Can Early Disadvantage Be Overcome? A Life Course Approach to Understanding How Disadvantage, Education, and Social Integration Impact Mortality into Middle Adulthood Among a Black American Cohort.

Health equity research has identified fundamental social causes of health, many of which disproportionately affect Black Americans, such as early life socioeconomic conditions, neighborhood disadvantage, and racial discrimination. However, the role of life course factors in premature mortality among Black Americans has not been tested extensively in prospective samples into later adulthood. To better understand how social factors at various life stages impact mortality, this study examines the effect of life course poverty, neighborhood disadvantage, and discrimination on mortality and factors that may buffer their effect (i.e., education, social integration) among the Woodlawn cohort (N = 1242), a community cohort of urban Black Americans followed since 1966. Taking a life course perspective, we analyze mortality data for deaths through age 58 years old, as well as data collected at ages 6, 16, 32, and 42. At age 58, 204 (16.4%) of the original cohort have died, with ages of death ranging from 9 to 58.98 (mean = 42.9). Cox proportional hazard models adjusting for confounders show statistically significant differences in mortality risk based on timing and persistence of poverty; those who were never poor or poor only in early life had lower mortality risk at ages 43-58 than those who were persistently poor from childhood to adulthood. Education beyond high school and high social integration were shown to reduce the risk of mortality more for those who did not experience poverty early in their life course. Findings have implications for the timing and content of mortality prevention efforts that span the full life course.

Associations Between Family Factors, Social Integration, and Suicidal Ideation Across the Life Course of an Urban African American Cohort.

Suicide is a problem on the rise but not studied extensively among African Americans. It is critical to identify risk factors for suicidal ideation to reduce risk. This study examines whether family and social factors over the life course predict suicidal ideation among African American adults in midlife. We conducted multiple logistic regression analyses on data from a longitudinal cohort of African Americans first assessed in childhood to identify associations with suicidal ideation in midlife (ages 33-42). Findings suggested living without one's mother in childhood (vs. living with mother alone; aOR = 3.69, p = .017) and parental rule-setting in adolescence (aOR = 0.79, p = .047) were associated with suicidal ideation. Having a lifetime drug disorder (aOR = 2.19, p = .046) or major depression by young adulthood (aOR = 3.58, p < .001) was also associated with an increased risk of suicidal ideation. Findings highlight the importance of intervention for children in mother-absent homes for improving mental health outcomes. Family interventions that promote parental rule-setting and addressing drug problems and depressive symptoms early in the life course offer an area for intervention to reduce suicide over the long term.

Offending and the Long-Term Risk of Death: An Examination of Mid-Life Mortality Among an Urban Black American Cohort.

Research on the long-term relationship between offending and mortality is limited, especially among minorities who have higher risk of premature mortality and criminal offending, particularly arrest. Using Cox proportional hazard models, we estimate the relationship between young adult offending and later mortality (to age 58) among a community cohort of Black Americans (n = 1,182). After controlling for a wide range of covariates, results indicate that violent offenders are at heightened risk of mortality from young adulthood through midlife compared with both non-violent only offenders and non-offenders. Further analysis shows that this result is driven by the frequent, largely non-violent, arrests incurred among violent offenders. Criminal justice reform and collaboration with public health practitioners might be fruitful avenues to reduce mortality disparities.

Early Childhood Behavioral and Academic Antecedents of Lifetime Opioid Misuse among Urban Youth.

OBJECTIVE: Opioid misuse has become an epidemic in the United States. In the present study, we examine potential malleable early childhood predictors of opioid misuse including whether childhood achievement, aggressive behavior, attention problems, and peer social preference/likability in first grade predicted opioid misuse and whether these relationships differed depending on participant sex. METHOD: Data are drawn from three cohorts of participants (N = 1,585; 46.7% male) recruited in first grade as part of a series of elementary school-based, universal preventive interventions conducted in a Mid-Atlantic region of the US. In first grade, participants completed standardized achievement tests, teachers reported on attention problems, and peers nominated their classmates with respect to their aggressive behavior and social preference/likability. At approximately age 20, participants reported on their misuse of opioids defined as lifetime use of heroin or misuse of prescription opioids. RESULTS: Higher levels of peer nominations for aggressive behavior in first grade predicted a greater likelihood of opioid misuse. An interaction between participant sex and attention problems was observed such that females higher in attention problems were more likely to misuse opioids, particularly prescription opioids, than females lower in attention problems. An interaction was also found between participant sex and peer likability such that males lower in peer-nominated likability were more likely to misuse opioids relative to males higher in likability. CONCLUSION: Given the malleable nature of attention problems, aggression, and social skills in early childhood, prevention programs that target these behaviors during this developmental period may attenuate risk for opioid misuse.

