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. Author manuscript; available in PMC: 2015 Jan 1.
Published in final edited form as: Addict Behav. 2013 Sep 17;39(1):338–340. doi: 10.1016/j.addbeh.2013.09.014

Trends in Use of Electronic Nicotine Delivery Systems by Adolescents

Deepa R Camenga 1, Jennifer Delmerico 2, Grace Kong 3, Dana Cavallo 3, Andrew Hyland 2, K Michael Cummings 4, Suchitra Krishnan-Sarin 3
PMCID: PMC3951195  NIHMSID: NIHMS530061  PMID: 24094920

Abstract

Electronic Nicotine Delivery Systems (ENDS) have been gaining in popularity. The few prevalence studies in adults have found that most ENDS users are current or former smokers. The objectives of this study were to estimate the prevalence of ENDS usage in adolescents, and examine the correlates of use. Self-administered written surveys assessing tobacco use behaviors were conducted in multiple waves as part of a larger intervention study in two large suburban high schools. The prevalence of past-30 day ENDS use increased from 0.9% in February 2010 to 2.3% in June 2011 (p = 0.009). Current cigarette smokers had increased odds of past-30 day ENDS use in all study waves. When adjusted for school, grade, sex, race and smoking status, students in October 2010 (Adjusted OR 2.12; 95% Confidence Interval (CI): 1.12–4.02) and June 2011 (Adjusted OR 2.51; 95% CI: 1.17–4.71) had increased odds past-30 days ENDS use compared to February 2010. The prevalence of ENDS use doubled in this sample of high school students, and current cigarette smoking is the strongest predictor of current use. Continued monitoring of ENDS is needed to determine whether it increases the likelihood of cigarette smoking initiation and maintenance in youth.

Keywords: Tobacco, epidemiology, adolescent

1. Introduction

Electronic Nicotine Delivery Systems (ENDS) are marketed as harm reducing alternatives to cigarette smoking and have been gaining in availability and popularity recently (Ayers, Ribisl, & Brownstein, 2011). Proponents of ENDS maintain that they are a safer alternative to smoking, exposing the user to fewer chemicals and that they could aid in cessation or smoking reduction (Cahn & Siegel, 2011). Although ENDS have not been thoroughly evaluated by the Food and Drug Administration, preliminary testing has found low levels of tobacco toxicants, such as tobacco specific nitrosamines (Westenberger, 2009), however early studies have also demonstrated that electronic cigarettes have significantly less cytotoxic effects compared to traditional cigarettes (Romagna et. al, 2013). As of this time, the FDA Center for Tobacco Products (CTP) has reported intention to regulate ENDS, although has not exerted its authority as of yet (FDA, 2009).

Since the introduction of ENDS to the market in 2007 (Pauly, Li, & Barry, 2007), many concerns have arisen regarding their safety for adolescent populations as a whole. It is unknown if the availability of ENDS serves to alter use of cigarettes among current smokers or leads to increased initiation among non-using youth. Nevertheless, there is concern that ENDS use may undermine social norms about tobacco (Mejia, Ling, & Glantz, 2010), serve as a starter product for cigarettes among youth, or delay smoking cessation among current adolescent smokers.

Given these concerns, it is important to understand the patterns of ENDS use among adolescents. Existing data in adolescents are lacking, although few studies have begun to explore the prevalence and correlates of ENDS use in adults. (Pearson et al, 2012; Regan et al, 2013). For example, a 2010 nationally representative online survey of adults (Pearson et al, 2012) found that the prevalence of ever use of ENDS in the adult general public was 3.4%, with an 11.4% usage rate among adult smokers and 2.0% in former smokers. Only one study to our knowledge has assessed trends in ENDS use over time. A consumer-based mail-in survey of over 10,000 US adults found that ever ENDS use increased from 0.6% to 2.7% between 2009 and 2010. Furthermore, this same study showed that awareness of ENDS doubled from 16.4% to 32.2% in the same timer period. Given the unanswered questions about the safety of ENDS in youth, and the preliminary trends of usage among adults, it is essential to understand these same trends in youth.

