Assessment of Patterns in e-Cigarette Use Among Adults in the US, 2017-2020.

Importance: Updated data on the patterns of e-cigarette use among adults in the US are needed. Objective: To examine recent patterns in current and daily e-cigarette use among US adults. Design, Setting, and Participants: This repeated cross-sectional study used data from the 2017, 2018, and 2020 Behavioral Risk Factor Surveillance System, a nationally representative state-based survey of noninstitutionalized US adults. A total of 994 307 adults 18 years and older who were living in states and territories that provided data on e-cigarette use in 2017 (53 states and territories), 2018 (36 states and Guam), and 2020 (42 states and Guam) were included. Main Outcomes and Measures: The weighted prevalence of current (past 30 days) and daily e-cigarette use was estimated for each year, and changes in prevalence from 2017 to 2020 were assessed, first overall and then stratified by participant characteristics, including state or territory of residence. Results: Among 994 307 adults from states with data on e-cigarette use, 429 370 individuals (weighted 51.3% female) were participants in the 2017 survey, 280 184 (weighted 52.1% female) were participants in the 2018 survey, and 284 753 (weighted 52.1% female) were participants in the 2020 survey. The weighted proportions of young adults aged 18 to 24 years were 12.6% in 2017, 11.8% in 2018, and 11.9% in 2020. Across all 3 years, 17 035 participants (weighted, 1.0%) were American Indian or Alaska Native, 22 313 (weighted, 4.6%) were Asian, 75 780 (weighted, 12.2%) were Black, 72 190 (weighted, 15.1%) were Hispanic, 4817 (weighted, 0.2%) were Native Hawaiian, 757 140 (weighted, 65.1%) were White, 20 332 (weighted, 1.3%) were multiracial, and 6245 (weighted, 0.5%) were of other races and/or ethnicities. The prevalence of current e-cigarette use was 4.4% (95% CI, 4.3%-4.5%) in 2017, which increased to 5.5% (95% CI, 5.4%-5.7%) in 2018 and decreased slightly to 5.1% (95% CI, 4.9%-5.3%) in 2020. The recent decrease, though modest, was observed mainly among young adults aged 18 to 20 years (from 18.9% [95% CI, 17.2%-20.7%] to 15.6% [95% CI, 14.1%-17.1%]; P = .004). However, the prevalence of daily e-cigarette use increased consistently from 1.5% (95% CI, 1.4%-1.6%) in 2017 to 2.1% (95% CI, 2.0%-2.2%) in 2018 and 2.3% (95% CI, 2.2%-2.4%) in 2020. Among young adults aged 21 to 24 years, there was a slight, albeit insignificant, increase in the prevalence of current e-cigarette use (from 13.5% [95% CI, 12.3%-14.7%] to 14.5% [95% CI, 13.2%-15.9%]; P = .28) but a significant increase in the prevalence of daily e-cigarette use (from 4.4% [95% CI, 3.8%-5.1%] to 6.6% [95% CI, 5.6%-7.6%]; P < .001) between 2018 and 2020. State-level patterns in the prevalence of current e-cigarette use were heterogeneous, with states like Massachusetts (from 5.6% [95% CI, 4.8%-6.5%] to 4.1% [95% CI, 3.1%-5.3%]; P = .03) and New York (from 5.4% [95% CI, 4.9%-5.9%] to 4.1% [95% CI, 3.5%-4.7%]; P = .001) recording significant decreases between 2018 and 2020. In contrast, Guam (from 5.9% [95% CI, 4.5%-7.9%] to 11.4% [95% CI, 8.7%-14.8%]; P = .002) and Utah (from 6.1% [95% CI, 5.5%-6.7%] to 7.2% [95% CI, 6.5%-8.0%]; P = .02) recorded significant increases in current e-cigarette use over the same period. Conclusions and Relevance: In this study, a slight decrease in the prevalence of current e-cigarette use was found between 2018 and 2020; this decrease was mainly observed among young adults aged 18 to 20 years. In contrast, daily e-cigarette use consistently increased, particularly among young adults aged 21 to 24 years. This increase in daily use suggests greater nicotine dependence among those who use e-cigarettes, warranting continued surveillance.

Perceptions of electronic cigarettes among ethno-culturally diverse Latino adults in four US urban centers.

