Factors driving switching from vaping of e-cigarettes to smoking tobacco and initiation of multi-inhalant use.

The prevalence of e-cigarette use in adolescents is concerning, particularly because of high rates of vapers transitioning to combustible tobacco. It is unclear why young, never smoker, e-cigarette vapers decide to start smoking cigarettes, but the transition may be influenced by perceptions of health risks and accessibility. We designed a social media questionnaire to assess factors driving switches from vaping to smoking, smoking to vaping, and multi-inhalant use. Among respondents (n=864) who switched from vaping to smoking (n=104), primary reasons included: 1. perception that smoking was healthier (44%); and 2. greater accessibility of cigarettes (40%). For switchers from smoking to vaping (n=178), predominant motivations included: 1. having friends or family who vape (40%); and 2. perception that vaping was healthier (36%). Among multi-inhalant users (n=223), key factors driving this behavior included: 1. increased enjoyment (47%); and 2. greater variety (42%). Our findings imply that there is no single, dominant reason driving switching from vaping to smoking. Further, tobacco users are receiving mixed messaging, leading many to believe that combustible tobacco is the healthier option. Public health interventions are needed to prevent initiation of e-cigarette vaping by youth and education of the public about health effects across tobacco products.