Abstract
Objectives. To investigate use of electronic nicotine delivery systems (ENDS) among priority populations.
Methods. Using 2016 through 2017 US nationally representative surveys (n = 11 688), we examined ENDS use by sociodemographic variables (age, education, poverty status, insurance, employment, race/ethnicity, sexual orientation) and combustible tobacco use.
Results. Among individuals who currently use noncigarette combustible tobacco, those from certain backgrounds (young adults, those living below the poverty level, those less educated, sexual minorities, Blacks, Hispanics, and those without health insurance) were more likely to use ENDS. Among current cigarette smokers, those who were younger, living at or above poverty (ever use), with higher education (current use), sexual minority, and non-Black were more likely to use ENDS.
Conclusions. Associations between sociodemographic variables and ENDS use varied depending on combustible tobacco use status, highlighting the need to consider multiple types of tobacco products to understand ENDS use among priority populations. The impact on tobacco disparities will ultimately depend on whether ENDS are used to transition completely away from combustible tobacco products and how this may differ across priority populations who use diverse tobacco products.
Profound tobacco-related disparities exist, with certain sociodemographic groups experiencing higher risk for cigarette smoking, more difficulty quitting, and greater tobacco-related morbidity and mortality.1,2 Whereas cigarette smoking prevalence has declined substantially in the general US population, smoking prevalence has remained disproportionately high among individuals with low-socioeconomic status; certain racial/ethnic minority groups; and people identifying as lesbian, gay, bisexual, or transgender (LGBT).2 Considering the striking rates of tobacco-related illness and mortality in these populations, there is an urgent need to identify strategies to combat disparities.1
The tobacco product marketplace has changed dramatically in recent years.3,4 Electronic nicotine delivery systems (ENDS), battery-powered devices that aerosolize liquids with nicotine, have emerged as products that could offer a lower-risk alternative to traditional cigarettes.5 Current evidence suggests that ENDS, although not harmless, are less harmful than traditional cigarettes.6 Although research is needed on the long-term health effects of ENDS, these products have the potential to reduce harm if current smokers switch completely to ENDS.5–8 Switching from smoking to exclusive ENDS use (rather than continued dual use) appears necessary to reduce harm.9,10 However, evidence for ENDS as a smoking cessation tool is inconclusive, and ENDS might introduce or maintain nicotine addiction and hinder attempts to quit smoking.6,11,12
Given the increased availability of novel tobacco products, it is critical to understand ENDS use among populations that experience tobacco disparities. Certain populations that have suffered disproportionate burden from combustible tobacco arguably have the most to gain or lose from the emergence of ENDS. On one hand, ENDS could offer a harm-reduction tool for low-socioeconomic status, racial/ethnic minority, or LGBT smokers who are otherwise unable or unwilling to quit if they switch completely to ENDS (although this will depend on long-term evidence on ENDS health effects). On the other hand, ENDS could increase health disparities if smokers from certain backgrounds are “left behind” without the benefit of new technologies or if their ENDS use impedes smoking cessation. For example, low-socioeconomic status smokers may be less likely able to afford certain products (e.g., rechargeable ENDS might be more effective for relieving smoking cravings13 but have greater up-front costs than do disposables14) or receive appropriate education or medical services encouraging ENDS use in a manner that increases their harm-reduction potential.15
ENDS have the potential to increase tobacco disparities if they are less used for harm reduction by disparity groups who bear the greatest burden from tobacco. Additionally, it will be important to understand ENDS use among never smokers from specific backgrounds considering that, for never smokers, experimenting with ENDS has the potential to lead to nicotine addiction.16
Little research has focused on ENDS use specifically among adult priority populations, most of which collapsed analyses across smoking status. In their systematic review of sociodemographic correlates of ENDS awareness and use including studies up to 2015, Hartwell et al.17 reported that people with higher education and Whites were more likely to be aware of ENDS and to have used ENDS. On the basis of 2013 to 2014 US nationally representative surveys, Kasza et al.18 and Huang et al.19 found that lower-income and LGBT adults were more likely to currently use ENDS. Using 2012 to 2013 US nationally representative data, Chou et al.20 reported that adults with lower levels of education and income were more likely to have used ENDS. However, White adults were more likely to have used ENDS than were Black, Asian/Pacific Islander, or Hispanic participants. On the basis of 2014 to 2017 US National Health Interview Surveys (NHIS), adults with lower income, sexual minorities, and those with Medicaid or no health insurance were more likely to currently use ENDS.21,22 Whites were also more likely to use ENDS than were Black and Hispanic adults.21
These studies suggest that racial/ethnic minority adults are less likely to use ENDS. However, most studies have not examined these associations by smoking status, which limits our understanding of the implications for smokers versus nonsmokers. Two recent studies have focused on US smokers. Using 2014 to 2016 NHIS data, Friedman and Horn23 found that among ever cigarette smokers, those with higher (vs lower) education were more likely and Black and Hispanic participants (vs Whites) were less likely to be exclusive ENDS users. Second, Harlow et al.24 found that among cigarette smokers who did not use ENDS at wave 1 of the Population Assessment of Tobacco and Health study (2013–2014), Black, Hispanic, and low-income smokers were less likely to become ENDS exclusive users by 12 months later.
Together these studies suggest that lower-income, Black and Hispanic smokers may be less likely to switch from cigarette smoking to exclusive ENDS use. However, patterns of ENDS use by priority populations of never smokers are unknown. Whereas exclusive ENDS use could reduce harm for current smokers, ENDS could be a potential gateway to nicotine addiction or other health consequences among never smokers.16,25 Moreover, it is important to consider ENDS use by any combustible tobacco use status (rather than only cigarette smoking), considering that people who do not smoke cigarettes may use other combustible tobacco products.18
To understand implications for priority populations and inform future studies and regulation, surveillance of ENDS use by both sociodemographic variables and combustible tobacco use status is needed. We examined the prevalence of ENDS awareness and use by combustible tobacco use status and sociodemographic variables relevant to tobacco disparities (age, education, poverty status, insurance status, employment, race/ethnicity, sexual orientation) using 2016 through 2017 data from 2 US nationally representative surveys.
