Associations of Electronic Cigarette Nicotine Concentration With Subsequent Cigarette Smoking and Vaping Levels in Adolescents | Tobacco and e-Cigarettes | JAMA Pediatrics | JAMA Network
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Johnston  LD, O’Malley  PM, Miech  RA, Bachman  JG, Schulenberg  JE.  Monitoring the Future National Survey Results on Drug Use, 1975-2016: Overview, Key Findings on Adolescent Drug Use. Ann Arbor: Institute for Social Research, The University of Michigan; 2017.
Leventhal  AM, Strong  DR, Kirkpatrick  MG,  et al.  Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence.  JAMA. 2015;314(7):700-707.PubMedGoogle ScholarCrossref
Wills  TA, Knight  R, Sargent  JD, Gibbons  FX, Pagano  I, Williams  RJ.  Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii.  Tob Control. 2017;26(1):34-39.PubMedGoogle ScholarCrossref
Primack  BA, Soneji  S, Stoolmiller  M, Fine  MJ, Sargent  JD.  Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults.  JAMA Pediatr. 2015;169(11):1018-1023.PubMedGoogle ScholarCrossref
Barrington-Trimis  JL, Urman  R, Berhane  K,  et al.  E-cigarettes and future cigarette use.  Pediatrics. 2016;138(1):e20160379.PubMedGoogle ScholarCrossref
Miech  R, Patrick  ME, O’Malley  PM, Johnston  LD.  E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students.  [published online February 6, 2017].  Tob Control. doi:10.1136/tobaccocontrol-2016-053291PubMedGoogle Scholar
Leventhal  AM, Stone  MD, Andrabi  N,  et al.  Association of e-cigarette vaping and progression to heavier patterns of cigarette smoking.  JAMA. 2016;316(18):1918-1920.PubMedGoogle ScholarCrossref
US Department of Health and Human Services, Public Health Service, Office of the Surgeon General. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014. 2014. Accessed March 24, 2017.
Grana  R, Benowitz  N, Glantz  SA.  E-cigarettes: a scientific review.  Circulation. 2014;129(19):1972-1986.PubMedGoogle ScholarCrossref
Lopez  AA, Hiler  MM, Soule  EK,  et al.  Effects of electronic cigarette liquid nicotine concentration on plasma nicotine and puff topography in tobacco cigarette smokers: a preliminary report.  Nicotine Tob Res. 2016;18(5):720-723.PubMedGoogle ScholarCrossref
Dawkins  LE, Kimber  CF, Doig  M, Feyerabend  C, Corcoran  O.  Self-titration by experienced e-cigarette users: blood nicotine delivery and subjective effects.  Psychopharmacology (Berl). 2016;233(15-16):2933-2941.PubMedGoogle ScholarCrossref
Krishnan-Sarin  S, Morean  ME, Camenga  DR, Cavallo  DA, Kong  G.  E-cigarette use among high school and middle school adolescents in Connecticut.  Nicotine Tob Res. 2015;17(7):810-818.PubMedGoogle ScholarCrossref
Miech  R, Patrick  ME, O’Malley  PM, Johnston  LD.  What are kids vaping? results from a national survey of US adolescents.  Tob Control. 2017;26(4):386-391.PubMedGoogle ScholarCrossref
Morean  ME, Kong  G, Cavallo  DA, Camenga  DR, Krishnan-Sarin  S.  Nicotine concentration of e-cigarettes used by adolescents.  Drug Alcohol Depend. 2016;167:224-227.PubMedGoogle ScholarCrossref
Food and Drug Administration, HHS.  Deeming tobacco products to be subject to the Federal Food, Drug, and Cosmetic Act, as amended by the Family Smoking Prevention and Tobacco Control Act; restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products: final rule.  Fed Regist. 2016;81(90):28973-29106.PubMedGoogle Scholar
Goniewicz  ML, Kuma  T, Gawron  M, Knysak  J, Kosmider  L.  Nicotine levels in electronic cigarettes.  Nicotine Tob Res. 2013;15(1):158-166.PubMedGoogle ScholarCrossref
Foulds  J, Veldheer  S, Yingst  J,  et al.  Development of a questionnaire for assessing dependence on electronic cigarettes among a large sample of ex-smoking e-cigarette users.  Nicotine Tob Res. 2015;17(2):186-192.PubMedGoogle ScholarCrossref
