IMPORTANCE: Many studies have reported a positive association of youth electronic cigarette (e-cigarette) use with subsequent cigarette smoking initiation, but it remains unclear whether e-cigarette use is associated with continued cigarette smoking after initiation.

OBJECTIVE: To assess the association of youth baseline e-cigarette use with their continued cigarette smoking 2 years after initiation.

DESIGN, SETTING, AND PARTICIPANTS: The Population Assessment of Tobacco and Health (PATH) Study is a national longitudinal cohort study. This sample consisted of youth who participated in waves 3, 4, and 5 of the study (wave 3 was from October 2015 to October 2016, wave 4 was from December 2016 to January 2018, and wave 5 was from December 2018 to November 2019) and had never used cigarettes (cigarette-naive) by wave 3. The current analysis used multivariable logistic regressions in August 2022 to assess the association between e-cigarette use among cigarette-naive adolescents aged 12 to 17 years in 2015 and 2016 and subsequent continued cigarette smoking. PATH uses audio computer-assisted self-interviewing and computer-assisted personal interviewing to collect data. Exposure was ever and current (past 30-day) use of e-cigarettes in wave 3.

MAIN OUTCOMES AND MEASURES: Continued cigarette smoking in wave 5 after initiating smoking in wave 4.

RESULTS: The current sample included 8671 adolescents who were cigarette naive in wave 3 and also participated in waves 4 and 5; 4823 of the participants (55.4%) were aged 12 to 14 years, 4454 (51.1%) were male, and 3763 (51.0%) were non-Hispanic White. Overall, regardless of e-cigarette use, few adolescents (362 adolescents [4.1%]) initiated cigarette smoking at wave 4, and even fewer (218 participants [2.5%]) continued smoking at wave 5. Controlling for multiple covariates, the adjusted odds ratio of baseline ever e-cigarette use, compared with never e-cigarette use, was 1.81 for continued smoking measured as past 30-day smoking at wave 5. However, the adjusted risk difference (aRD) was small and not significant. The aRD was 0.88 percentage point for continued smoking, with the absolute risk being 1.19% for never e-cigarette users and 2.07% for ever e-cigarette users. Similar results were found using an alternative measure of continued smoking (lifetime ≥100 cigarettes and current smoking at wave 5) and using baseline current e-cigarette use as the exposure measure.

CONCLUSIONS AND RELEVANCE: In this cohort study, absolute and relative measures of risks yielded findings suggesting very different interpretations of the association. Although there were statistically significant odds ratios of continued smoking comparing baseline e-cigarette users with nonusers, the minor risk differences between them, along with the small absolute risks, suggest that few adolescents are likely to continue smoking after initiation regardless of baseline e-cigarette use.