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Transitions between cigarette, ENDS and dual use in adults in the PATH study (waves 1–4): multistate transition modelling accounting for complex survey design
  1. Andrew F Brouwer1,
  2. Jihyoun Jeon1,
  3. Jana L Hirschtick1,
  4. Evelyn Jimenez-Mendoza1,
  5. Ritesh Mistry2,
  6. Irina V Bondarenko3,
  7. Stephanie R Land4,
  8. Theodore R Holford5,
  9. David T Levy6,
  10. Jeremy M G Taylor3,
  11. Nancy L Fleischer1,
  12. Rafael Meza1
  1. 1Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
  2. 2Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan, USA
  3. 3Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
  4. 4Tobacco Control Research Branch, National Cancer Institute Division of Cancer Control and Population Sciences, Rockville, Maryland, USA
  5. 5Biostatistics, Yale University, New Haven, Connecticut, USA
  6. 6Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
  1. Correspondence to Dr Andrew F Brouwer, Epidemiology, University of Michigan, Ann Arbor, MI 48109, USA; brouweaf{at}


Introduction Even prior to 2018, electronic nicotine delivery systems (ENDS) began to dramatically change the landscape of tobacco products and product use patterns in the USA.

Methods Using a Markov multistate transition model accounting for complex survey design, transition rates between never, non-current, cigarette, ENDS and dual use states were estimated for 23 253 adult participants in waves 1–4 (approximately 2013–2017) of the Population Assessment of Tobacco and Health study. We made short-term transition projections and estimated HRs for age, sex, race/ethnicity, education and income.

Results Cigarette use was persistent among adults, with 89.7% (95% CI 89.1% to 90.3%) of exclusive cigarette users and 86.1% (95% CI 84.4% to 87.9%) of dual users remaining cigarette users (either exclusive or dual) after one wave. In contrast, ENDS use was less persistent, with 72.1% (95% CI 69.6% to 74.6%) of exclusive ENDS users and 50.5% (95% CI 47.8% to 53.3%) of dual users remaining ENDS users (with or without cigarettes) after one wave. Exclusive ENDS users were more likely to start cigarette use after one wave than either never users (HR 25.2; 95% CI 20.9 to 30.5) or non-current users (HR 5.0; 95% CI 4.3 to 5.8). Dual users of ENDS and cigarettes were more likely to stop using cigarettes than exclusive cigarette users (HR 1.9; 95% CI 1.6 to 2.3). Transition rates varied among sociodemographic groups.

Conclusions Multistate transition models are an effective tool for uncovering and characterising longitudinal patterns and determinants of tobacco use from complex survey data. ENDS use among US adults was less persistent than cigarette use prior to 2018.

  • electronic nicotine delivery devices
  • non-cigarette tobacco products
  • surveillance and monitoring
  • disparities

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  • Contributors Conceptualisation: RMeza. Data curation: JJ, JLH, EJM. Methodology: AFB, JMGT, RMeza. Analysis: AFB. Original draft preparation: AFB. Review and editing: AFB, JJ, JLH, RMistry, IVB, SRL, TRH, DTL, JMGT, NLF, RMeza. Funding acquisition: RMeza, DTL.

  • Funding This project was funded through National Cancer Institute (NCI) and Food and Drug Administration (FDA) grant U54CA229974 and the University of Michigan Rogel Cancer Center core grant P30CA046592.

  • Disclaimer The opinions expressed in this article are the authors’ own and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services or the US government.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. Data from the PATH study are available for download as Public Use Files in a public, open access repository ( Conditions of use are available on the website above.