OBJECTIVES : The prevalence of e-cigarettes among American youth has drastically increased in the past decade. It is a growing public health concern as the early exposure to nicotine via e-cigarettes increases subsequent cigarette smoking. This study examined factors associated with early initiation of e-cigarette smoking among youth.

METHODS : Children (age<18) participated in the 2017 National Youth Tobacco Survey who reported using e-cigarettes the first time within a 1-year period were included. Early initiation was defined as those who started using e-cigarettes in a middle school (11-13 years) age and late initiation was those who started in a high school (14-17 years) age. Potential predictors for early initiation included state-level factors (cigarette tax rates, marijuana legalization), cues to action (curiosity towards e-cigarette, friends or family being smokers, TV or movie stars being smokers, easy access, flavors, advertisements), perceived susceptibility (using any other tobacco product(s)), perceived benefits (trying to quit tobacco, relative costs, relative harm). Multi-variable logistic regression with backward selection was performed to retain the most significant predictors of early initiation of e-cigarettes.

RESULTS : A total of 358 and 1,496 were identified as early and late initiators of e-cigarettes. Those who tried to quit tobacco (OR=2.49, 95%CI=1.160-5.341), lived with e-cigarette smokers (OR=2.43, 95%CI=1.557-3.799) and cigarettes smokers (OR=1.67, 95%CI=1.078-2.596) were more likely to start e-cigarettes early.

CONCLUSIONS : Home environment has a major impact on whether children will become e-cigarette smokers. It is alarming that middle school children reported starting e-cigarettes in order to quit tobacco smoking as there is limited evidence of using e-cigarettes as smoking cessation aid. Dual use of e-cigarettes and cigarettes may extend the nicotine addiction which will pose a greater health risk when exposed in early age. Schools should consider promoting a youth e-cigarette prevention campaign to curb the epidemic of e-cigarettes in early school age children.