Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2018 Jan 1.
Published in final edited form as: Prev Med. 2016 Oct 20;94:65–71. doi: 10.1016/j.ypmed.2016.10.019

Adolescents' Attitudes towards E-cigarette Ingredients, Safety, Addictive Properties, Social Norms, and Regulation

Anuradha Gorukanti 1, Kevin Delucchi 2, Pamela Ling 3, Raymond Fisher-Travis 4, Bonnie Halpern-Felsher 4,*
PMCID: PMC5373091  NIHMSID: NIHMS836443  PMID: 27773711

Abstract

E-cigarette use has dramatically increased. While studies have examined adolescents’ attitudes towards smoking, few have extended this research to adolescents’ attitudes towards e-cigarettes. The goal of this study was to examine adolescents' attitudes regarding e-cigarette ingredients, safety, addictive properties, social norms, accessibility, price, and regulation; and determine whether attitudes differ by past cigarette/e-cigarette use. Participants were 786 9th and 12th graders from California (63.21% females; mean age = 16.10 years [SD = 1.6]; 26.61% White, 21.98% Asian/Pacific Islander, 29.82% Hispanic, and 21.59% other). Results indicated that 19.05% of participants believed smoke from e-cigarettes is water; 23.03% believed e-cigarettes aren't a tobacco product; 40.36% considered e-cigarettes to be for cessation, and 43.13% felt they were safer than cigarettes. Participants felt it was more acceptable to use e-cigarettes indoors and outdoors compared to cigarettes (p < .0001), 23.13% felt raising e-cigarette taxes is a bad idea, 63.95% thought e-cigarettes were easier to get than cigarettes, 54.42% felt e-cigarettes cost too much, 64.33% felt the age for buying e-cigarettes should be raised, and 64.37% favored e-cigarette regulation. Adolescents who used e-cigarettes and/or cigarettes had significantly more favorable e-cigarette attitudes than non-users. This study indicates that adolescents are aware of some of the risks of e-cigarettes, although many harbor misperceptions and hold more favorable attitudes towards e-cigarettes than cigarettes. Of concern is the relationship between favorable e-cigarette attitudes and use. Findings suggest the need to provide adolescents with correct information about e-cigarette ingredients, risks, and the insufficient evidence of their role in cigarette cessation.

Keywords: public health, adolescent health, adolescent substance use, e-cigarettes, adolescent perceptions

1. Introduction

Electronic cigarettes (also known as vapes, vaporizers, or vape pens) were introduced into the US market in 2007. They are generally battery-powered products that heat liquid into an aerosol that is inhaled by the user. These devices are designed to deliver nicotine and flavors; they also contain chemicals such as propylene glycol, glycerin, and many other constituents. Use of e-cigarettes has dramatically increased over the past 4 years, tripling among high school students from a rate of 4.5% in 2011 to 27.4% in 2014 (CDC, 2015,2016). Further, 27.4% of adolescents in the U.S. have ever used e-cigarettes (CDC, 2015), with 30% of California youth reporting ever using an e-cigarette (California Department of Public Health, 2015).

Although research on the health effects of e-cigarettes is nascent, studies show that use of e-cigarettes likely increases lung inflammatory markers (Lerner et al., 2015; Wu et al., 2014) and impacts cardiovascular health (Dwyer et al., 2009; Lippi et al., 2014). Certain flavorants in e-cigarettes, when inhaled, cause toxicity, respiratory disease, and respiratory flow resistance (Barrington-Trimis et al., 2014; Behar et al., 2014; Farsalinos et al., 2015; Gardiner, 2013; Wu et al., 2014); and there are concerns about the impact of nicotine on the developing adolescent brain (Dwyer et al., 2009; England et al., 2015). There are also broader public health implications concerning adolescent e-cigarette use, with several studies showing that adolescents who use e-cigarettes are more susceptible to smoking combustible cigarettes (Barrington-Trimis et al., 2016; Bunnell et al., 2015; Leventhal et al., 2015; Moore et al., 2014; Primack et al., 2015; Wills et al., 2015; 2016).

Despite studies showing the health effects of e-cigarettes, adolescents harbor misperceptions, including believing that e-cigarettes are safer than cigaretes, help people quit smoking conventional cigarettes, and do not contain any or just limited amounts of nicotine. Adolescents also consider e-cigarettes to be trendier, more prevalent, and more acceptable than conventional cigarettes (Anand et al., 2015; Hammal & Finegan, 2016; Roditis & Halpern-Felsher, 2015; Trumbo & Harper, 2013). The lowest perceptions of harm and more positive attitudes regarding e-cigarettes have been reported by adolescents who have used e-cigarettes (Ambrose et al., 2014, 2015; Anand et al., 2015; Chaffee et al., 2015; Kong et al., 2015; Roditis and Halpern-Felsher, 2015; Roditis et al., 2015; Trumbo & Harper, 2013).

The literature on e-cigarette attitudes thus far has predominantly focused on harm perceptions and general acceptability of and attitudes towards e-cigarettes and cigarettes. To our knowledge, there are few studies that have more comprehensively examined adolescents’ specific attitudes towards and knowledge about e-cigarettes, and/or whether such attitudes differ between those who have and have not used e-cigarettes or other tobacco. Data on these more specific e-cigarette attitudes will guide public health officials, healthcare providers, and educators develop more detailed, salient health messages and prevention efforts to address adolescents’ misperceptions and ultimately deter e-cigarette use.