OBJECTIVE: The aim of this study was to examine perceptions including knowledge, attitudes, and beliefs about e-cigarettes among ethno-culturally diverse Latino adults living in the US, a rapidly growing minority group for which we know little about their e-cigarette perceptions. DESIGN: A total of 25 focus groups with Latinos (n = 180; ages 18-64 years) were conducted in 2014. E-cigarettes users and non-users were recruited via purposive sampling techniques. Participants completed brief questionnaires on sociodemographic factors and tobacco use. Focus group discussions were conducted in English and Spanish, audio-recorded, and transcribed. Data were analyzed using thematic analysis procedures. RESULTS: Participants were of diverse Latino backgrounds. Over one-third (35%) reported current cigarette smoking and 8% reported current e-cigarette or hookah use. Nonsmokers reported experimenting with e-cigarettes and hookah during social occasions. Participants' perceptions towards e-cigarettes were generally formed in comparison to conventional cigarettes. Perceived benefits of using e-cigarettes included their utility as a smoking cessation aid, higher social acceptability, and lower harm compared to conventional cigarettes. Negative perceptions of e-cigarettes included lower overall satisfaction compared to conventional cigarettes and high content of toxins. Socio-cultural factors (e.g. gender roles, familismo, and simpatía) also influenced perceptions of e-cigarette of study participants. CONCLUSIONS: Overall, Latino adults knew relatively little about the potential health risks associated with e-cigarette use. The limited knowledge about and misinformation of e-cigarettes among this rapidly growing minority group have important public health implications. Findings may inform culturally tailored health communication campaigns, which are much needed among underserved US Latino populations in light of low effectiveness of tobacco control and regulatory efforts.

Racial/Ethnic Differences in Associations of Non-cigarette Tobacco Product Use With Subsequent Initiation of Cigarettes in US Youths.

INTRODUCTION: Understanding which non-cigarette tobacco products precede smoking in youth across different racial/ethnic groups can inform policies that consider tobacco-related health disparities. METHODS: We used nationally representative, longitudinal data from the Population Assessment of Tobacco and Health Study waves 1-4. The sample was a dynamic cohort of cigarette-naïve youth aged 12-17 years. Mixed-effects models were used to assess non-cigarette product (e-cigarette, cigar product, or other product) use with cigarette use over 1-year intervals. RESULTS: Of the 28 788 observations pooled across waves 1-4, respondents were 48.7% non-Hispanic white, 13.9% non-Hispanic black, and 23.1% Hispanic. Odds of cigarette initiation over 1-year follow-up were higher among youth with prior use of e-cigarettes (odds ratio [OR], 2.76; 95% confidence interval [CI], 2.21-3.45), cigars (OR, 2.00; 95% CI, 1.42-2.80), or other products (OR, 1.66; 95% CI, 1.28-2.14) compared to never users. At the population level, 20.6% of cigarette initiation was attributable to e-cigarette use among white youth and 21.6% among Hispanic youth, while only 3.5% of cigarette initiation was attributable to e-cigarette use among black youth. In contrast, 9.1% of cigarette initiation for black youth was attributable to cigar use compared to only 3.9% for both white and Hispanic youth. CONCLUSIONS: Prior use of e-cigarettes, cigars, and other non-cigarette products were all associated with subsequent cigarette initiation. However, white and Hispanic youth were more likely to initiate cigarettes through e-cigarette use (vs. cigar or other product use), while black youth were more likely to initiate cigarettes through cigar use (vs. e-cigarette or other product use). IMPLICATIONS: Our findings suggest that previous studies on effects of non-cigarette tobacco products may overlook the critical role of cigar products as a pathway into cigarette smoking among US youth, particularly black youth. While our data support the importance of e-cigarette use as a pathway into smoking, regulatory actions aimed at addressing youth e-cigarette use alone may contribute to disparities in black versus white tobacco use and further exacerbate inequities in tobacco-related disease. Thus, contemporary policy development and discourse about the effects of non-cigarette tobacco products on cigarette initiation should consider cigar and other non-cigarette products as well as e-cigarettes.

Tobacco Point-of-Sale Influence on U.S. Adult Smokers.

