Associations Between Perceptions of e-Cigarette Harmfulness and Addictiveness and the Age of E-Cigarette Initiation Among the Population Assessment of Tobacco and Health (PATH) Youth.

Introduction: Youth perceptions of harmfulness and addictiveness of e-cigarettes may impact the age that they initiate e-cigarette use, but this has not been investigated previously. Methods: Youth (12-17 years old) never e-cigarette users at their first wave of PATH participation (waves 1-3, 2013-2016) were included. PATH questions on absolute perceptions of e-cigarette harmfulness and addictiveness were used as exposures. Interval-censored Cox proportional hazards models were used to estimate the impact of perceptions of harmfulness, and perceptions of addictiveness on (i) the age of initiation of e-cigarette use and (ii) age of first reporting past 30-day e-cigarette use, while controlling for covariates. Results: Youth who perceive e-cigarettes as having no/little harm had increased risk of initiating both ever e-cigarette use (AHR = 2.04; 95%CI = 1.74-2.40) and past 30-day e-cigarette use (AHR = 2.64; 95%CI = 2.07-3.37) at earlier ages compared to youth who perceive e-cigarettes as having a lot of harm. Youth who perceive the likelihood of becoming addicted to e-cigarettes to be very/somewhat unlikely had increased risk of an earlier age of both ever (AHR = 1.28; 95%CI = 1.07-1.52) and past 30-day (AHR = 1.36; 95%CI = 1.04-1.79) e-cigarette initiation compared to youth who perceived the likelihood of becoming addicted to e-cigarettes to be somewhat/very likely. Conclusion: These results highlight the importance of communicating to youth the potential for health harms and addiction from e-cigarette use in prevention and intervention campaigns, as those with the lowest perceptions of harmfulness and addictiveness had the earliest ages of e-cigarette initiation.

The association of perceptions of harmfulness and addictiveness on the age of initiation of cigar product use among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2017.

Background: Perceptions of cigar products' harmfulness and addictiveness in youth are associated with subsequent cigar product initiation, but their association on the age of initiation of cigar product use is unknown. Methods: The association of perceptions of harmfulness and addictiveness at youth's first wave of PATH participation (waves 1 or 2 in years 2013-2015) on the age of initiation of (i) ever. (ii) past 30-day, and (iii) fairly regular use of any cigar products (cigarillos, filtered cigars, or traditional cigars) during the followed-up in PATH waves 2-4 (2014-2017) was estimated using weighted interval-censored Cox proportional hazards models. Also, the association of the interaction between perceptions of harmfulness and addictiveness and the age of initiation of any cigar use are reported. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. Results: Among youth who had ever heard of cigar products, youth who perceived cigars to be "low-medium harmfulness and low-medium addictiveness" had 60% (HR: 1.60, 95%CI: 1.36-1.89) higher hazard risk to initiate ever cigar product use at an earlier age, and had 46% (HR:1.46, 95%CI: 1.14-1.86) higher hazard risk to initiate past 30-day cigar product use at younger ages than those who perceived cigars to be "high harmfulness and high addictiveness." Moreover, youth who perceived cigars to be "low-medium harmfulness and high addictiveness" had 33% (HR: 1.33, 95%CI: 1.15-1.53) higher hazard risk to initiate ever cigar product use at younger ages than those who perceived cigars to be "high harmfulness and high addictiveness." Youth who reported "high harmfulness and low-medium addictiveness" (HR: 0.24, 95% CI: 0.07-0.83) had 76% lower hazard risk to initiate fairly regular use of cigar products at younger ages compared to youth who reported "high harmfulness and high addictiveness." Conclusions: Prevention and awareness campaigns should reinforce the unique potential for harm and addiction of cigar products to curb cigar product initiation among US youth.

The Longitudinal Impact of Seeing and Posting Tobacco-related Social Media on Tobacco Use Behaviors Among Youth (Aged 12-17): Findings From the 2014-2016 Population Assessment of Tobacco and Health (PATH) Study.

