Tobacco and Nicotine Use Among US Adult "Never Smokers" in Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health Study

Abstract

Introduction: A common criterion for being labeled a "never smoker" is having smoked <100 lifetime cigarettes. This category is often used as an unexposed reference group to estimate the relative harm from cigarettes. We examined the amount of current and past cigarette and non-cigarette tobacco/nicotine use among adults who met this "never smoker" criterion.

Methods: We analyzed cross-sectional data from 17 179 adult "never smokers" (ie, reported <100 lifetime cigarettes) in Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health (PATH) Study, a United States nationally representative sample. We used PATH-derived variables to describe "never smokers'" demographics as well as cigarette and non-cigarette tobacco/nicotine use.

Results: Approximately half of "never smokers" were young adults (49.3%). Most were white (68.6%) with some college or more (64.4%). Most "never smokers" had tried any cigarette or non-cigarette tobacco/nicotine in their lifetime (66.7%), 8.5% smoked cigarettes in the past 30 days, and 5.3% were current experimental (ie, some days or every day) cigarette smokers. By definition, "never smokers" reported smoking <100 lifetime cigarettes. One fifth (22.8%) had a lifetime history of established regular non-cigarette tobacco/nicotine use and 8.6% were current established regular non-cigarette tobacco/nicotine users. In total, 9.4% of "never smokers" were current experimental or established regular users of combustible tobacco.

Conclusions: The 100-cigarette lifetime threshold includes substantial amounts of current and past tobacco use and thus does not represent lack of exposure to cigarette or non-cigarette tobacco. "Never smoker" reference groups may produce underestimates of the relative harms from cigarettes.

Implications: The <100 lifetime cigarettes criterion may not capture what many would consider true "never smokers." Relying on the current definition of "never smokers" as a reference group will include a substantial number of those currently and recently using combustible tobacco and thus produce data that may underestimate the relative harm from cigarettes. Prospective longitudinal research is needed to compare how the 100-cigarette lifetime threshold versus other definitions of regular cigarette smoking differ in predictive validity of clinically meaningful outcomes and health harms to determine the optimal criteria to define established cigarette smoking.

Figure 1.

Any tobacco/nicotine product, any combustible tobacco product, and cigarette use categories among “never cigarette smokers” (ie, adults who report <100 lifetime cigarettes; N = 17 179) within the Population Assessment of Tobacco and Health (PATH) Study. ^aAny tobacco/nicotine includes use of cigarette and non-cigarette tobacco products and e-cigarettes for the Ever tried, Used in past 30 days, and Current experimental use categories but only includes use of non-cigarette tobacco products and e-cigarettes for the, Current established use categories. ^bAny combustible tobacco includes use of cigarettes, cigars, pipes, and hookah for the Ever tried, Used in past 30 days, and Current experimental use categories but only includes use of cigars, pipes, and hookah for the, Current established use categories. All denominators for weighted percentages (95% confidence intervals) are from the preceding category. Weighted percentages using the overall sample of “never smokers” (N = 17 179) as the denominator are displayed in Table 3. The terms used in this figure represent PATH Study-derived variables and are defined in Table 1. Data were collected cross-sectionally and do not represent within-participant change.