Parental Dual use of E-cigarettes and Traditional Cigarettes

Abstract

Background:

E-cigarettes are growing in popularity. Dual use of e-cigarettes and cigarettes is an increasingly common practice, but little is known about patterns of dual use in parents.

Objectives:

To describe smoking-related behaviors among dual-users.

Methods:

Parent exit surveys were conducted following their child’s visit in five control pediatric practices in five states participating in the CEASE trial. We examined factors associated with dual use of e-cigarettes and cigarettes vs. cigarette-only smokers, assessed by self-report.

Results:

Of 1382 smokers or recent quitters screened after their child’s visit between April-October 2017, 943 (68%) completed the survey. Of these, 727 parents reported current use of cigarettes; and of those, 81 (11.1%) also reported e-cigarette use, meeting the definition of dual use. Compared to cigarette-only smokers, dual users were more likely to have a child younger than 1-year old, planned to quit in the next 6 months, and had tried to quit in the past (had a quit attempt in the past 3 months, called the quitline or used medicine to quit in the past 2 years; P<.05 for each).

Conclusion:

Parents who use both e-cigarettes and cigarettes may have higher rates of contemplating smoking cessation than parents who only smoke cigarettes. These parents may be using e-cigarettes for harm reduction or as a step towards cessation. Identification of these parents may provide an opportunity to deliver effective treatment, including nicotine replacement therapies that do not expose infants and children to e-cigarette aerosol.

Background:

Electronic cigarettes (e-cigarettes) include a diverse group of devices that allow users to inhale an aerosol, which typically contains nicotine, flavorings, and other additives.¹ These devices are referred to as “e-cigarettes,” “e-cigs,” “cigalikes,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems”, and JUUL. For this paper, the term e-cigarettes is used to represent all such products in this diverse category. E-cigarettes vary widely in design and appearance, but generally operate in a similar manner and have similar components. They heat the liquid in the cartridge to create an aerosol that users inhale.² The concentration of nicotine can vary across cartridges and in “e-liquids” across different brands.^2,3 A 2014 study showed that current e-cigarette users have systemic nicotine and/or cotinine concentrations similar to those seen in traditional cigarette users.³

E-cigarettes are easily available and growing in popularity in adults.^4-6 When used as a replacement for cigarettes, e-cigarettes may serve as a potential smoking cessation aid^7,8 and are perceived by users as a less harmful alternative to cigarette smoking.^9,10 Although e-cigarettes could help with cigarette smoking cessation,¹¹ there is limited evidence regarding long-term adverse effects and their long-term impact on tobacco smoking reduction or cessation.^12,13 Recommendations from the United States (U.S.) Preventive Services Task Force,¹⁴ and an expert committee of the National Academies of Sciences, Engineering, and Medicine⁹ concluded that the current evidence is insufficient to recommend e-cigarettes for tobacco cessation and as of 2019, the US Food and Drug Administration (FDA) has not approved e-cigarettes as a cessation aid.

Although data from the 2016 NHIS survey showed that current e-cigarette use declined among current smokers since 2014, it increased among former and never smokers.¹⁵ This trend is particularly worrisome as it could indicate that e-cigarettes are renormalizing smoking behavior for former smokers¹⁶ and becoming gateways of nicotine use for never smokers.¹⁷ Long-term prospective data is needed to understand the patterns and trends of e-cigarette use in current, former, and never smokers.

Importantly, most adults who use e-cigarettes continue to smoke cigarettes (referred to as dual users). In 2015, National Health Interview Survey data showed that 58.8 percent of adult e-cigarette users also smoked cigarettes in the U.S.⁴ and the 2016 BRFSS reported similar findings, estimating that 54.6 percent of current e-cigarette users were also current smokers.⁶ A recent study showed that dual users exhibited higher concentrations of nearly all biomarkers of nicotine and toxicants compared to cigarette only smokers.¹⁸

Parental use of traditional cigarettes is strongly associated with later use of cigarettes by their children¹⁹ but it is not yet known whether this association holds true for parental e-cigarette use. E-cigarette use by parents may facilitate adolescent use of nicotine products through behavioral role modeling, direct effects of increased nicotine exposure on the developing brain, and increased access to the products themselves in the home.^20,21 Additionally, the concentrated nicotine present in e-liquid can be toxic if absorbed through the skin or ingested accidentally, posing a particular risk to children.²² Despite the increasing dual use of cigarettes and e-cigarettes in adults, and the implications for child health, there is limited data on dual use in parents.^21,23 This is the first study to explore the readiness to quit smoking and use of FDA approved tobacco treatments by parents who are dual users of cigarettes and e-cigarettes vs. cigarette-only smokers.