METHODS
We analyzed pooled data from 2016 and 2017 Tobacco Products and Risk Perceptions Surveys conducted by the Georgia State University Tobacco Center of Regulatory Science. In partnership with GfK, we recruited participants through GfK’s KnowledgePanel (a probability-based web panel, weighted to be representative of noninstitutionalized US adults), with a representative oversample of cigarette smokers. We collected data September through October 2016 (n = 6061) and August through September 2017 (n = 6033; there was no overlap between the 2016 and 2017 samples). After we excluded participants for not answering more than half the questions (47 in 2016; 22 in 2017), unreasonably fast completion (< 3 minutes) or highly improbable or incompatible responses (19 in 2017), sample sizes for 2016 and 2017 were 6014 and 5992, respectively. We computed a study-specific poststratification weight using an iterative proportional fitting procedure to adjust for survey nonresponse and smoker oversampling. We used demographic and geographic distributions from the most recent Current Population Surveys as benchmarks for adjustment, and we included gender, age, race/ethnicity, census region, education, household income, and metropolitan area. The study included 11 688 participants with complete data on demographics, combustible tobacco use status, and ENDS variables.
Measures
Sociodemographic characteristics.
We obtained age, education, annual household income, family size and number of children, health insurance status, employment status, race/ethnicity, and sexual orientation from GfK profile surveys. We dichotomized education as less than or equal to high school or general equivalency diploma versus some college or more.21 Poverty status was on the basis of 2016 and 2017 federal poverty thresholds considering family size and number of children26 and dichotomized as below versus at or above the poverty level.27 We categorized health insurance as follows: private or insured; Medicare; Medicaid or state assistance; Veterans Affairs, Department of Defense, or military program; or uninsured. We categorized employment as working; not working, laid off or looking for work; not working, disabled; not working, retired; or not working, other. We categorized race/ethnicity as Hispanic, non-Hispanic Black, non-Hispanic White, or non-Hispanic other. We categorized sexual orientation as heterosexual or sexual minority (gay, lesbian, bisexual, or other).
Combustible tobacco use status.
We determined combustible tobacco product use by assessing use of cigarettes, little cigars and cigarillos, traditional cigars, and hookah. We asked participants who had smoked at least 100 cigarettes in their lifetime, “Do you currently smoke cigarettes every day, some days, or not at all?” We considered those who responded, “every day” or “some days” current cigarette smokers. For little cigars and cigarillos, traditional cigars, and hookah, we provided participants product descriptions with pictures. We asked those who indicated having “ever seen or heard of” the product, “Have you ever smoked [PRODUCT], even one or two puffs?” We considered those who answered “yes” ever users and those who answered “no” never users.
We asked ever users, “Do you now use [PRODUCT] every day, some days, rarely, or not at all?” We considered those who responded “every day,” “some days,” or “rarely” current combustible tobacco users. Former combustible tobacco users were ever users of any combustible tobacco product (including cigarettes) who responded “not at all” to now using any of these products. Never combustible tobacco users were those who denied having smoked 100 cigarettes in their lifetime and any use of other combustible products. We conducted sensitivity analyses where current combustible use was limited to users who responded “every day” or “some days.” We separated current combustible tobacco users into 2 categories: cigarette smokers (including mono use and dual and poly use with other combustible products) and noncigarette combustible tobacco users.
Electronic nicotine delivery systems awareness and use.
We gave participants a description of ENDS (“e-cigarettes, e-cigars, e-hookahs, e-pipes, vape pens, hookah pens, personal vaporizers/mods”) and showed them example pictures. We considered those who indicated having “ever seen or heard of” any of these products before this study “aware” of ENDS. We asked aware participants, “Have you ever used electronic vapor products, even one or two times?” We considered those who responded, “yes” “ever” ENDS users and we asked them, “Do you now use electronic vapor products every day, some days, rarely, or not at all?” We considered those who responded, “every day,” “some days,” or “rarely” current ENDS users.28 In the aforementioned sensitivity analyses, we limited current ENDS use to users who responded, “every day” or “some days.”
Statistical Analyses
We conducted analyses in 2018 to 2019. We obtained weighted point estimates and 95% confidence intervals (CIs) for ENDS awareness and ever and current ENDS use by each sociodemographic variable and combustible tobacco use status using SAS 9.4 (SAS Institute, Cary, NC). We used the Rao-Scott χ2 test to examine associations between sociodemographic variables and ENDS use.
RESULTS
Sociodemographic characteristics overall and by combustible tobacco use status are shown in Table 1. Combustible tobacco use status varied by all sociodemographic variables. Rates of current cigarette smoking were disproportionately high among those living in poverty, those uninsured or on Medicaid or state assistance, those not working or disabled, those younger than 45 years, those with high school or lower education, sexual minorities, and Blacks.