Community Health Worker Knowledge, Attitudes, Practices and Readiness to Manage Intimate Partner Violence.

Intimate partner violence (IPV) is an important public health concern with higher prevalence among women. Community health workers (CHWs) are trusted frontline public health workers that bridge gaps between communities and healthcare services. Despite their effectiveness in delivering services and improving outcomes for different chronic conditions, there is a dearth of understanding regarding CHW management of IPV. The purpose of this study is to examine knowledge, attitudes, practices, and readiness to manage IPV among a sample of CHWs (n = 152). Participants completed an online version of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), which was modified for CHW practice. Psychometrics of the newly adapted tool, along with empirical relationships between knowledge, attitudes, and readiness to manage IPV were examined. Most sub-scales yielded moderate to high reliability (0.70 < α's < 0.97), some sub-scales had low reliability (0.57 < α's < 0.64), and construct validity was established for several of the subscales. On average, many CHWs had low scores on objective knowledge of IPV (mean = 15.4 out of 26), perceived preparation to manage IPV (mean = 3.8 out of 7), and perceived knowledge of IPV (mean = 3.7 out of 7). About 56% of CHWs indicated having no previous IPV training, 34% did not screen for IPV, and 65% were in the contemplation stage of behavior change. Multiple regression models indicated that knowledge, staff capabilities and staff preparation were significant predictors of perceived preparedness to manage IPV (all p's < 0.05). Results can inform future credentialing requirements and training programs for CHWs to better assist their clients who are victims of IPV.

Long-term Consequences of Criminal Justice System Intervention: The Impact of Young Adult Arrest on Midlife Health Behaviors.

While there is a growing literature on the relationship between incarceration and health, few studies have expanded the investigation of criminal justice system involvement and health to include the more common intervention of arrest. This study uses a quasi-experimental design to evaluate the long-term effect of arrest in young adulthood on health behaviors in midlife for African Americans. We use propensity score matching methods and gender-specific multivariate regression analyses to equate those who did and did not incur an arrest in young adulthood from a subsample (n = 683) of the Woodlawn cohort, an African American community cohort followed from childhood into midlife. The results suggest that, for men, having been arrested in young adulthood has a direct effect on smoking, daily drinking, and risky sexual behaviors into midlife while young adult arrest does not seem to impact midlife health risk behaviors for women. This study adds health risk behaviors to the growing list of detrimental outcomes, such as crime, drug use, education, and mental health that are related to criminal justice contact for African American men, in particular.

Stressful life events and transitions in problematic alcohol use involvement among US adults.

OBJECTIVE: We investigated the impact of stressful life events (SLEs) for males and females on transitions in problematic alcohol involvement, both progression and recovery, over a 3-year interval. METHOD: Participants of both Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were stratified by sex (14,233 males and 19,550 females). Latent transition analysis estimated the impact of experiencing ≥3 SLE in the year preceding the Wave 1 interview on the probability of transitioning between three empirically-derived stages of alcohol involvement (patterns of alcohol use disorder [AUD] symptoms), across waves. Propensity score methods adjusted for confounding. RESULTS: For males, three or more SLEs were associated with progression from the moderate to the severe problem stage (odds ratio [OR] = 2.23, 95% confidence interval [CI] = 1.17, 4.26). Among those in the severe problem stage, SLEs negatively impacted recovery regardless of sex. Employment/Financial SLEs were associated with a higher odds of transition from the moderate to the no problem stage (OR = 1.60, 95% CI = 1.03, 2.46) and lower odds of transitions from the severe to the moderate problem stage (OR = 0.40, 95% CI = 0.16, 0.99) among males, and from the severe to the no problem stage (OR = 0.26, 95% CI = 0.07, 0.88) among females. CONCLUSION: Stressful life events appear to affect transitions in alcohol involvement over time among those who already have alcohol problems, rather than impacting a transition among those without AUD problems.

