Background: Electronic nicotine products (ENPs) such as e-cigarettes have emerged as the most commonly used tobacco products among middle and high school students in the United States (U.S.). In 2019, almost 1 in 10 and 1 in 4 middle and high school students used e-cigarettes, respectively. Although familial relations and access to ENPs continue to play a major role in the uptake of e-cigarettes among adolescents, little is known about the role of social media in this phenomenon. Therefore, this study aimed to assess the role of social media in the uptake of e-cigarettes among students in Appalachian Tennessee. Methods: In March 2019, data involving high school students in an Appalachian Regional Commission (ARC)-designated distressed county in Appalachian Tennessee were collected (N=399). We ascertained the study’s outcomes (current e-cigarette use), the exposure (use of social media and the type of social media used to discuss e-cigarette) and covariates using validated questions. Descriptive statistics, bi-variate and multi-variable analyses were performed. The Odds Ratios (ORs), confidence intervals (CI), and the significance level (p ≤ 0.05) have been reported. Results: About 15.5% of the population were current e-cigarette users, with 9.8% of them ever discussed electronic cigarettes/JUUL on social media, more commonly with snap-chat (8.33%) and Instagram (4.31%). Use of social media (OR = 0.56, CI = 0.37 - 0.83, p = 0.0042) and type of social media used (OR = 0.80, CI = 0.65 - 0.99, p =0.0375) were significantly associated with decreased number of days of e-cigarette use in the last 30 days, after controlling for the covariates. Conclusion: The use of social media was associated with current e-cigarettes users. As such, there is need for more in-depth examination of social media contents as it relates to ENPs, to understand the mechanism of reduced ENP use among school-going youths in rural Appalachia.

Objective. To examine alternative tobacco product (ATP) use and associated factors among middle school students in Appalachian Tennessee. Method. Data (2015– 2016; N=573) from school-based tobacco surveys in 11 middle schools in Appalachian Tennessee were analyzed. Multiple logistic regression model described factors associated with ATP use. Results. More than one-tenth (13.2%) of participants have ever used ATPs. Approximately 9%, 7%, 6%, and 2% of participants have ever used e-cigarettes, cigarettes, smokeless tobacco, and little cigars or cigarillos, respectively. The following were significantly associated with ever use of ATPs: believing tobacco users have more friends, owning tobacco-branded item(s), living with a tobacco user, having ever smoked cigarettes, and living in homes where smoking is allowed. Conclusion. More than one in 10 of participants have ever used at least one ATP, and association with desirable objects and situations may promote ATP use. Interventions should seek to reduce these positive images and make all tobacco products unappealing.