INTRODUCTION: Prior research has shown that tobacco companies target point-of-sale (POS) marketing to low-income communities. This research assessed the association between demographic characteristics and venue type with purchasing tobacco products in response to marketing. METHODS: Using Population Assessment of Tobacco and Health (PATH) Study Wave 1 Adult data, this analysis compared promotion awareness and purchase influence among current smokers. RESULTS: Tobacco promotions were more likely to be noticed at convenience stores, gas stations, or tobacco stores than at other outlets. Smokers who bought their cigarettes at these outlets were more likely to purchase a brand other than their usual brand because of marketing. Smokers below the poverty level had greater odds than others to have noticed tobacco ads and to indicate purchase influence. CONCLUSIONS: Point-of-sale marketing is effective in garnering the attention of low-income populations and influencing their tobacco purchases. Enforcing retailers' adherence to regulations is vital.

Socioeconomic and Demographic Status and Perceived Health Risks of E-Cigarette Product Contents Among Youth: Results From a National Survey.

Background. The prevalence of e-cigarette use among youth is rising and may be associated with perceptions of health risks for these products. We examined how demographic factors and socioeconomic status (SES) are correlated with the perceived health risks of e-cigarette product contents among youth. Method. Data were from a national online survey of youth aged 13 to 18 between August and October 2017, weighted to be representative of the overall U.S. population in age, sex, race/ethnicity, and region. Survey analysis procedures were used. Results. Of 1,549 e-cigarette users and 1,451 never-e-cigarette users, 20.9% were Hispanic, 13.7% Black, 21.7% LGBTQ (lesbian/gay/bisexual/transgender/queer), and 49.3% in low-income families. With adjustment for e-cigarette use status, perceived health risks of nicotine and toxins/chemicals in e-cigarettes significantly differed by gender, race, sexual orientation, and SES (ps < .05). For example, adjusted odds of perceiving harm from nicotine were 60% higher in girls versus boys, 34% lower in non-Hispanic Blacks versus non-Hispanic Whites, 33% lower in urban versus suburban residents, 40% higher in LGBTQ versus straight-identifying individuals, and 28% lower in low-income versus high-income families. Lower parental education level also was associated with children's lower health risk perception of e-cigarette product contents. Conclusions. For youth, the perceived health risks of e-cigarette product contents were associated with demographics, sexual orientation, and SES. The findings may have relevance for developing communication and education strategies addressing specific youth audiences, especially those in vulnerable groups. These strategies could improve awareness among youth concerning the health risks of e-cigarettes, helping to prevent or reduce e-cigarette uptake and continued use.

Perceived health risks of electronic nicotine delivery systems (ENDS) users: The role of cigarette smoking status.

INTRODUCTION: Use of electronic nicotine delivery systems (ENDS) has increased markedly. We examined how current ENDS users differ in perceptions of tobacco and ENDS-related health risks as a function of cigarette smoking status. METHODS: We classified 1329 current ENDS users completing a national online survey based on cigarette smoking status, and employed linear and logistic regression to assess group differences in perceptions of tobacco-related health risks. RESULTS: The sample consisted of 38% Current Cigarette Smokers, 40% Former Cigarette Smokers, and 22% Non-Smokers. Our targeted recruitment strategy yielded a balance of key descriptive variables across participants. Significant differences were observed in race, employment and marital status across cigarette smoking status, but not in gender, education, income, or sexual orientation. Participants reported considerable perceived knowledge about health risks associated with tobacco use, but less regarding ENDS use. Current Smokers rated ENDS use as riskier than Non-Smokers, and considered cigarette use less risky for both users and bystanders. Current Smokers were more likely to perceive cardiovascular diseases, diabetes and cancer as the health risks associated with ENDS use. Former Smokers were more likely to perceive such risks with traditional tobacco use. Further, regardless of smoking status, perceived knowledge about the health risks of tobacco or ENDS use was positively associated with perceived likelihood of high risks of cardiovascular diseases and cancer. CONCLUSIONS: Among current ENDS users, there were significant differences in perceived health risks based on cigarette smoking history. Improved health messaging can be achieved when cigarette smoking status is taken into account.

The social patterning of electronic nicotine delivery system use among US adults.