Design/Methods:

Data were collected between April-October 2017 from five practices in five states (TN, IN, VA, NC, OH) randomized to the control arm of the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study.²⁴ This trial tested the effectiveness and sustainability of an intervention to address parental tobacco use in the pediatric office setting. It was conducted in partnership with the American Academy of Pediatrics Julius Richmond Center of Excellence. The study protocol was approved by the Institutional Review Boards (IRB’s) of the AAP and Massachusetts General Hospital, and by individual practice IRBs where required.

Participant enrollment

Exit surveys were conducted with parents following their child’s visit to the pediatric office. The exit screener survey gathered the following information: parent’s demographic information (age, gender, race and ethnicity, and level of education); parent’s current and past smoking status; the age of the youngest child present at the visit; and how the visit was paid for. Parents were eligible for inclusion in the study if they reported smoking at least 100 cigarettes in their lifetime and if they had smoked a cigarette, even a puff, in the last 7 days or had quit smoking within the past 2 years. Eligible parents were invited to complete a detailed survey. Exclusion criteria included: (1) parents under age 18; (2) parents whose child had a medical emergency; (3) non-English speakers; or (4) completion of the detailed survey during a previous visit. Eligible parents who agreed to do a detailed survey signed a consent form and received $5 for completion. Screening continued until approximately 200 eligible parents completed the detailed survey at each practice. The detailed survey asked additional questions about their tobacco use and behavior, readiness to quit, quit attempts in the past 3 months, smoke-free and e-cigarette-free home and car rules, if someone had used cigarettes or e-cigarettes in their home and car in the last 3 months, use of other tobacco products including e-cigarettes, and if the child’s healthcare provider asked them about their smoking status and discussed using medications or quitline enrollment to help them quit smoking.

Parents were considered to be dual users of cigarettes and e-cigarettes if they reported smoking a cigarette, even a puff, in the past 7 days and using e-cigarettes within the past 30 days. Bivariate analyses were conducted using chi-square tests to explore the association between parent and child characteristics and dual use.

Variables that were significant (p<0.10) in the bivariate analysis and those that had theoretical plausibility (infant seen at the visit, gender and education of the parent, number of cigarettes smoked per day) were added step-wise to a logistic regression model. We combined the people who reported making a quit attempt in the past 3 months, or reported using NRT or calling the quitline to help them quit smoking in the past 2 years and created a variable ‘tried to quit in the past’. Odds ratios (OR) and 95% Confidence Intervals (CI) were reported for each variable from the final model. All p values are 2-sided and were considered significant at p<0.05. Analyses were conducted using Stata statistical software (StataCorp, 2017. Stata Statistical Software: Release 15. College Station, TX: Stata Corporation).

Results:

Of 1382 eligible smokers and recent quitters screened after their child’s office visit between April-October 2017, 943 (68%) completed the detailed survey. Of these, 727 parents reported current use of cigarettes and of these, 81 (11.1%) also reported e-cigarette use, meeting the definition of dual use. In our sample of 216 parents who quit smoking in the past 2 years, 34 (15.7%) reported current e-cigarette use.

Of the 81 dual users, 73% were in the age group 25 to 44 years, 46% were high school graduates, 36% had some college education or had graduated college, 83% smoked everyday, and 84% and 70% intended to quit smoking in the next 6 months and 30 days, respectively. As well, 56 (69%) of dual users had made an unsuccessful quit attempt in the previous 3 months, 23 (28%) had tried FDA approved medications to help them quit smoking, and 8 (10%) had called a quitline in the previous 2 years (Table 1).