Individual and Neighborhood Factors Associated With Sexual Behavior Classes in an Urban Longitudinal Sample.

BACKGROUND: This study aimed to increase understanding of the clustering of sexual behaviors in an urban sample of emerging adults, and the individual and neighborhood factors associated with sexual behavior patterns to provide insight into reducing the disproportionate burden of poor sexual outcomes among urban African Americans. METHODS: We draw on 2 cohorts of urban, predominantly African American youth first assessed at age 6 years and follow-up to emerging adulthood (mean age, 20 years; n = 1618). Latent class analyses by gender identified co-occurrence of sexual behavior. RESULTS: We found 3 classes for both males and females: high-risk (13% of males, 15% of females), low-risk (54% of males, 56% of females) and no-risk (33% of males, 29% of females). Membership in the high-risk class was associated with school dropout, a substance use disorder diagnosis, having a criminal arrest, pregnancy, and sexually transmitted diseases for both males and females. High-risk females also had higher rates of depression. Low-risk males and females also had elevated risk of pregnancy and parenthood. Neighborhood factors distinguished the high- and no-risk classes for males and females, including the neighborhood environment scale, which assessed poverty, safety, drug activity, and crime/violence in the neighborhood. Neighborhood religiosity was inversely associated with membership in the high-risk class compared with the no-risk class for females only. Neighborhood racism distinguished those in the high-risk class compared with the no-risk class for males. CONCLUSIONS: Future work should take into account the clustering of sexual risk behaviors. Specific neighborhood factors could be addressed to reduce sexual health disparities.

The Impact of the Urban Neighborhood Environment on Marijuana Trajectories During Emerging Adulthood.

Although there is little difference in rates of marijuana use between White and Black youth, Blacks have significantly higher rates of marijuana use and disorder in young adulthood. Theory suggests that factors tied to social disadvantage may explain this disparity, and neighborhood setting may be a key exposure. This study sought to identify trajectories of marijuana use in an urban sample during emerging adulthood, neighborhood contexts that predict these trajectories and social role transitions or "turning points" that may redirect them. Data are from a longitudinal cohort study of 378 primarily Black emerging adults who were first sampled in childhood based on their residence in low-income neighborhoods in Baltimore City and followed up annually. Group-based trajectory modeling identified three groups: No Use (68.8%), Declining Use (19.6%), and Chronic Use (11.7%). Living in close proximity to an alcohol outlet, and living in a neighborhood with more female-headed households and higher rates of violent crime increased the odds of membership in the Chronic Use group relative to No Use. Living in a neighborhood with more positive social activity increased the odds of membership in the Declining Use group relative to No Use. Not receiving a high school diploma or GED, pregnancy, and parenting also increased the odds of membership in the Declining Use group relative to No Use. These findings provide support that minority youth living in socially toxic and disordered neighborhoods are at increased risk of continuing on a trajectory of marijuana use during emerging adulthood while positive social activity in neighborhoods has the potential to redirect these negative trajectories. Besides taking on the responsibilities of parenting, emerging adults in the marijuana user groups had similar educational and family outcomes, suggesting that early marijuana use may have long-term implications.

A Sequential Explanatory Mixed Methods Study of Young Adult Tobacco and Marijuana Co-Use.

Background: The co-occurring use of tobacco and marijuana among young adults is an important behavioral phenomenon within the field of substance use. Studying tobacco and marijuana use together among young adults can provide important insight into patterns of initiation and continuation. Objectives: The primary goal of this study was to examine characteristics associated with co-use among young adults and to discover the ways experiences of co-users can help contextualize trends in co-use. Methods: This study employed a sequential explanatory mixed methods design. Quantitative analyses used 12 years of nationally representative National Health and Nutrition Examination Survey (NHANES) data (2005-2016) to assess the characteristics and experiences of young adult (21-30) co-users. Results from analyses of NHANES, prior literature, and theoretical constructs were used to develop a guide for 20 in-depth, semi-structured interviews with young adult co-users living in the state of Maryland. Interviews were analyzed using thematic analysis. Quantitative results and qualitative findings were integrated. The original NHANES analysis occurred during October and November 2017, interviews took place during December 2017 and January 2018, and all mixed methods integration was conducted in 2018. Results: Tobacco and marijuana co-users have unique characteristics and experiences compared to single product users; the experiences of co-users can offer unique insights on co-use. Meta-inferences emerged from integration. Conclusions/importance: Co-users conceptualize tobacco and marijuana differently and hold different risk perceptions for each substance. Co-users may be at risk for polytobacco product use. These findings highlight the profound influence these two substances have on young adult co-users' experiences and behaviors.