We thus examined a broad array of adolescents’ knowledge and attitudes regarding e-cigarette ingredients, addictive properties, safety, cessation, perceived prevalence, accessibility, price, and regulation. We also examined whether these attitudes differ between adolescents who have and have not used cigarettes and/or e-cigarettes. Based on the small body of literature on e-cigarette attitudes, the larger set of literature on adolescents’ attitudes towards cigarettes, and the relationship between such attitudes and tobacco use (e.g., Halpern-Felsher et al., 2004; Krosnick et al., 2006; Song et al., 2009), we hypothesized that: (1) adolescents will believe that a greater number of parents, siblings, and peers are using e-cigarettes compared to cigarettes; (2) adolescents will hold more favorable attitudes towards e-cigarettes compared to cigarettes; (3) adolescents lack knowledge about the ingredients and harms associated with e-cigarettes; (4) adolescents will not support e-cigarette regulation; and (5) adolescents who have used e-cigarettes or cigarettes in the past will harbor more favorable attitudes and greater misperceptions about e-cigarettes compared to non-users.

2. Methods

2.1. Participants

Researchers visited school classes or assemblies, introducing the study and inviting ninth and 12th graders to participate. Consent forms and project information sheets were provided to students to take home and discuss with parents or guardians. An assent form signed by the prospective participant and a consent form signed by the parent or guardian was returned to school. Students more than 18 years old provided their own consent.

Approximately 4,000 students learned about the study, of whom 1,299 returned signed forms. Of these, 405 (31.1%) students were withdrawn from the study due to invalid contact information, ineligibility (wrong grade) or did not respond to subsequent contact by the researchers. Overall, 786 (87.9%) of eligible consented students completed the survey. The sample had fewer males and more females and a higher percentage of Asian students than schools from which we recruited. However, mother’s education did not vary between those who did and did not complete the survey, and neither sex nor race/ethnicity had a significant main effect on the study outcomes. Further, rates of tobacco use among study participants were consistent with rates of use for California youth (Tamika et al., 2016).

The sample size was designed to allow sufficient power (80%) to detect the contrasts of interest. The sample included 63.21% females and 36.67% males; mean age = 16.1 (SD=1.6). Participants came from diverse ethnic backgrounds with 207 (26.61%) White, 171 (21.98%) Asian/Pacific Islander, 232 (29.82%) Hispanic, and 168 (21.59%) other. Demographics of the students who participated in the study reflected the demographic make-up of their respective schools. Of the 786 participants, 4.90% had used cigarettes only, 11.08% had used e-cigarettes only, 7.73% had used both e-cigarettes and cigarettes, and 76.29% had used neither product (see Table 1).

Table 1.

Rates of E-cigarette and Cigarette Use, Overall and by Gender, Age and Race/Ethnicity

Used Neither (n; %) Used Cigarettes Only (n; %) Used E-cigarettes Only (n; %) Used Both Cigarettes and E-cigarettes (n; %)
Total Sample (n=776) 592; 76.29 38; 4.90 86; 11.08 60; 7.73
Males (n=284) 203; 71.48 14; 4.93 39; 13.73 28; 9.86
Females (n=491) 388; 79.02 24; 4.89 47; 9.57 32; 6.52
13–15 Year Olds (n=311) 271; 87.14 8; 2.57 22; 7.07 10; 3.22
16–19 Year Olds (n=465) 321; 69.03 30; 6.45 64; 13.76 50; 10.75
White (n=207) 159; 76.81 7; 3.38 21; 10.14 20; 9.66
Asian (n=168) 134; 79.76 3; 1.79 21; 12.50 10; 5.95
Latino (n=228) 166; 72.81 18; 7.89 26; 11.40 18; 7.89
Other (n=165) 128; 77.58 10; 6.06 17; 10.30 10; 6.06
Open in a new tab

2.2. Procedures

Participants were e-mailed a link to the survey administered through Qualtrics. To ensure privacy, participates were advised to complete the survey at one time, and at no point were their responses and names linked. Participants received a $10 gift card for completing the survey. Participants took the survey from 07/2014 to 10/2015. All procedures were approved by our institutional review board.

2.3. Measures

Below describes the measures used for this study. Many items were derived from past surveys on adolescents’ attitudes towards tobacco (e.g., Chaffee et al., 2015; Halpern-Felsher et al., 2004; Roditis et al., 2015; Song et al., 2009). All measures were pilot tested with adolescents of the same age and demographics of our sample; adolescents identified any items that were unclear. Through this process, we made adjustments to measures, and re-piloted the entire survey until all measures were clear.

2.3.1. Demographics

Race/ethnicity was categorized into: Latino, white, Asian, and other. Age groups were combined into ages 13–15 and 16–19.

2.3.2. Cigarette and E-cigarette Use

Participants were asked, “During your entire life, how many times have you EVER used [e-cigarettes/cigarettes], even 1 or 2 puffs.” Response choices include: never, 1–2 times, 3–10 times, 11–19 times, 20–30 times, 31–99 times, 100 or more times.

2.3.3. Perceived Prevalence of Use of Cigarettes and E-cigarettes

Participants were asked: (a) if their mother/female guardian, father/male guardian, siblings, or closest friends had ever used e- cigarettes or cigarettes; and (b) to evaluate how many teens out of 100 who were the same age, gender, and race-ethnicity were using e-cigarettes/cigarettes. See Table 2 for specific items asked. Similar questions have been asked in other studies on tobacco use and perceived prevalence (Lazuras et al., 2011; Pedersen et al., 2013; Sussman et al., 1988).

