Electronic cigarettes, nicotine use trends and use initiation ages among US adolescents from 1999 to 2018.

BACKGROUND AND AIMS: Recent nicotine use trends raise concerns that electronic cigarettes (ECs) may act as a gateway to cigarettes among adolescents. The aims of this study were to examine prevalence trends of exclusive EC use, exclusive cigarette use and dual use to determine the corresponding ages of initiation and to investigate hypothetical trends in total nicotine use and cigarette use in the absence of ECs among US adolescents. DESIGN: Observational study using data from the National Youth Tobacco Survey (NYTS) to statistically model trends in the prevalences of each user group and their initiation ages. Projections from counterfactual models based on data from 1999 to 2009 (before EC introduction) were compared with actual trends based on data from 1999 to 2018. Rigorous error analyses were applied, including Theil proportions. SETTING: USA. PARTICIPANTS AND MEASUREMENTS: Adolescents aged 12-17 years who were established exclusive cigarette users (≥ 100 cigarettes smoked and ≤ 100 days vaped), established exclusive EC users (< 100 cigarettes smoked and > 100 days vaped) and established dual users (≥ 100 cigarettes smoked and > 100 days vaped), based on cumulative life-time exposure (n ≈ 12 500-31 000 per wave). FINDINGS: Exclusive cigarette use prevalence declined from 1999 to 2018, while exclusive EC use and dual use prevalences increased since their introduction in 2009. The age of cigarette initiation began a slight increase after 2014, whereas the age for EC use remained approximately constant and was higher than that of cigarettes. The counterfactual comparison results were consistent with ECs not increasing the number of US adolescent nicotine users, and in fact diverting adolescents from cigarettes. CONCLUSIONS: Electronic cigarettes may have offset conventional smoking among US adolescents between 2010 and 2018 by maintaining the total nicotine use prevalence and diverting them from more harmful conventional smoking. Additionally, electronic cigarette users appear to initiate at older ages relative to conventional smokers, which is associated with lower risk.