Tobacco use and harm perceptions among Appalachian youth

•Over one-third had tried tobacco and over one-fifth had tried two or more products.•Most participants recognized harms associated with conventional tobacco use.•E-cigarettes were perceived as less harmful than conventional tobacco products.•Smokers and polytobacco users had lower odds of indicating tobacco health risks.•E-cigarette users were less likely to perceive e-cigarettes as harmful or addictive. Appalachian youth tobacco use rates exceed the national average. Additional inquiry is needed to better understand youth product perceptions and use patterns. This study examined tobacco harm perceptions and their relationship with tobacco use among Appalachian youth. From 2014 to 2016, a survey of Appalachian middle and high school students (N = 1,136) was conducted. Tobacco harm perceptions were assessed by tobacco use status, categorized as never user, cigarette only user, smokeless only user, e-cigarette only user, or polytobacco user. Descriptive characteristics were compared by tobacco use status and harm perceptions. Adjusted multivariable logistic regression models assessed the relationship between tobacco use status and harm perceptions. Over one-third of participants were tobacco users (34.6%; 4.7% cigarette only users, 3.3% smokeless only users, 5.6% e-cigarette only users, and 21.0% polytobacco users). Approximately half agreed that e-cigarettes cause health problems (54.4%), and 64.7% agreed that e-cigarettes are addictive. Most participants (83.4–92.3%) agreed that smoking and smokeless tobacco cause health problems and are addictive. Tobacco users more often disagreed that tobacco products cause health problems than did never users. Compared to never users, e-cigarette only users were more likely to disagree that smoking (AOR: 2.99, 95% CI: 1.30–6.90) and e-cigarettes cause health problems (AOR: 2.79, 95% CI: 1.64–4.75) and that e-cigarettes cause addiction (AOR: 2.48, 95% CI: 1.48–4.16). Most youth were aware of health dangers associated with smoking, but perceptions were split on whether e-cigarettes were associated with health problems or addiction. The findings indicate the need for additional youth tobacco use prevention efforts.