Progression from e-cigarette use to conventional cigarette smoking among adolescents in the United States

Conventional cigarette smoking remains a major cause of significant morbidity and mortality in the United States. Although adolescent cigarette smoking rates have declined over the past decades, e-cigarette use is an emerging public health threat that can potentially stall or reverse this decline. Currently, e-cigarette use has become a social norm with its prevalence surpassing that of conventional cigarette smoking among adolescents. Adolescent e-cigarette users are at heightened risk of nicotine addiction and progressing to conventional cigarette smoking. However, factors underlying this progression are yet to be fully elucidated. Using the Theory of Planned Behavior as a conceptual framework, I conducted three studies that aimed to identify factors that potentially underlie progression from e-cigarette use to conventional cigarette smoking among US adolescents. With data obtained from two national surveys on adolescent risk behaviors: Monitoring the Future Survey and Population Assessment on Tobacco and Health, I examined smoking-related perceptions that make adolescent e-cigarette users susceptible to conventional cigarette smoking (Study 1); identified subgroups of adolescent e-cigarette users at most risk of exhibiting smoking intention (Study 2); and investigated how e-cigarette use moderates the transition from smoking intention to conventional cigarette smoking (Study 3). These three studies identify actionable predictors of conventional cigarette smoking among adolescent e-cigarette users and highlight potential foci for smoking prevention efforts. Findings suggest that negative attitudes and norms toward conventional cigarette smoking are major factors underlying progression to smoking among adolescent e-cigarette users. Also, three distinct subgroups of adolescent e-cigarette users were identified with each having particular smoking-related characteristics that determine their intention to smoke conventional cigarettes. Finally, transition from smoking intention to smoking initiation is moderated by e-cigarette use status, with smoking intention predicting smoking initiation only among adolescent never e-cigarette users. Adolescent e-cigarette users are at risk of progressing to smoking initiation whether or not they exhibit smoking intention, an indication that the influence of e-cigarette use on cigarette smoking may potentially override the protective effect of lack of smoking intention. Adolescents least likely to initiate conventional cigarette smoking in the current tobacco landscape do not have smoking intention and are abstaining from e-cigarettes