This study characterized patterns of polytobacco use among U.S. Black high school students. Our findings indicate that the prevalence of past 30-day use of each of the four tobacco use behaviors was < 10%. Approximately 80% of the students were best classified as Nnon-Users, meaning they were largely not engaged in any of the tobacco use behaviors. This is consistent with studies demonstrating large declines in tobacco use among youth (12); however, 14% were characterized as E-cigarette Users” and approximately 5% were characterized as Polytobacco Users. The importance of this investigation is highlighted by the persistence of tobacco-related health disparities experienced by Blacks, targeted marketing of the most harmful products to Black people by the tobacco industry, and comparatively limited access to tobacco use cessation programs among Black Americans (33–35).
We found only one recent study that examined polytobacco use among Black youth(22). The results of that study identified two classes, which were deemed “Non-Users” and “Cigarette/cigar” groups. Males were more likely to be classified in “Cigarette/cigar” group and this class had higher odds of increased nicotine dependence. Those results are similar to the findings of the current study (males reporting higher odds of multiple tobacco product use); however, a key difference is the focus on current use only and smaller sample size (n = 852) (22). The current study included lifetime use, which gives us an insight into what tobacco products Black youth might be more likely to experiment with. These data could be used to design preventive interventions before youth become current or frequent tobacco product users.
E-cigarette Users had a high likelihood of lifetime use of e-cigarettes and nearly 50% chance of ever smoking a cigarette. The 30% chance that youth in this class were currently using e-cigarettes is concerning. Assessments of the harm potential of e-cigarettes are very limited. The e-liquids available for these products have a wide variation in nicotine content, and the amount of nicotine in many vials could be fatal if ingested orally or transdermally (20). The variation in the amount of nicotine and other potentially harmful ingredients contained in tobacco products as well as differences in how products are used (e.g., how often and quantity consumed) (36) increase the importance of understanding which products are being used by youth. Little is known about the true harm reduction value or addiction reduction potential of alternate products (e.g., hookah or e-cigs) relative to combustible cigarettes. For example, there is research that suggests one hookah session could be the equivalent of toxicant exposure of smoking 1 to 50 cigarettes (37). Further, Freiberg et al. (2009) found that hookah produced a significantly higher carbon monoxide exposure while delivering the same amount of nicotine in a laboratory-controlled experiment compared to cigarettes (38).
Polytobacco Users had a high likelihood of current use of all four forms of tobacco/nicotine use included in the present study. Specifically, Polytobacco Users had a 54% chance of past 30 day smokeless tobacco use, 81% chance of current cigar use, and 77% chance of past 30 day electronic cigarette use. Further analysis indicates that 75% of these youth had used two or three tobacco products concurrently in the last 30 days, with cigars and cigarettes having the highest use prevalence. Our findings raise the possibility that a sizeable subgroup of Black teens may benefit from interventions targeting multiple product use, and e-cigarette and cigar use specifically. Concurrent use of tobacco products places Black polytobacco users at increases risk of poor health consequences among Black Polytobacco Users. The literature has long supported that U.S. Blacks smoke fewer cigarettes per day (1, 39), take fewer puffs per cigarette (40)—all while experiencing higher rates of tobacco-related deaths from coronary heart disease, stroke and lung cancer (1, 11).
Relative to the non-user class, boys (vs. girls) were more likely to be Polytobacco Users and 9th graders (vs. 12th graders) were less likely be in the Polytobacco Users. Black males and older youth are at greater risk of being Polytobacco Users and could benefit from targeted programming. Further, youth classified as E-cigarette Users or Polytobacco Users had over 20-fold increased odds of being current marijuana users compared to Non-Users. The present study confirms prior findings of the significant association of marijuana use with tobacco use (14, 16) and highlights the need for prevention scientists to consider comorbid intervention designs.
The present study has limitations. Data were self-reported from youth and as such substance use behaviors could have been over- or under-reported. The YRBSS survey is not all inclusive of all tobacco products (e.g., hookahs) and the data are cross-sectional, so causality cannot be determined. Notwithstanding, these findings represent a nationally representative sample of Black youth and fill an important gap in the pertinent literature.