Impact of e-cigarette characteristics and marketing on tobacco use and health: A longitudinal study among U.S. youth and adults

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PROJECT SUMMARY/ABSTRACT E-cigarette use has increased rapidly, particularly among youth and young adults. The appealing flavors are a primary reason for young people to initiate and continue to use e-cigarettes. Young adult nonsmokers are more likely to initiate e-cigarette use with non-tobacco and non-menthol (NTM) flavors rather than tobacco and menthol (TM) flavors compared to current smokers, which is worrisome because e-cigarette use leads to cigarette initiation. The types of e-cigarette may also contribute to the surge in e-cigarette use. Advanced generation (open-system) devices deliver nicotine faster than old generation (closed-system) devices and can rapidly reduce withdrawal symptoms. Understanding if and how e-cigarette flavors and device types affect tobacco use behaviors is fundamental to developing regulatory activities that address the epidemic of e- cigarette use. In addition, e-cigarettes have been marketed aggressively using strategies that are appealing to young people. Youth exposure to e-cigarette advertising leads to e-cigarette initiation and greater susceptibility. But the underlying mechanism has not been fully explored. A potential mechanism is that advertising exposure reduces perceived harms and addictiveness of e-cigarettes, which in turn, lead to e- cigarette initiation and susceptibility. Last, e-cigarette use is associated with elevated risks for cardiopulmonary and periodontal diseases. However, evidence has been predominantly from cross-sectional data or on relatively small samples. To fill the knowledge gap, we will use longitudinal data (Waves 1-4) from the Population Assessment of Tobacco and Health (PATH) Study to accomplish three specific aims: (1) identify the impact of e-cigarette flavors and types on e-cigarette use among youth (12-17 years), young adults (18-34 years), and older adults (35 years and older). We will perform multivariate logistic regression with propensity score weights to assess the overall impact of e-cigarette flavors (NTM vs. TM) and types (open vs. closed- system) on e-cigarette use frequency. We will perform causal mediation analysis to test the hypothesis that, compared to TM flavors, NTM flavored e-cigarette use reduces harm and addiction perceptions of e-cigarettes, which lead to more frequent e-cigarette use; (2) determine the impact of exposure to e-cigarette advertising on e-cigarette initiation, use frequency, and susceptibility. Similar to Aim 1, we will perform multivariate logistic regression to assess the effect of e-cigarette advertising exposure on the outcomes, and conduct causal mediation analyses to assess the mediating effect of harm and addiction perceptions of e-cigarettes; and (3) identify the effect of e-cigarette use on cardiovascular, respiratory, and periodontal health, and compare the effects among different types of tobacco users (e.g., exclusive e-cigarette users never cigarette smokers, exclusive e-cigarette users former cigarette smokers, dual users, and cigarette-only smokers). Findings from our study will be directly relevant to regulatory decision-making that address e-cigarette flavors, product design and marketing practices, and will inform future interventions that tackle the epidemic of e-cigarette use.