The Effects of Marijuana Use on Transitions through Stages of Alcohol Involvement for Men and Women in the NESARC I and II.

Background: With the changing context of marijuana use, it is critical to identify effects of use. We extend previous work by examining whether marijuana use influences progression and remission through alcohol involvement stages for men and women. Methods: Data come from Waves I and II of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, n = 34,432). We assess the potential influence of marijuana use at Wave 1 on transitions across three latent statuses of alcohol involvement between waves. We apply propensity score weighting to account for shared risk factors. Results: Marijuana use was associated cross-sectionally and longitudinally with alcohol involvement statuses for both sexes. After propensity score adjustment, men with marijuana histories were 3.50 times as likely as men without such histories to transition from no to severe problems across waves relative to staying in the same status (p < .001). Women with marijuana histories were 1.74 times as likely as women without such histories to transition from no problems at Wave 1 to moderate problems at Wave 2 (p = .030) and 0.13 times as likely as women without such histories to transition from severe problems to no problems (p = .006). Conclusions: Results suggest that marijuana use impacts progression to more serious stages of alcohol involvement for both men and women, as well as hinders remission among women. Findings point to the importance of screening those with marijuana histories for alcohol problems, as well as the need to understand the mechanism of why marijuana use may increase the risk of alcohol problems.

Neighborhood context and transitions in marijuana use among urban young adults.

BACKGROUND: In emerging adulthood when many youth are maturing out of marijuana use, Blacks continue to have high rates of use and disorder. Theory suggests that factors tied to neighborhood disadvantage may partially explain this phenomenon but research is limited. OBJECTIVES: This study examines the influence of neighborhood physical and social disorder on transitions in marijuana use during emerging adulthood in a low-income urban sample. METHODS: 379 primarily Black young adults residing in low-income neighborhoods in Baltimore City were followed-up annually from ages 18 to 21. Neighborhood environment was evaluated using a valid and reliable field-rater assessment of the residential block. Longitudinal latent class and latent transition analyses were performed. RESULTS: Fit indices supported three-classes of marijuana use: no use, infrequent use and frequent use. Between ages 18 and 21, young adults tended to transition toward lower levels of use. However, neighborhood physical disorder was associated with transitioning to increased marijuana use (no use to frequent use; AOR = 2.712; p = .023) while positive neighborhood social activity was associated with a decreased risk (AOR = 0.002; p = .013). Neighborhood social activity was also associated with decreases in use (frequent to infrequent use; AOR = 2.342; p = .020). Conclusions/Importance: These findings demonstrate that physical disorder within the context of a low-income urban neighborhood adversely impacts marijuana use. However, even in the presence of physical disorder, interventions that foster collective efficacy among residents through positive social activity may prevent initiation and progression of marijuana use.

Young Adult Victimization and Midlife Consequences: Sensitization or Steeling Effects of Childhood Adversity?

The interrelationship between victimization, violence, and substance use/abuse has been well established, yet those who experience victimization do not necessarily respond with violence or substance use or escalate to experiencing substance abuse symptoms. Drawing on literature from both the syndemic research from medical anthropology and the resilience research from psychology, this study examines the interaction between early childhood adversity and young adult violent victimization on later substance use/abuse and violent offending to provide insight into conditional effects. Data are derived from the Woodlawn Study, an African American cohort of men and women from a socioeconomically heterogeneous community in the South Side of Chicago, who were followed from first grade through age 42. Results indicate that those with lower levels of childhood adversity are more likely to suffer the negative consequences of violent victimization than those with higher childhood adversity, providing support for a "steeling" effect.

Developmental Patterns of Adolescent Marijuana and Alcohol Use and Their Joint Association with Sexual Risk Behavior and Outcomes in Young Adulthood.