The purpose of this study is to describe the trends of ENDS usage in two high schools in Connecticut and New York over a 16-month period in 2010 and 2011 and examine the correlates of use. The findings from this study will help determine which youth use ENDS, and whether use of ENDS increased over time.

2. Materials and Methods

This is a data analysis of three self-administered written surveys assessing tobacco use behaviors conducted in two suburban high schools in Connecticut and New York between 2010 and 2011. The anonymous surveys were conducted as part of an evaluation of a tobacco use prevention program and also contained questions assessing interest in tobacco cessation services (data not included). The students in grades 9–12 were surveyed in February 2010/Wave 1 (n=1719; response rate = 76.2%), October 2010/Wave 2 (n=1702; response rate = 76.4%), and June 2011/Wave 3 (n=1345; response rate = 56.7%).

Information about the surveys was mailed home to parents and they were asked to inform the school or the researchers if they did not want their child to participate. Surveys were conducted in an assembly setting. On the day of the survey, research staff informed students about the confidentiality and voluntary and anonymous nature of the survey. These procedures were approved by the Institutional Review Boards of Yale University and Roswell Park Cancer Institue and by the local school boards.

The survey included questions on past-30 day use of ENDS. Correlates examined included grade, gender, race, survey year, and any cigarette use in the 30 days prior to the survey (see Table 1). Past-30 day use of ENDS was measured by the response to the question ‘In the PAST 30 DAYS, have you used any of the following tobacco products?’ by selecting the option “E-cigarettes (An electronic cigarette that is filled with liquid nicotine)”.

Table 1.

Demographics by Study Wave

February 2010 October 2010 June 2011 p-value
n=1719 n=1702 n=1345
n (%) n (%) n (%)
School A/CT 848 49.3 855 50.2 612 45.5 0.03
School B/NY 871 50.7 847 49.8 733 54.5
9th 478 27.8 446 26.2 264 19.6 <0.001
10th 469 27.3 459 27.0 385 28.6
11th 397 23.1 444 26.1 370 27.5
12th 368 21.4 347 20.4 322 23.9
Male 784 45.6 774 45.5 603 44.8 0.8
Female 903 52.5 903 53.1 723 53.8
Non-white 470 34.9 500 37.2 410 30.5 0.14
White 1249 72.7 1202 70.6 935 69.5
Cigarette Smokers 200 11.6 183 10.8 183 13.6 0.05
ENDS users 16 0.9 29 1.7 31 2.3 0.009
Cigarette and ENDS users 14 0.8 24 1.4 26 1.9 0.03
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ENDS=Electronic Nicotine Delivery System

Descriptive statistics by study wave on prevalence of past-30 day use of ENDS were conducted using chi square tests. Multivariate logistic regression was conducted to assess trends and correlates of past-30 day use of ENDS. The dependent variable was current ENDS use (yes/no), and the categorical predictor variables were study wave (February 2010 as the reference), school (Connecticut or New York), grade, race (white vs. non-white), and cigarette smoking status (current smoker vs. non-smoker)

