Associations of Electronic Cigarette Nicotine Concentration With Subsequent Cigarette Smoking and Vaping Levels in Adolescents

JAMA Pediatr. 2017 Dec 1;171(12):1192-1199. doi: 10.1001/jamapediatrics.2017.3209.


Importance: Research indicates that electronic cigarette (e-cigarette) use (vaping) among adolescents is associated with the initiation and progression of combustible cigarette smoking. The reasons for this association are unknown.

Objective: To evaluate whether use of e-cigarettes with higher nicotine concentrations is associated with subsequent increases in the frequency and intensity of combustible cigarette smoking and vaping.

Design, setting, and participants: In this prospective cohort study involving students from 10 high schools in the Los Angeles, California, metropolitan area, surveys were administered during 10th grade in the spring (baseline) and 11th grade in the fall (6-month follow-up) of 2015 to students who reported using e-cigarettes within the past 30 days and the nicotine concentration level they used at baseline.

Exposures: Self-report of baseline e-cigarette nicotine concentration of none (0 mg/mL), low (1-5 mg/mL), medium (6-17 mg/mL), or high (≥18 mg/mL) typically used during the past 30 days.

Main outcomes and measures: Frequency of combustible cigarette smoking and e-cigarette use within the past 30 days (0 days [none], 1-2 days [infrequent], or ≥3 days [frequent]) and daily intensity of smoking and vaping (number of cigarettes smoked per day, number of vaping episodes per day, and number of puffs per vaping episode) at the 6-month follow-up.

Results: The analytic sample included 181 students (96 boys [53.0%] and 85 girls [47.0%]; mean [SD] age, 16.1 [0.4] years). Each successive increase in nicotine concentration (none to low, low to medium, and medium to high) vaped was associated with a 2.26 (95% CI, 1.28-3.98) increase in the odds of frequent (vs no) smoking and a 1.65 (95% CI, 1.09-2.51) increase in the odds of frequent (vs no) vaping at follow-up after adjustment for baseline frequency of smoking and vaping and other relevant covariates. Use of e-cigarettes with high (vs no) nicotine concentration was associated with a greater number of cigarettes smoked per day at follow-up (adjusted rate ratio [RR], 7.03; 95% CI, 6.11-7.95). An association with a significantly greater number of vaping episodes per day was found with use of low (adjusted RR, 3.32; 95% CI, 2.61-4.03), medium (adjusted RR, 3.32; 95% CI, 2.54-4.10), and high (adjusted RR, 2.44; 95% CI, 1.63-3.24) nicotine concentrations (vs no nicotine) at baseline. Similar results were found for the number of puffs per vaping episode for low (adjusted RR, 2.05; 95% CI, 1.41-2.70), medium (adjusted RR, 3.39; 95% CI, 2.66-4.11), and high (adjusted RR, 2.23; 95% CI, 1.42-3.03) nicotine concentrations.

Conclusions and relevance: The results of this study provide preliminary evidence that use of e-cigarettes with higher nicotine concentrations by youths may increase subsequent frequency and intensity of smoking and vaping.

MeSH terms

  • Adolescent
  • Adolescent Behavior*
  • Electronic Nicotine Delivery Systems / methods*
  • Electronic Nicotine Delivery Systems / statistics & numerical data
  • Female
  • Humans
  • Longitudinal Studies
  • Los Angeles / epidemiology
  • Male
  • Nicotine / administration & dosage*
  • Risk Factors
  • Self Report
  • Smoking / epidemiology*
  • Tobacco Products


  • Nicotine