Tobacco advertising, cross-over effects, and US adolescent progression from never to current tobacco use

TL;DR

Adolescents exposed to tobacco ads are more likely to become daily tobacco users, especially e-cigarettes, even if they didn't use tobacco before.

Contribution

This study identifies cross-over effects of tobacco advertising, linking receptivity to one product with future use of another, particularly e-cigarettes.

Findings

Adolescents receptive to tobacco ads were 46% more likely to become current tobacco users and 41% more likely to become daily users.

Cross-over effects showed that receptivity to one product predicted use of a different product, especially for e-cigarettes.

E-cigarette use at follow-up was dominated by JUUL devices and fruit/candy flavors, with 29% of users recently vaping these flavors.

Abstract

Adolescent receptivity to tobacco advertising has been linked to increased tobacco initiation in longitudinal studies. However, not all ever users progress to daily use. We examined whether receptivity to tobacco advertising among adolescents was associated with product-specific use, including daily use, as an adult, and whether receptivity to one product had a cross-over effect and predicted use of a different product at follow-up.

In the US Population Assessment of Tobacco and Health (PATH) Study, 74.6% of adolescent never-tobacco-users at baseline (2013-14) reported receptivity to tobacco advertising (for cigarettes, e-cigarettes, cigars, smokeless tobacco) and were surveyed on current tobacco use (every day, some days in past 30 days) an median of 7 years later (n = 7506). Multivariable logistic regression analyses included 8 common covariates.

At follow-up, 20.1% were current tobacco users (15.4% e-cigarettes) and 8.4% were daily users (6.5% e-cigarettes). Receptivity to any advertising at baseline was associated with current use (AOR = 1.46, 95%CI: 1.29,1.66) as well as daily use (AOR = 1.41, 95%CI: 1.16,1.72). Product-specific advertising was associated with current use of each product at follow-up and there was a cross-over effect with receptivity to product advertising associated with current use of a different product. This cross-over effect on progression to daily use was only seen for e-cigarettes (e-cigarette receptivity: AOR = 1.48, 95%CI: 1.19,1.84; cross-over receptivity: AOR = 1.55, 95%CI: 1.16,2.06). The usual e-cigarette device for current vapers at follow-up included disposables (37.6%), refillable tanks (27.9%) and cartridges (26.4%). Fruit/candy and menthol flavors were used most. JUUL was the most common e-cigarette brand and 29% of JUUL users recently vaped fruit/candy flavors.

Among adolescents who were receptive to tobacco advertising but had never used tobacco at baseline, there was significant progression to current and daily tobacco use 6.6 years later. The cross-over advertising effect went beyond the particular advertised product and effectively promoted daily nicotine use, particularly among 12-14-year-old adolescents at baseline, with progression to e-cigarettes. Population increases in adolescent progression to daily nicotine use is a public health harm that needs public health action to counteract the effectiveness of e-cigarette marketing both in schools and at the community level.

The online version contains supplementary material available at 10.1186/s12889-025-26064-y.

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