Prev Med. 2014;47(2S1).

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