Table 2.

Adolescents’ Perception of Friends’ and Family Use of E-cigarettes and Cigarettes, Total and by Past E-Cigarette and Cigarette Use

E-Cigarette (n; %)1 Cigarette (n; %)1 p-Value
Total Sample (a) Users2 (b) Non- Users2 (c) Total Sample (d) Users2 (e) Non- Users2 (f) Total Sample: Perceived Prevalence of E- cigarette vs. Cigarette Use (a vs d) Users vs Non- Users: Perceived Prevalence of E- cigarette Use (b vs c) Users vs Non- Users: Perceived Prevalence of Cigarette Use (e vs f)
As far as you know, has your mother/female guardian ever used any of the following products? 48; 8.16 26; 14.05 22 5.45 199; 33.00 91; 45.50 109; 26.98 <.001 0.0002 <.0001
As far as you know, has your dad/male guardian ever used any of the following products? 42; 7.87 23; 13.14 20; 5.56 247; 44.58 94; 51.56 154; 41.29 <.001 <.0001 .0007
As far as you know, have your siblings ever used any of the following products? 83; 15.43 54; 30.17 30; 8.33 99; 18.17 54; 29.67 146; 12.64 <.001 <.0001 <.0001
As far as you know, have your closest friends ever used any of the following products? 195; 32.28 118; 55.40 77; 19.64 31.80 119; 56.13 74; 18.69 NS (.86) <.0001 <.0001
Open in a new tab
1

n = number of participants who responded “yes” to the question; % = percentage of participants who responded “yes” to the question

2

“Users” were those who had ever used an e-cigarette and/or a cigarette; “non-users” were those who had never used either an e-cigarette or a cigarette.

2.3.4. Knowledge and Attitudes regarding E-cigarette Ingredients, Safety, and Addictive Properties

Participants were asked if they agree or disagree with specific statements about e-cigarette ingredients, safety, and addictive properties (see Table 3). Response options were: strongly disagree (1), disagree, agree, and strongly agree (4). The content of these items were derived from qualitative interviews (Roditis & Halpern-Felsher, 2015) and pilot studies in which we elicited adolescents’ knowledge and perceptions about e-cigarettes.

Table 3.

Knowledge and Attitudes regarding E-Cigarette Ingredients, Addictive Properties, Safety, and Cessation

Total Sample Mean (SD) Users1 Mean (SD) Non- Users1 Mean (SD) Users vs. Non-Users1: Knowledge and Attitudes towards E-cigarettes p value
Smoke from e-cigarettes is just water 1.82 (.79) 2.06 (.82) 1.68(.73) <.0001
E-cigarettes don't contain tar 1.96 (.83) 2.18 (.83) 1.85 (.80) <.0001
E-cigarettes aren't addictive 1.82 (.81) 2.08 (.88) 1.68 (.72) <.0001
E-cigarettes aren't a tobacco product 1.88 (.82) 2.02 (.83) 1.80 (.80) <.0001
E-cigarettes don't produce smoke 1.85 (.76) 1.95 (.79) 1.80 (.74) .0022
Using e-cigarettes feels cleaner than smoking 2.27 (.86) 2.43 (.88) 2.19 (.84) <.0001
E-cigarettes are safer than smoking 2.24 (.90) 2.36 (.89) 2.18 (.89) .0002
Teens use e-cigarettes to get the same buzz they get from tobacco cigarettes 2.37 (.86) 2.24 (.85) 2.44 (.85) NS (.11)
E-cigarettes help people quit using cigarettes 2.22 (.86) 2.41 (.84) 2.12 (.85) <.0001
E-cigarette vapor is dangerous to babies and kids 2.82 (1.01) 2.69 (.93) 2.88 (1.03) (.019)
Open in a new tab

Notes:

1

“Users” were those who had ever used an e-cigarette and/or a cigarette; “non-users” were those who had never used either an e-cigarette or a cigarette.

Response scale ranged from strongly agree (4) to strongly disagree (1).

2.3.5. E-cigarette and Cigarette Acceptability

Participants were asked about their perceived acceptability of e-cigarettes and cigarettes (Kong et al., 2015; Roditis & Halpern- Felsher, 2015). See Table 4 for specific items asked. Response options again ranged from strongly disagree (1) to strongly agree (4).

Table 4.

Perceived E-cigarette and Cigarette Acceptability

Total Sample Mean (SD) Users1 Mean (SD) Non-users1 (SD) Mean Total Sample: Attitudes towards E-cigarette vs. Cigarette p Value Users and Non- users1: Attitudes towards E- cigarettes and Cigarettes p Value
E-cigarettes should be allowed in indoor spaces such as malls and theatres 1.63 (.73) 1.88 (.77) 1.51 (.68) <.0001 <.0001
Smoking cigarettes should be allowed in indoor spaces such as malls and theatres 1.27 (.62) 1.37 (.68) 1.23 (.58) ----- .0008
E-cigarettes should be allowed in outdoor spaces such as parks 1.94 (.90) 2.27 (.92) 1.78 (.85) <.0001 <.0001
Smoking cigarettes should be allowed in outdoor spaces such as parks 1.57 (.78) 1.76 (.81) 1.47 (.74) ----- .0004
Friends think it's okay to use e- cigarettes 1.91 (.93) 2.40 (.94) 1.66 (.83) <.0001 <.0001
Friends think it’s okay to use cigarettes 1.63 (.77) 1.90 (.86) 1.50 (.69) ----- <.0001
It's okay to use e-cigarettes in the house 1.80 (.83) 2.13 (.87) 1.62 (.74) ----- <.0001
E-cigarettes are futuristic 1.99 (.78) 2.12 (.74) 1.93 (.79) ----- .0004
Open in a new tab

Notes:

1

“Users” were those who had ever used an e-cigarette and/or a cigarette; “non-users” were those who had never used either an e-cigarette or a cigarette.