TABLE 1—
Combustible Tobacco Use Status by Sociodemographic Characteristics: United States, 2016–2017
| Sociodemographic Characteristic | Sociodemographic Characteristics, (n = 11 688), % (95% CI) or P | Never Combustible Tobacco User (n = 3935), % (95% CI) or P | Former Combustible Tobacco User (n = 4266), % (95% CI) or P | Current User of Noncigarette Combustible Tobacco (n = 997), % (95% CI) or P | Current Cigarette Smokera (n = 2490), % (95% CI) or P |
| Overall | 39.0 (38.0, 40.1) | 37.4 (36.4, 38.5) | 9.5 (8.8, 10.1) | 14.1 (13.4, 14.7) | |
| Age, y | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 |
| 18–29 | 20.6 (19.7, 21.6) | 45.7 (43.0, 48.4) | 24.7 (22.4, 26.9) | 13.8 (11.9, 15.7) | 15.9 (14.0, 17.7) |
| 30–44 | 24.7 (23.7, 25.7) | 38.1 (35.8, 40.5) | 32.6 (30.3, 34.8) | 11.7 (10.2, 13.2) | 17.6 (16.0, 19.2) |
| 45–59 | 26.2 (25.2, 27.1) | 38.2 (36.2, 40.2) | 37.5 (35.5, 39.5) | 8.4 (7.4, 9.5) | 15.9 (14.6, 17.1) |
| ≥ 60 | 28.5 (27.6, 29.4) | 35.9 (34.1, 37.6) | 50.8 (49.0, 52.6) | 5.4 (4.6, 6.1) | 8.0 (7.2, 8.8) |
| Poverty levelb | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 |
| Below poverty level | 9.8 (9.1, 10.4) | 36.0 (32.5, 39.6) | 22.8 (19.7, 25.8) | 7.0 (5.1, 8.9) | 34.2 (30.9, 37.4) |
| At or above poverty level | 90.2 (89.6, 90.9) | 39.4 (38.2, 40.5) | 39.0 (37.9, 40.1) | 9.7 (9.0, 10.4) | 11.9 (11.2, 12.6) |
| Education level | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 |
| High school/GED or less | 39.9 (38.8, 41.0) | 38.3 (36.4, 40.2) | 35.8 (33.9, 37.6) | 4.9 (4.1, 5.8) | 21.0 (19.6, 22.4) |
| Some college or more | 60.1 (59.0, 61.2) | 39.6 (38.3, 40.8) | 38.5 (37.3, 39.8) | 12.5 (11.6, 13.4) | 9.4 (8.8, 10.1) |
| Sexual orientationc | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 |
| Sexual minority | 6.8 (6.3, 7.4) | 31.3 (27.3, 35.2) | 31.7 (28.0, 35.5) | 14.2 (11.3, 17.1) | 22.8 (19.6, 26.0) |
| Heterosexual | 93.2 (92.6, 93.7) | 39.6 (38.4, 40.7) | 37.9 (36.8, 39.0) | 9.2 (8.5, 9.9) | 13.4 (12.7, 14.1) |
| Race/ethnicity | |||||
| Non-Hispanic White | 64.8 (63.7, 65.9) | 36.8 (35.6, 38.0) | 40.9 (39.7, 42.1) | 9.1 (8.4, 9.9) | 13.2 (12.5, 14.0) |
| Non-Hispanic Black | 11.7 (10.9, 12.4) | 39.2 (35.9, 42.6) | 29.9 (26.7, 33.0) | 10.7 (8.5, 12.9) | 20.2 (17.6, 22.8) |
| Non-Hispanic other | 7.9 (7.2, 8.6) | 52.4 (47.7, 57.2) | 25.1 (21.1, 29.0) | 8.8 (6.2, 11.5) | 13.7 (10.7, 16.6) |
| Hispanic | 15.7 (14.8, 16.6) | 41.6 (38.4, 44.8) | 34.9 (31.9, 38.0) | 10.3 (8.3, 12.3) | 13.2 (11.3, 15.1) |
| Primary insurance | |||||
| Private/insured | 62.6 (61.5, 63.6) | 41.2 (39.8, 42.6) | 37.5 (36.2, 38.9) | 10.9 (10.0, 11.8) | 10.4 (9.6, 11.1) |
| Medicare | 18.3 (17.6, 19.1) | 35.3 (33.0, 37.6) | 47.9 (45.7, 50.2) | 4.9 (3.9, 5.8) | 11.9 (10.5, 13.2) |
| Medicaid/state assistance | 8.8 (8.2, 9.5) | 33.0 (29.2, 36.8) | 27.3 (23.8, 30.9) | 8.6 (6.3, 10.9) | 31.1 (27.7, 34.4) |
| VA/DOD/military program | 3.0 (2.6, 3.3) | 34.4 (28.4, 40.4) | 42.3 (36.5, 48.1) | 11.4 (7.7, 15.1) | 11.9 (8.9, 15.0) |
| Uninsured | 7.3 (6.7, 7.9) | 39.5 (35.1, 44.0) | 20.4 (17.0, 23.7) | 8.6 (6.1, 11.1) | 31.5 (27.6, 35.4) |
| Employment type | |||||
| Working | 62.3 (61.2, 63.3) | 38.1 (36.7, 39.5) | 36.8 (35.4, 38.1) | 11.9 (11.0, 12.9) | 13.2 (12.3, 14.0) |
| NW, laid off/looking for work | 5.8 (5.3, 6.4) | 45.4 (40.3, 50.4) | 22.6 (18.7, 26.6) | 8.9 (6.1, 11.6) | 23.1 (19.2, 27.1) |
| NW, retired | 18.8 (18.0, 19.6) | 36.3 (34.1, 38.5) | 51.0 (48.8, 53.2) | 4.7 (3.8, 5.6) | 8.0 (7.1, 9.0) |
| NW, disabled | 5.2 (4.7, 5.7) | 29.3 (24.6, 33.9) | 29.0 (24.5, 33.4) | 6.8 (3.8, 9.7) | 35.0 (30.6, 39.4) |
| NW, other | 7.9 (7.2, 8.5) | 55.0 (50.6, 59.4) | 26.8 (22.8, 30.7) | 3.4 (1.9, 4.9) | 14.9 (12.1, 17.7) |
Note. CI = confidence interval; DOD = Department of Defense; GED = general equivalency diploma; NW = not working; VA = Veteran Affairs. P values indicate significant associations between sociodemographic characteristics and combustible tobacco use status, as determined by the Rao-Scott χ2 test.
Current cigarette smokers (including mono use and dual and poly use with other combustible products).
Defined by the 2016 and 2017 US Censuses.
Because of missing data on sexual orientation, analyses related to sexual orientation included 11 400 participants: 3833 never combustible tobacco users, 4167 former combustible tobacco users, 976 current users of noncigarette combustible tobacco, and 2424 current cigarette smokers.
Electronic Nicotine Delivery Systems Awareness
ENDS awareness by sociodemographic characteristics and combustible tobacco use status is shown in Table 2. Overall, those younger than 60 years; people living at or above the poverty level; those with at least some college education; Whites; people with private or Veterans Affairs, Department of Defense, or military health insurance; and those currently employed were more likely to be aware of ENDS. However, ENDS awareness was generally high across all sociodemographic groups.
