Negative health symptoms reported by youth e-cigarette users: Results from a national survey of US youth

Abstract

Background:

E-cigarettes are the most prevalent tobacco product among US youth, but little is known about the health symptoms users experience.

Methods:

Between August 2016 and May 2017, we conducted a nationally representative cross-sectional telephone survey of 975 US youth ages 13–17. Respondents who reported ever trying e-cigarettes were asked whether they ever experienced six physical health symptoms they thought were caused by e-cigarette use. We examined whether symptoms varied by demographics and tobacco use.

Results:

Approximately 12.4% of respondents (n = 141) reported ever trying e-cigarettes. Of lifetime e-cigarette users, 37.0% reported past 30-day e-cigarette use, 17.2% reported past 30-day cigarette use, and 23.7% reported past 30-day use of another tobacco product. Most (63.3%) reported a symptom, most often cough (42.3%), followed by dizziness or lightheadedness (31.5%), headache or migraine (25.4%), dry or irritated mouth or throat (14.9%), shortness of breath (13.7%), change in or loss of taste (3.5%), and other (5.7%; nausea, dry eyes, earache, and tight chest). Headaches were more common among past 30-day e-cigarette users than non-users (43.8% vs. 14.6%). Shortness of breath was more common among past 30-day cigarette (33.8% vs. 9.5%) and other tobacco users (31.6% vs. 8.2%). Past 30-day cigarette users were also more likely to report any symptom (86.0% vs. 58.6%).

Conclusions:

Most youth e-cigarette users attribute health symptoms to their e-cigarette use. Past 30-day users were more likely to report certain symptoms than non-users. Findings can educate health practitioners and school nurses about common symptoms youth may experience and inform prevention messages.

1. Introduction

Electronic cigarettes (e-cigarettes) are the most prevalent tobacco product used among US youth, with 27.7% reporting past 30-day use in 2018, according to the National Youth Tobacco Survey (Cullen, 2018; Wang, 2018). Youth report using e-cigarettes because of friend or family use, availability of flavors, and because they are less harmful than other tobacco products (Tsai et al., 2018). Additionally, polytobacco use is common among youth e-cigarette users, with over 40% reporting using e-cigarettes and at least one other tobacco product in the past 30 days (King et al., 2018; Lee et al., 2018; Osibogun, Taleb, Bahelah, Salloum, & Maziak, 2018).

Previous research has highlighted potential health outcomes adult e-cigarette users may report experiencing, including pulmonary disease and myocardial infarction (King et al., 2019; Pisinger & Døssing, 2014; Soule, Nasim, & Rosas, 2016). However, the National Academies of Science, Engineering, and Medicine Report (NASEM) examined 800 articles and concluded additional research is needed to fully understand the health effects of e-cigarettes (National Academies of Sciences, 2018). The only youth-specific conclusion in the NASEM report found moderate evidence for increased coughing, wheezing, and asthma ex-acerbations (National Academies of Sciences, 2018). More recently, the US Food and Drug Administration announced that some e-cigarette users reported experiencing seizures, with most reports involving youth and young adults (US Food and Drug Administration, 2019).

To date, most studies have focused on health outcomes associated with e-cigarette use. Health outcomes may be reflected in physical health symptoms self-reported by e-cigarette users. Few studies have examined health symptoms among youth, most of which examined youths’ first experiences. In a study of 29 ever e-cigarette using youth, approximately 25% reported feeling bad, coughing, or dizziness after their first use (Chen et al., 2017). A study of Texas youth’s first experiences with e-cigarettes found 15% reported coughing and 4% reported dizziness (Mantey et al., 2017). A study among California youth examined associations between e-cigarette use and wheezing or symptoms of bronchitis, and found youth who used e-cigarettes had increased rates of bronchitis symptoms (i.e., chronic cough, phlegm) (McConnell et al., 2017). We extend this work by examining the prevalence of self-reported negative health symptoms attributed to any e-cigarette use among a national sample of US youth. Identifying the negative health symptoms that may precede health outcomes is important for informing education and regulation of e-cigarettes.

2. Methods

2.1. Participants and procedures

From August 2016 through May 2017, we conducted a nationally representative cross-sectional telephone survey of 975 US youth; the weighted response rate was 33% (Agans et al., 2018; Jeong et al., 2019). To recruit youth, the Carolina Survey Research Laboratory (CSRL) at University of North Carolina (UNC) recruited a probability sample of adults living in the US using two independent and non-overlapping random-digit-dial landline and cell phone frames. Coverage extended to 98% of all US households. Additional details on sampling design, sampling weights (estimated from the American Community Survey) and adjustments, and sample characteristics are published elsewhere (Agans et al., 2018; Boynton et al., 2016). The CSRL recruited youth participants through the adult households and from a supplemental electronic white page frame targeting households with 13–17 year olds. Before contacting youth, interviewers obtained verbal informed consent from the parent or guardian. Youth provided verbal assent prior to completing the survey. Further details are published elsewhere (Jeong et al., 2019). The UNC Institutional Review Board approved this study.