Urban populations disproportionately experience poor sexual outcomes, including high rates of teenage pregnancy and sexually transmitted infections. However, the contribution of substance use across adolescence to poor sexual outcomes in young adulthood has not been investigated in depth, despite offering opportunities for more targeted prevention. This study aimed to estimate joint trajectories of adolescent alcohol and marijuana use to determine if they relate differently to four sexual outcomes: multiple sexual partners, sex without a condom, teenage pregnancy, and contraction of a sexually transmitted infection in young adulthood (by age 25). Data came from a longitudinal study of urban youth followed from age 6 to age 25, with annual assessments during adolescence and young adulthood (n = 608). The sample showed high levels of sexual risk, with young adults on average having sex without a condom once in the past month, 28.5% having multiple sexual partners in the past month, one quarter having contracted a sexually transmitted infection, and over 60% of the women being pregnant as a teenager and 36% of the men having gotten a partner pregnant. Applying longitudinal latent profile analysis to estimate joint trajectories of alcohol and marijuana use from grades 8-12, we identified four classes representing high dual use, moderate alcohol use, moderate alcohol use with increasing marijuana use, and non-use. Class membership differently predicted all four outcomes investigated with high dual users having the highest level of teenage pregnancy and the increasing marijuana trajectory having the highest risk of engaging with multiple sexual partners in the past month. Results suggest implications for both sexual risk and substance use prevention for urban youth.

Long-term consequences of adolescent cannabis use: Examining intermediary processes.

BACKGROUND: In the United States, perceptions of marijuana's acceptability are at an all-time high, risk perceptions among youth are low, and rates are rising among Black youth. Thus, it is imperative to increase the understanding of long-term effects of adolescent marijuana use and ways to mitigate adverse consequences. OBJECTIVES: To identify the midlife consequences of heavy adolescent marijuana use and the mechanisms driving effects among a Black, urban population. METHODS: This study analyzed the propensity score-matched prospective data from the Woodlawn Study, a community cohort study of urban Black youth followed from ages 6-42. After matching the 165 adolescents who used marijuana heavily to 165 non-heavy/nonusers on background confounders to reduce selection effects (64.5% male), we tested the association of heavy marijuana use by age 16 with social, economic, and physical and psychological health outcomes in midlife and the ability of adult drug trajectories (marijuana, cocaine, and heroin use from ages 17-42) and school dropout to mediate effects. RESULTS: Heavy adolescent marijuana use was associated with an increased risk of being poor and of being unmarried in midlife. Marijuana use also predicted lower income and greater anxious mood in midlife. Both adult drug use trajectories and school dropout significantly mediated socioeconomic effects but not marital or anxious mood outcomes. CONCLUSION: Heavy adolescent marijuana use seems to set Black, urban youth on a long-term trajectory of disadvantage that persists into midlife. It is critical to interrupt this long-term disadvantage through the prevention of heavy adolescent marijuana use, long-term marijuana and other drug use, and school dropout.

African American Girls' Ideal Dating Relationship Now and In the Future.

Adolescence is a particularly important and challenging time for developing long lasting romantic relationship patterns. However, limited empirical research has explored teen perceptions of ideal partner characteristics during adolescence or their significance to the quality of current and future relationships. Semi-structured in-depth interviews were conducted with 33 African American high school girls to shed light on the qualities desired in their dating relationships and relational factors that influence teen dating behaviors. Guided by the Social Ecological Framework, interviews were transcribed verbatim and entered into ATLAS.ti, for coding and analysis. Girls discussed the important influence of parents in choosing a partner and provided positive depictions of friendship and marriage with a suitable partner. More research is needed to understand how and why adolescents desire particular characteristics, how socialization shapes teen perceptions and how these preferences may be related to current and future adolescent dating choices, including violence perpetration and victimization.

Racial differences and the role of neighborhood in the sequencing of marijuana and tobacco initiation among urban youth.