TABLE 2—
Electronic Nicotine Delivery Systems (ENDS) Awareness by Sociodemographic Characteristics and Combustible Tobacco Use Status: United States, 2016–2017
| Sociodemographic Characteristic | Overall Awareness (n = 11 688), % (95% CI) or P | Never Combustible Tobacco User (n = 3935), % (95% CI) or P | Former Combustible Tobacco User (n = 4266), % (95% CI) or P | Current User of Noncigarette Combustible Tobacco (n = 997), % (95% CI) or P | Current Cigarette Smokera (n = 2490), % (95% CI) or P |
| Overall ENDS awareness | 87.2 (86.4, 87.9) | 79.6 (78.0, 81.1) | 92.1 (91.1, 93.1) | 94.4 (92.8, 96.0) | 90.4 (88.6, 92.0) |
| Age, y | < .05 | ≤ .001 | < .05 | ||
| 18–29 | 87.9 (86.2, 89.7) | 84.2 (81.2, 87.2) | 91.4 (88.6, 94.2) | 93.5 (90.2, 97.0) | 88.3 (84.1, 92.4) |
| 30–44 | 87.0 (85.2, 88.7) | 79.0 (75.5, 82.5) | 91.9 (89.4, 94.4) | 96.6 (94.3, 98.9) | 88.7 (85.3, 92.1) |
| 45–59 | 88.7 (87.3, 90.2) | 81.1 (78.1, 84.0) | 93.5 (91.7, 95.2) | 96.3 (93.8, 98.8) | 92.1 (89.7, 94.5) |
| ≥ 60 | 85.4 (84.0, 86.7) | 74.4 (71.4, 77.3) | 91.5 (90.0, 93.0) | 89.1 (84.6, 93.7) | 93.0 (90.1, 95.8) |
| Poverty levelb | ≤ .001 | ≤ .001 | ≤ .001 | < .05 | ≤ .01 |
| Below poverty level | 77.0 (73.8, 80.2) | 64.4 (58.1, 70.7) | 80.5 (74.1, 86.9) | 88.3 (79.9, 96.7) | 85.6 (81.6, 89.5) |
| At or above poverty level | 88.3 (87.5, 89.1) | 81.1 (79.5, 82.6) | 92.8 (91.9, 93.8) | 94.9 (93.3, 96.5) | 91.8 (90.0, 93.6) |
| Education level | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .01 | |
| High school/GED or less | 82.8 (81.3, 84.3) | 72.6 (69.6, 75.6) | 89.1 (87.0, 91.1) | 92.0 (87.7, 96.2) | 88.4 (85.9, 90.9) |
| Some college or more | 90.1 (89.3, 90.9) | 84.0 (82.4, 85.7) | 94.0 (93.0, 94.9) | 95.1 (93.4, 96.7) | 93.1 (91.3, 95.0) |
| Sexual orientationc | |||||
| Sexual minority | 86.1 (82.9, 89.3) | 75.9 (68.3, 83.5) | 91.7 (87.6, 95.8) | 91.8 (85.6, 97.9) | 88.7 (83.5, 93.9) |
| Heterosexual | 87.4 (86.6, 88.2) | 80.1 (78.5, 81.7) | 92.2 (91.1, 93.2) | 94.7 (93.0, 96.3) | 90.6 (88.8, 92.3) |
| Race/ethnicity | ≤ .001 | ≤ .001 | ≤ .01 | ≤ .01 | |
| Non-Hispanic White | 89.4 (88.6, 90.2) | 82.5 (80.8, 84.2) | 93.1 (92.0, 94.1) | 95.1 (93.4, 96.8) | 93.0 (91.4, 94.7) |
| Non-Hispanic Black | 81.0 (78.2, 83.8) | 72.2 (67.0, 77.3) | 87.0 (82.5, 91.6) | 91.1 (85.8, 96.5) | 83.9 (78.6, 89.2) |
| Non-Hispanic other | 84.3 (80.7, 87.8) | 76.7 (70.7, 82.7) | 92.6 (88.4, 96.9) | 98.9 (96.9, 100.0) | 88.5 (81.2, 95.9) |
| Hispanic | 84.2 (81.7, 86.6) | 75.9 (71.2, 80.5) | 90.4 (87.4, 93.4) | 92.6 (87.1, 98.0) | 87.2 (81.8, 92.6) |
| Primary insurance | ≤ .001 | ≤ .001 | ≤ .01 | ||
| Private/insured | 89.1 (88.1, 90.0) | 83.1 (81.3, 84.9) | 93.1 (91.9, 94.3) | 94.5 (92.6, 96.4) | 92.4 (90.2, 94.6) |
| Medicare | 84.9 (83.2, 86.7) | 74.2 (70.4, 77.9) | 91.1 (89.2, 93.1) | 89.8 (84.6, 95.0) | 90.0 (86.4, 93.6) |
| Medicaid/state assistance | 81.5 (78.1, 84.9) | 68.0 (60.9, 75.2) | 85.0 (78.8, 91.3) | 95.1 (89.3, 100.0) | 89.9 (84.7, 93.2) |
| VA/DOD/military program | 91.1 (87.7, 94.5) | 88.2 (81.5, 94.8) | 91.5 (86.3, 96.8) | 98.8 (96.4, 100.0) | 90.8 (82.6, 98.9) |
| Uninsured | 81.8 (78.3, 85.3) | 68.8 (61.8, 75.9) | 93.6 (89.8, 97.4) | 97.0 (93.3, 100.0) | 86.2 (81.1 91.4) |
| Employment type | ≤ .001 | ≤ .01 | |||
| Working | 88.9 (88.0, 89.9) | 82.2 (80.4, 84.1) | 93.0 (91.8, 94.2) | 95.0 (93.4, 96.6) | 91.6 (89.5, 93.6) |
| NW, laid off/looking for work | 83.7 (79.7, 87.6) | 78.0 (71.2, 84.8) | 87.9 (81.0, 94.7) | 89.1 (76.2, 100.0) | 88.6 (82.3, 94.9) |
| NW, retired | 85.5 (83.8, 87.1) | 74.5 (70.9, 78.1) | 91.8 (90.1, 93.5) | 91.5 (86.6, 96.4) | 91.5 (87.6, 95.4) |
| NW, disabled | 83.9 (80.1, 87.7) | 73.8 (64.7, 82.9) | 86.3 (79.6, 93.1) | 100.0 (100.0, 100.0) | 87.3 (82.5, 92.0) |
| NW, other | 81.9 (78.3, 85.6) | 76.0 (70.4, 81.6) | 90.5 (84.9, 96.2) | 90.4 (76.5, 100.0) | 86.7 (79.4, 93.9) |
Note. CI = confidence interval; DOD = Department of Defense; GED = general equivalency diploma; NW = not working; VA = Veteran Affairs. P values indicate significant associations between sociodemographic characteristics and ENDS awareness (overall and separately by combustible tobacco smoking status), as determined by the Rao-Scott χ2 test.
Current cigarette smokers (including mono use and dual and poly use with other combustible products).