2.2. Measures

Participants were read text introducing e-cigarettes: “The next few questions are about electronic or e-cigarettes and other vaping devices, such as vape pens. Popular brands include Blu, Vuse, NJOY, and Flavor Vapes.” Next, we asked participants whether they ever used an e-cigarette or other vaping device, even one or two times. We asked participants who ever used an e-cigarette “Have you ever experienced any of the following symptoms or side effects you think were caused by using e-cigarettes or other vaping devices” prior to listing six specific symptoms and an open-ended “other” option. The six health symptoms were cough, dizziness or lightheadedness, headache or migraine, dry or irritated mouth or throat, shortness of breath, and change in or loss of taste. Participants responded “yes” or “no” following each symptom. We identified the six health symptoms through a two-stage process involving a literature review and convenience sample survey, the details of which are described elsewhere (King et al., 2019).

We asked participants who reported ever using cigarettes, e-cigarettes, hookah, or little cigars/cigarillos how many of the past 30 days they used that particular product. We later asked on how many of the past 30 days participants used any other tobacco products, including chewing tobacco, dip, snus, premium cigars or any other tobacco. We compared health symptoms of those who reported past 30-day use of e-cigarettes, cigarettes, and any other products (hookah, little cigars or cigarillos, other tobacco; combined due to low rates of use) compared to not reporting past 30-day use. We examined whether using more than one tobacco product (polytobacco use) was associated with likelihood of reporting symptoms compared to using only one product or zero products. We examined demographic characteristics (age, sex, race, ethnicity, mother’s education) using standard items previously cognitively tested (Boynton et al., 2016).

2.3. Analyses

We calculated descriptive statistics to describe the sample’s demographic characteristics, tobacco use, and health symptoms. We estimated weighted percentages using PROC SURVEYFREQ and weighted means using PROC SURVEYMEANS in SAS V9.4 to account for sampling design features. The number of symptoms reported by demographic and tobacco use factors were estimated using PROC SURVEYREG and compared using F-tests. The prevalence of individual symptoms by demographic and tobacco use factors was estimated using PROC SURVEFREQ and compared using Rao-Scott Chi-Square tests. All tests were two-sided with a 0.05 significance level.

3. Results

Of 975 youth surveyed, 12.4% reported ever using e-cigarettes. Thus, our analytic sample consisted of 141 ever e-cigarette users, from 34 of 50 US states. Participants were 39.8% female, 80.6% white, with mean age 16.0. Less than half (37.0%) reported past 30-day e-cigarette use. See Table 1 for additional sample characteristics.

Table 1.

Sample Characteristics, n = 141.

	Unweighted n (Weighted %)
Age	16.0 (0.1)
Sex
Male	55 (39.8%)
Female	85 (60.2%)
Race
Nonwhite	20 (19.4%)
White	121 (80.6%)
Ethnicity
Non-Latino	136 (93.1%)
Latino	5 (6.9%)*
Mother’s Education
< 4 Year Degree	47 (32.4%)
≥4 Year Degree	94 (67.6%)
Past 30-day E-cig Use
No	91 (63.0%)
Yes	50 (37.0%)
Past 30-day Cigarette Use
No	120 (82.8%)
Yes	21 (17.2%)
Past 30-day Other Tobacco Use
No	107 (76.3%)
Yes	34 (23.7%)
Polytobacco Use
0 Products (past 30 days)	109 (52.2%)
1 Product	10 (25.4%)
2+ Products	29 (22.4%)

Note:

^*indicates cell count < 5.

Over half (63.3%) of youth ever e-cigarette users attributed one or more symptoms to their e-cigarette use (range 0–5 symptoms). On average, youth reported 1.4 (SE = 0.2) symptoms, most frequently cough (42.3%), dizziness or lightheadedness (31.5%), headache or migraine (25.4%), dry or irritated mouth or throat (14.9%), and shortness of breath (13.7%; see Table 2). Few youth reported change in or loss of taste (3.5%) or other symptoms (5.7%), including nausea, dry eyes, earache, and tight chest; these were excluded from further analyses due to small sample sizes (n < 5).

Table 2.

Symptoms Reported among Ever E-Cigarette Users (Weighted).

