Teens may think they're playing it safe by using e-cigarettes, hookahs and smokeless tobacco, but they're twice as likely to have smoked cigarettes a year later if they use alternative tobacco products, a new report says.
Consequently, the gains made in public health as cigarette smoking has declined in recent years may be at risk if the use of novel tobacco products continues to rise, according to the authors of the study, published Tuesday in the journal JAMA Pediatrics.
Researchers at the University of California, San Francisco, examined the records of 13,651 adolescents enrolled in the Population Assessment of Tobacco and Health, a nationwide study begun in 2013 by the National Institutes of Health and the Food and Drug Administration.
At the beginning of the study period, the teens, ages 12-17, had not smoked a cigarette, and a year later, a majority of them were still not tobacco users.
However, youths who reported using e-cigarettes or other non-cigarette forms of tobacco the first year of the study were twice as likely to have smoked at least one cigarette or smoked in the past 30 days one year later.
These alternative forms include hookah tobacco, smokeless tobacco and other types of combustible tobacco, such as bidis, cigarillos, filtered and traditional cigars, kreteks and pipes.
Having smoked at least once is significant in teens, the study authors said, because of how fast tobacco addiction can take hold.
About 90 percent of adult smokers had their first cigarette before they turned 18, and smoking only one cigarette a month in adolescence is associated with future daily smoking in adulthood, the report said.
"Cigarette 'ever' use is a meaningful outcome given that nicotine dependence can manifest in adolescents soon after their first puff, but other smoking milestones, such as daily smoking, can take years to develop," the report said. "Past 30-day use is the standard surveillance measure for current smoking among youths and is associated with smoking in adulthood."
The lead author of the study said that previous research has shown an association between e-cigarette use and future cigarette smoking, but this study is the first to demonstrate that the association is consistent across every alternate type of tobacco delivery.
"We hear so much talk about e-cigarettes, which are now the most used tobacco product among adolescents, even higher use than cigarettes. And there is a lot of talk about cigarettes, which is absolutely justified. But when you look at these other products too, like smokeless tobacco and cigarillos, they're having the same magnitude of relationship with future smoking," said Shannon Lea Watkins, a postdoctoral fellow at the Center for Tobacco Control Research and Education at the University of California, San Francisco.
"Even a little bit of use of these products can get kids addicted," she said.
The findings are also important because some of the novel tobacco products have especially high rates of use among adolescents in vulnerable populations. For example, smokeless tobacco use is higher among rural white adolescents, while cigarillo use is seen more often among lower-income African-American teens, she said.
Although rates of smoking among teens have declined steadily in the past 20 years, in 2016 about 3.9 million middle and high school students were using at least 1 tobacco product, and 1.8 million were using two or more, the JAMA Pediatrics report said.
In Utah, about 15.5 percent of high school seniors reported using e-cigarettes in 2017, according to the state Department of Health. Among all high school students, about 11 percent reported vaping last year, compared to 5.8 percent in 2013.
The new findings can help public-health officials better target anti-tobacco messaging and also shows that it's important for such campaigns to include all types of tobacco delivery, not just e-cigarettes, Watkins said.
"We should think about the overall public health burden, and their potential to convert non-cigarette users to cigarette users, when we are making choices about the regulation of these product," Watkins said.
"We should think not only the harm these types of products cause, but also the potential harm that comes from cigarettes. And even if kids use these products and don't convert to cigarette smoking, it's not the only relevant health concern."
In 2016, the Food and Drug Administration announced its intention to begin regulating all tobacco products, including e-cigarettes, hookahs and cigars, as it does cigarettes. Companies that make e-cigarettes and other non-combustible products have until 2022 to submit applications for approval; manufacturers of combustibles such as cigars and hookah tobacco must apply by 2021. They are allowed to continue to sell the products while the FDA reviews their applications.
E-cigarettes — also known as "vapes" or "vape pens" — deliver nicotine and flavorings through vapors that users inhale. Critics, which include the Campaign for Tobacco-Free Kids, want the FDA to ban flavoring that attracts kids.
"It's not surprising that products like e-cigarettes and cigars have become popular with kids when they are sold in sweet flavors like gummy bear and cherry dynamite," said Vince Willmore, vice president of communications for the Campaign for Tobacco-Free Kids, which was not involved in the research.
"Our nation has made enormous progress in reducing youth cigarette smoking. We can't allow a new generation of tobacco products to undermine these gains," Willmore said.
E-cigarettes are commonly marketed as a safer alternative to conventional smoking, a claim that is not supported by research, according to a new study by researchers at the Keck School of Medicine at the University of Southern California. In that report, the authors examined more than 2 million social media posts that involved e-cigarettes and found that automated bots were using fake accounts to promote the idea that e-cigarettes help people quit smoking.
And in another report released Tuesday, researchers said that nearly 3 million American teens had been exposed to online marketing of tobacco, as cigarette manufacturers have shifted their marketing strategies from traditional forms of media to the internet.
"Online marketing may make these adolescents more susceptible to tobacco use initiation by altering perceived norms and risk perceptions regarding tobacco use," the authors wrote.
Tobacco use is the leading cause of preventable disease and death among Americans, the Centers for Disease Control and Prevention says. If current smoking rates continue, more than 5 million people who are now under the age of 18 will die prematurely from smoking-related conditions, according to the CDC.