Response scale ranged from strongly agree (4) to strongly disagree (1).

2.3.6. Attitudes toward E-cigarette and Cigarette Price and Government Regulation

Participants responded to statements such as: e-cigarettes and cigarettes cost too much; raising taxes on e-cigarettes or cigarettes is a bad idea; e-cigarettes or cigarettes should be regulated by the federal government; and raising the age at which you can use e-cigarettes or cigarettes is a good idea. Response options ranged from strongly disagree (1) to strongly agree (4). See Table 5 for specific items asked.

Table 5.

Attitudes Towards E-cigarette Accessibility. Price, and Regulation

Total Sample Mean (SD) User s1 Mean (SD) Non- Users1 Mean (SD) Total Sample: Attitudes toward E- cigarette Regulation p value Users vs Non- Users: Attitudes toward E- cigarette Regulation
E-cigarettes cost too much 2.46 (.84) 2.49 (.80) 2.46 (.86) 0.0107 NS (0.19)
Cigarettes cost too much money 2.62 (.98) 2.69 (.95) 2.60 (.99) ----- NS (0.54)
If e-cigarettes were more 2.89 (.89) 2.71 (.91) 2.98 (.86) 0.0498 0.0001
If cigarettes were more expensive, teens would be less likely to use them 2.94 (.86) 2.84 (.89) 2.99 (.85) ----- NS (0.07)
Raising the age at which you can use e- cigarettes is a good 2.77 (.94) 2.51 (.92) 2.90 (.92) 0.000 .0001
Raising the age at which you can use cigarettes is a 2.86 (.96) 2.67 (.94) 2.95 (.96) ----- .002
Raising taxes on e- cigarettes is a bad idea 1.93 (.82) 2.13 (.84) 1.83 (.79) <.0001 <.0001
Raising taxes on cigarettes is a bad idea 1.76 (.80) 1.90 (.86) 1.70 (.77) 0.0003
E-cigarettes should be regulated by the federal 2.72 (.91) 2.47 (.87) 2.85 (.91) <.0001 <.0001
Cigarettes should be regulated by the federal 2.89 (.95) 2.72 (.93) 2.98 (.95) ----- <.0001
Cigarettes are easier to get than e-cigarettes 2.20 (.90) 2.13 (.87) 2.24 (.91) ----- NS (.21)
Cigarettes are cheaper than e-cigarettes 2.32 (.89) 2.19 (.85) 2.34 (.90) ----- NS (.47)
Open in a new tab

Notes:

1

“Users” were those who had ever used an e-cigarette and/or a cigarette; “non-users” were those who had never used either an e-cigarette or a cigarette.

Response scale ranged from strongly agree (4) to strongly disagree (1).

3. Analysis

Descriptive statistics including means, standard deviations, and percentages were used to describe the data. Within and between participant comparisons were tested by a generalized linear model using Proc Genmod in SAS 9.4. A linear regression model was used for continuously distributed dependent measures, and a logistic model was used for dichotomous measures. For analyses concerning tobacco use, given that few participants only used e-cigarettes or cigarettes (see Table 1), we collapsed the data as follows: individuals who had ever used an e-cigarette or cigarette were labeled as “ever users,” and those who had never used either e-cigarettes or cigarettes were labeled as “never users.” Covariates in the models included age category (13–15, 16–19), race (White, Asian, Latino, Other) and sex. All models accounted for clustering by school. Missing data, which varied item to item, were left as missing.

4. Results

4.1. Perceived Prevalence of E-cigarette Compared to Cigarette Use among Parents and Youth

A greater number of participants reported that their parents were using cigarettes (33.00% of moms and 44.58% of dads) compared to e-cigarettes (8.16% for moms and 7.87% for dads; p <.001). Similarly, more participants reported their siblings used cigarettes compared to e-cigarettes (18.17% and 15.43% respectively; p <.001), while they reported similar numbers of close friends used e-cigarettes and cigarettes, 32.28% and 31.80% respectively (p > .05). See Table 2 for specific numbers and statistics.

Adolescents who had ever used an e-cigarette and/or a cigarette reported a greater prevalence of both e-cigarette and cigarette use among parents, siblings, and closest friends, compared to those who hadn’t used either product. Specifically, among users, 14.05% reported that their mom/female guardian used e-cigarettes, and 13.14% reported that their dad/male guardian used e-cigarettes, compared to 5.45% and 5.56% of non-users who reported their mom/female guardian and dad/male guardian used e-cigarettes, respectively (p < .002 and p < .001, respectively). With respect to cigarettes, among users, 45.50% reported their mom and 51.56% reported their dad used cigarettes (p < .0001), whereas non-users reported that 26.98% of their mom/female guardians and 41.29% of their dad/male guardians used. Among users, 30.17% and 29.67% believed their siblings had used e-cigarettes or cigarettes, compared to 8.33% and 12.64% of non-users respectively (p <.0001). Among users, 55.40% perceived a close friend used e-cigarettes, and 56.13% believed a close friend used cigarettes, compared to 19.64% and 18.69%, respectively, of non-users (p < .0001). See Table 2 for more details.