Kim  H, Davis  AH, Dohack  JL, Clark  PI.  E-cigarettes use behavior and experience of adults: qualitative research findings to inform e-cigarette use measure development.  Nicotine Tob Res. 2017;19(2):190-196.PubMedGoogle ScholarCrossref
Tyas  SL, Pederson  LL.  Psychosocial factors related to adolescent smoking: a critical review of the literature.  Tob Control. 1998;7(4):409-420.PubMedGoogle ScholarCrossref
Radloff  LS.  The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults.  J Youth Adolesc. 1991;20(2):149-166.PubMedGoogle ScholarCrossref
Thompson  MP, Ho  CH, Kingree  JB.  Prospective associations between delinquency and suicidal behaviors in a nationally representative sample.  J Adolesc Health. 2007;40(3):232-237.PubMedGoogle ScholarCrossref
Whiteside  SP, Lynam  DR.  The Five Factor Model and impulsivity: using a structural model of personality to understand impulsivity.  Pers Individ Dif. 2001;30(4):669-689.Google ScholarCrossref
Wagner  B, Riggs  P, Mikulich-Gilbertson  S.  The importance of distribution-choice in modeling substance use data: a comparison of negative binomial, beta binomial, and zero-inflated distributions.  Am J Drug Alcohol Abuse. 2015;41(6):489-497.PubMedGoogle ScholarCrossref
Rubin  DB.  Multiple Imputation for Nonresponse in Surveys. New York, NY: John Wiley & Sons; 1987.Crossref
Breslau  N, Fenn  N, Peterson  EL.  Early smoking initiation and nicotine dependence in a cohort of young adults.  Drug Alcohol Depend. 1993;33(2):129-137.PubMedGoogle ScholarCrossref
Riggs  NR, Chou  C-P, Li  C, Pentz  MA.  Adolescent to emerging adulthood smoking trajectories: when do smoking trajectories diverge, and do they predict early adulthood nicotine dependence?  Nicotine Tob Res. 2007;9(11):1147-1154.PubMedGoogle ScholarCrossref
Slotkin  TA.  Nicotine and the adolescent brain: insights from an animal model.  Neurotoxicol Teratol. 2002;24(3):369-384.PubMedGoogle ScholarCrossref
England  LJ, Bunnell  RE, Pechacek  TF, Tong  VT, McAfee  TA.  Nicotine and the developing human: a neglected element in the electronic cigarette debate.  Am J Prev Med. 2015;49(2):286-293.PubMedGoogle ScholarCrossref
Dwyer  JB, McQuown  SC, Leslie  FM.  The dynamic effects of nicotine on the developing brain.  Pharmacol Ther. 2009;122(2):125-139.PubMedGoogle ScholarCrossref
Murthy  VH.  E-cigarette use among youth and young adults: a major public health concern.  JAMA Pediatr. 2017;171(3):209-210.PubMedGoogle ScholarCrossref
Poorthuis  RB, Goriounova  NA, Couey  JJ, Mansvelder  HD.  Nicotinic actions on neuronal networks for cognition: general principles and long-term consequences.  Biochem Pharmacol. 2009;78(7):668-676.PubMedGoogle ScholarCrossref
DeBry  SC, Tiffany  ST.  Tobacco-induced neurotoxicity of adolescent cognitive development (TINACD): a proposed model for the development of impulsivity in nicotine dependence.  Nicotine Tob Res. 2008;10(1):11-25.PubMedGoogle ScholarCrossref
Swan  GE, Lessov-Schlaggar  CN.  The effects of tobacco smoke and nicotine on cognition and the brain.  Neuropsychol Rev. 2007;17(3):259-273.PubMedGoogle ScholarCrossref
Jacobsen  LK, Krystal  JH, Mencl  WE, Westerveld  M, Frost  SJ, Pugh  KR.  Effects of smoking and smoking abstinence on cognition in adolescent tobacco smokers.  Biol Psychiatry. 2005;57(1):56-66.PubMedGoogle ScholarCrossref
Davis  B, Dang  M, Kim  J, Talbot  P.  Nicotine concentrations in electronic cigarette refill and do-it-yourself fluids.  Nicotine Tob Res. 2015;17(2):134-141.PubMedGoogle ScholarCrossref
Ramôa  CP, Hiler  MM, Spindle  TR,  et al.  Electronic cigarette nicotine delivery can exceed that of combustible cigarettes: a preliminary report.  Tob Control. 2016;25(e1):e6-e9.PubMedGoogle ScholarCrossref
St Helen  G, Havel  C, Dempsey  DA, Jacob  P  III, Benowitz  NL.  Nicotine delivery, retention and pharmacokinetics from various electronic cigarettes.  Addiction. 2016;111(3):535-544.PubMedGoogle ScholarCrossref
Original Investigation
December 2017