Table 1:

Characteristics of parental dual users and cigarette only users seen in pediatric practices (N=727)

Characteristic	Dual users N=81 n (%)	Cigarette-only users N=646 n (%)	p-value
Parent Age			0.581
18–24	16 (20)	99 (15)
25–44	59 (73)	474 (73)
≥ 45	6(7)	73(11)
Relationship to the child			0.855
Father	12 (15)	100 (15)
Mother	62 (77)	501 (78)
Other	45 (9)	45 (7)
Race and Ethnicity			0.615
Hispanic	3 (4)	8 (1)
Non-Hispanic Black or African American	5 (6)	67 (10)
Other or > 1 race	3 (4)	29 (5)
Non-Hispanic White	70 (86)	540 (84)
Education			0.338
<High school	14 (18)	85 (13)
High school graduate	37 (46)	303 (47)
Some college	24 (30)	176 (27)
College graduate	5 (6)	79 (12)
# Cigarettes/Day			0.754
1-10 cigarettes/day	38 (47)	315 (49)
≥11 cigarettes/day	43 (53)	331 (51)
Plan to Quit
Next 6 months	65 (84)	411 (67)	0.002
Next 30 days	44 (70)	233 (61)	0.172
Quit attempt in the last 3 months			0.000
Yes	56 (69)	303 (47)
Daily smoker	66 (83)	528 (82)	0.215
Youngest Child seen Age			0.437
≤1 year	30 (37)	199 (31)
2-4 years	16 (20)	114 (18)
5-9 years	19 (23)	155 (24)
≥10 years	16 (20)	178 (28)
Home and Car Smoking Policy
Someone smoked in their home in past 3 months	26 (32)	224 (35)	0.625
Someone smoked in their car in past 3 months	52 (72)	327 (56)	0.009
Someone used e-cig in their home in past 3 months	50 (62)	69 (11)	0.000
Someone used e-cig in their car in past 3 months	45 (63)	49 (8)	0.000
Assistance used the last 2 years
NRT	23 (28)	142 (22)	0.199
Quitline	8 (10)	23 (4)	0.008
Child’s insurance Coverage			0.707
Medicaid	46 (57)	385 (60)
Self Pay	2 (3)	26 (4)
Private insurance/HMO	32 (40)	231 (36)

^*Note: Missing data not included. Car items limited to parents who reported they have a car.

Of the 81 dual user parents, 32% and 72% reported that someone had smoked in their homes and cars respectively in the past 3 months. Of the 646 cigarette only smokers, 35% and 56% reported that someone had smoked in their home and car respectively in the past 3 months. Of the dual users, 62% and 63% reported that someone had used an e-cigarette in their home and car respectively in the past 3 months. Of the cigarette only smokers, 11% and 8% reported that someone had used an e-cigarette in their home and car respectively in the past 3 months.

Figure 1 shows that 84% of dual users planned to quit smoking in the next 6 months, compared to 67% of cigarette only smokers; and 70% of dual users planned to quit smoking in the next 30 days, compared to 61% of cigarette only smokers. Of the dual users, 69% had already attempted to quit in the last 3 months, compared to 47% of cigarette only smokers.

Figure 1:

Readiness to quit and use of assistance to quit among parental dual users and parental cigarette only users (N=727)

Of the 81 dual users, 28 (34.5%) reported either calling the quitline or using NRT in the last 2 years to help them quit smoking, whereas out of the 646 cigarette only smokers, 157 (24.3%) reported calling the quitline or using NRT in the last 2 years to help them quit smoking (p<0.05). Of those parents who reported calling the quitline or using NRT in the past 2 years, 82.1% dual users and 59.9% cigarette only smokers reported making a quit attempt in the past 3 months (p=0.02).

Bivariate analyses (Table 1) demonstrated an association between being a dual user and intention to quit in the next 6 months, having made a quit attempt in the past 3 months, having called a quitline in the past 2 years, smoking cigarettes in the car in the past 3 months, and smoking e-cigarettes in the home and the car in the past 3 months. We did not find any association between parent’s age, race and ethnicity, education, intention to quit smoking in the next 30 days, or smoking cigarettes inside the home, with parental dual use.

