E-cigarette Dual Users, Exclusive Users and Perceptions of Tobacco Products

Adolescent Dual Product Use

Increasingly, youth who use tobacco products are using more than one type of product.^7,8 Between 2002 and 2011, rates of poly-tobacco use increased significantly among users under age 26.⁹ According to estimates from the National Youth Tobacco Survey, the majority of current tobacco users in middle and high school report use of more than one tobacco product.^10,11 Thus, use of multiple tobacco products by youth is more common than exclusive use of one product alone. As such, it is important to understand the correlates associated with and characteristics of adolescent users of multiple tobacco products. To date, evidence suggests that, in general, adolescents who use 2 or more tobacco products are demographically distinct from those who use one product. Dual product users (in particular, those who use cigarettes and smokeless tobacco) are more likely to be male and white than female and non-white.^7,12 In addition, current cigarette/smokeless tobacco dual product users are more likely to be in high school than middle school,¹³ and current cigar/cigarette dual users are more likely to have a lower grade point average as compared to non-users.¹⁴ However, the demographic characteristics of adolescent dual product e-cigarette and cigarette users are largely unknown.

The literature describes the deleterious effects of multiple tobacco product use among adolescents, including increased nicotine dependence, as well as increased risk for substance use disorders.^7,15,16 However, to date, there is limited research examining the characteristics of adolescents who use e-cigarettes and at least one other tobacco product. Some studies have explored youth e-cigarette use with a focus on the prevalence of concomitant cigarette use, motivations for e-cigarette use, abstinence from cigarettes and intentions to use other tobacco products,^17-20 but with a limited focus on social-cognitive risk factors. An exception is a study by Wills et al²¹ that examined current e-cigarette and cigarette use among high school students in Hawaii. The researchers assessed differences in risk factors and protective factors among students reporting no tobacco use, exclusive current e-cigarette or cigarette use, and dual use. Findings indicated that risk status varied across usage groups, with dual users of e-cigarettes and cigarettes reporting the most risk factors and the fewest protective factors, and e-cigarette-only users representing an intermediate category between non-users and dual users.

Perceptions of Harm and Peer Use of E-cigarettes

According to the theory of planned behavior, individuals’ perceptions, including their attitude toward a behavior, normative beliefs, and perceived control, influence their decision to take part in a particular behavior.²² Consistent with this theory, adolescents who use tobacco products are expected to be less likely to perceive risks from their use than non-users.²³ Therefore, users of multiple tobacco products are likely to hold the lowest harm perceptions as compared to users of only one tobacco product and non-users of tobacco; this relationship has been demonstrated already.²⁴ Moreover, adolescent ever smokers who believe it is safe to smoke are more likely than their peers to use tobacco products other than cigarettes (smokeless tobacco, cigars, and bidis).²⁵ However, few studies have examined harm perceptions as they relate to adolescents’ use of e-cigarettes, and even fewer have focused on adolescents who use e-cigarettes with at least one other tobacco product. This is particularly important given the controversies around the harmful effects of e-cigarette use,¹ and the need for more substantive research to document the potentially harmful effects of e-cigarette use in adolescence.²⁶

To our knowledge, only 3 studies assess harm perceptions of e-cigarettes in an adolescent population. Amrock et al²⁷ found that several characteristics were associated with adolescents’ perceptions of e-cigarettes as relatively safer than cigarettes: being white, using other tobacco products, and having family members who used tobacco. In addition, adolescents who had ever used e-cigarettes perceived them as less harmful than cigarettes, as compared to those who had never used e-cigarettes. Ambrose et al²⁸ found that whereas one in 3 adolescents believed e-cigarettes were less harmful than cigarettes, the majority of current smokers (54%) held this belief as compared to fewer of the ever smokers (41%) and never smokers (25%). Additionally, ever use of an e-cigarette had a strong relationship with perceiving e-cigarettes as less harmful than cigarettes. In particular, dual users of e-cigarettes with cigarettes were more than twice as likely to perceive e-cigarettes as less harmful compared to exclusive cigarette smokers, and adolescents who used e-cigarettes alone had a 6-fold increase in their likelihood of perceiving e-cigarettes as less harmful than cigarettes, compared to adolescents who had never used either product. Wills et al²¹ found that current e-cigarette-only users were more likely to report that e-cigarettes were a healthy alternative to cigarettes as compared to non-users, but no differences were found between exclusive e-cigarette and cigarette user groups or between exclusive e-cigarette and dual use groups.

As stated in the theory of planned behavior, normative beliefs are influenced by perceptions about whether others in an individual’ s social network perform the behavior of interest.²² Prior research demonstrates that peers have a strong influence on both adolescents’ initiation and escalation in cigarette use.²⁹ Interestingly, perceived prevalence of smoking rather than actual prevalence of peer smoking is associated with an increased risk of smoking among youth.³⁰ There are few published articles, however, that describe peer use in relation to youth use of tobacco products other than cigarettes. The limited evidence suggests that having peers who used other tobacco products or exposure to peer smoking are both significant predictors of adolescent use of alternative tobacco products such as cigars, smokeless tobacco, bidis and kreteks.^25,12 Wills et al²¹ reported that among high school students, perceptions of peer smoking differed according to tobacco usage group. Perceived peer smoking was higher among exclusive e-cigarette users as compared to non-users as well as higher among dual users as compared to exclusive e-cigarette users. No differences were found for peer smoking between e-cigarette-only and cigarette-only groups.

