Tobacco product transition patterns in rural and urban cohorts: Where do dual users go?

Introduction: Understanding diverse tobacco product consumption represents a crucial area for tobacco regulatory science. With the increase in dual/poly use of tobacco products, transition patterns among exclusive and dual users are of considerable interest. We describe transition patterns of dual users over 18 months. Methods: A cohort of 145 adults in urban and rural Ohio who reported dual tobacco product use at least some days/week was enrolled during 2014–17. Participants completed follow-up interviews every six months where they were classified into one of five categories: 1) exclusive combustible, 2) exclusive smokeless, 3) exclusive e-cigarette, 4) dual (at least 2 of the previous 3 categories), and 5) less than some days/week. Participants categorized as exclusive and dual (1–4) used their products at least some days per week. Separately within the rural and urban cohorts, 6, 12, and 18 month transition probabilities between the categories were estimated. Results: The probability of remaining a dual user after 6 months is 43% in the rural and 37% in the urban cohort. The decline continues through 18 months with 24% of rural and 22% of urban dual users remaining in the category. The probability of a dual user consuming combustibles and e-cigarettes transitioning to exclusive combustible use in 6 months is over 50% in both the rural and urban cohorts. Conclusions: Dual use is an unstable state with users being more likely to transition to exclusive combustible use than to remain in the dual use category. Transitions are similar in the rural and urban cohorts. Keywords: Urban and rural differences, Longitudinal research, Trajectories, Multiple tobacco product us