Defined by the 2016 and 2017 US Censuses.
Because of missing data on sexual orientation, analyses related to sexual orientation included 11 400 participants: 3833 never combustible tobacco users, 4167 former combustible tobacco users, 976 current users of noncigarette combustible tobacco, and 2424 current cigarette smokers.
Ever Electronic Nicotine Delivery Systems Use
Overall, those aged 18 to 29 years, those living in poverty, those with high school education or less, sexual minorities, Hispanics, those on Medicaid or state assistance or uninsured, and those not working or disabled were more likely to have ever used ENDS (Table 3).
TABLE 3—
Ever Electronic Nicotine Delivery Systems (ENDS) Use by Sociodemographic Characteristics and Combustible Tobacco Smoking Status: United States, 2016–2017
| Sociodemographic Characteristic | Overall Ever ENDS Use (n = 11 688), % (95% CI) or P | Never Combustible Tobacco User (n = 3935), % (95% CI) or P | Former Combustible Tobacco User (n = 4266), % (95% CI) or P | Current User of Noncigarette Combustible Tobacco (n = 997), % (95% CI) or P | Current Cigarette Smokera (n = 2490), % (95% CI) or P |
| Overall ever ENDS use | 18.2 (17.4, 19.0) | 2.6 (2.0, 3.3) | 16.0 (14.6, 17.3) | 30.8 (27.3, 34.2) | 59.0 (56.4, 61.5) |
| Age, y | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 | |
| 18–29 | 29.6 (27.2, 32.0) | 6.5 (4.3, 8.8) | 37.1 (32.1, 42.0) | 48.7 (41.2, 56.2) | 67.7 (61.6, 73.7) |
| 30–44 | 22.8 (20.9, 24.7) | 2.6 (1.4, 3.8) | 20.9 (17.6, 24.3) | 32.7 (26.1, 39.4) | 63.3 (58.7, 68.0) |
| 45–59 | 16.3 (14.9, 17.7) | 1.4 (0.5, 2.3) | 14.9 (12.4, 17.3) | 19.2 (14.2, 24.2) | 53.9 (49.6, 58.1) |
| ≥ 60 | 7.7 (6.8, 8.6) | . . . | 6.5 (5.2, 7.8) | 10.2 (5.9, 14.5) | 47.4 (42.4, 52.4) |
| Poverty levelb | ≤ .001 | ≤ .01 | < .05 | ||
| Below poverty level | 27.9 (24.8, 31.0) | 4.1 (1.5, 6.8) | 20.4 (14.4, 26.5) | 51.2 (37.0, 65.3) | 53.3 (47.7, 58.8) |
| At or above poverty level | 17.1 (16.3, 18.0) | 2.5 (1.8, 3.2) | 15.7 (14.3, 17.0) | 29.1 (25.6, 32.7) | 60.7 (57.9, 63.5) |
| Education level | ≤ .001 | < .05 | |||
| High school/GED or less | 21.0 (19.4, 22.5) | 3.2 (1.9, 4.6) | 16.3 (13.9, 18.7) | 38.3 (29.3, 47.3) | 57.1 (53.5, 60.7) |
| Some college or more | 16.4 (15.4, 17.3) | 2.2 (1.6, 2.9) | 15.8 (14.2, 17.3) | 28.8 (25.1, 32.4) | 61.7 (58.4, 64.9) |
| Sexual orientationc | ≤ .001 | ≤ .01 | < .05 | < .05 | |
| Sexual minority | 29.6 (26.0, 33.2) | 3.5 (0.9, 6.1) | 24.0 (18.1, 29.9) | 41.0 (30.2, 51.8) | 65.9 (58.7, 73.1) |
| Heterosexual | 17.3 (16.5, 18.2) | 2.6 (1.9, 3.3) | 15.4 (14.1, 16.8) | 29.7 (26.0, 33.4) | 57.8 (55.1, 60.6) |
| Race/ethnicity | < .05 | ≤ .001 | ≤ .01 | ≤ .001 | |
| Non-Hispanic White | 17.5 (16.5, 18.4) | 2.1 (1.4, 2.8) | 15.1 (13.7, 16.6) | 25.3 (21.5, 29.1) | 62.0 (59.1, 64.9) |
| Non-Hispanic Black | 17.3 (14.8, 19.8) | 2.7 (1.0, 4.3) | 9.9 (6.4, 13.5) | 37.9 (27.5, 48.4) | 45.6 (38.7, 52.6) |
| Non-Hispanic other | 18.9 (15.3, 22.5) | 4.8 (1.7, 7.9) | 19.1 (12.0, 26.3) | 37.8 (22.4, 53.2) | 60.7 (49.8, 71.6) |
| Hispanic | 21.6 (19.0, 24.2) | 3.3 (1.2, 5.4) | 22.6 (18.2, 27.1) | 42.0 (31.8, 52.3) | 60.6 (53.2, 68.0) |
| Primary insurance | ≤ .001 | ≤ .001 | ≤ .001 | ||
| Private/insured | 16.7 (15.7, 17.8) | 2.2 (1.5, 3.0) | 17.4 (15.7, 19.2) | 29.2 (25.2, 33.3) | 58.5 (54.9, 62.1) |
| Medicare | 11.2 (9.8, 12.6) | . . . | 7.8 (5.9, 9.7) | 11.6 (5.8, 17.4) | 57.3 (51.4, 63.1) |
| Medicaid/state assistance | 31.0 (27.6, 34.4) | 5.9 (2.5, 9.2) | 24.0 (17.7, 30.2) | 38.2 (25.1, 51.2) | 62.0 (56.0, 68.1) |
| VA/DOD/military program | 18.1 (13.8, 22.3) | . . . | 14.1 (8.2, 20.1) | 34.3 (17.1, 51.6) | 60.9 (48.3, 73.4) |
| Uninsured | 32.9 (28.8, 37.0) | 8.1 (3.1, 13.1) | 29.5 (21.4, 37.7) | 63.1 (49.8, 76.5) | 58.0 (50.9, 65.1) |
| Employment type | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .01 | |
| Working | 20.5 (19.3, 21.6) | 3.0 (2.1, 4.0) | 19.8 (18.0, 21.7) | 33.0 (29.0, 37.1) | 61.3 (58.1, 64.6) |
| NW, laid off/looking for work | 25.0 (20.8, 29.1) | 6.2 (2.2, 10.2) | 20.6 (12.5, 28.7) | 34.3 (19.4, 49.2) | 62.6 (53.5, 71.7) |
| NW, retired | 7.1 (6.1, 8.1) | . . . | 5.2 (3.7, 6.6) | 12.2 (6.4, 18.0) | 47.0 (40.9, 53.0) |
| NW, disabled | 28.4 (24.2, 32.6) | . . . | 18.1 (11.5, 24.8) | 16.7 (4.5, 29.0) | 59.8 (52.8, 66.9) |
| NW, other | 14.9 (12.1, 17.8) | . . . | 18.6 (12.6, 24.6) | 39.3 (17.8, 60.9) | 52.2 (42.3, 62.1) |
Note. CI = confidence interval; DOD = Department of Defense; GED = general equivalency diploma; NW = not working; VA = Veteran Affairs. P values indicate significant associations between sociodemographic characteristics and ENDS awareness (overall and separately by combustible tobacco smoking status), as determined by the Rao-Scott χ2 test.