There is little research examining the social patterning of electronic nicotine delivery system (ENDS) use. This study investigated the association between socioeconomic status (SES) (education, income, and employment status) and current and former ENDS use. Data were collected from 2561 participants from the American Heart Association Tobacco Regulatory and Addiction Center (A-TRAC) online survey. Participants were 18-64 years old and reported demographic, SES, and ENDS use. Poisson regression was used to estimate prevalence ratios (PR 95% confidence interval-CI) of participants' current and former (vs. never) ENDS use. Models were adjusted for age, sex, sexual orientation, race/ethnicity, marital status, and reasons for ENDS use. In the unadjusted analysis, ENDS use was primarily patterned by education and employment status. College educated persons (vs. those with less than a high school diploma) had a 37% greater prevalence of current ENDS use (PR 1.37, 95% CI 1.20-1.55), and a 16% greater prevalence of former ENDS use (PR 1.16, 95% CI 1.06-1.28) in the fully-adjusted model. Persons with household incomes above $90 K (vs. less than $20,000) had a greater prevalence of current (PR 1.30, 95% CI 1.19-1.41) and former (PR 1.17, 95% CI 1.05-1.30) ENDS use. Those who were employed (vs. not employed) had a 13% greater prevalence of current ENDS use (PR 1.13, 95% CI 1.07-1.19) after full adjustment. Higher SES (vs. lower SES) persons were more likely to use ENDS.

The impact of prevention on reducing the burden of cardiovascular disease.

OBJECTIVE: Cardiovascular disease (CVD) is prevalent and expensive. While many interventions are recommended to prevent CVD, the potential effects of a comprehensive set of prevention activities on CVD morbidity, mortality, and costs have never been evaluated. We therefore determined the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs in the U.S. RESEARCH DESIGN AND METHODS: We used person-specific data from a representative sample of the U.S. population (National Health and Nutrition Education Survey IV) to determine the number and characteristics of adults aged 20-80 years in the U.S. today who are candidates for different prevention activities related to CVD. We used the Archimedes model to create a simulated population that matched the real U.S. population, person by person. We then used the model to simulate a series of clinical trials that examined the effects over the next 30 years of applying each prevention activity one by one, or altogether, to those who are candidates for the various activities and compared the health outcomes, quality of life, and direct medical costs to current levels of prevention and care. We did this under two sets of assumptions about performance and compliance: 100% success for each activity and lower levels of success considered aggressive but still feasible. RESULTS: Approximately 78% of adults aged 20-80 years alive today in the U.S. are candidates for at least one prevention activity. If everyone received the activities for which they are eligible, myocardial infarctions and strokes would be reduced by approximately 63% and 31%, respectively. If more feasible levels of performance are assumed, myocardial infarctions and strokes would be reduced approximately 36% and 20%, respectively. Implementation of all prevention activities would add approximately 221 million life-years and 244 million quality-adjusted life-years to the U.S. adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Of the specific prevention activities, the greatest benefits to the U.S. population come from providing aspirin to high-risk individuals, controlling pre-diabetes, weight reduction in obese individuals, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing coronary artery disease (CAD). As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years. CONCLUSIONS: Aggressive application of nationally recommended prevention activities could prevent a high proportion of the CAD events and strokes that are otherwise expected to occur in adults in the U.S. today. However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently.

The impact of prevention on reducing the burden of cardiovascular disease.

OBJECTIVE: Cardiovascular disease (CVD) is prevalent and expensive. While many interventions are recommended to prevent CVD, the potential effects of a comprehensive set of prevention activities on CVD morbidity, mortality, and costs have never been evaluated. We therefore determined the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs in the United States. RESEARCH DESIGN AND METHODS: We used person-specific data from a representative sample of the US population (National Health and Nutrition Education Survey IV) to determine the number and characteristics of adults aged 20-80 years in the United States today who are candidates for different prevention activities related to CVD. We used the Archimedes model to create a simulated population that matched the real US population, person by person. We then used the model to simulate a series of clinical trials that examined the effects over the next 30 years of applying each prevention activity one by one, or altogether, to those who are candidates for the various activities and compared the health outcomes, quality of life, and direct medical costs to current levels of prevention and care. We did this under two sets of assumptions about performance and compliance: 100% success for each activity and lower levels of success considered aggressive but still feasible. RESULTS: Approximately 78% of adults aged 20-80 years alive today in the United States are candidates for at least one prevention activity. If everyone received the activities for which they are eligible, myocardial infarctions and strokes would be reduced by 63% and 31%, respectively. If more feasible levels of performance are assumed, myocardial infarctions and strokes would be reduced 36% and 20%, respectively. Implementation of all prevention activities would add approximately 221 million life-years and 244 million quality-adjusted life-years to the US adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Of the specific prevention activities, the greatest benefits to the US population come from providing aspirin to high-risk individuals, controlling pre-diabetes, weight reduction in obese individuals, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing coronary artery disease (CAD). As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years. CONCLUSIONS: Aggressive application of nationally recommended prevention activities could prevent a high proportion of the CAD events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently.