Adolescents on average thought that 32.5 out of 100 (SD = 27.40) teens their age, gender, and ethnicity were using e-cigarettes, compared to 34.7 out of 100 (SD = 25.09) teens who were using cigarettes, with significant differences between users and non-users (p = 0.043; p <.001). Users believed more peers were using e-cigarettes than did non-users (36.20%, SD= 27.99, versus 30.55%, SD = 26.88, respectively; p < .01). In contrast, users perceived fewer teens use cigarettes than did non-users (32.30%, SD= 24.68 versus 35.47%, SD= 24.99, respectively; p < .01).

4.2. Knowledge and Attitudes regarding E-cigarette Ingredients, Addictive Properties, and, Safety

Almost one out of five participants (19.05%) agreed or strongly agreed that smoke from e-cigarettes is water, 23.03% felt e-cigarettes aren’t a tobacco product, 26.38% believed e-cigarettes don’t contain tar, and 18.98% believed e-cigarettes don’t produce smoke. Almost two-thirds (66.72%) of adolescents agreed or strongly agreed that e-cigarette vapor is dangerous to babies and kids. Approximately 43.99% and 43.13% of participants believed that e-cigarettes feel cleaner and safer than smoking cigarettes, and 40.36% felt e-cigarettes help people quit cigarettes. 49.70% of participants agreed that teens use e-cigarettes to get the same buzz they get from tobacco cigarettes. See Table 3 for the means and standard deviations for each item.

Compared to non-users, adolescents who had ever used cigarettes or e-cigarettes were more likely to agree that e-cigarettes just produce water, don’t contain tar, aren’t addictive, aren’t a tobacco product, don’t produce smoke, feel cleaner and are safer than smoking, and help people quit cigarettes (p-values ranged from p < .0001 to < .0022). Non-users were more likely to agree that e-cigarette vapor is dangerous to babies and children (p = .019). There were no difference between users and non-users when asked if teens use e-cigarettes to get the same buzz they get from tobacco cigarettes (p = .11). See Table 3 for specific numbers and statistics.

4.3. E-cigarette and Cigarette Acceptability

Participants were generally more accepting of e-cigarette use in both indoor and outdoor spaces, compared to cigarettes, with 28.27% agreeing or strongly agreeing that e-cigarettes should be allowed in outdoor spaces such as parks, compared to 13.51% who agreed/strongly agreed that cigarette smoking should be allowed in those spaces (p<.0001). 11.34% of participants agreed e-cigarettes should be allowed in indoor spaces, while only 5.21% agreed cigarettes should be allowed indoors (p<.0001). Of the respondents, 20.92% agreed it was okay to use e-cigarettes in the house. Participants generally reported that their friends were more accepting of e-cigarette than cigarette use (p<.0001), and 26.22% agreed that e-cigarettes are futuristic. See Table 4 for details on the means and standard deviations for each variable.

Participants who used e-cigarettes and/or cigarettes generally had more favorable views towards e-cigarette and cigarette use in indoor and outdoor spaces compared to those without such use experiences (p <.001). Users were also more likely to believe their friends are accepting of e-cigarette and cigarette use (p < .01; see Table 4 for means, SDs and significance tests).

4.4. E-cigarette and Cigarette Accessibility, Price, Taxation, and Regulation

Among participants, 64.33% and 65.53% agreed/strongly agreed that the age for buying e-cigarettes and cigarettes should be raised; 64.37% and 71.28% favored e-cigarette and cigarette regulation respectively; 23.13% and 15.22% felt that raising e-cigarette and cigarette taxes was a bad idea; 38.87% agreed/strongly agreed that cigarettes were easier to get than e-cigarettes; 47.47% thought that cigarettes are cheaper; 49.63% and 54.84% of participants felt that e-cigarettes and cigarettes cost too much; and 69.79% and 73.21% felt that if e-cigarettes and cigarettes were more expensive, teenagers would be less likely to use them. See Table 5 for means, SDs, and statistics.

Compared to e-cigarette and cigarette users, non-users were more likely to believe that teens would be less likely to use e-cigarettes if they were more expensive (p<.0001), that raising the age for buying e-cigarettes as well as cigarettes is good (p<.0001 and <.002, respectively), and were more in favor of governmental regulation of e-cigarettes and cigarettes (p’s<.0001). Users were more likely to feel that raising taxes on e-cigarettes and cigarettes is a bad idea (p’s < .0001 and <.003, respectively). There were no significant differences between users and non-users about whether cigarettes were easier to get or cheaper than e-cigarettes, whether cigarettes or e-cigarettes cost too much, and whether teens would be less likely to use cigarettes if they were more expensive. See Table 5 for specific numbers and statistics.