Current cigarette smokers (including mono use and dual and poly use with other combustible products).
Defined by the 2016 and 2017 US Censuses.
Because of missing data on sexual orientation, analyses related to sexual orientation included 11 400 participants: 3833 never combustible tobacco users, 4167 former combustible tobacco users, 976 current users of noncigarette combustible tobacco, and 2424 current cigarette smokers.
However, different patterns emerged when stratifying by combustible tobacco use status. Among former and current combustible tobacco users (including cigarette smokers and noncigarette product users), those aged 18 to 29 years and sexual minorities were more likely to have used ENDS, whereas no statistical differences were found among never combustible tobacco users. Among current cigarette smokers, those living in poverty were less likely to have used ENDS than were their counterparts living at or above the poverty line. However, among users of noncigarette combustible tobacco, individuals living in poverty were more likely to have used ENDS. Among noncigarette combustible tobacco users, those with a high school education or less were more likely to have used ENDS than were those with at least some college education.
Ever ENDS use by race/ethnicity differed in that Blacks were least likely to have used ENDS among former and current cigarette smokers, but Whites were least likely to have used ENDS among those who currently used noncigarette combustible tobacco. Individuals without health insurance were most likely to have used ENDS among former combustible tobacco users as well as current users of noncigarette combustible tobacco. Regarding employment status, retired individuals were least likely to have used ENDS, and those laid off or looking for work were generally most likely to have used ENDS regardless of combustible tobacco use status.
Current Electronic Nicotine Delivery Systems Use
Overall sociodemographic patterns of current ENDS use (Table 4) were similar to those found with ever ENDS use, with individuals aged 18 to 29 years, those living in poverty, those with high school or less education, sexual minorities, Hispanics, those on Medicaid or state assistance or uninsured, and those looking for work or disabled more likely to currently use ENDS. Again, different patterns emerged when stratified by combustible tobacco use status. Among former and current combustible (both cigarette smokers and noncigarette product users) tobacco users, those aged 18 to 29 years were more likely to currently use ENDS. Among never combustible users and current noncigarette combustible tobacco users, current ENDS use was more prevalent among those below the poverty level.
TABLE 4—
Current Electronic Nicotine Delivery Systems (ENDS) Use (Rarely, Some Days, Daily) by Sociodemographic Characteristics and Combustible Tobacco Smoking Status: United States, 2016–2017
| Sociodemographic Characteristic | Overall Current ENDS Use (n = 11 688), % (95% CI) or P | Never Combustible Tobacco User (n = 3935), % (95% CI) or P | Former Combustible Tobacco User (n = 4266), % (95% CI) or P | Current User of Noncigarette Combustible Tobacco (n = 997), % (95% CI) or P | Current Cigarette Smokera (n = 2490), % (95% CI) or P |
| Overall current ENDS use | 7.0 (6.5, 7.6) | 0.8 (0.4, 1.1) | 4.3 (3.6, 5.1) | 15.6 (12.8, 18.4) | 25.8 (23.5, 28.2) |
| Age, y | ≤ .001 | ≤ .001 | ≤ .001 | ≤ .001 | |
| 18–29 | 12.1 (10.4, 13.9) | 1.9 (0.8, 3.0) | 7.9 (5.4, 10.5) | 25.9 (19.3, 32.5) | 36.3 (30.1, 42.4) |
| 30–44 | 9.4 (8.1, 10.7) | 0.5 (0.0, 1.1) | 5.5 (3.6, 7.4) | 17.9 (12.4, 23.4) | 30.2 (25.6, 34.8) |
| 45–59 | 5.7 (4.8, 6.6) | . . . | 4.3 (2.9, 5.7) | 8.2 (4.8, 11.6) | 19.9 (16.5, 23.3) |
| ≥ 60 | 2.5 (1.9, 3.0) | . . . | 2.4 (1.5, 3.3) | 2.7 (0.7, 4.8) | 13.4 (9.9, 17.0) |
| Poverty levelb | ≤ .001 | < .05 | ≤ .001 | ||
| Below poverty level | 11.9 (9.7, 14.2) | 2.0 (0.0, 4.0) | 3.3 (0.8, 5.9) | 34.9 (20.8, 49.0) | 23.5 (18.8, 28.2) |
| At or above poverty level | 6.5 (5.9, 7.1) | 0.6 (0.3, 1.0) | 4.4 (3.6, 5.2) | 14.1 (11.3, 16.8) | 26.6 (23.8, 29.3) |
| Education level | ≤ .001 | < .05 | ≤ .01 | < .05 | |
| High school/GED or less | 8.4 (7.3, 9.4) | 0.8 (0.2, 1.4) | 5.3 (3.8, 6.7) | 24.4 (16.1, 32.6) | 23.6 (20.3, 26.9) |
| Some college or more | 6.1 (5.5, 6.8) | 0.7 (0.3, 1.2) | 3.7 (2.9, 4.5) | 13.3 (10.5, 16.0) | 29.1 (25.8, 32.5) |
| Sexual orientationc | ≤ .001 | ≤ .001 | < .05 | ||
| Sexual minority | 13.3 (10.7, 16.0) | 0.8 (0.0, 1.9) | 5.0 (2.0, 8.0) | 28.9 (18.9, 38.9) | 32.4 (25.2, 39.6) |
| Heterosexual | 6.5 (5.9, 7.1) | 0.8 (0.4, 1.1) | 4.2 (3.4, 5.0) | 14.0 (11.1, 16.9) | 25.0 (22.4, 27.5) |
| Race/ethnicity | < .05 | ≤ .01 | |||
| Non-Hispanic White | 6.5 (5.9, 7.2) | 0.7 (0.3, 1.1) | 4.4 (3.5, 5.2) | 12.3 (9.2, 15.3) | 25.4 (22.6, 28.1) |
