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Transitions to smokeless tobacco use among adult cigarette smokers in the Population Assessment of Tobacco and Health (PATH) Study, Waves 3–5 (2015–2019)
  1. Rebecca A Jackson1,
  2. Chunfeng Ren1,
  3. Blair Coleman1,
  4. Hannah R Day1,
  5. Cindy M Chang1,
  6. Justina Kofie1,
  7. Derick Rivers1,
  8. Moana Kanel2,3,
  9. Bridget K Ambrose1
  1. 1Center for Tobacco Products, US Food and Drug Administration, Silver Spring, Maryland, USA
  2. 2National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
  3. 3Kelly Government Solutions, Rockville, Maryland, USA
  1. Correspondence to Dr Cindy M Chang, Center for Tobacco Products, US Food and Drug Administration, Silver Spring, MD 20993, USA; Cindy.Chang{at}


Objective Examine patterns of dual use of cigarettes and smokeless tobacco and complete switching over time among adult current cigarette smokers using data from the Population Assessment of Tobacco and Health Study Wave 3 (2015–2016), Wave 4 (2016–2018) and Wave 5 (2018–2019).

Methods We examined four tobacco use states among 6834 exclusive smokers and 372 dual users at Wave 3 with two waves of follow-up data: exclusive cigarette use, exclusive smokeless tobacco use, dual use and use of neither product.

Results Among exclusive smokers at Wave 3, only 1.6% (95% CI: 1.3% to 2.1%) transitioned to dual use at Wave 4, and 0.1% (95% CI: 0.07% to 0.2%) switched to exclusive smokeless tobacco use. Among exclusive smokers who switched to dual use, 53.1% (95% CI: 40.9% to 64.9%) returned to exclusive cigarette smoking, 34.3% (95% CI: 23.8% to 46.6%) maintained dual use and 12.6% (95% CI: 7.0% to 21.7%) did not smoke cigarettes after an additional wave of follow-up. Dual users at Wave 3 were likely to maintain their dual use status at Wave 4, 51.2% (95% CI: 46.1% to 56.3%) and Wave 5, 47.9% (95% CI: 40.1% to 55.8%).

Conclusions Very few cigarette smokers transition to smokeless tobacco use, and among those who do, dual use is more common than exclusive smokeless tobacco use. Further, the majority of exclusive cigarette smokers who transition to dual use at Wave 4 continue smoking cigarettes at Wave 5, either as dual users or as exclusive smokers.

  • harm reduction
  • non-cigarette tobacco products
  • cessation

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  • Contributors RAJ and HRD led the conceptual design. RAJ drafted the initial manuscript and all authors critically revised it. CR and DR conducted the statistical analysis and all authors contributed to interpretation of results. All authors approved the work for journal publication and agree to be accountable for all aspects of the work.

  • Funding This manuscript is supported with federal funds from the National Institute on Drug Abuse, National Institutes of Health, and the Center for Tobacco Products, Food and Drug Administration, Department of Health and Human Services, under contract to Westat (contract nos. HHSN271201100027C and HHSN271201600001C).

  • Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Department of Health and Human Services or any of its affiliated institutions or agencies. Contributions from HRD, BC, and RAJ were completed during their employment at the FDA Center for Tobacco Products.

  • Competing interests None declared.

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