Differences in Young Adults’ Perceptions of E-Cigarettes by History of Use

Abstract

Objective:

The current study examined group differences in college students’ views on e-cigarettes in terms of safety, popularity, health risks, social acceptability, efficacy as a cessation aid, and promoting combustible cigarette use.

Participants:

337 undergraduates (M_age = 20.84, SD = 3.79; 72.1% female; 68.5% White) divided into three groups: Never Users (n = 178), Ever Users (n = 108), and Current Users (n = 51).

Methods:

Participants completed questionnaires for course credit.

Results:

Compared to Ever and Never Users, Current Users believed e-cigarettes were safer, healthier, a useful tool to quit smoking, did not lead to combustible cigarette smoking, and that nicotine was less dangerous. Current Users also were less likely to endorse boosting social image as a motive for use.

Conclusions:

Public health campaigns could benefit from targeting current users’ positive beliefs about e-cigarettes to reduce the prevalence of e-cigarette use among college students.

While the United States has seen substantial declines in the prevalence of combustible cigarette use in recent years, rates of e-cigarette use have increased significantly. These trends are especially notable among college students where rates of past-month e-cigarette use increased from 6.1% in 2017 to 22% in 2019.¹ The emergence of e-cigarette or vaping use-associated lung injury (EVALI) cases in 2019, the ban of flavored e-cigarette products in 2020, and the COVID-19 pandemic may have impacted rates of e-cigarette use and beliefs about e-cigarettes. However, epidemiological data for college students from this time period are not yet available. Results from research on e-cigarette use conducted early in the pandemic using convenience samples have been mixed; some found decreased rates of e-cigarette use^2,3, whereas others found that approximately equal numbers of users increased their use as decreased since the start of the COVID-19 pandemic.⁴

These high prevalence rates are particularly alarming because of the increased physical health risks associated with e-cigarette use, including impaired immune and lung function and increased risk for cardiovascular and respiratory diseases.^5-9 There is also emerging evidence of an association between e-cigarettes and seizures in youth and young adults as well as a greater risk of transitioning to combustible cigarette use.^10,11 Moreover, some of the newer vaping products (e.g., Juul) deliver nicotine at levels as high or higher than combustible cigarettes.¹² Nicotine not only puts users at risk for dependence, but also harms the developing brain, which continues until the mid-20s.¹³ Indeed, nicotine exposure can contribute to learning difficulties and result in long-lasting cognitive deficits.^14,15 Thus, although many had hoped e-cigarettes would serve as a healthier alternative to combustible cigarettes, they appear to not only confer more significant physical health risks than initially understood but also may be contributing to increased rates of nicotine addiction.¹³

Given these shifting use patterns and increased health risks, it is important to understand how young adults view e-cigarettes. The perception of e-cigarettes as healthier or safer than combustible cigarettes is common among young adults regardless of use status.^16,17 Indeed, Cooper and colleagues¹⁸ found that 79% of college students believe e-cigarettes posed little to moderate harm, and 71% saw e-cigarettes as not or somewhat addictive. Unfortunately, perceiving e-cigarettes as less harmful and addictive is predictive of future initiation of e-cigarette use.^19,20 Although college students do see some potential disadvantages to e-cigarette use in terms of potential negative health consequences and social stigma related to use, by and large it appears that young adults hold fairly positive views of e-cigarettes.¹⁷ These views become even more positive when comparing users to non-users. Adult and college student e-cigarette users tend to hold significantly more positive views of e-cigarettes than non-users and are less likely to agree with statements about the potential harms of e-cigarettes.^18,21

Taken together, extant research findings indicate that positive beliefs about e-cigarettes may be promoting e-cigarette initiation as well as helping to maintain use. Therefore, understanding the views that college students hold about e-cigarettes is critically important in order to develop effective public health campaigns to reduce rates of e-cigarette use in this population. However, several limitations to the existing body of research need to be addressed. First, assessments of participant perceptions have used categorical rating scales rather than continuous scales, which provide greater sensitivity. Second, the outcome variables have been primarily limited to views on health risks and the use of e-cigarettes as a cessation aid, and studies have yet to examine other aspects of e-cigarettes, such as popularity and risk for transitioning to combustible smoking. Along these same lines, many studies explored perceptions of e-cigarettes compared to combustible cigarettes rather than perceptions of e-cigarettes in isolation.^16,19,21 Third, no studies have examined views of the health risks associated with nicotine separate from method of use. Finally, although two studies examined differences between ever users and non-users, no studies among college students have looked at current users as a separate group.^17,21 Moreover, these studies were conducted when knowledge of the health risks of e-cigarette use was relatively limited and prior to the outbreak of EVALI cases. Thus, current views of e-cigarette safety may have changed. Addressing these limitations will allow for a more nuanced understanding of college students’ views on e-cigarettes across a number of domains.