5. Discussion

This is one of the first studies to more comprehensively examine adolescents’ knowledge of and attitudes towards e-cigarette ingredients, addictive properties, safety, perceived prevalence, acceptability, and regulation (including taxation, age requirements, and price regulation). In our study of 9th and 12th graders, participants had more favorable attitudes towards and perceived less risk from e-cigarettes than cigarettes, and they expressed less support for policies that applied to e-cigarette than cigarette regulation. Participants believed that about 30% of their closest friends used e-cigarettes, which is approximately 10% higher than the self-reported rates in the sample. Their perceived prevalence is similar to the national rate of e-cigarette ever-use of 27.4% in the National Youth Tobacco Survey (Gilreath et al., 2016) and 30% in a California survey (California Department of Public Health, 2015), but much higher than the Monitoring the Future rate of 17.4% (NIDA, 2016). As we hypothesized, adolescents who have ever used tobacco perceive greater prevalence of e-cigarette use among their parents, siblings, and peers. While there have been few studies published on the impact of adolescents’ perceived prevalence of e-cigarette use, there are numerous studies that have focused on the relationship between adolescents’ perceived prevalence, initiation, and acceptability of use of conventional cigarettes (D’Amico & McCarthy, 2006; Maxwell, 2002; Page et al., 2002; Pedersen et al., 2013; Tucker et al., 2011), showing that those who perceive cigarette use as more prevalent and acceptable are more likely to initiate tobacco use (Olds et al., 2005; Page et al., 2002). These findings are consistent with behavioral decision-making models, which argue that perceptions of risk and social norms influence behavioral engagement (Fishbein & Ajzen, 1975). These findings demonstrate the importance of developing educational and health messages that correct misperceptions about use rates of e-cigarettes, since it is plausible that beliefs about how many peers use e-cigarettes can translate into increased adolescent e-cigarette use.

While some adolescents in our study had correct general knowledge of e-cigarette ingredients and risks, many did not. Our findings are particularly concerning considering that positive perceptions of e-cigarettes may be increasingly common among teens (Berg et al., 2015; Kong et al., 2015). In a study conducted in 2013 among adolescents in North Carolina, 50–60% perceived e-cigarettes to be safer and less harmful than conventional cigarettes. In that sample, only 7.5% felt e-cigarettes were healthier than cigarettes, 3.5% felt they were trendier, and only 2% felt e-cigarettes were easy to get (Anand et al., 2015). While these samples are not directly comparable, the increase in positive perceptions towards e-cigarettes in our sample may be reflective of a changing shift in social norms around e-cigarette use that has occurred over the past 2 years, corresponding with the increase in actual use rates. It is thus important to educate adolescents about e-cigarettes, including harm from nicotine and flavorants (Barrington-Trimis et al., 2014; Behar et al., 2014; Dwyer et al., 2009), and the lack of clear evidence on its role as a cessation tool. Further, it is concerning that adolescents appear to be initiating tobacco use with e-cigarettes, which then can lead to cigarette use (Leventhal et al., 2015; Primack et al., 2015; Wills et al., 2016).

Overall, adolescents in our study are more accepting of e-cigarette use in both indoor and outdoor settings, compared to cigarette use. One out of 10 adolescents believe that e-cigarettes should be allowed indoors, 3 out of 10 felt that e-cigarettes should be allowed in outdoor spaces, and 1 out of 5 adolescents felt it was okay to use e-cigarettes in their house. These numbers may reflect a shift in perceptions regarding e-cigarette use in public places, compared to perceptions of indoor and outdoor cigarette use. Interestingly, despite greater acceptance of e-cigarettes among the adolescents in our study, they were largely supportive of both e-cigarette and cigarette regulation, with 3 out of 5 adolescents feeling that the federal government should regulate e-cigarettes. This statement was particularly endorsed among adolescents who have not used cigarettes or e-cigarettes. A majority favored raising the age for buying e-cigarettes and cigarettes. This finding is important, especially given the recent IOM report showing the health effects of raising the minimum purchase age of tobacco to 21, as well as several states and localities raising their minimum purchase age to 21 (Bonnie et al., 2015). Adolescents also felt that e-cigarettes were easier to obtain than cigarettes, and a majority felt that if e-cigarettes cost more, teenagers would be less likely to use them.

This study was limited to a school-based convenience sample recruited from California schools, and given the relatively low response rate, as is true with other convenience samples, it is unclear how representativeness and generalizable the sample is compared to California adolescents. Nevertheless, our sample was similar to California adolescents with respect to tobacco use. Further, it is important to understand the perspectives of adolescents who grew up in a state with strong tobacco-free policies and anti-smoking social norms. The increased acceptability and positive attitudes towards e-cigarettes by adolescents in California may be magnified in states with less stringent anti-tobacco laws.

In sum, these findings suggest that we need to provide adolescents with messages concerning e-cigarettes, including their ingredients, nicotine content, addictive properties, and risks. In addition, health care providers need to understand basic facts concerning e-cigarettes as well as adolescents’ attitudes towards these products since e-cigarettes are becoming a more predominant tobacco product amongst adolescents. Healthcare providers need to regularly screen for e-cigarette use, and educate patients and parents about misconceptions associated with e-cigarettes (AAP, 2015).

Highlights.

  • Adolescents held more favorable attitudes towards e-cigarettes than cigarettes.

  • Adolescents support e-cigarette regulation, taxation, and increasing cost.

  • Adolescents who used tobacco held more positive perceptions of e-cigarettes.

  • Adolescents who used tobacco were less supportive of regulation.

Acknowledgments

Funding Source: Research reported in this paper was supported by grant number 1P50CA180890 from the National Cancer Institute and the Food and Drug Administration Center for Tobacco Products. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration. We would like to thank the teachers and students who participated in this study.

Abbreviations

SD

Standard Deviation

n

number

Footnotes

Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.

Contributors’ Statements

Ms. Gorukanti helped conceptualize and design the study, drafted the initial manuscript, and approved the final manuscript as submitted.

Dr. Delucchi carried out all analyses, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Dr. Ling helped conceptualize the study, reviewed and revised the manuscript and approved the final manuscript as submitted.