Associations of Electronic Cigarette Nicotine Concentration With Subsequent Cigarette Smoking and Vaping Levels in Adolescents

Author Affiliations
  • 1Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles
  • 2Department of Psychology, University of Southern California, Los Angeles
JAMA Pediatr. 2017;171(12):1192-1199. doi:10.1001/jamapediatrics.2017.3209
Key Points

Question  Is the use of electronic cigarettes with higher nicotine concentrations prospectively associated with greater frequency and intensity of combustible cigarette smoking and vaping in adolescents?

Findings  In this cohort study of 181 adolescent electronic cigarette users, use of electronic cigarettes with higher nicotine concentrations at baseline was associated with greater levels of combustible cigarette and electronic cigarette use in the past 30 days at the 6-month follow-up and greater intensity of daily use after controlling for baseline use.

Meaning  Use of electronic cigarettes with higher nicotine concentrations may contribute to the progression to smoking and vaping at higher levels of frequency and intensity among youths.


Importance  Research indicates that electronic cigarette (e-cigarette) use (vaping) among adolescents is associated with the initiation and progression of combustible cigarette smoking. The reasons for this association are unknown.

Objective  To evaluate whether use of e-cigarettes with higher nicotine concentrations is associated with subsequent increases in the frequency and intensity of combustible cigarette smoking and vaping.

Design, Setting, and Participants  In this prospective cohort study involving students from 10 high schools in the Los Angeles, California, metropolitan area, surveys were administered during 10th grade in the spring (baseline) and 11th grade in the fall (6-month follow-up) of 2015 to students who reported using e-cigarettes within the past 30 days and the nicotine concentration level they used at baseline.

Exposures  Self-report of baseline e-cigarette nicotine concentration of none (0 mg/mL), low (1-5 mg/mL), medium (6-17 mg/mL), or high (≥18 mg/mL) typically used during the past 30 days.

Main Outcomes and Measures  Frequency of combustible cigarette smoking and e-cigarette use within the past 30 days (0 days [none], 1-2 days [infrequent], or ≥3 days [frequent]) and daily intensity of smoking and vaping (number of cigarettes smoked per day, number of vaping episodes per day, and number of puffs per vaping episode) at the 6-month follow-up.

Results  The analytic sample included 181 students (96 boys [53.0%] and 85 girls [47.0%]; mean [SD] age, 16.1 [0.4] years). Each successive increase in nicotine concentration (none to low, low to medium, and medium to high) vaped was associated with a 2.26 (95% CI, 1.28-3.98) increase in the odds of frequent (vs no) smoking and a 1.65 (95% CI, 1.09-2.51) increase in the odds of frequent (vs no) vaping at follow-up after adjustment for baseline frequency of smoking and vaping and other relevant covariates. Use of e-cigarettes with high (vs no) nicotine concentration was associated with a greater number of cigarettes smoked per day at follow-up (adjusted rate ratio [RR], 7.03; 95% CI, 6.11-7.95). An association with a significantly greater number of vaping episodes per day was found with use of low (adjusted RR, 3.32; 95% CI, 2.61-4.03), medium (adjusted RR, 3.32; 95% CI, 2.54-4.10), and high (adjusted RR, 2.44; 95% CI, 1.63-3.24) nicotine concentrations (vs no nicotine) at baseline. Similar results were found for the number of puffs per vaping episode for low (adjusted RR, 2.05; 95% CI, 1.41-2.70), medium (adjusted RR, 3.39; 95% CI, 2.66-4.11), and high (adjusted RR, 2.23; 95% CI, 1.42-3.03) nicotine concentrations.

Conclusions and Relevance  The results of this study provide preliminary evidence that use of e-cigarettes with higher nicotine concentrations by youths may increase subsequent frequency and intensity of smoking and vaping.