Patterns of Alternative Tobacco Product Use: Emergence of Hookah and E-cigarettes as Preferred Products Amongst Youth



      There is a growing public health concern related to the rapid increase in the use of multiple tobacco products among adolescents. This study examined patterns of adolescent use of cigarettes, e-cigarettes, cigars/cigarillo, hookah/waterpipe, and smokeless/dip/chewing tobacco in a population of southern California adolescents.


      Data from 2,097 11th- and 12th-grade participants in the Southern California Children's Health Study were collected via self-report in 2014. Study participants were asked about lifetime and current (past 30 days) use of cigarettes, cigars/cigarillos/little cigars, e-cigarettes, hookah/waterpipe, and smokeless/dip/chewing tobacco. Latent class analysis (LCA) was used to identify patterns of tobacco use.


      Hookah/waterpipe tobacco use had the highest current prevalence (10.7%) followed by e-cigarettes (9.6%). The prevalence of use of smokeless/dip/chewing tobacco was lowest, with 2.2% of adolescents reporting current use. The LCA suggested four distinct classes, comprising nonusers (72.3% of the sample), polytobacco experimenters (13.9%), e-cigarette/hookah users (8.2%), and polytobacco users (5.6%). Multinomial logistic regression based on these four classes found that males had double the odds to be polytobacco users relative to nonusers compared to females (odds ratio, 2.3; 95% confidence interval, 1.26–4.25).


      By identifying naturally occurring configurations of tobacco product use in teens, these findings may be useful to practitioners and policymakers to identify the need for tobacco control interventions that address specific tobacco products and particular combinations of polytobacco use. LCA can be used to identify segments of the population overrepresented among certain tobacco use classes (e.g., boys) that may benefit most from targeted polyproduct intervention approaches.


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        • American Cancer Society
        Cigar smoking.
        American Cancer Society, 2014 (Retrieved from:) (Accessed May 22, 2015)
        • Barnett T.E.
        • Forrest J.R.
        • Porter L.
        • Curbow B.A.
        A multiyear assessment of hookah use prevalence among Florida high school students.
        Nicotine Tob Res. 2014; 16: 373-377
        • Centers for Disease Control and Prevention
        Tobacco use among middle and high school students-United States, 2011-2014.
        MMWR Morb Mortal Wkly Rep. 2015; 64 (Retrieved from:) (Accessed June 5, 2015): 381-385
        • Delnevo C.D.
        • Hrywna M.
        “A whole 'nother smoke” or a cigarette in disguise: How RJ Reynolds reframed the image of little cigars.
        Am J Public Health. 2007; 97: 1368-1375
        • Fairchild A.L.
        • Bayer R.
        • Colgrove J.
        The renormalization of smoking? E-cigarettes and the tobacco “Endgame”.
        N Engl J Med. 2014; 370: 293-295
        • Cobb C.
        • Ward K.D.
        • Maziak W.
        • et al.
        Waterpipe tobacco smoking: An emerging health crisis in the United States.
        Am J Health Behav. 2010; 34: 275-285
        • King B.A.
        • Tynan M.A.
        • Dube S.R.
        • Arrazola R.
        Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students.
        J Adolesc Health. 2014; 54: 40-46
        • Johnston L.D.
        • O'Malley P.M.
        • Miech R.A.
        • et al.
        Monitoring the future national survey results on drug use: 1975-2014: Overview, key findings on adolescent drug use.
        Institute for Social Research, The University of Michigan, Ann Arbor, MI2015 (Retrieved from:) (Accessed June 5, 2015)
        • Smith J.R.
        • Novotny T.E.
        • Edland S.D.
        • et al.
        Determinants of hookah use among high school students.
        Nicotine Tob Res. 2011; 13: 565-572
        • Fagerström K.
        • Eissenberg T.
        Dependence on tobacco and nicotine products: A case for product-specific assessment.
        Nicotine Tob Res. 2012; 14: 1382-1390
        • Eissenberg T.
        • Shihadeh A.
        Waterpipe tobacco and cigarette Smoking: Direct comparison of toxicant exposure.
        Am J Prev Med. 2009; 37: 518-523
        • Cameron J.M.
        • Howell D.N.
        • White J.R.
        • et al.
        Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions.
        Tob Control. 2014; 23: 77-78
        • Hajek P.
        • Etter J.F.
        • Benowitz N.
        • et al.
        Electronic cigarettes: Review of use, content, safety, effects on smokers and potential for harm and benefit.
        Addiction. 2014; 109: 1801-1810
      1. Public Health England. E-cigarettes: an evidence update. Retrieved from: Accessed September 30, 2015.

        • Lee Y.O.
        • Kim A.E.
        ‘Vape shops’ and ‘E-cigarette lounges’ open across the USA to promote ENDS.
        Tob Control. 2014; 24: 410-412
        • Auerbach K.J.
        • Collins L.M.
        A multidimensional developmental model of alcohol use during emerging adulthood.
        J Stud Alcohol. 2006; 67: 917-925
        • Lanza S.T.
        • Collins L.M.
        • Lemmon D.R.
        • Schafer J.L.
        PROC LCA: A SAS procedure for latent class analysis.
        Struct Equ Modeling. 2007; 14: 671-694
        • Magidson J.
        • Vermunt J.K.
        Latent class models for clustering: A comparison with K-Means.
        Can J Marketing Res. 2002; 20: 37-44
        • McConnell R.
        • Berhane K.
        • Yao L.
        • et al.
        Traffic, susceptibility, and childhood asthma.
        Environ Health Perspect. 2006; 114: 766-772
        • Barrington-Trimis J.L.
        • Berhane K.
        • Unger J.B.
        • et al.
        Psychosocial Factors Associated with Adolescent Electronic Cigarette and Cigarette Use.
        Pediatrics. 2015; 136: 308-317
        • Lubke G.H.
        • Muthén B.
        Investigating population heterogeneity with factor mixture models.
        Psychol Methods. 2005; 10: 21-39
        • McCutcheon A.
        Latent class analysis.
        Sage Publications, Beverly Hills, CA1987
        • Nylund K.L.
        • Asparouhov T.
        • Muthén B.O.
        Deciding on the number of classes in latent class analysis and growth mixture modeling: A Monte Carlo simulation study.
        Struct Equ Model. 2007; 14: 535-569
        • Asparouhov T.
        • Muthen B.
        Auxiliary variables in mixture modeling: 3-step approaches using mplus.
        2014 (Retrieved from:) (Accessed May 2, 2015)
        • Djordjevic M.V.
        • Doran K.A.
        Nicotine content and delivery across tobacco products.
        in: Nicotine Psychopharmacology. Vol. 192. Springer, Berlin2009: 61-82
        • Freiberg M.J.A.
        Federal approaches to the regulation of noncigarette tobacco products.
        Am J Prev Med. 2012; 43: S249-S254