Therefore, the purpose of the current study was to examine group differences in college students’ views on e-cigarettes in terms of their safety, popularity, health risk, social acceptability, utility as a cessation aid, and risk of promoting the transition to combustible cigarette use. It was expected that current (past 30-day) e-cigarette users and those who had used e-cigarettes but not in the past 30 days would report more positive views about e-cigarettes than those who had never used e-cigarettes. Given the paucity of research in this area, no hypotheses were generated about significant group differences between current and ever e-cigarette users.

Method

Participants

Participants included 337 undergraduates (M_age = 20.84, SD = 3.79) who reported no combustible cigarette use in the past 30 days. The sample was 72.1% female, 26.7% male, 0.6% non-binary, and 0.3% transgender. In terms of racial and ethnic background, 9.2% reported Hispanic ethnicity, and 68.5% identified as White, 16.3% as Black or African American, 5.9% as Asian, 4.2% as multi-racial, 0.6% as American Indian or Alaska Native, 4.2% as Other, and 0.3% did not specify. Participants were divided into three groups based on e-cigarette use history: (1) those who had never used e-cigarettes (Never Users; n = 178), (2) those who had tried e-cigarettes but had not used in the past 30 days (Ever Users; n = 108), and (3) those who had used e-cigarettes within the past 30 days (Current Users; n = 51). Table 1 presents the demographic information by group. The groups did not significantly differ in terms of age, gender, or ethnicity, but there were significant group differences for race. White participants were more likely to be in the Current Users group, and Black/African American participants and those from all other racial backgrounds were less likely to be in the Current Users group.

Table 1.

Sample Demographic Information

	Total N = 337	Never Users n = 178	Ever Users n = 108	Current Users n = 51
Age [M (SD)]	20.84 (3.79)	20.96 (4.80)	20.80 (2.21)	20.50 (2.11)
Gender [% (n)]
Female	72.1 (243)	73.0 (130)	70.4 (76)	72.5 (37)
Male	26.7 (90)	25.3 (45)	28.7 (31)	27.5 (14)
Non-Binary	0.6 (2)	0.6 (1)	0.9 (1)	0.0 (0)
Transgender	0.3 (1)	0.6 (1)	0.0 (0)	0.0 (0)
Other	0.3 (1)	0.6 (1)	0.0 (0)	0.0 (0)
Race [% (n)]
White	68.5 (231)	62.4 (111)	66.7 (72)	94.1 (48)
Black/African American	16.3 (55)	21.3 (38)	14.8 (16)	2.0 (1)
Asian	5.9 (20)	7.9 (14)	5.6 (6)	0.0 (0)
Multi-racial	4.2 (14)	3.4 (6)	6.5 (7)	2.0 (1)
American Indian or Alaska Native	0.6 (2)	1.1 (2)	0.0 (0)	0.0 (0)
Other	4.5 (15)	4 (7)	6.5 (7)	2.0 (1)
Ethnicity [% Hispanic (n)]	9.2 (31)	7.9 (14)	13.0 (14)	5.9 (3)

Note. There were significant group differences for race, but no other demographic variables [X² (12) = 26.64, p < .01]

Measures

Demographic Questionnaire.

Participants were asked to provide general demographic information (i.e., age, gender identity, race, and ethnicity).

Perceptions of E-cigarettes.

Participants were asked to rate their views about various aspects of e-cigarettes (e.g., safety, changes in popularity over the past 6 months, health risks, social acceptance, utility as a cessation aid, dangers of nicotine) on a scale of 0 to 100 with higher scores indicating more negative views of e-cigarettes. Participants were also asked to rate whether e-cigarettes were likely to lead people to smoke on a scale from 0 = likely to lead people to smoke to 100 = unlikely to lead people to smoke. Two additional questions asked participants to compare the health risks of e-cigarettes to combustible cigarettes (less risky, equally risky, more risky) and to cite the main reason they think people use e-cigarettes (e.g., to quit smoking, boost social image, friends and family smoke, can be used where combustible cigarettes can’t, other).

