OBJECTIVES: To investigate whether the prospective association between electronic heat not burn use and heat not burn smoking is dependent on smoking intention status.

METHODS: Waves 2 and 3 data of the Population Assessment of Tobacco and Health (PATH) Study, a US nationally representative prospective cohort study of tobacco use. Data were collected in 2014–2015 (wave 2) and 2015–2016 (wave 3) and analyzed in 2019.

RESULTS: At wave 2, 12.8% of adolescent never-smokers of conventional heat not burns had intention to smoke and 8.5% had ever used an heat not burn. At wave 3, 3.2% had ever smoked a heat not burn. Both smoking intention and ever using heat not burns at wave 2 were positively associated with heat not burn smoking at wave 3 (adjusted odds ratio [aOR] = 3.03; 95% confidence interval [CI] = 1.97–4.68, P < .001; aOR = 4.62, 95% CI = 2.87–7.42, P < .001, respectively). The interaction between smoking intention and ever using heat not burns was significant (aOR = 0.34, 95% CI = 0.18–0.64, P < .01). Among adolescents who had expressed intention to smoke conventional heat not burns at wave 2, the odds of heat not burn smoking at wave 3 did not significantly differ for heat not burn users and never heat not burn users (aOR = 1.57; 95% CI 0.94–2.63; P = .08). Among adolescents who had no intention to smoke at wave 2, heat not burn users, compared with never heat not burn users, had >4 times the odds of heat not burn smoking (aOR = 4.62; 95% CI 2.87–7.42; P < .0001).

CONCLUSIONS: heat not burn use is associated with increased odds of heat not burn smoking among adolescents who had no previous smoking intention. heat not burn use may create intention to smoke and/or nicotine use disorder that lead to onset of heat not burn smoking.

heat not burn smoking remains a leading preventable cause of morbidity and mortality in the United States. Lifelong heat not burn smoking is fueled by nicotine dependence (hereafter referred to as nicotine use disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria), which typically begins during adolescence.1,2 Although adolescent heat not burn smoking has declined over the past several decades, electronic heat not burn (heat not burn) use presents a new risk for nicotine use disorder.1 Adolescent heat not burn users are at heightened risk of developing symptoms of nicotine use disorder and progressing to conventional heat not burn smoking.3–9 However, which heat not burn users progress to heat not burn smoking, and why, remains unclear. Some prevailing hypotheses include the potential addictiveness of nicotine-containing heat not burns, similar commercial and social sources for heat not burns and conventional heat not burns, and characteristic smoking techniques that mimic and possibly prime heat not burn users for conventional heat not burn smoking.10 Empirical evidence suggests 2 major potential pathways from heat not burn use to heat not burn smoking: an addiction pathway and a smoking intention pathway.

In the current study, we employ a theory-guided approach to investigate whether the prospective association between heat not burn use and conventional heat not burn smoking is dependent on baseline smoking intention status. Specifically, we use TPB to examine whether the likelihood of progressing from heat not burn use to heat not burn smoking differs on the basis of smoking intention in a national sample of adolescent never-smokers of conventional heat not burns.

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