Modeling the longitudinal transitions of electronic cigarettes and conventional cigarettes with time-dependent covariates among adolescents

E-cigarettes may help combustible cigarette smokers switch to a less harmful alternative, or may increase the risk of subsequent initiation of cigarettes among non-smokers. Among youth, it is not clear whether both pathways occur equally, or whether one direction is more likely than the other. We used data from a prospective cohort study of youth in Southern California followed twice annually from Fall 2013 (9th grade) to Fall 2015 (11th grade) (N = 1977). A polytomous logistic regression model was used to simultaneously estimate transition rates for initiation of and abstention from e-cigarettes and cigarettes. Use of e-cigarettes was positively associated with initiation of cigarettes (OR = 7.57; 95%CI:[5.32, 10.8]) and negatively associated with cigarette abstention (OR = 0.58; 95%CI:[0.33, 0.99]) in adjusted models; cigarette use was positively associated with e-cigarette initiation (OR = 2.54; 95%CI:[1.45, 4.47]) and negatively associated with e-cigarette abstention (OR = 0.31; 95%CI:[0.17,0.57]). Uni-directional transition from e-cigarettes only to cigarettes only occurred less frequently than expected under independence (OR = 0.33; 95% CI [0.20, 0.55]), whereas simultaneously initiating both products (OR = 9.79; 95%CI:[7.22, 13.3]) and simultaneously abstaining (OR = 2.84; 95%CI:[1.50, 5.37]) were more frequent than expected. E-cigarettes were more strongly associated with subsequent cigarette initiation than the reverse, though both models indicated that use of either product seems to encourage use of the other. Models also indicated that use of either e-cigarettes or cigarettes resulted in reduced abstention of the other product. Findings suggest that prevention efforts for that continue to focus on both e-cigarettes and cigarettes are needed.