	Any Symptom % (95% CI)	Cough % (95% CI)	Dizziness or Lightheadedness % (95% CI)	Headache or Migraine % (95% CI)	Dry or Irritated Mouth or Throat % (95% CI)	Shortness of Breath % (95% CI)
All Participants n (%)	84 (63.3%)	62 (42.3%)	37 (31.5%)	31 (25.4%)	20 (14.9%)	15 (13.7%)
Age (mean age)	15.9 vs 16.0	15.9 vs 16.1	16.1 vs 15.8	16.0 vs 15.8	16.0 vs 15.9	16.0 vs 15.7
Sex
Female	73.1 (59.8–86.4)	51.5 (34.0–69.0)	41.7 (23.2–60.1)	27.0 (11.4–42.6)	14.7 (2.1–27.4)	7.4 (0.1–14.6)*
Male	56.3 (42.4–70.2)	35.4 (22.1–48.7)	23.9 (11.4–36.4)	24.7 (11.7–37.7)	15.1 (4.8–25.5)	18.1 (5.6–30.6)
Race
Nonwhite	62.9 (41.0–84.8)	43.9 (16.1–71.7)	36.3 (8.9–63.7)	19.6 (0.0–40.1)*	8.3 (0.0–24.9)*	15.6 (0.0–36.9)*
White	63.4 (52.3–74.4)	41.9 (29.9–53.8)	30.3 (19.2–41.5)	26.8 (15.9–37.8)	16.4 (7.5–25.4)	13.2 (4.8–21.7)
Ethnicity
Non-Latino	64.6 (55.0–74.3)	42.1 (31.0–53.1)	33.8 (22.8–44.8)	27.3 (17.2–37.4)	14.9 (6.9–23.0)	14.7 (6.0–23.4)
Latino	24.4 (0.0–93.5)*	45.2 (0.0–93.5)*	–	–	13.8 (0.0–40.9)*	–
Mother’s Education
< 4yr degree	56.0 (38.6–73.5)	35.2 (16.6–53.9)	20.7 (4.1–37.4)	17.2 (4.5–30.0)	21.8 (6.8–36.7)	19.0 (4.0–34.1)
4 year degree+	66.8 (55.2–78.4)	45.7 (32.4–58.9)	36.7 (23.6–49.7)	29.4 (16.8–41.9)	11.6 (1.9–21.2)	11.2 (1.9–20.4)
E-cig Use Status
Ever User	58.1 (44.6–71.6)	43.3 (29.3–57.3)	25.6 (12.2–39.0)	14.6 (4.2–25.0)	12.5 (3.6–21.3)	8.6 (0.4–16.8)
Past 30-Day User	72.1 (59.2–84.9)	40.5 (23.4–57.6)	41.6 (24.4–58.7)	43.8 (28.0–59.6)	18.9 (3.7–34.1)	22.4 (6.4–38.5)
Cigarette Use Status
Non User	58.6 (47.3–69.8)	38.4 (26.7–50.1)	26.8 (15.6–38.1)	23.2 (13.0–33.5)	13.0 (4.6–21.5)	9.5 (2.3–16.8)
Past 30-Day User	86.0 (76.1–95.9)	61.1 (34.0–88.1)	53.9 (25.5–82.3)	36.0 (10.1–62.0)	23.6 (0.6–46.6)	33.8 (5.3–62.3)
Other Tobacco Use
Non User	60.7 (49.1–72.4)	40.1 (27.5–52.7)	26.5 (14.8–38.3)	22.6 (11.7–33.4)	13.9 (4.8–23.0)	8.2 (0.9–15.4)
Past 30-Day User	71.4 (57.1–85.8)	49.4 (27.6–71.2)	47.6 (25.4–69.7)	34.7 (14.1–55.2)	18.0 (1.0–35.1)	31.6 (9.3–54.0)
Polytobacco Use
0 Products (past 30 days)	56.5 (41.2–71.7)	42.8 (27.0–58.6)	20.5 (6.2–34.8)	11.7 (1.7–21.7)	13.2 (2.8–23.5)	4.6 (0.0–10.0)*
1 Product	64.7 (47.1–82.3)	30.7 (13.5–47.9)	35.2 (15.8–54.7)	41.4 (21.2–61.7)	12.4 (0.0–28.9)*	14.9 (0.0–32.2)*
2+ Products	77.6 (65.1, 90.0)	54.2 (31.7–76.8)	52.9 (29.8–75.9)	39.1 (17.8–60.5)	21.6 (3.0–40.3)	33.5 (10.1–56.8)

Note: Bold indicates significant at p < 0.05;

^*indicates cell count < 5.

Those who reported past 30-day e-cigarette use were more likely than those who did not report past 30-day use to report experiencing headache or migraine (43.8% vs 14.6%, p = .002). Similarly, those who reported past 30-day cigarette use were more likely to attribute any symptom to e-cigarette use (86.0% vs 58.6%, p = .001) and shortness of breath (33.8% vs 9.5%, p = .03). Additionally, those who reported using another tobacco product within the past 30-days were more likely to report shortness of breath from e-cigarettes (31.6% vs 8.2%, p = .01). Finally, those who reported using more than one product in the past 30 days were more likely to report headache or migraine than those who reported using no products in the past 30 days (39.1% vs. 11.7%).

