Initiation of Electronic Cigarette Use by Age Among Youth in the U.S.


      The rapid increase in electronic cigarette (e-cigarette) smoking among U.S. youth requires data regarding the age pattern of initiation risk for effective tobacco use prevention.


      Data from the 2014 National Youth Tobacco Survey (N=20,680, aged 11–19 years, 50.6% male) were analyzed using survival analysis in 2016 to quantify the likelihood of e-cigarette use initiation by age, overall and by gender and racial/ethnic groups.


      The estimated mean age of e-cigarette initiation was 17.50 (95% CI=17.47, 17.52) years. The estimated hazards of e-cigarette use initiation were 0 up to age 6 years, increased slowly from age 7 to 11 years, and continued with an accelerated increase up to age 17 years before it slowed down. There were significant gender (male > female) and racial/ethnicity (from high to low: multiracial, white, Hispanic, African, and Asian) differences in the age pattern.


      E-cigarette smoking is initiated as young as age 7 years. Different from conventional cigarette smoking with peak initiation risk at age 14–15 years, the likelihood of initiating e-cigarette smoking continues to increase up to age 18 years. The unique age pattern and significant gender and racial/ethnic differences provide useful data to support further research to strengthen tobacco use prevention in the U.S.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Grana R.
        • Benowitz N.
        • Glantz S.A.
        E-cigarettes a scientific review.
        Circulation. 2014; 129: 1972-1986
        • Schoenborn C.A.
        • Gindi R.M.
        Electronic cigarette use among adults: United States, 2014.
        NCHS Data Brief: National Center for Health Statistics, 2015
        • Singh T.
        • Arrazola R.A.
        • Corey C.G.
        • et al.
        Tobacco use among middle and high school students - United States, 2011-2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 361-367
        • Johnston L.D.
        • O’Malley P.M.
        • Miech R.A.
        • Bachman J.G.
        • Schulenberg J.E.
        Monitoring the Future national survey results on drug use, 1975-2015: overview, key findings on adolescent drug use. 2016; (Accessed November 21, 2016)
        • U.S. DHHS
        Tobacco use.
        Healthy People 2020. 2016; (Accessed November 22, 2016)
        • WHO
        2012 Global progress report on implementation of the WHO Framework Convention on Tobacco Control.
        WHO, Geneva2012
        • Walton K.M.
        • Abrams D.B.
        • Bailey W.C.
        • et al.
        NIH electronic cigarette workshop: developing a research agenda.
        Nicotine Tob Res. 2015; 17: 259-269
        • Agrawal A.
        • Grant J.D.
        • Waldron M.
        • et al.
        Risk for initiation of substance use as a function of age of onset of cigarette, alcohol and cannabis use: findings in a Midwestern female twin cohort.
        Prev Med. 2006; 43: 125-128
        • Chen X.
        • Unger J.B.
        Hazards of smoking initiation among Asian American and non-Asian adolescents in California: a survival model analysis.
        Prev Med. 1999; 28: 589-599
        • Chen X.
        • Yu B.
        • Lasopa S.
        • Cottler L.
        Current patterns of marijuana use initiation by age among U.S. adolescents and emerging adults: implications for intervention.
        Am J Drug Alcohol Abuse. In press. Online. May 21, 2016;
        • Machin D.
        • Cheung Y.B.
        • Parmar M.
        Survival Analysis: A Practical Approach.
        John Wiley & Sons, New York2006
        • Chen X.
        • Li Y.
        • Unger J.B.
        • Gong J.
        • Johnson C.A.
        • Guo Q.
        Hazard of smoking initiation by age among adolescents in Wuhan, China.
        Prev Med. 2001; 32: 437-445
        • Kandel D.B.
        • Kiros G.-E.
        • Schaffran C.
        • Hu M.-C.
        Racial/ethnic differences in cigarette smoking initiation and progression to daily smoking: a multilevel analysis.
        Am J Public Health. 2004; 94: 128-135
        • Whaley A.L.
        • Francis K.
        Behavioral health in multiracial adolescents: the role of Hispanic/Latino ethnicity.
        Public Health Rep. 2006; 121: 169-174
        • Choi Y.
        • He M.
        • Herrenkohl T.I.
        • Catalano R.F.
        • Toumbourou J.W.
        Multiple identification and risks: examination of peer factors across multiracial and single-race youth.
        J Youth Adolesc. 2012; 41: 847-862
        • Courtney R.
        The health consequences of smoking-50 years of progress: a report of the Surgeon General, 2014.
        Drug Alcohol Rev. 2015; 34: 694-695
        • Choi Y.
        • Harachi T.W.
        • Gillmore M.R.
        • Catalano R.F.
        Are multiracial adolescents at greater risk? Comparisons of rates, patterns, and correlates of substance use and violence between monoracial and multiracial adolescents.
        Am J Orthopsychiatry. 2006; 76: 86-97

      Linked Article

      • E-cigarettes and the Youngest, Not a Problem in Europe: No Data Yet
        American Journal of Preventive MedicineVol. 54Issue 4
        • Preview
          Chen et al.1 provided frightening facts: “e-cigarette smoking is initiated as young as age 7 years while peak initiation of conventional cigarette is 14–15 years.” The term gateway appeared soon in titles of articles about e-cigarettes because nicotine, smoked or vaped, is a most potent addictive product, even more when associated with flavor.2 Nevertheless, no one expected initiation could have been so early. As the early age of smoking initiation is a major risk factor for smoking-related morbidities and all-cause mortality,3 Chen et al.’s finding needs robust and rapid responses.
        • Full-Text
        • PDF