Online Pro-Tobacco Marketing Exposure Is Associated With Dual Tobacco Product Use Among Underage US Students

Purpose: To understand the effect of pro-tobacco marketing on electronic cigarette and combustible cigarette dual use among US middle and high school students under 18 years of age. Design: Data were derived from the 2018 National Youth Tobacco Survey, an annual self-administered school-based cross-sectional survey. Setting: The survey was administered in public and private middle and high schools across the United States. Participants: The probability sample size was 15 238 middle and high school students with complete responses who were under 18 years of age during the study period. Measures: The study measured self-reported exposure to online combustible and electronic cigarette advertisements, dual use of combustible and electronic cigarettes during the past 30 days, exposure to the Real Cost antitobacco campaign advertisements, and other sociodemographic factors (eg, race/ethnicity, gender, and grade). Analysis: Logistic regressions were used to measure pro-tobacco marketing exposure and dual use as a function of pro-tobacco marketing exposure. Results: Descriptive analyses show that 59.0% of respondents were exposed to pro-tobacco online marketing, and 2.9% were dual users. Dual users (odds ratio [OR] = 1.73) and high school students (OR = 1.43) were more likely to report exposure to online pro-tobacco marketing. Conclusions: Findings indicate that a gap in electronic cigarette pro-tobacco marketing regulatory oversight may exist. Further policy action may be warranted to protect the public health of minors and other vulnerable populations who are most susceptible to pro-tobacco marketing.