According to the Campaign for Tobacco-free Kids, Texas ranks 32^nd out of 50 US states in prevalence of conventional cigarette smoking among high school students.³¹ Additionally, our 2015 paper showed that e-cigarette use was higher in Texas than both national estimates and those documented in other states.³² Furthermore, Texas receives more tobacco industry marketing dollars than any other state except California³³ and ranks 40^th among states in spending for tobacco prevention.³⁴ Therefore, youth in Texas, who represent 9.6% of all US youth,³⁵ are a vulnerable population, making the state an important backdrop to understand characteristics and perceptions associated with tobacco use in adolescents.

The purpose of the current study was to examine Texas adolescents’ harm perceptions of various tobacco products and perceived peer use of e-cigarettes based on usage group. There were 3 aims. First, we examined pairwise differences among 4 usage groups—non-cigarette and non-e-cigarette users, cigarette-only users, e-cigarette-only users and dual users—in their demographic characteristics and tobacco use behaviors. Second, we examined pairwise differences among the 4 usage groups in perceptions about the harms of various tobacco products and alcohol use, as well as perceived peer use of tobacco products. Third, we examined differences in cigarette harm perceptions and e-cigarette harm perceptions by usage group. We hypothesized that dual users would more likely be older, white, and male as compared to other usage groups. We also hypothesized that dual users would have higher rates of perceived peer use as well as lower reported rates of perceived harm for all tobacco products. This study furthers understanding of perceptions of tobacco products and peer use among both exclusive and dual users of e-cigarettes and cigarettes.

METHODS

RESULTS

DISCUSSION

The current study adds to the limited body of literature describing patterns of e-cigarette use among middle and high school students, perceptions of harm, and peer use for these relatively new products whose prevalence of use is on the rise, as well as other types of tobacco products. Findings from the 2014 Texas Youth Tobacco Survey confirm results from other studies on the emerging patterns of e-cigarette use among youth, showing that a large number of youth are using e-cigarettes only, and many are using e-cigarettes in conjunction with conventional cigarettes.^2,4

Findings highlight demographic differences based on usage group. Interestingly, non-users and e-cigarette-only users did not differ on any of the sociodemographic characteristics we examined. Dual users had the most differences across groups. They were more likely to be male, older, white, and have lower mean grades than non-users. They were also more likely to be older and white compared to the cigarette-only group. Dual users consistently had the highest prevalence of other tobacco product use, except for lifetime hookah use, indicating that teens using both e-cigarettes and cigarettes are more likely to use other types of products, such as chew, snus and any flavored product.

Across the various tobacco products, harm perceptions differed among usage groups. For example, e-cigarette-only users viewed conventional cigarettes as more harmful than the dual user group. This is a novel finding that has not been reported previously in the literature. The same pattern was not seen for e-cigarettes, however. Interestingly, there were no differences in how harmful the e-cigarette-only and the dual user groups rated e-cigarettes, however, the cigarette-only group rated e-cigarettes as more harmful than the dual user group. This study differs from one performed by Wills et al²¹ in that it measures absolute harm of e-cigarettes rather than relative harm compared to cigarettes; our results follow similar trends. For example, no differences in perceived harmfulness of e-cigarettes were found between e-cigarette-only and dual user groups. Findings also generally confirm results from studies by Amrock et al²⁷ and Ambrose et al²⁸ that found that adolescents who use e-cigarettes perceive them as less harmful than those who do not. Consistent with Ambrose et al,²⁸ dual users in our sample were more likely to perceive e-cigarettes as less harmful compared to exclusive cigarette smokers, and in terms of differences between harm perceptions of e-cigarettes and cigarettes, our results also generally align with the finding that the highest risk of perceiving e-cigarettes as less harmful than cigarettes was held by the exclusive e-cigarette users. Specifically, although the current study found that all 4 usage groups rated cigarettes as more harmful than e-cigarettes, the magnitude of the difference in harm perceptions was greatest for the e-cigarette-only users followed by the dual users. These findings are consistent with the theory of planned behavior.²² According to the theory, dual users would perceive e-cigarettes to be less harmful than non-users and cigarette-only users, which may be why they would use them. Students who perceive e-cigarettes as more harmful would be less likely than their counterparts to initiate use of these products.

Another striking finding was that harm perceptions for hookah followed the same pattern as that of e-cigarettes in that, unlike all other tobacco product comparisons, perceptions of harm did not differ between e-cigarette-only and dual user groups. Few studies offer explanation as to why perceptions of harm may be similar for both products. One study, however, highlighted a connection between e-cigarette and hookah use, finding that adolescent e-cigarette-only users were more likely than cigarette smokers to use hookah.¹⁹ Given the limited evidence, we can only speculate that similar ratings of harmfulness between e-cigarettes and hookah may be related to both products having a multitude of available flavorings or similarities between the sensation of inhaling e-cigarette aerosol and hookah smoke which has been cooled by the water pipe. For perceptions of chew and snus, group comparisons were generally consistent with prior literature that has found that perceived risk of harm for smokeless tobacco varied by the tobacco product use groups, with a higher proportion of nonsmokers perceiving great risk of harm.³⁶

Our results on perceived peer cigarette smoking are consistent with Wills et al’ s²¹ finding that differences exist between exclusive e-cigarette users and dual users. Perceived peer use of e-cigarettes and chew differed only between non-users and dual users, a finding that has not been reported previously. Consistent with the theory of planned behavior, students who perceive higher levels of peer use are more likely to use tobacco products.²² These findings highlight the need to better understand the role of peers in adolescents’ e-cigarette use.