BACKGROUND: With patterns of initiation of tobacco and marijuana changing, there is increasing evidence that marijuana use may serve as an antecedent to tobacco use among adolescents. However, studies have not fully characterized the prevalence of these patterns among vulnerable youth and have rarely examined the factors that predict the sequencing of onset of tobacco and marijuana use. METHODS: Utilizing longitudinal data from a sample of urban youth followed from age 6 to age 18, the authors identify the sequencing of initiation of tobacco and marijuana and test whether race and 5 neighborhood factors (i.e., perceived disorder, drug activity, drug access, exposure to violence, and exposure to violent victimization) predict onset sequencing. RESULTS: Various sequencing patterns were observed, with 12.4% of the sample initiating marijuana use before tobacco use was initiated. In adjusted logistic regression models, black youth were 2.66 times as likely as whites to initiate marijuana before tobacco compared with initiating tobacco before marijuana (P = .032). Youth with greater exposure to violent victimization were 3.89 times as likely to initiate marijuana first than initiate tobacco first (P = .002). Other neighborhood factors were not statistically significantly associated with sequencing. CONCLUSIONS: Black youth and youth with greater exposure to victimization had an increased risk of initiating marijuana before tobacco, which suggests that this pattern may be rooted in specific risk factors. Substance use prevention efforts should consider taking into account that marijuana use may put certain youth at risk of initiating tobacco. Future research needs to monitor sequencing, as well as risk factors for and consequences of the various patterns, particularly since marijuana use and the mixing of tobacco and marijuana use are gaining acceptability in general populations.

Mutual Influences Between Parental Psychological Distress and Alcohol Use and Child Problem Behavior in a Cohort of Urban African Americans.

Parental psychological distress, parental alcohol involvement, and child/adolescent behavior problems frequently occur together with deleterious effects on individuals and families. Extant evidence suggests that parental and child problems are related; however, less is known about the patterns and directions of their relationships over time, particularly among African Americans. This study examined mutual influences between parental psychological distress and alcohol use, and child/adolescent problem behavior over a 10-year period (N = 459), using data from a prospective cohort study of urban African Americans. Using structural equation modeling, we found statistically significant effects between young adult parents' alcohol use and later adolescent problem behavior, as well as child problem behavior and parental alcohol use 10 years later, even after taking into account potential extraneous influences. Findings also demonstrated continuity in parental and child behaviors over time, and several contemporaneous associations. These findings have potential implications for intervention planning among African American families.

Examining the Consequences of the "Prevalent Life Events" of Arrest and Incarceration among an Urban African-American Cohort.

The life course perspective has traditionally examined prevalent adult life events, such as marriage and employment, and their potential to redirect offending trajectories. However, for African Americans, the life events of arrest and incarceration are becoming equally prevalent in young adulthood. Therefore, it is critical to understand how these "standard" criminal justice practices, which are designed to deter as well as punish, affect deviance among this population. This study evaluates the long-term consequences of criminal justice intervention on substance use and offending into midlife among an African American community cohort using propensity score matching and multivariate regression analyses. The results largely point to a criminogenic effect of criminal justice intervention on midlife deviance with a particularly strong effect of young adult arrest on rates of violent and property arrest counts into midlife. The theoretical and policy implications of the findings are discussed.

Association between electronic cigarette use and openness to cigarette smoking among US young adults.

INTRODUCTION: Use of electronic nicotine delivery systems (ENDS), including electronic cigarettes (e-cigarettes), is increasing. One concern is the appeal of these products to youth and young adults and the potential to influence perceptions and use of conventional cigarettes. METHODS: Using data from the 2012-2013 National Adult Tobacco Survey, characteristics of adults aged 18-29 years who had never established cigarette smoking behavior were examined by ever use of e-cigarettes, demographics, and ever use of other tobacco products (smokeless tobacco, cigars, hookah, and cigarettes). Multivariate logistic regression was used to examine the relationship between e-cigarette use and openness to cigarette smoking among young adults, defined as the lack of a firm intention not to smoke soon or in the next year. RESULTS: Among young adults who had never established cigarette smoking behavior (unweighted n = 4,310), 7.9% reported having ever tried e-cigarettes, and 14.6% of those who reported having ever tried e-cigarettes also reported current use of the product. Ever e-cigarette use was associated with being open to cigarette smoking (adjusted odds ratio = 2.4; 95% confidence interval = 1.7, 3.3), as was being male, aged 18-24 years, less educated, and having ever used hookah or experimented with conventional cigarettes. CONCLUSIONS: Ever use of e-cigarettes and other tobacco products was associated with being open to cigarette smoking. This study does not allow us to assess the directionality of this association, so future longitudinal research is needed to illuminate tobacco use behaviors over time as well as provide additional insight on the relationship between ENDS use and conventional cigarette use among young adult populations.