Prevalence and correlates of concurrent use of cigarettes, electronic cigarettes, and waterpipes among Serbian youth

INTRODUCTION: Concurrent use of tobacco products is associated with an increased risk of nicotine dependence and smoking-related health complications. Growing popularity of concurrent use of cigarettes and electronic cigarettes and/or waterpipe tobacco is of concern, especially due to the adolescents’ exposure to nicotine and call for the better understanding of patterns and predictors of multiple product use. METHODS: This is a secondary analysis of cross-sectional data obtained through the 2017 Global Youth Tobacco Survey conducted in Serbia on a nationally representative sample of 3362 students aged 13–15 years. Students were categorized into eight groups based on their experience with cigarette, e-cigarette and waterpipe use. To explore differences in sociodemographic and psychosocial characteristics, students were further placed in four groups: non-users; exclusive cigarette users; users of e-cigarette and/or waterpipe who do not smoke cigarettes; cigarette and other product users. RESULTS: We show that among the 13–15 years old students, the most common pattern of tobacco/nicotine use is waterpipe and/or e-cigarette use with no cigarette smoking (7.5%, 95% CI: 6.6–8.4) followed by exclusive cigarette use (5.8 %, 95% CI: 5.0–6.6). Among cigarette smokers, 52.8% were exclusive cigarette smokers. Having the majority of their friends smoking is a mutual predictor for exclusive cigarette (AOR=33.2, 95% CI: 14.52–75.90) waterpipe and/or e-cigarette (AOR=2.57, 95% CI: 1.56–4.25) and cigarette and other products use (AOR=52.3, 95% CI:12.28–223.22) compared to no use of any product, and the same in the case of exposure at the point-of-sale marketing: exclusive cigarette vs not any product users (AOR=1.82, 95% CI: 1.22–2.73); waterpipe and or/e-cigarette vs not any product users (AOR=1.64, 95% CI:1.18–2.28); and cigarette and other products vs not any product users (AOR=3.40, 95% CI: 1.99–5.80). CONCLUSIONS: Tobacco control interventions should address dual- and poly-tobacco use with special focus on inter-personal factors and protection from exposure to advertising of e-cigarettes and waterpipes.