| Non-Hispanic Black | 7.4 (5.6, 9.1) | 1.8 (0.4, 3.3) | 2.6 (0.5, 4.6) | 21.2 (12.2, 30.1) | 17.9 (12.6, 23.3) |
| Non-Hispanic other | 7.4 (5.0, 9.8) | . . . | 3.4 (0.9, 6.0) | 13.8 (3.2, 24.3) | 35.8 (24.7, 46.9) |
| Hispanic | 8.6 (6.9, 10.4) | . . . | 5.5 (3.0, 7.9) | 24.2 (15.6, 32.9) | 31.7 (24.5, 38.9) |
| Primary insurance | ≤ .001 | ≤ .001 | |||
| Private/insured | 6.1 (5.4, 6.7) | 0.7 (0.3, 1.1) | 4.4 (3.5, 5.3) | 14.0 (10.8, 17.1) | 25.0 (21.6, 28.4) |
| Medicare | 4.5 (3.5, 5.5) | . . . | 3.1 (1.8, 4.4) | 6.4 (1.8, 10.9) | 22.3 (16.7, 27.9) |
| Medicaid/state assistance | 14.1 (11.5, 16.6) | 3.8 (0.8, 6.7) | 6.4 (2.7, 10.1) | 26.1 (14.6, 37.5) | 28.5 (23.0, 34.1) |
| VA/DOD/military program | 4.3 (2.2, 6.4) | . . . | . . . | 14.4 (2.4, 26.4) | 12.9 (3.7, 22.0) |
| Uninsured | 14.3 (11.3, 17.4) | . . . | 8.7 (3.0, 14.4) | 34.3 (18.7, 49.8) | 30.4 (23.7, 37.1) |
| Employment type | ≤ .001 | ≤ .01 | ≤ .001 | ||
| Working | 7.9 (7.2, 8.7) | 0.7 (0.3, 1.2) | 5.1 (4.1, 6.1) | 16.6 (13.3, 19.9) | 28.7 (25.6, 31.9) |
| NW, laid off/looking for work | 12.2 (9.1, 15.2) | 2.7 (0.4, 5.0) | 2.7 (0.0, 5.5) | 24.1 (10.9, 37.2) | 35.5 (26.4, 44.6) |
| NW, retired | 2.3 (1.7, 3.0) | . . . | 2.3 (1.2, 3.3) | 4.8 (1.2, 8.4) | 11.2 (7.6, 14.7) |
| NW, disabled | 9.4 (6.6, 12.2) | . . . | 3.5 (0.9, 6.2) | . . . | 21.1 (14.7, 27.4) |
| NW, other | 5.8 (4.0, 7.6) | . . . | 6.9 (3.0, 10.9) | 22.0 (3.9, 40.1) | 20.8 (13.0, 28.5) |
Note. CI = confidence interval; DOD = Department of Defense; GED = general equivalency diploma; NW = not working; VA = Veteran Affairs. P values indicate significant associations between sociodemographic characteristics and ENDS awareness (overall and separately by combustible tobacco smoking status), as determined by the Rao-Scott χ2 test.
Current cigarette smokers (including mono use and dual and poly use with other combustible products).
Defined by the 2016 and 2017 US Censuses.
Because of missing data on sexual orientation, analyses related to sexual orientation included 11 400 participants: 3833 never combustible tobacco users, 4167 former combustible tobacco users, 976 current users of noncigarette combustible tobacco, and 2424 current cigarette smokers.
Lower education was associated with higher current ENDS use overall, among former combustible tobacco users, and among current users of noncigarette combustible tobacco. However, among current cigarette smokers, those with lower education were less likely to currently use ENDS. Sexual minority adults were more likely to currently use ENDS than were heterosexuals among current combustible tobacco users (both cigarette smokers and noncigarette product users). Blacks and Hispanics were most likely to currently use ENDS among current users of noncigarette combustible tobacco. However, among current cigarette smokers, Blacks were least likely to currently use ENDS. Individuals without health insurance were most likely to currently use ENDS only among current users of noncigarette combustible tobacco. Individuals who were laid off or looking for work were less likely to currently use ENDS among former combustible tobacco users but most likely to currently use ENDS among current cigarette smokers.
Current ENDS use prevalence among never combustible tobacco users was miniscule (0.8%; 95% CI = 0.4, 1.1) and more than 75% of the 27 never users of combustible products who currently used ENDS reported using ENDS rarely (Table A [available as a supplement to the online version of this article at http://www.ajph.org]). Thus, because of low rates of current ENDS use (even including rarely users) some prevalence statistics cannot be reported. Overall, 92.5% (95% CI = 88.5, 96.5) of “some days” ENDS users reported using ENDS in the past 30 days (mean number of days 10.4; 95% CI = 9.2, 11.6) compared with 43.6% (95% CI = 37.8, 49.4) of “rarely” ENDS users (mean number of days 3.3; 95% CI = 2.7, 3.8; Figure A [available as a supplement to the online version of this article at http://www.ajph.org]).
In analyses with current ENDS use defined as “some day” or “daily” use (Table B [available as a supplement to the online version of this article at http://www.ajph.org]), several results found using the definition including “rarely” users were attenuated (viz., by poverty status, race/ethnicity, and primary insurance). Findings by employment type were found only among current cigarette smokers; by age, among former and current cigarette smokers; and by education, among former users. Regarding sexual orientation, current user findings were attenuated, but an association emerged among former users suggesting that sexual minorities were more likely to currently use ENDS some days or daily than were heterosexuals.