Introduction: This study examined the impact of seeing and posting tobacco-related content on social media on tobacco use outcomes in youth. Methods: Longitudinal secondary analyses of youth in the nationally representative 2014-2015 Population Assessment of Tobacco and Health (PATH) study were conducted to examine the association between the interaction of (i) seeing and (ii) posting tobacco-related social media content with previous ever use of each tobacco product, and 3 outcomes in 2015-2016: past 30-day e-cigarette use, past 30-day combustible product use, and past 30-day dual use of e-cigarettes and at least one combustible product. Six weighted multiple logistic regression models (2 interaction exposures*3 outcomes) were used to assess these associations, while adjusting for covariates. Results: Among youth never users in 2014-2015, seeing tobacco-related social media content was significantly associated with past 30-day e-cigarette use (AOR 1.92; 95% CI= 1.36-2.71), and past 30-day dual use of e-cigarettes and at least one combustible product (AOR= 2.11; 95% CI= 1.08- 4.13) in 2015-2016. Among youth ever users in 2014-2015, posting tobacco-related content on social media was significantly associated with all 3 outcomes: past 30-day day e-cigarette use (AOR= 2.09;95%CI=1.23-3.55), past 30-day combustible product use (AOR=2.86; 95%CI=1.67-4.88), and past 30-day dual use of these products (AOR=3.02;95%CI=1.45-6.31), after adjusting for covariates. Conclusions: Seeing and posting tobacco-related content on social media predicts tobacco use among youth, nationwide. Results suggest that interventions and policies prohibiting tobacco-related content on social media are needed to curb the impact of social media on youth tobacco-use.

The Effect of Perceptions of Hookah Harmfulness and Addictiveness on the Age of Initiation of Hookah Use among Population Assessment of Tobacco and Health (PATH) Youth.

Despite the negative health consequence of hookah, hookah risk perceptions are misguided among youth. Secondary data analysis of 12-17-year-old never hookah users at their first wave of PATH participation (2013-2019) was performed. The effect of perceptions of hookah harmfulness and addictiveness on the age of initiation ever, past 30-day, and fairly regular hookah use were estimated using interval-censored Cox proportional hazards models. The distribution of the age of initiation of hookah outcomes by perception levels of harmfulness and addictiveness are reported as cumulative incidence and 95% CI. Youth who perceived hookah to be neither harmful nor addictive were 173% more likely to initiate ever, 166% more likely to first report past 30-day use, and 142% more likely to first report fairly regular hookah use at earlier ages compared to youth who considered hookah to be both harmful and addictive. By age 18, 25.5% of youth who perceived hookah as neither harmful nor addictive were estimated to initiate ever hookah use while 9.3% of youth who perceived hookah as harmful and addictive were estimated to initiate ever hookah use. These findings indicate the need to provide prevention and education campaigns to change perceptions of the harmfulness and addictiveness of hookah to delay the age of initiation of hookah use.

Precise Estimation for the Age of Initiation of Tobacco Use Among U.S. Youth: Finding from the Population Assessment of Tobacco and Health (PATH) Study, 2013-2017.

Context: Youth tobacco use remains a prominent United States public health issue with a high economic and health burden. Method: We pooled never and ever users at youth's first wave of PATH participation (waves 1-3) to estimate age of initiation for hookah, e-cigarettes, cigarettes, traditional cigars, cigarillos, and smokeless tobacco prospectively (waves 2-4). Age of initiation of each tobacco product was estimated using weighted interval-censored survival analyses. Weighted interval censoring Cox-proportional hazards regression models were used to assess the association of ever use of the TP at the first wave of PATH participation, sex, and race/ethnicity on the age of initiation of ever use of each tobacco product. Sensitivity analyses were performed to understand the impact of the recalled age of initiation for the left-censored participants by replacing the recalled age of initiation with a uniform "6" years lower bound. Results: The proportion of those who ever used each tobacco product at the first wave of PATH participation ranged from 1.8% for traditional cigars to 10.4% for cigarettes. There was a significant increase in ever use of each tobacco product after the age of 14, with e-cigarettes and cigarettes showing the highest cumulative incidence of initiation by age 21, while smokeless and cigarillos recorded the lowest cumulative incidence by age 21. The adjusted Cox models showed boys initiated at earlier ages for all of these tobacco products except for hookah, which showed no difference. Similarly, apart from ever use of hookah, non-Hispanic White youth were more likely to initiate each tobacco product at earlier ages compared to Hispanic, non-Hispanic Black, and non-Hispanic Other youth. Conclusion: The increased sample size and the inclusion of ever users yielded greater precision for age of initiation of each tobacco product than analyses limited to never users at the first wave of PATH participation. These analyses can help elucidate population selection criteria for estimating the age of initiation of tobacco products.