Mr. Fisher-Travis conducted a literature review, reviewed and revised the manuscript and approved the final manuscript as submitted.

Dr. Halpern-Felsher conceptualized and designed the study and survey, supervised the analysis, drafted the initial manuscript, and approved the final manuscript as submitted.

Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.

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.

References

  1. Ambrose BK, Rostron BL, Johnson SE, et al. Perceptions of the relative harm of cigarettes and e-cigarettes among U.S. youth. Am J Prev Med. 2014;47(2 Suppl 1):S53–60. doi: 10.1016/j.amepre.2014.04.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. American Academy of Pediatrics Section on Tobacco Control. Policy statement: Electronic Nicotine Delivery Systems. Pediatrics. 2015;136(5):1018–1026. doi: 10.1542/peds.2015-3222. [DOI] [PubMed] [Google Scholar]
  3. Anand V, McGinty KL, O'Brien K, Guenthner G, Hahn E, Martin CA. E-cigarette Use and Beliefs Among Urban Public High School Students in North Carolina. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2015;57(1):46–51. doi: 10.1016/j.jadohealth.2015.03.018. [DOI] [PubMed] [Google Scholar]
  4. Barrington-Trimis JL, Berhane K, Unger JB, et al. The E-cigarette Social Environment, E-cigarette Use, and Susceptibility to Cigarette Smoking. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2016 doi: 10.1016/j.jadohealth.2016.03.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in Electronic Cigarettes An Unrecognized Respiratory Health Hazard? JAMA. 2014;312(23):2493. doi: 10.1001/jama.2014.14830. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Behar RZ, Davis B, Wang Y, Bahl V, Lin S, Talbot P. Identification of toxicants in cinnamon-flavored electronic cigarette refill fluids. Toxicology in vitro : an international journal published in association with BIBRA. 2014;28(2):198–208. doi: 10.1016/j.tiv.2013.10.006. [DOI] [PubMed] [Google Scholar]
  7. Berg CJ, Stratton E, Schauer GL, et al. Perceived harm, addictiveness, and social acceptability of tobacco products and marijuana among young adults: marijuana, hookah, and electronic cigarettes win. Substance use & misuse. 2015;50(1):79–89. doi: 10.3109/10826084.2014.958857. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bonnie RJ, Stratton K, Kwan LY. IOM (Institute of Medicine) Washington, DC: The National Academies Press; 2015. Public health implications of raising the minimum age of legal access to tobacco products. [PubMed] [Google Scholar]
  9. Bunnell R, Agaku I, Arrazola R, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011–2013. Nicotine Tob Res. 2015;17(2):228–235. doi: 10.1093/ntr/ntu166. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. California Department of Public Health, California Tobacco Control Program. State Health Officer’s Report on E-Cigarettes: A Community Health Threat. Sacramento, CA: 2015. [Google Scholar]
  11. Centers for Disease Control and Prevention. National Youth Tobacco Survey (NYTS) 2015. Web. 22 Aug. 2016. [Google Scholar]
  12. Centers for Disease Control and Prevention. Youth and Tobacco Use. 2016. Web. 22 Aug. 2016. [Google Scholar]
  13. Chaffee BW, Gansky SA, Halpern-Felsher B, Couch ET, Essex G, Walsh MM. Conditional risk assessment of adolescents' electronic cigarette perceptions. American journal of health behavior. 2015;39(3):421–432. doi: 10.5993/AJHB.39.3.14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. D'Amico EJ, McCarthy DM. Escalation and initiation of younger adolescents' substance use: the impact of perceived peer use. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2006;39(4):481–487. doi: 10.1016/j.jadohealth.2006.02.010. [DOI] [PubMed] [Google Scholar]
  15. Dwyer JB, McQuown SC, Leslie FM. The dynamic effects of nicotine on the developing brain. Pharmacol Ther. 2009;122(2):125–139. doi: 10.1016/j.pharmthera.2009.02.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing human: a neglected element in the electronic cigarette debate. Am J Prev Med. 2015;49(2):286–293. doi: 10.1016/j.amepre.2015.01.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Farsalinos KE, Kistler KA, Gillman G, Voudris V. Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2015;17(2):168–174. doi: 10.1093/ntr/ntu176. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Fishbein M, Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley; 1975. [Google Scholar]
  19. Gardiner P. E-Cigarettes: The Vapor This Time? University of California Office of the President; 2013. [Google Scholar]
  20. Gilreath TD, Leventhal A, Barrington-Trimis JL, et al. Patterns of Alternative Tobacco Product Use: Emergence of Hookah and E-cigarettes as Preferred Products Amongst Youth. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2016;58(2):181–185. doi: 10.1016/j.jadohealth.2015.10.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Halpern-Felsher BL, Biehl M, Kropp RY, Rubinstein ML. Perceived risks and benefits of smoking: differences among adolescents with different smoking experiences and intentions. Prev Med. 2004;39(3):559–567. doi: 10.1016/j.ypmed.2004.02.017. [DOI] [PubMed] [Google Scholar]
  22. Hammal F, Finegan BA. Exploring Attitudes of Children 12–17 Years of Age Toward Electronic Cigarettes. Journal of Community Health. 2016:1–7. doi: 10.1007/s10900-016-0178-6. [DOI] [PubMed] [Google Scholar]