3. Results

Table 1 demonstrates that the prevalence of past-30 day ENDS use increased from 0.9% in February 2010 to 2.3% in June 2011 (p = 0.009). The prevalence of current (past-30 day) cigarette smoking ranged from 11.6% in February 2010, 10.8% in October 2010 to 13.6% in June 2011 (p=0.05). The prevalence of dual cigarette and ENDS use increased from February 2010 (0.8%) to June 2011 (1.9%) (p=0.03) and the majority of ENDS users also used cigarettes (n=14/16 (87.5%) in wave 1; n= 24/29 (82.8%) in wave 2; n=26/31(83.9%) in wave 3). The study waves had similar gender and race distributions, although a larger proportion of respondents in June 2011 were in 9th grade (27.8% February 2010 vs. 26.2% October 2010 vs. 19.6% June 2011; p<0.001). Table 2 demonstrates the adjusted odds of past-30 day ENDS use by study wave. When adjusted for all variables included in the unadjusted models (school, grade, sex, race and smoking status), students in Fall 2010 (Adjusted OR (AOR) 2.12; 95% Confidence Interval (CI) 1.12–4.02) and Spring 2011 (AOR 2.51; 95% CI 1.17–4.71) had increased odds of past-30 day ENDS use compared to Spring 2010. Current cigarette smokers had increased adjusted odds of past-30 day ENDS use in all study waves. Additionally, white students had an increased AOR of past 30-day ENDS use in wave 1 (AOR 3.92; 95% CI 1.30–11.78) but similar odds of use in waves 2 and 3 (Table 2).

Table 2.

Predictors of Past-30 day ENDS Use by Study Wave

February 2010 October 2010 June 2011
Crude OR (95% CI) Adj. OR (95% CI) Crude OR (95% CI) Adj. OR (95% CI) Crude OR (95% CI) Adj.OR (95% CI)
School A/NY Ref Ref Ref Ref Ref Ref
School B/CT 0.76 (0.28–2.04) 1.16 (0.40–3.43) 0.52 (0.24–1.12) 0.48 (0.21–1.10) 1.01 (0.48–2.02) 1.14 (0.51–2.55)
9th Ref Ref Ref Ref Ref Ref
10th 1.71 (0.41–7.18) 1.24 (0.27–5.61) 0.06 (0.36–2.61) 0.73 (0.24–2.18) 0.82 (0.30–2.20) 0.34 (0.10–1.10)
11th 0.40 (0.04–3.90) 0.21 (0.02–2.16) 1.13 (0.43–2.96) 0.59 (0.20–1.68) 0.71 (0.26–1.91) 0.28 (0.08–0.95)
12th 3.07 (0.8–12.0) 2.44 (0.57–10.4) 0.64 (0.19–2.14) 0.28 (0.08–0.99) 0.82 (0.30–2.20) 0.39 (0.12–1.24)
Male Ref Ref Ref Ref Ref Ref
Female 0.70 (0.26–1.89) 1.01 (0.34–2.96) 0.80 (0.38–1.66) 0.93 (0.42–2.07) 0.67 (0.32–1.41) 0.76 (0.34–1.69)
Non-white Ref Ref Ref Ref Ref Ref
White 4.56 (1.65–12.62) 3.92 (1.30–11.78) 1.28 (0.59–2.78) 0.89 (0.38–2.06) 1.92 (0.94–3.94) 1.25 (0.55–2.81)
Non-smoker Ref Ref Ref Ref Ref Ref
Smokers 57.17 (12.9–253.2) 55.63 (12.58–254.9) 45.52 (17.13–121.0) 54.89 (20.04–150.03) 38.47 (14.56–101.6) 54.50 (17.93–165.9)
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4. Discussion

This study provides one of the first reports of increasing prevalence of ENDS use among adolescents. We found that past-30 day ENDS use had more than doubled over a recent 16- month period. Furthermore, similar to findings in adults, we found that current cigarette use strongly predicts ENDS use in adolescents, and that a majority of ENDS users concurrently use cigarettes. Although the overall prevalence of ENDS use was low (0.9% to 2.3%), the increasing trend of use is concerning given the unknown health effects of ENDS.

These findings are similar to studies in adults, which demonstrate increasing prevalence of ENDS use, especially among smokers (Pearson et al, 2012). Among adults, dual use of ENDS and combustible tobacco products is the most common pattern of use (Pearson et. al, 2012). A recent study of a sample of male adolescents found that cigarettes smokers were more willing to try an electronic cigarette than non-smokers, and non-smokers had more negative beliefs about ENDS (Pepper et al. 2013), suggesting that the same factors that promote cigarette use may promote ENDS use in youth. For example, high levels of sensation-seeking among cigarette- smoking adolescents (Sargent, 2010) may increase their likelihood of trying ENDS. Alternatively, adolescent smokers may use ENDS in an effort to quit smoking. Future studies in adolescents are needed to determine the etiology of dual use in this population. Additionally, we found an increased odds of ENDS use among white students in wave 1 only, suggesting that the product was initially used among white youth, but is now used among non-white youth as well. Future studies are needed to more thoroughly examine the demographic correlates of trends in ENDS use.