There were no differences in symptoms attributed to e-cigarette use across demographic factors, including age, sex, race, ethnicity, and mother’s education.

4. Discussion

Among a national sample of US youth, most ever e-cigarette users reported at least one negative health symptom related to their e-cigarette use. The most common symptoms attributed to e-cigarette use were cough and dizziness or lightheadedness, which is consistent with findings from studies of self-reported or observed symptoms related to e-cigarette use among adults (King et al., 2019; Pisinger & Døssing, 2014). Symptoms were generally consistent across demographic groups of ever e-cigarette users.

For each of the tobacco use groups we examined (e-cigarettes, cigarettes, other tobacco), past 30-day users were more likely to report at least one of the symptoms compared to non-users, including headache or migraine and shortness of breath. Additionally, past 30-day cigarette users were more likely to report any symptom of e-cigarette use compared to non-users. It is possible youth using other tobacco products experience more symptoms when using e-cigarettes. It is also possible youth using other tobacco products may attribute symptoms caused by the other product(s) to e-cigarette use. For example, combustible product use is often associated with shortness of breath (An et al., 2009; United States et al., 2014), which may explain the increased reporting of this symptom among cigarette users and other tobacco users. Further research is needed to disentangle these findings. Regardless, the data suggest youth who are experimenting with or using multiple tobacco products are at increased risk for experiencing adverse e-cigarette symptoms. Considering nearly 40% of youth e-cigarette users also use another tobacco product (King et al., 2018), additional prevention and cessation efforts are critical for this priority population.

In the present study we found that dry or irritated mouth or throat was less prevalent among youth, compared to similar analyses among adults (King et al., 2019). In contrast, dizziness or lightheadedness and headache or migraine were more prevalent among youth compared to adults. It is possible youth are relatively naïve to all tobacco compared to adults, and therefore, are more likely to report symptoms related to initial nicotine use, such as dizziness or headache (DiFranza et al., 2000). It is also possible youth prefer different products or flavors than adults, which may result in experiencing different symptoms (National Academies of Sciences, 2018).

We found few differences in health symptoms reported across demographic groups, which contrasts findings from other research (Griesler, Hu, & Kandel, 2016). Demographic groups may have different preferences of flavor, brand, or device type, which might influence symptoms (National Academies of Sciences, 2018). We do not know which brands or flavors were used by youth and were unable to conduct analyses by device type due to small samples. An increasing amount of research suggests flavors and devices vary exposure to toxic chemicals (Allen et al., 2016; Benowitz & Fraiman, 2017; National Academies of Sciences, 2018; Romagna et al., 2013). Therefore, future research should examine flavors, brands, and device type used by demographic groups in examining health symptoms or health outcomes.

There are limitations to this study. First, the symptoms were self-reported by youth. While perceptions are important, verifying symptoms and identifying the frequency and severity of symptoms would strengthen our understanding of potential health outcomes associated with use. Second, we do not know whether the devices used contained nicotine; however, studies have found even non-nicotine e-cigarettes can increase levels of toxic volatile organic compounds, which may cause nose and throat discomfort, headache, and nausea (Rubinstein, Delucchi, Benowitz, & Ramo, 2018). Future research may monitor nicotine content and whether it is associated with symptoms. Additionally, despite being a national sample of youth, our sample of ever e-cigarette users was small, which did not allow for additional comparisons across symptoms or demographic groups (e.g., controlling for demographic factors), or subgroup analyses by frequency of use or among users of different devices. Finally, our study was conducted August 2016 through May 2017, prior to the rapid increase in JUUL use that was reported in 2018 (Cullen, 2018). Thus, we likely captured youth use of non-pod style devices. Youth using pod style devices may experience additional or other symptoms.

5. Conclusions

As the first national sample of US youth in which physical health symptoms of e-cigarette use were examined, this study highlights the prevalence of health symptoms users self-report from e-cigarette use. A large proportion of youth e-cigarette users attribute at least one health symptom to their e-cigarette use. Those using e-cigarettes, cigarettes, or other tobacco products in the past 30 days were more likely to report symptoms from e-cigarettes, suggesting youth polytobacco users are a particularly important population for e-cigarette education efforts. These findings can be used to educate health practitioners and school nurses about common symptoms youth may experience, and to develop prevention messages targeting specific health symptoms.

HIGHLIGHTS.

• This is the first national sample of US youth that examines e-cigarette use symptoms.

• Most ever-e-cigarette users attribute at least one symptom to their e-cigarette use.

• Those who reported past 30-day e-cigarette or other product use reported more symptoms.