DISCUSSION
This study provides 2016 to 2017 data on associations between sociodemographic variables relevant to tobacco disparities (age, education, poverty status, insurance status, employment, race/ethnicity, sexual orientation) and ENDS awareness and use, by combustible tobacco product use status. These results add information critical to understanding ENDS use in priority populations, namely, that among individuals who currently use combustible tobacco other than cigarettes, those from certain backgrounds (viz., young adults, those living below the poverty level, those less educated, sexual minorities, Blacks and Hispanics, and those without health insurance) are using ENDS at disproportionately high rates. However, in several instances these patterns were the opposite among current cigarette smokers, with those living in poverty and Blacks less likely to be ever ENDS users, and those with less education and Blacks less likely to currently use ENDS.
Other US nationally representative studies found that overall, lower-socioeconomic status adults were more likely,18–21 and racial/ethnic minorities less likely,20,21 to use ENDS. Our findings indicate that associations vary depending on combustible tobacco use status, highlighting the need to consider both cigarette smoking status and use of other combustible tobacco products to understand ENDS use among priority populations. Although users of noncigarette combustible tobacco products may use these products less frequently or intensely, noncigarette combustible tobacco products carry many of the negative health consequences associated with cigarettes.29
Among people who do not smoke cigarettes but do use other combustible tobacco products, certain priority populations may be particularly likely to engage in dual or poly tobacco use with ENDS. This could lead to worsening disparities and health outcomes among priority populations if they continue dual/poly use. Conversely, these populations have the potential to reap harm-reduction benefits if they transition to exclusive ENDS use or eventually discontinue all tobacco use. Among cigarette smokers, lower current ENDS use among Blacks and those with less education could exacerbate tobacco-related disparities (i.e., if these priority populations of smokers are less likely to obtain any potential harm-reduction benefits of ENDS). However, this will depend on long-term effects of ENDS on smoking cessation and other health outcomes.
Continued research is needed to understand the reasons for ENDS use among noncigarette combustible tobacco users and examine long-term trajectories and associated health outcomes among priority populations and poly tobacco users. Research is also needed to understand perceptions of ENDS and reasons for use versus nonuse by sociodemographic variables, with few examinations of these variables specifically among priority populations. Webb Hooper and Kolar30 found that although Black current and former smokers were less likely to have used e-cigarettes than were Whites and Hispanics, Blacks were more likely to use e-cigarettes specifically to quit smoking. In another study among current and former smokers, Blacks had less knowledge about e-cigarettes and perceived lower health risks of e-cigarettes than did White and Hispanic participants.31
Given that current ENDS use was disproportionately high among former combustible tobacco users with less education, research is needed to understand whether these individuals remain abstinent from combustible tobacco over time, rather than reinitiating smoking or engaging in dual use. Ever and current ENDS use prevalence rates among never combustible tobacco users were especially low, and most of those who were current ENDS users reported using these products rarely or infrequently. Subsample sizes among never combustible tobacco users were quite small, limiting our ability to understand whether ENDS use differs by sociodemographic characteristics among never smokers. Continued monitoring efforts are needed to examine trajectories of ENDS use among priority populations of both never and former combustible tobacco users over time.
This study revealed high rates of ever and current ENDS use among young adults aged 18 to 29 years and sexual minorities, among both former and current combustible tobacco users. About one third of young adults and sexual minorities who currently smoked cigarettes and more than one quarter of young adults and sexual minorities who used noncigarette combustible tobacco currently used ENDS. Use prevalence tends to be disproportionately high among young adults and LGBT populations across various tobacco products.18,32 The tobacco industry has targeted LGBT populations33 and young adults,34 which may contribute to the high rates of combustible tobacco and ENDS use among these populations. Continued surveillance is needed to understand ENDS use and potential cessation benefits among cigarette smokers and noncigarette combustible tobacco users identifying as LGBT and young adults.
Limitations
This study is limited by self-reported, cross-sectional data, and longitudinal studies are needed to examine patterns over time by sociodemographic variables. Additionally, we focused on ENDS use prevalence rather than on reasons for use or utility for smoking cessation, and we were unable to stratify former combustible tobacco users by how long ago they quit (which might offer some insight into whether they used ENDS to help them quit combustible tobacco). Furthermore, evidence on the effectiveness of ENDS for smoking cessation is mixed and less is known about effects of ENDS use on smoking cessation for priority populations. A recent systematic review found insufficient evidence regarding ENDS effectiveness for smoking cessation among certain at-risk groups (e.g., individuals who were homeless or had mental health conditions).35 More rigorous studies are needed to examine ENDS use over time and whether ENDS increase or decrease the likelihood of smoking cessation for priority populations under controlled and real-world use conditions. Despite limitations, this study is strengthened by a large, nationally representative sample; stratification by combustible tobacco status; and recent data.
Conclusions
ENDS use appears to vary by sociodemographic variables relevant to tobacco-related disparities. In 2016 to 2017, ENDS use was disproportionately high among adult current combustible tobacco users, particularly young adults and sexual minorities. For other priority populations, patterns differed by cigarette smoking and other combustible tobacco use status. Among current cigarette smokers who may also use other combustible products, those who identify as Black and reported less education appear less likely to use ENDS, but among combustible tobacco users who do not smoke cigarettes, certain priority populations were more likely to use ENDS. The impact on tobacco-related health disparities will ultimately depend on whether ENDS are used to transition completely away from combustible tobacco use and how this may differ across priority populations who use diverse tobacco products. Continued surveillance of ENDS use by sociodemographic variables, stratified by combustible tobacco use status, will be critical for understanding whether ENDS increase or reduce the tremendous burden of tobacco for priority populations.
ACKNOWLEDGMENTS
This research was supported by the National Institute on Drug Abuse, National Institutes of Health (NIH; grant P50DA036128), the Food and Drug Administration (FDA) Center for Tobacco Products, and the National Center for Complementary and Integrative Health, NIH (grant K23AT008442).
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.
CONFLICTS OF INTEREST
The authors declare that they have no competing interests. M. P. E. receives research funding support from Pfizer (“Diffusion of Tobacco Control Fundamentals to Other Large Chinese Cities,” Michael Eriksen, principal investigator). No financial disclosures were reported by the other authors of this article.
HUMAN PARTICIPANT PROTECTION
The Georgia State University institutional review board approved this study. A waiver of consent was approved because the research presents no more than minimal risk of harm to participants; the waiver does not adversely affect the rights and welfare of the participants; and because of the use of KnowledgePanel, the research could not be practicably carried out without the waiver.
Footnotes
See also Giovenco, p. 1162.
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