The increasing prevalence of ENDS use in general may be due to its increasing promotion in convenience stores (Herzog, Metrano & Gerberi, 2012) and youth-dominated media outlets such as social networking and internet advertising (Ayers 2011). Furthermore, as prevalence increases among adults, youth may be exposed to ENDS products through older family members. Lastly, youth may increasingly use ENDS in place of traditional cigarettes due to the perception that they are a healthier product.

This study has several limitations. It is possible that our low response rates (76.2% in wave 1 to 56.7% during wave 3) may have biased the trend results in that ENDS user may have been more likely to respond during wave 3. Given the small sample size of ENDS users, the estimates for use among cigarette smokers have wide confidence intervals and larger studies are needed to validate these results. Data are self-reported, which may result in underreporting in the school setting (Patrick et al., 1994). We found that less than 15% of the sample reported current smoking, which is less than that reported in other school-based surveys such as the Youth Risk Behavior Surveillance Survey (Centers for Disease Control and Prevention, 2012), although similar to the 2010 and 2011 Monitoring the Future estimates (Johnston, O’Malley, Bachman, & Schulenberg, 2013). ENDS prevalence between the second and third surveys may have been due to the aging of the sample within the school year, which may have naturally resulted in increased experimentation with ENDS, as experimentation increases with age (Messer & Pierce, 2010). However, the prevalence also increased across school years. Future studies are needed to examine the effect of age on ENDS experimentation, as well as other potential important correlates of use, such as sensation- seeking and sensitivity to existing advertising. Furthermore, the generalizability of the findings may be limited by the inclusion of two suburban schools from the northeast United States.

4.1 Conclusions

In summary, this study demonstrates that ENDS use increased over a 16 month period in 2010–2011 in a sample of high school students. Current cigarette use is the strongest predictor of ENDS use in adolescents, indicating the need for future research about dual use of these products. Overall, prospective data are needed to understand these critical potential consequences of youth ENDS use when trying to estimate the net population health impact of these products.

Highlights.

  • We examined trends in current electronic nicotine delivery system use in high school students in 2 high schools in Connecticut and New York.

  • The prevalence of electronic nicotine delivery system use doubled between 2010 and 2011.

  • Current cigarette smoking is the strongest predictor of electronic nicotine delivery system use in high school students.

Acknowledgments

Role of Funding Sources : Funding for this study was provided by NIAAA Grant This work was supported by NIDA grant #DA026450. NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

Contributors : Authors SKS, AH and KMC designed the study and wrote the protocol. Author DRC and JD conducted literature searches and provided summaries of previous research studies. Authors JD, GK, and DC collected and cleaned the data. Authors DRC and JD are co-first authors, listed alphabetically. JD and DRC conducted the statistical analysis. Author JD and DRC wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.

Conflict of Interest: All authors declare that they have no conflicts of interest.

Note: Deepa R. Camenga and Jennifer Delmerico are co-first authors, listed alphabetically

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributor Information

Deepa R. Camenga, Email: deepa.camenga@yale.edu.

Jennifer Delmerico, Email: Jennifer.delmerico@roswellpark.org.

Grace Kong, Email: grace.kong@yale.edu.

Dana Cavallo, Email: dana.cavallo@yale.edu.

Andrew Hyland, Email: Andrew.hyland@roswellpark.org.

K. Michael Cummings, Email: cummingk@musc.edu.

Suchitra Krishnan-Sarin, Email: suchitra.krishnan-sarin@yale.edu.

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