The final multivariable logistic regression model (Table 2), adjusting for parent gender and education, showed that dual users, compared to cigarette smokers only, had 1.7 times greater odds of having a child less than one year old (infant) at the visit, 1.99 times greater odds of having the intention to quit smoking in the next 6 months and 1.85 times greater odds of having tried to quit in the past (called the quitline or used medicine in the past 2 years to help them quit or made a quit attempt in the past 3 months) compared to cigarette only users. Parent gender, education or numbers of cigarettes smoked per day were not associated with dual use.

Table 2:

Characteristics associated with e-cigarette use among current cigarette smoking parents (N= 727)

Characteristic	OR	95% CI	p-value
Infant at home (<1 year old)	1.68	1.01, 2.79	0.044
Male	1.01	0.55, 1.86	0.953
Attended college	0.94	0.57, 1.54	0.813
Smokes >10 cigarettes per day	1.42	0.85, 2.37	0.172
Plan to quit in next 6 months	1.99	1.08, 3.67	0.027
Tried to quit*	1.85	1.05, 3.25	0.031

^*Parent is classified as ‘tried to quit’ it if they reported making a quit attempt in the past 3 months, using medication for quitting, or calling the quitline in the past 2 years for assistance

^**Results from multiple logistic regression analysis

In our sample of cigarette smokers, we found that 114 (17.6%) cigarette only users and 21 (25.9%) dual users were asked about their smoking status; however medication to help them quit smoking was discussed with 16 (2.4%) cigarette only users and 0 (0%) dual users. Similarly, 13 (2.0%) cigarette only users and 2 (2.5%) dual users were advised enrollment in the quitline.

Discussion:

In our sample of current cigarette smoking parents, we found that almost 11% were dual users of cigarettes and e-cigarettes. Dual users are more likely to have a child less than one year old at home, have the intention to quit smoking in the next 6 months and tried to quit in the past (called the quitline or used medicine in the past 2 years to help them quit smoking or made a quit attempt in the past 3 months) relative to cigarette only users.

Having a child less than one year old was associated with dual use of cigarettes and e-cigarettes. Data shows that two-fifths of US adults believe that children’s exposure to e-cigarette aerosol causes some or little harm, while one-third do not know whether it causes harm.²⁵ Such beliefs may also be the reason that dual users had relatively high rates of smoking e-cigarettes in their home and car.^21,23 A recent paper from the CEASE trial examined parents’ strict rules about prohibiting e-cigarette and regular tobacco use in homes and cars, concluding that dual users were less likely than cigarette only smokers to report a variety of child-protective measures for the home and car.²³ The particles and toxicants released in e-cigarette aerosols although in much lower concentrations than in combusted cigarettes,²⁶ may still pose health risks to users and bystanders.^12,13 Another report entitled the Public Health Consequences of E-Cigarettes, an expert committee of the National Academies of Sciences, Engineering, and Medicine⁹ reported that there is conclusive evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels. The report also concluded that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances. Additionally, just like combusted tobacco smoke, the nicotine from e-cigarette aerosol can remain on indoor surfaces for weeks to months, causing thirdhand exposure to toxicants.²⁸ Nicotine exposure is particularly harmful to the developing brains of children and adolescents.^29,30 Considering recent evidence highlighting the harms of e-cigarette aerosols,⁹ there is a need for clinicians to deliver appropriate education and advice to e-cigarette users and dual user parents.

Dual users in our study were more likely to have tried to quit smoking than cigarette only smokers. Almost 7 in 10 dual users had made a quit attempt in the past 3 months compared to less than 5 in 10 cigarette only smoking parents. This finding is consistent with studies that have shown that dual users are significantly more likely than exclusive cigarette smokers to have made a quit attempt.^31,32 This finding could suggest that these parents may have started using e-cigarettes as a method of harm reduction or a path to smoking cessation but since our data is cross-sectional,we cannot derive that inference. However, these data are consistent with existing evidence that current smokers report using these products to help reduce the number of cigarettes smoked or to quit smoking,¹³ despite insufficient evidence to recommend e-cigarettes for tobacco cessation.⁹

Significantly higher percentages of dual users in our study reported calling the quitline or using NRT in the past 2 years to help them quit smoking compared to cigarette only smokers. These findings reinforce the opportunity for pediatric clinicians to promote the use of evidence-based treatment for nicotine dependence in the growing population of dual user parents.³³

Parents who use both e-cigarettes and cigarettes appear to have higher rates of contemplating quitting.³⁴ This finding is consistent with studies that have shown that higher proportions of dual users have high intention to quit compared to cigarette smokers,³⁵ further suggesting that this group may be more likely to accept effective cessation assistance treatments offered by their child’s pediatrician.

In our sample, the majority of e-cigarette users (70%) also smoked cigarettes and almost one in six recent quitters of combusted tobacco were vaping e-cigarettes. Even though a comparison between the harmful substances released by cigarettes and e-cigarettes suggest that e-cigarettes are likely safer than cigarettes,³⁶ their overall effect on population health depends on how e-cigarettes are used.³⁷ Recent research suggests that even though vaping may reduce or partially replace cigarette use, e-cigarette dependence may increase over time without further reductions in smoking among those who maintain dual use.³⁸

Our data shows that although some pediatric offices may have systems to prompt clinicians to screen for parental tobacco product use, few routinely deliver evidence-based tobacco control treatments to help parents quit. Pediatricians are in a unique position to help parents who use e-cigarettes and cigarettes^39,40 in the following ways:

• Screening: Pediatric clinical settings could use systems like the CEASE intervention to routinely screen all families for combusted and non-combusted tobacco use.

• Motivational messaging: Pediatric settings have an opportunity to deliver evidence-based messages to parents about the harmful effects of nicotine and other toxins in both e-cigarette aerosol and combusted tobacco smoke.

• Advising strict smoke-free and vape-free environments: Considering the recent research about harms from e-cigarette aerosol,^1,9,30 parents should be advised to protect their children from second- and third- hand tobacco smoke and e-cigarette aerosol by having strict smoke-free and e-cigarette aerosol-free homes and cars.

• Treating with medications: Pediatricians should prescribe evidence-based,³³ non-aerosolized, FDA-approved nicotine replacement therapy (NRT) in the form of patch, lozenge and gum to help parents completely replace combusted tobacco and e-cigarettes.

• Enrolling: Pediatric offices should enroll tobacco product users in free resources like tobacco quitlines, cessation support websites, and texting services like smokefreeTXT.⁴⁰

Limitations

The results presented in this paper were generated from a secondary analysis of the data collected for the CEASE trial²⁴ and therefore the statistical tests were not specifically powered for the research questions posed in this paper. The sample size of dual users is small so the results should be interpreted cautiously. Although surveys were administered in-person and directly following the pediatric office visit, the results are based on parental self-report and thus, are subject to recall and response bias. In addition, the results are based on cross-sectional exit-survey data and no causal inferences should be made for the observed associations. Despite these limitations, the statistically significant results add to the limited knowledge base about dual use of cigarettes and e-cigarettes in the parent population.

Conclusion:

In this study, 11% of parents who smoked cigarettes were dual users of cigarettes and e-cigarettes, and the majority had made a quit attempt in the past 3 months. This study suggests that parents who smoke may view e-cigarettes as a cessation tool or as a harm reduction aide despite insufficient evidence to support the efficacy or safety of e-cigarettes as a tobacco dependence treatment product. The fact that 70% of e-cigarette users were still smoking combusted cigarettes, highlights the need for providing specific messaging and evidence based tobacco dependence treatment to parents in this prevalent dual user group. Early identification of dual user parents could be helpful in identifying smokers who have recently tried quitting and may be particularly motivated to accept referral for effective treatment and prescription of safe forms of nicotine replacement therapy that do not expose infants and children to e-cigarette aerosols. Finally, this research study highlights the need for pediatric clinicians to provide a new message to parents about keeping homes and cars completely smoke-free and vape free.

What’s New.

This study identifies factors associated with dual use of cigarettes and electronic cigarettes in parents and highlights the need for early identification of dual user parents in the pediatric setting. These findings have the potential to help protect children from exposure to both cigarette smoke and e-cigarette aerosol.

Abbreviations:

CEASE

Clinical Effort Against Secondhand Smoke Exposure

AAP

American Academy of Pediatrics

FDA

Food and Drug Administration

OR

Odds Ratio

CI

Confidence Interval

NRT

Nicotine Replacement Therapy