Procedure

Data were collected between March 2020 and April 2020 as part of a larger survey on college student health. Undergraduate students at a large, Southern university who were over the age of 18 were invited to participate in the study. Students were provided with a link to complete study measures online. Study data were collected and managed using REDCap (Research Electronic Data Capture).²² In order to ensure anonymity, information regarding participants’ IP addresses was not collected. Participants were granted course credit for their participation. The Institutional Review Board approved all study materials and procedures prior to data collection.

Data Analytic Plan

There were a total of 510 survey responses. To ensure data quality, data were examined for correct responses to three quality control questions that were randomly distributed throughout the survey (e.g., “Choose option A for this question”) and an affirmative answer to the question “Have you carefully and accurately answered all the questions” at the end of the survey. As a result, data from 161 participants were removed. Responses from another 12 participants were removed because they endorsed past 30-day combustible cigarette use. Data analyses were completed on the remaining 337 participants using SPSS version 27.

A multivariate analysis of covariance (MANCOVA) was conducted to evaluate differences between Never, Ever, and Current Users in terms of their perceptions of (1) how safe e-cigarettes are; (2) whether the popularity of e-cigarettes had changed in the past 6 months; (3) how healthy e-cigarettes are; (4) how socially acceptable e-cigarettes are; (5) whether e-cigarettes are a useful tool to quit smoking; (6) whether e-cigarettes are likely to lead people to start smoking combustible cigarettes; and (7) how dangerous nicotine is. Based on the group differences, race was included as a covariate (0 = White, 1 = all other races). Post hoc univariate analyses of variance (ANOVAs) were conducted to examine the specificity of group differences. Partial eta squared (η_p²) served as an index of effect size of mean differences (small = .01, medium = .09, large = .25).²³ Chi-square analyses were used to examine group differences in health risks of e-cigarettes compared to combustible cigarettes and motivations for using e-cigarettes.

Results

Significant group differences emerged for perceptions of e-cigarettes [F(14,622) = 7.78, p < .001, η_p² = .15]. There were significant univariate differences for e-cigarette safety [F(2,316) = 40.11, p < .001, η_p² = .20], healthiness [F(2,316) = 27.14, p < .001, η_p² = .15], social acceptability [F(2,316) = 3.84, p = .023, η_p² = .02], effectiveness as a cessation aid [F(2,316) = 5.05, p = .007, η_p² = .03], likelihood of leading to combustible cigarette smoking [F(2,316) = 11..9, p < .001, η_p² = .07], and dangerousness of nicotine [F(2,316) = 30.95, p < .001, η_p² = .16]. Specifically, for safety, healthiness, and dangerousness of nicotine the three groups were significantly different from one another with Current Users endorsing the most positive views of e-cigarettes, Never Users the least positive, and Ever Users in between (see Figure 1). For social acceptability, Never Users were significantly different from Ever and Current Users, but Ever and Current Users were not significantly different from one another. For effectiveness as a cessation aid and likelihood of leading to combustible cigarette smoking, Current Users were significantly different from Never and Ever users, but Never and Ever Users were not significantly different from one another. There were no significant group differences for perceptions of changes in popularity over the past 6 months. When comparing the risks of smoking e-cigarettes to combustible cigarettes, Current Users were more likely and Never Users were less likely to view e-cigarettes as safer than combustible cigarettes [χ² (4) = 42.49, p < .001]. Current Users were also much less likely to cite boosting social image as the primary motivation for using e-cigarettes [χ² (8) = 17.93, p = .022].

Figure 1. Estimated Marginal Means for Never, Ever, and Current E-Cigarette Users.

Note. Safety: Ratings of perceptions of e-cigarette safety on a scale of 0 = completely safe to 100 = completely unsafe; Healthy: Ratings of how healthy e-cigarettes are on a scale from 0 = very healthy to 100 = very unhealthy; Acceptability: Ratings of how socially acceptable e-cigarettes are on a scale from 0 = accepted socially to 100 = not accepted socially; Cessation Aid: Ratings of whether e-cigarettes as a smoking cessation aid on a scale from 0 = a useful tool to quit smoking to 100 = not a useful tool to quit smoking; Smoking Risk: Ratings of whether using e-cigarettes puts people at risk for combustible cigarette use on a scale from 0 = likely to lead people to smoke to 100 = unlikely to lead people to smoke; Nicotine: Ratings of how dangerous nicotine is from 0 = not at all dangerous to 100 = extremely dangerous. Error bars show standard errors.

Discussion

Building on work suggesting that positive beliefs about e-cigarettes promote their use, the current study sought to examine differences in college students’ views on e-cigarettes based on their history of use. Results indicated that Current Users believe e-cigarettes are safer and healthier and that nicotine is less dangerous compared to Ever and Never Users. Ever Users had significantly more positive views in these areas than Never Users. Current Users were also less likely to believe that e-cigarettes would lead people to begin combustible cigarette smoking and more likely to view e-cigarettes as a useful tool to quit smoking compared to Ever and Never Users, who did not significantly differ from one another. Current and Ever Users viewed e-cigarettes as more socially acceptable than Never Users. Current Users were also more likely to view e-cigarettes as safer than combustible cigarettes and less likely to endorse boosting social image as a motive for use.

These findings suggest that current e-cigarette users hold the most positive beliefs about the safety of e-cigarettes and nicotine. Such beliefs likely motivate continued e-cigarette use because users do not see significant health risks. Despite their beliefs to the contrary, such views could also put current users at risk for transitioning to combustible cigarette use.¹¹ These findings are broadly consistent with previous work.^16,18 It should be noted that Case et al.¹⁷ did not see differences based on use status. However, this study had a substantially smaller sample size (n = 30) compared to the current study, and, due to its qualitative design, formal tests of significance were not conducted. Given our medium-sized effects, the group differences found in the current study seem to be fairly robust. These findings build on extant work by demonstrating that the positive views hold even when looking at e-cigarettes separate from combustible cigarettes and nicotine separate from method of use. Further, the current study demonstrates the utility of looking at current and ever users as two separate groups.

Interestingly, the overall ratings of health and safety by Current Users were actually relatively neutral to negative. That is, although Current Users had the most positive view of e-cigarettes, the estimated marginal means ranged from 59.8 to 72.9 on a scale where 0 was an entirely positive view and 100 was an entirely negative view. Thus, there appears to be some recognition of the health risks associated with e-cigarette use. Given that Cooper and colleagues¹⁸ found that nearly 80% of college students did not view e-cigarettes as posing significant health risks, the current findings suggest that public health campaigns or media reports of the outbreak of EVALI cases may have changed college students’ views about e-cigarettes, even among current users. Unfortunately, these potentially positive changes do not seem to have resulted in decreased rates of e-cigarette use. The present study would suggest that targeting the positive beliefs of current users, specifically, would be one potentially useful way to decrease prevalence rates. Further research is needed to identify which beliefs are most strongly associated with use or motives for use and how best to target such beliefs.

There are, however, a number of limitations to the current study that should be taken into consideration. First, the present cross-sectional design does not permit causal-oriented hypothesis testing. Longitudinal studies are needed to better understand how e-cigarette use and perceptions of use impact each other over time. Second, the current study, by design, did not look at combustible cigarette users or dual e-cigarette and combustible cigarette users. It will be important for future studies to include these groups, particularly in longitudinal work, to better understand how perceptions of e-cigarettes and nicotine impact trajectories of use.

Third, the demographic characteristics of our sample are not entirely consistent with the demographics of e-cigarette users in the United States, particularly in terms of gender. Our sample had a higher proportion of female users than what is found in epidemiological work.²⁴ Undergraduate samples tend to be predominantly female; therefore, it will be important in future work using undergraduate samples to oversample for males. Finally, the current study relied solely on self-report measures, which increases the possibility for shared method variance and reporting errors. Future studies could build on the present work by utilizing a multi-method approach. Along these same lines, while the current study assessed broad-based beliefs about e-cigarettes in general regardless of user and use status, it will also be important to incorporate measures of e-cigarette outcome expectancies into future work as beliefs about what an individual expects e-cigarettes to do for them have been shown to motivate use.^25-27

Despite these limitations, the findings suggest that current e-cigarette users hold more positive views of e-cigarettes and nicotine. These beliefs likely motivate continued e-cigarette use and increase the risk not only for negative health consequences related to use, but also for initiation of combustible cigarette use. Current users would therefore likely benefit from targeted public health messaging campaigns to address these beliefs and promote awareness of e-cigarette health risks.

Data Availability Statement:

The data that support the findings of this study are available from the corresponding author, A.C.M., upon reasonable request.