  23. Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults. Nicotine & tobacco research. 2015;17(7):847–854. doi: 10.1093/ntr/ntu257. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Krosnick JA, Chang L, Sherman SJ, Chassin L, Presson C. The Effects of Beliefs About the Health Consequences of Cigarette Smoking on Smoking Onset. Journal of Communication 2006 [Google Scholar]
  25. Lazuras L, Rodafinos A, Eiser RJ. Adolescents' Support for Smoke-Free Public Settings: The Roles of Social Norms and Beliefs About Exposure to Secondhand Smoke. Journal of Adolescent Health. 2011;49(1):70–75. doi: 10.1016/j.jadohealth.2010.10.013. [DOI] [PubMed] [Google Scholar]
  26. Lerner CA, Sundar IK, Yao H, et al. Vapors produced by electronic cigarettes and e-juices with flavorings induce toxicity, oxidative stress, and inflammatory response in lung epithelial cells and in mouse lung. PloS one. 2015;10(2):e0116732. doi: 10.1371/journal.pone.0116732. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of Electronic Cigarette Use With Initiation of Combustible Tobacco Product Smoking in Early Adolescence. JAMA. 2015;314(7):700–707. doi: 10.1001/jama.2015.8950. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Lippi G, Favaloro EJ, Meschi T, Mattiuzzi C, Borghi L, Cervellin G. E-cigarettes and cardiovascular risk: beyond science and mysticism. Paper presented at: Seminars in Thrombosis and Hemostasis; 2014. [DOI] [PubMed] [Google Scholar]
  29. Maxwell KA. Friends: The Role of Peer Influence Across Adolescent Risk Behaviors. Journal of Youth and Adolescence. 2002;31(4):267–277. [Google Scholar]
  30. Moore GF, Littlecott HJ, Moore L, Ahmed N, Holliday J. E-cigarette use and intentions to smoke among 10–11-year-old never-smokers in Wales. Tobacco control. 2014 doi: 10.1136/tobaccocontrol-2014-052011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. NIH National Institute on Drug Abuse (NIDA) Drug Facts: High School and Youth Trends. Jun, 2016. N.p., Web. 22 Aug. 2016. [Google Scholar]
  32. Olds RS, Thombs DL, Tomasek JR. Relations between normative beliefs and initiation intentions toward cigarette, alcohol and marijuana. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2005;37(1):75. doi: 10.1016/j.jadohealth.2004.09.020. [DOI] [PubMed] [Google Scholar]
  33. Page RM, Hammermeister J, Roland M. Are high school students accurate or clueless in estimating substance use among peers? Adolescence. 2002;37(147):567–573. [PubMed] [Google Scholar]
  34. Pedersen ER, Miles JN, Ewing BA, Shih RA, Tucker JS, D'Amico EJ. A longitudinal examination of alcohol, marijuana, and cigarette perceived norms among middle school adolescents. Drug and alcohol dependence. 2013;133(2):647–653. doi: 10.1016/j.drugalcdep.2013.08.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to Traditional Cigarette Smoking After Electronic Cigarette Use Among US Adolescents and Young Adults. JAMA Pediatr. 2015;169(11):1018–1023. doi: 10.1001/jamapediatrics.2015.1742. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Roditis ML, Halpern-Felsher B. Adolescents' Perceptions of Risks and Benefits of Conventional Cigarettes, E-cigarettes, and Marijuana: A Qualitative Analysis. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2015;57(2):179–185. doi: 10.1016/j.jadohealth.2015.04.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Roditis M, Delucchi K, Cash D, Halpern-Felsher B. Adolescents’ Perceptions of Health Risks, Social Risks, and Benefits Differ across Tobacco Products. Journal of Adolescent Health. 2016;58:558–566. doi: 10.1016/j.jadohealth.2016.01.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Song AV, Morrell HE, Cornell JL, Ramos ME, Biehl M, Kropp RY, Halpern-Felsher BL. Perceptions of Smoking-Related Risks and Benefits as Predictors of Adolescent Smoking Initiation. American Journal of Public Health. 2009;99:487–92. doi: 10.2105/AJPH.2008.137679. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Sussman S, Dent CW, Mestel-Rauch J, Johnson CA, Hansen WB, Flay BR. Adolescent Nonsmokers, Triers, and Regular Smokers' Estimates of Cigarette Smoking Prevalence: When Do Overestimations Occur and by Whom? Journal of Applied Social Psychology. 1988;18(7):537–551. [Google Scholar]
  40. Trumbo CW, Harper R. Use and perception of electronic cigarettes among college students. J Am Coll Health. 2013;61(3):149–155. doi: 10.1080/07448481.2013.776052. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Tucker JS, Green HD, Jr, Zhou AJ, Miles JN, Shih RA, D'Amico EJ. Substance use among middle school students: associations with self-rated and peer-nominated popularity. Journal of adolescence. 2011;34(3):513–519. doi: 10.1016/j.adolescence.2010.05.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, Williams RJ. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tobacco control. 2016 doi: 10.1136/tobaccocontrol-2015-052705. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Wills TA, Knight R, Williams RJ, Pagano I, Sargent J. Risk Factors for Exclusive E-Cigarette Use and Dual E-Cigarette Use and Tobacco Use in Adolescents. Pediatrics. 2015;135(1) doi: 10.1542/peds.2014-0760. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Wu Q, Jiang D, Minor M, Chu HW. Electronic cigarette liquid increases inflammation and virus infection in primary human airway epithelial cells. PloS one. 2014;9(9):e108342. doi: 10.1371/journal.pone.0108342. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES