Electronic Nicotine Delivery System (ENDS) Use Patterns And Its Associations with Cigarette Smoking and Nicotine Addiction among Asian Americans: Findings from the National Adult Tobacco Survey (NATS) 2013-2014

Abstract

This study examined the ENDS use and their associations with conventional cigarette smoking and nicotine addiction among Asian Americans (AAs). The study sample was restricted to Non-Hispanic Asian Americans (n=1,956) using the National Adult Tobacco Survey (NATS) 2013-2014. Chi-square tests and logistic regressions were employed. AAs who ever used ENDS reported they were more likely to smoke conventional cigarettes, smoke ≤100 cigarettes in a lifetime, and felt more difficulty concentrating without using tobacco than those who never used END. Study findings indicate that ENDS use may be associated with conventional cigarette smoking and may lead to nicotine addiction among AAs.

INTRODUCTION

The use of electronic nicotine delivery systems (ENDS), or e-cigarettes, has rapidly increased in recent years and has gained popularity in the United States (Coleman et al., 2017; King et al., 2015; Levy et al., 2017; McMillen et al., 2015; Pepper & Brewer, 2014; U.S. Department of Health & Human Services, 2016; Weaver et al., 2016). ENDS are available in a wide range of designs, appearances, and flavors that are particularly attractive to youth and young adults (Breland et al., 2014; U.S. Department of Health & Human Services, 2016; Willett et al., 2019). Moreover, ENDS use is associated with an increased risk of conventional cigarette smoking and nicotine addiction or dual use of ENDS and conventional cigarettes among youth and adults (Barrington-Trimis et al., 2016, 2018; Bold et al., 2018; Bunnell et al., 2015; Soneji et al., 2017; Wills et al., 2016, 2017). For example, a systematic review and meta-analysis of 6,959 studies suggested that ENDS use was associated with greater risk for subsequent cigarette smoking initiation and past 30-day cigarette smoking among youth and young adults between 14 and 30 years old (Soneji et al., 2017). Other studies also suggested that adolescents who had never smoked cigarettes but had used ENDS were more likely to subsequently smoke conventional cigarettes regularly than those who had never used conventional cigarettes or ENDS (Bold et al., 2018; Wills et al., 2016, 2017).

Many conventional cigarette smokers use ENDS as a potential harm reduction strategy and a smoking cessation aid (Goniewicz et al., 2013; Hecht et al., 2015; Rhoades et al., 2019). Studies suggested that the primary reason for ENDS use among adults was smoking cessation, followed by less second-hand smoke and chemical exposure to others, and convenience (Etter & Bullen, 2011; Patel et al., 2016). Some studies also indicated that ENDS use might expose users to fewer toxins and carcinogens than conventional cigarettes (Goniewicz et al., 2013; Hecht et al., 2015). Although these studies suggested positive perceptions about ENDS, the benefits of ENDS for successful smoking cessation is inconclusive due to the lack of conclusive data and methodological limitations (Bell & Keane, 2012; Benowitz et al., 2017; Maziak, 2014). However, the majority of public health researchers and the medical community in the U.S. remain concerned regarding the safety and harmful health effects of ENDS, their utility as smoking cessation devices, and their potential as a gateway to future use of conventional tobacco products and marijuana. (Crowley, 2015; Dai et al., 2018; National Academies of Sciences, Engineering, and Medicine et al., 2018; U.S. Department of Health & Human Services, 2016).

Although Asian Americans have the lowest prevalence of any tobacco use compared to other racial groups (Nguyen, 2019; Odani, 2018), ENDS use among Asian American communities is a growing concern (Chen et al., 2017; Huh & Leventhal, 2016; Maglalang et al., 2016; Nguyen, 2019). A study found that the risks of ENDS initiation increased sharply after age 17 for Asian American youth (Chen et al., 2017). A national survey suggested that, among Asian American sub-ethnic groups, ENDS ever use was high for Japanese (20.74%), Filipinos (18.01%) and Koreans (17.85%) (Nguyen, 2019). Another study suggested that ENDS ever use was higher among Filipinos (53%) and Vietnamese (53%) compared to Chinese (31%) (Maglalang et al., 2016). Moreover, dual use of ENDS and conventional cigarette is particularly a concern among certain sub-ethnic groups of Asian Americans (Huh & Leventhal, 2016). For example, a study suggested that ENDS use is linked with conventional cigarette smoking among Korean American young adults, and that conventional cigarette smoking craving played a role in dual use of ENDS and conventional cigarettes among female Korean Americans (Huh & Leventhal, 2016). Taken together, these prior studies suggested some patterns of ENDS use and dual use of ENDS and conventional cigarettes among Asian Americans.

While the prevalence of cigarette smoking among Asian Americans declined over the past decade and Asian Americans have the lowest current cigarette smoking prevalence across various races and ethnic groups in the United States (Martell et al., 2016), ENDS use continues to gain popularity among Asian Americans (U.S. Department of Health & Human Services, 2016; Wu et al., 2013). Since ENDS use is linked to future cigarette smoking behavior, tobacco dual use, and nicotine dependence, increased ENDS use prevalence may contribute to future tobacco-related morbidities and mortalities among Asian Americans. Thus, to further protect the health of Asian Americans and maintain this group’s low tobacco use status, research is needed to examine this group’s ENDS use patterns as related to their conventional cigarette smoking behavior, as well as whether ENDS use is associated with nicotine addiction. Little is known, however, about the patterns and associations of ENDS use and conventional cigarette smoking among Asian Americans due to limited data availability (Lew & Tanjasiri, 2003). As mentioned earlier, to date very few studies have examined ENDS use among Asian Americans (Huh & Leventhal, 2016; Maglalang et al., 2016; Nguyen, 2019; Wills et al., 2015). These studies have either focused on individual Asian American ethnic groups or relied on a convenient, local sample. Thus, it is important to examine ENDS use at a national level using more generalized Asian American samples. Therefore, to fill the research gap, this study examined the associations between 1) ENDS use and conventional cigarette smoking, and 2) ENDS use and nicotine addiction among Asian Americans, using the 2013-2014 National Adult Tobacco Survey.

METHODS

Data Source

Data were obtained from the 2013-2014 National Adult Tobacco Survey (NATS), a stratified, random digit-dialed telephone survey of non-institutional adults 18 years of age and older residing in the 50 states and District of Columbia (DC) in the United States (Centers for Disease Control and Prevention, 2018). The survey was conducted from October 2013 to October 2014 (Centers for Disease Control and Prevention, 2016). The purpose of the survey was to determine the prevalence and correlates of tobacco use behavior among a nationally representative sample of U.S. adults (Centers for Disease Control and Prevention, 2016; Centers for Disease Control and Prevention and Food and Drug Administration, 2015). The response rate of the 2013-2014 NATS was 36.1%, and 75,233 participants in the sample completed the survey (Centers for Disease Control and Prevention, 2016).

Sample Characteristics

From a total sample of 75,233 cases in the 2013-2014 NATS, non-Hispanic Asian samples were included in the study following the Office of Management and Budget (OMB)’s definition of non-Hispanic Asian (Government Printing Office, 1997). As a result, from the total study sample, 1,956 non-Hispanic Asian samples were obtained, which accounted for approximately 2.60% of the total sample. The sample was weighted with a multiple-stage process, and the total number of weighted Asian American samples was 8,106,892.

The institutional review board (IRB) of the University of Maryland reviewed and exempted this research for “human participant research.”

Measures

Questionnaires used in the NATS were designed in accordance with the Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs by the U.S. Centers for Disease Control and Prevention (CDC)’s Office on Smoking and Health (OSH) (Centers for Disease Control and Prevention, 2011, 2016). Questionnaires were cognitively tested in two phases with individuals from a variety of demographic backgrounds before fielding the final survey instrument (Centers for Disease Control and Prevention, 2011, 2016). More details about how questionnaires were created can be found at the following link: https://www.cdc.gov/tobacco/data_statistics/surveys/nats/index.htm (Centers for Disease Control and Prevention, 2011, 2016).

ENDS Awareness

Awareness of ENDS was assessed using the question: “Before today, had you ever heard of electronic cigarettes or e-cigarettes?” Responses were binary (Yes/No).

ENDS Ever Use

ENDS ever use was assessed using the question: “Have you ever used an electronic cigarette, even just one time in your entire life?” Responses were binary (Yes/No). The question was given only to respondents who had heard of electronic cigarettes or e-cigarettes.

Current ENDS Use

Current ENDS use status was assessed using the question: “Do you now use electronic cigarettes every day, some days, rarely or not at all?” Initial responses were 4-level responses (Every Day/Some Days/Rarely/Not at all). The variable was re-coded into the binary responses (Yes/No). Responses with Every Day and Some Days were re-coded into Yes, and responses with Rarely and Not at All were re-coded into No. This question was asked to respondents who had ever used ENDS.

Flavored ENDS Use

The use of flavored ENDS was assessed using the question: “Were any of the electronic cigarettes that you used in the past 30 days flavored to taste like menthol, mint, clove, spice, candy, fruit, chocolate, or other sweets?” Responses were binary (Yes/No).

Lifetime Cigarette Smoking Status

Lifetime cigarette smoking status was assessed using the question: “Have you smoked at least 100 cigarettes in your entire life?” Response for the lifetime smoking question was binary (Yes/No).

Current Cigarette Smoking

Current cigarette smoking is defined as conventional cigarette smoking. It was assessed using the question: “Do you now smoke cigarettes every day, some days, or not at all?” Responses for current smoking status had 3-level responses (Every Day/Some Days/Not At All). The responses were re-coded into the binary responses (Yes/No). Every Day and Some Days responses were re-coded into Yes, and Not At All response was re-coded into No.

Nicotine Addiction

Nicotine addiction measures were assessed using five items that are related to nicotine craving and withdrawal symptoms. These items were frequently used by prior studies to assess nicotine dependence among U.S. adults and adolescents (Apelberg et al., 2014; Liu et al., 2017; Rostron et al., 2016; Sung et al., 2018). Questions included: “Do you sometimes wake up at night in order to have a cigarette or other tobacco product?”; “During the past 30 days, have you had a strong craving to use tobacco products of any kind?”; “During the past 30 days, did you ever feel like you really needed to use a tobacco product?”; “During the past 30 days, was there a time when you want to use a tobacco product so much that you found it difficult to think of anything else?”; and “After not using tobacco for a while, would you say you feel restless and irritable?” Four questions used binary responses (Yes/No). The question about feeling restless and irritable used a four-level responses (Not at all true/Sometimes true/Often true/Always true); the responses were then re-coded into the binary response (Yes/No). Always true, Sometimes true and Often true were re-coded into Yes, and Not at all true was re-coded into No. These questions were asked to respondents who currently use any tobacco product.

Sociodemographic Measures

Key socioeconomic covariates of this study included age, sex, household income, and employment. Selection of key socioeconomic measures was based on covariates tested in a past study investigating ENDS use among Asian Americans (Maglalang et al., 2016). Age was re-coded into the 5-category response (18-29 years/30-39 years/40-49 years/50-64 years/65+ years). Sex was coded into the binary response (Male/Female). Household income was recoded into 3-level responses (Income<$50,000/$50,000<= Income <$100,000/Income over $100,000). Employment was recoded into the binary response (Employed/Unemployed). Education was re-coded into the 4-level response (Less than High School/Some College or Less than Bachelor’s Degree/Bachelor’s Degree/Postgraduate Degree). Specific response categories for each sociodemographic measure are listed in Table 1

Table 1.

Respondent or Participant Characteristics of ENDS Awareness and Use, NATS 2013-2014

Variable weighted (N=1956, Weighted N=8,106,892)	Heard About ENDS, % of Yes, sea, (N=1,634)b	Ever Used ENDSc, % of Yes, sea (N=212)	Using ENDS Every Day or Some Daysd, % of Yes, Sea (N=79)	Using Flavored ENDSe, % of Yes, sea (N=58)
Gender
Male	54.77 (1.54)**	68.02 (3.93)**	77.33 (5.29)**	78.10 (5.22)
Female	45.23 (1.54)**	31.98 (3.93)**	22.67 (5.29)**	21.90 (5.22)
Age in years
18-29 Years	34.23 (2.01)*	48.21 (4.15)**	44.48 (6.24)	46.83 (5.96)
30-39 Years	24.12 (1.64)*	28.49 (3.75)**	34.57 (7.03)	35.75 (6.86)
40-49 Years	18.04 (1.33)*	10.84 (2.34)**	7.20 (2.89)	7.19 (2.40)
50-64 Years	17.90 (1.53)*	11.64 (2.68)**	13.22 (4.49)	9.54 (3.46)
65+ Years	5.71 (0.70)*	0.82 (0.38)**	0.54 (0.54)	0.69 (0.70)
Household income in dollars
Income < $50,000	30.60 (1.90)	42.10 (4.95)*	40.70 (8.38)	42.50 (9.58)
$50,000 <= Income < $100,000	33.19 (1.71)	29.97 (4.12)*	30.60 (7.90)	30.33 (9.63)
Income over $100,000	36.21 (1.80)	27.93 (4.72)*	28.70 (7.75)	27.17 (6.38)
Employment
Employed in Part-Time or Full-Time/Self-Employed	73.99 (1.42)**	76.84 (4.11)	82.92 (4.56)	84.39 (4.77)
Unemployed	26.01 (1.42)**	23.16 (4.11)	17.08 (4.56)	15.61 (4.77)
Education
Less than High School and High School or Equivalent	20.31 (1.60)	32.07 (4.05)**	45.14 (6.96)*	54.93 (6.47)**
Some College or Less than Bachelor’s Degree	20.35 (1.28)	27.78 (3.74)**	24.20 (5.77)*	24.98 (6.29)**
Bachelor’s Degree	31.40 (1.50)	25.71 (3.27)**	22.75 (5.20)*	15.99 (3.51)**
Postgraduate Degree	27.93 (1.30)	14.44 (2.61)**	7.91 (2.83)*	4.10 (1.82)**

^a.standard error of percent

^b.33 missing cases

^c.Respondents were those who had ever heard about ENDS

^d.Respondents were those who had ever used ENDS

^e.Respondents were those who had used ENDS every day, some days or rarely

^*p<0.05

^**p<0.01

Note: Sum of percentage may not be exactly 100% because of decimal rounding

Analysis

The univariate analysis was first employed to examine the descriptive statistics of the study sample to see the distribution of samples. The bivariate analysis with chi-square tests was then employed to identify the difference in ENDS ever use and sociodemographic characteristics, comparing both between ENDS ever use and conventional cigarette use, and ENDS ever use and nicotine addiction. Lastly, multivariate logistic regressions were employed to determine the association between ENDS ever use and sociodemographic characteristics, both between ENDS use and conventional cigarette use and between ENDS ever use and nicotine addiction. Proc surveyfreq and proc surveylogistic procedures in SAS were used, and the final weight of sample and sample design stratification variables were included in all models to calculate a national estimate of Asian American samples in the survey. SAS ver.9.4 statistical software (SAS Institute Inc., Cary, NC) was used for all data analyses.

RESULTS

Table 1 shows the selected descriptive characteristics of ENDS awareness and use. Overall, 84.0% (N=1,634) of all Asian American respondents (n=1,956) had heard of ENDS, and about 13.0% (N=212) of those who had heard of ENDS before had ever used ENDS. Among those who had ever used ENDS, 37.3% (N=79) of them used ENDS every day or some days. Further, 74.4% (n=58) of ENDS users used flavored ENDS. About 68.0% (n=144) of Asian American males who ever tried ENDS, and 77% (n=58) of Asian American males who ever tried ENDS were current ENDS users (p<0.05). More than half of younger Asian Americans (ages 18-39) ever used ENDS (p<0.05). Among Asian American every day or some days ENDS users, about 58% were dual users of ENDS and conventional cigarettes (p<0.05). The majority of those who ever used ENDS reported more nicotine addiction symptoms than non-ENDS users who had heard about ENDS (p<0.05). Chi-square results in the study showed that employment and ENDS ever use were not significantly related, X² (1, N=557) = 1.23, p>0.05. Thus, the employment variable was excluded from the logistic regression model.

The results of logistic regressions for ENDS use and sociodemographic characteristics are listed in Table 2 Asian American males were more likely to ever use ENDS, compared to Asian American females (AOR=2.19, p<0.05, 95% CI=1.35, 3.55). Asian American samples who are between 18 and 29 years old were more likely to use ENDS (AOR= 24.61, p<0.05, 95% CI=4.92, 123.09), and Asian American samples between 30 and 39 years old were more likely to use ENDS (AOR= 28.06, p<0.05, 95% CI=5.48, 143.67), compared to Asian American samples over 65 years old. Asian American samples with a Bachelor’s Degree were more likely to use ENDS, compared to Asian American samples with high school or less education (AOR=0.44, p<0.05, 95% CI=0.24, 0.81). Asian American samples with a postgraduate degree were more likely to use ENDS, compared to Asian American samples with high school or less education (AOR=0.29, p<0.05, 95% CI=0.14, 0.58). The results of bivariate analysis of ENDS ever use, conventional cigarette smoking, and nicotine addiction showed that approximately 10.6% of ENDS users were current smokers, and that 64.2% of ENDS users smoked 100 or more cigarettes in lifetime (Table 3). About 68.9% of Asian American respondents who ever used ENDS had strong cravings for tobacco products (p<0.05), about 71.6% felt a strong need for tobacco products (p<0.05), about 83.9% wanted to use tobacco products and felt difficulty concentrating (p<0.05), and about 69.1% felt restless and irritable (p<0.05). The results of logistic regression for ENDS use, conventional cigarettes, and nicotine addiction are listed in Table 4 Asian Americans who ever used ENDS were more likely to smoke conventional cigarettes currently every day or some days (AOR=18.42, p<0.05, 95% CI=5.83, 58.23), and were more likely to smoke 100 or more cigarettes in a lifetime (AOR=9.15, p<0.05, 95% CI=4.77, 17.57). Controlling for sex, age, income, and education, those who ever used ENDS were more likely to want to use tobacco products and to feel difficulty concentrating (AOR=5.71, p=<0.05, 95% CI=1.72, 18.89).

Table 2.

The Results of Logistic Regressions between ENDS Use and Selected Sociodemographic characteristics, NATS 2013-2014

	Ever Used ENDSa, OR (95% CI)
	Unadjusted OR	Adjusted OR
Gender
Male	1.94* (1.33, 2.82)	2.19 (1.35, 3.55)*
Female (ref)
Age in years
18-29Years	12.27 (4.56, 32.98)*	24.61 (4.92, 123.09)*
30-39 Years	9.84 (3.58, 27.03)*	28.06 (5.48, 143.67)*
40-49 Years	4.50 (1.53, 13.25)	11.25 (2.11, 59.86)
50-64 Years	4.91 (1.66, 14.54)	10.46 (1.98, 55.26)
65+ Years (ref)
Household income in dollars
Income < $50,000 (ref)
$50,000 <= Income < $100,000	0.59 (0.36, 0.98)*	0.78 (0.45, 1.36)
Income over $100,000	0.50 (0.45, 0.85)*	0.86 (0.46, 1.62)
Education
Less than High School and High School or Equivalent (ref)
Some College or Less than Bachelor Degree	0.83 (0.50, 1.37)	1.04 (0.54, 2.00)
Bachelor Degree	0.45 (0.29, 0.71)*	0.44 (0.24, 0.81)*
Postgraduate Degree	0.27 (0.16, 0.46)*	0.29 (0.14, 0.58)*

^*p<0.05

^a.Asked of respondents who heard about ENDS

Table 3.

Bivariate Analysis of ENDS Ever Used, Conventional Cigarette Smoking and Nicotine Addiction, NATS 2013-2014

		Conventional Cigarette Smoking		Nicotine Addiction
	All Samples, % (N=1,956)	Current Cigarette Smoking	Smoke 100 or more Cigarettes in Lifetime	Awaken at Night	Strong Craving for Tobacco Products*	Strong Need for Tobacco Products*	Want to Use & Difficult to Concentrate**	Feeling Restless and Irritable*
		% of Yes, Sea	% of Yes, Sea	% of Yes, Sea	% of Yes, Sea	% of Yes, Sea	% of Yes, Sea	% of Yes, Sea
Ever Used ENDSb†
Yes	12.98	10.57 (1.93)**	64.19 (4.85)**	72.06 (9.53)	68.86 (6.03)*	71.58 (5.84)*	83.88 (7.27)**	69.13 (5.29)*
No	87.02	89.42 (1.93)**	35.81 (4.85)**	27.4 (9.53)	31.14 (6.03)*	28.42 (5.84)*	16.12 (7.27)**	30.87 (5.29)*

^a.standard error of percent

^b.Asked of respondents who heard about ENDS

^†323 missing cases

^*p<0.05

^**p<0.01

Note: Sum of percentage may not be exactly 100% because of decimal rounding

Table 4.

The Results of Logistic Regressions for ENDS Use, Conventional Cigarette Smoking, and Nicotine Addiction, NATS 2013-2014

	Current Cigarette Smoking, OR (95%CI)		Smoke 100 or More Cigarettes in Lifetime, OR (95% CI)
	Unadjusted OR	Adjusted OR	Unadjusted OR	Adjusted OR
Ever Used ENDS
No (Ref)
Yes	15.78 (6.22, 40.00)*	18.42 (5.83, 58.23)*	7.54 (4.67, 12.18)*	9.15 (4.77, 17.57)*
	Awaken at Night, OR (95% CI)		Strong Craving for Tobacco Products, OR (95% CI)		Strong Need for Tobacco Products, OR (95% CI)		Want to Use & Difficult to Concentrate, OR (95% CI)		Feeling Restless and Irritable, OR (95% CI)
	Unadjusted OR	Adjusted OR	Unadjusted OR	Adjusted OR	Unadjusted OR	Adjusted OR	Unadjusted OR	Adjusted OR	Unadjusted OR	Adjusted OR
Ever Used ENDS
No (Ref)
Yes	2.01 (0.77, 5.23)	2.35 (0.64, 8.69)	1.94 (1.01, 3.70)*	1.75 (0.75, 4.08)	2.29 (1.16, 4.52)*	2.39 (0.98, 5.79)	3.98 (1.40, 11.28)*	5.71 (1.72, 18.89)*	2.24 (1.19, 4.20)*	1.88 (0.85, 4.17)

Control variables: gender, age, income, education

^*p<0.05

DISCUSSION

First, the current study provides a snapshot of the associations between ENDS use and conventional cigarette smoking, and between ENDS use and nicotine addiction among Asian American samples in the United States. More Asian Americans who ever tried ENDS were dual users of ENDS and conventional cigarettes, and had some nicotine addiction symptoms, compared to Asian American non-ENDS users. Consistent with past literature, findings in the current study suggested some linkage between ENDS use and conventional cigarette smoking (Alcalá et al., 2016; Delnevo et al., 2016; Huh & Leventhal, 2016; Primack et al., 2015; Rodu & Plurphanswat, 2018). Although findings in the current study cannot determine if ENDS was used as an alternative to conventional cigarettes or if ENDS use leads to conventional cigarette use among Asian Americans, the dual use of ENDS and conventional cigarettes may be common among Asian Americans. For example, findings in the current study suggested that about 58% of Asian American every day or some days ENDS users were also smoking conventional cigarettes. Moreover, the results showed that tobacco product cravings and some nicotine addiction symptoms may play a role in dual use of ENDS and conventional cigarettes among Asian Americans. Findings in the current study were similar to those of Huh and Leventhal (2016) who suggested that potential nicotine symptoms like conventional cigarette cravings exist and may play a role in dual use of ENDS and conventional cigarette smoking. While Huh and Leventhal (2016) examined dual use and addiction among Korean Americans in California, the current study and represented more generalized Asian American samples in the United States.

Second, the current study suggested that differences exist between Asian American males and females with respect to ENDS use behavior. Findings in the current study align with past studies that showed that ENDS use is higher among Asian American males than Asian American females (Maglalang et al., 2016; Nguyen, 2019). One possible explanation for these findings is that most Asian cultures consider female smoking to be socially unacceptable (Huh et al., 2013; Maxwell et al., 2005; Morrow & Barraclough, 2010). Some studies suggested that the risk of any form of tobacco use increases among Asian American immigrant females as they acculturate to U.S. culture (An et al., 2008; Huh et al., 2013; Ma et al., 2004; Zhang & Wang, 2008). Another possible explanation is that sex-specific beliefs, preferences, and perceived risks toward ENDS may also influence differences between males and females in ENDS use (Piñeiro et al., 2016; Zhu et al., 2013). For example, males reported using ENDS to help them quit smoking conventional cigarettes, to enjoy the taste of ENDS, and due to health concerns associated with conventional cigarettes (Piñeiro et al., 2016). In contrast, females reported using ENDS due to positive perceptions of taste and a reduction in nicotine cravings due to ENDS flavoring (Zhu et al., 2013). Therefore, future studies need to investigate how these acculturation factors, sex-specific beliefs, perceived risks and perceptions toward ENDS use influence ENDS use behavior among Asian Americans; these factors, beliefs, and perceptions need to be taken into consideration in delivering appropriate sex-specific contexts and messages.

Third, findings in the current study indicated that ENDS use was more prevalent among Asian American younger generations between the ages of 18 and 39 than among older Asian American generations. Consistent with past studies, findings in the current study indicated that ENDS use was a more popular behavior among young adults than older Asian American adults (Huh & Leventhal, 2016; King et al., 2015; Maglalang et al., 2016; Rodu & Plurphanswat, 2018; Schoenborn & Gindi, 2015). These results suggested that Asian American young adults may also be at risk of ENDS use similar to young adults in other racial groups (Soneji et al., 2017). Although the results of logistic regression on age were statistically significant, we found wide confidence intervals due to a small cell size. Therefore, interpretation of these results needs further investigation. Future surveillance needs to include larger samples from diverse age groups of Asian Americans. It is necessary that researchers replicate the study on age differences in ENDS use among Asian Americans and investigate how the age differences impact Asian American communities.

Finally, the findings of the current study that higher educational attainment is protective against ENDS use is similar to previous studies on other racial groups (Assari et al., 2020; Stallings-Smith & Ballantyne, 2019). High educational attainment lowers prevalence of smoking conventional cigarettes and END use among racial minority groups (Harlow et al., 2019). These findings suggest that educational differences may contribute to widening disparities in ENDS use. Therefore, differences in educational attainment should be regarded as a contributor to ENDS use among Asian Americans.

This study is not without limitations. First, the cross-sectional data only provides a snapshot of ENDS use patterns. Causality with respect to whether ENDS use precedes conventional cigarette smoking or vice versa, and whether ENDS use causes addictive behavior among Asian American samples or vice versa, cannot be established. Second, the NATS survey was exclusively conducted in English, so it may have excluded Asian American samples with limited English proficiency. Past and current national health surveys underestimated the Asian American population’s ENDS use and smoking status and may have excluded people with limited English reading, writing, and speaking capacities; therefore, critical gaps need to be addressed in understanding patterns and associations of ENDS use among foreign-born Asian immigrants with limited English proficiency levels. Lastly, our study was not able to explore reasons for ENDS use among Asian American adults. To date, very few studies have examined Asian American adults’ ENDS use behavior and their reasons for ENDS use. In general, adults use ENDS as a strategy for reducing harm from conventional cigarettes, although the evidence is insufficient (Maziak, 2014; Patel et al., 2016; Pearson et al., 2012). However, different races may have culture-specific ENDS use experiences. Thus, more studies that examine cultural and social factors that influence ENDS use behavior among Asian American adults are needed.

CONCLUSION

In conclusion, the present study provides evidence that ENDS use may be associated with increased risk of conventional cigarette smoking and/or dual use of ENDS and conventional cigarettes among Asian Americans. Asian American ENDS users in this study were more likely to be dual users of ENDS and conventional cigarettes and had higher levels of nicotine addiction symptoms, compared to Asian American non-ENDS users. ENDS use may result in increased addiction to other tobacco products and marijuana. Furthermore, the study findings indicate that ENDS use was more prevalent among Asian American men who are less than 40 years old. The study also provided some evidence of patterns of sociodemographic differences in ENDS use among Asian Americans. Further monitoring of age, sex, and education level differences among Asian Americans, using larger samples of Asian Americans with limited English proficiency, may provide meaningful information for culturally appropriate nicotine dependence intervention. Future surveillance and research efforts need to collect more diverse Asian American sub-ethnic group samples to fill the current gaps in ENDS research and to better understand ENDS use patterns and associated outcomes. Future research also needs to explore factors associated with dual use behavior among Asian Americans, while expanding the current findings.