Preventing cancer, cardiovascular disease, and diabetes: a common agenda for theAmerican Cancer Society, the American Diabetes Association, and the American Heart Association.

Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for approximately two-thirds of all deaths in the United States and about 700 billion US dollars in direct and indirect economic costs each year. Current approaches to health promotion and prevention of cardiovascular disease, cancer, and diabetes do not approach the potential of the existing state of knowledge. A concerted effort to increase application of public health and clinical interventions of known efficacy to reduce prevalence of tobacco use, poor diet, and insufficient physical activity-the major risk factors for these diseases-and to increase utilization of screening tests for their early detection could substantially reduce the human and economic cost of these diseases. In this article, the American Cancer Society, the American Diabetes Association, and the American Heart Association review strategies for the prevention and early detection of cancer, cardiovascular disease, and diabetes, as the beginning of a new collaboration among the three organizations. The goal of this joint venture is to stimulate substantial improvements in primary prevention and early detection through collaboration between key organizations, greater public awareness about healthy lifestyles, legislative action that results in more funding for and access to primary prevention programs and research, and reconsideration of the concept of the periodic medical checkup as an effective platform for prevention, early detection, and treatment.

Preventing cancer, cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association.

Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for approximately two thirds of all deaths in the United States and about 700 billion dollars in direct and indirect economic costs each year. Current approaches to health promotion and prevention of cardiovascular disease, cancer, and diabetes do not approach the potential of the existing state of knowledge. A concerted effort to increase application of public health and clinical interventions of known efficacy to reduce prevalence of tobacco use, poor diet, and insufficient physical activity-the major risk factors for these diseases-and to increase utilization of screening tests for their early detection could substantially reduce the human and economic cost of these diseases. In this article, the ACS, ADA, and AHA review strategies for the prevention and early detection of cancer, cardiovascular disease, and diabetes, as the beginning of a new collaboration among the three organizations. The goal of this joint venture is to stimulate substantial improvements in primary prevention and early detection through collaboration between key organizations, greater public awareness about healthy lifestyles, legislative action that results in more funding for and access to primary prevention programs and research, and reconsideration of the concept of the periodic medical checkup as an effective platform for prevention, early detection, and treatment.

Preventing cancer, cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association.

Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for approximately two-thirds of all deaths in the U.S. and about US dollars 700 billion in direct and indirect economic costs each year. Current approaches to health promotion and prevention of cardiovascular disease, cancer, and diabetes do not approach the potential of the existing state of knowledge. A concerted effort to increase application of public health and clinical interventions of known efficacy to reduce prevalence of tobacco use, poor diet, and insufficient physical activity-the major risk factors for these diseases-and to increase utilization of screening tests for their early detection could substantially reduce the human and economic cost of these diseases. In this article, the American Cancer Society, American Diabetes Association, and American Heart Association review strategies for the prevention and early detection of cancer, cardiovascular disease, and diabetes, as the beginning of a new collaboration among the three organizations. The goal of this joint venture is to stimulate substantial improvements in primary prevention and early detection through collaboration between key organizations, greater public awareness about healthy lifestyles, legislative action that results in more funding for and access to primary prevention programs and research, and reconsideration of the concept of the periodic medical checkup as an effective platform for prevention, early detection, and treatment.

Preventing cancer, cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association.

Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for approximately two thirds of all deaths in the United States and about 700 billion dollars in direct and indirect economic costs each year. Current approaches to health promotion and prevention of cardiovascular disease, cancer, and diabetes do not approach the potential of the existing state of knowledge. A concerted effort to increase application of public health and clinical interventions of known efficacy to reduce prevalence of tobacco use, poor diet, and insufficient physical activity-the major risk factors for these diseases-and to increase utilization of screening tests for their early detection could substantially reduce the human and economic cost of these diseases. In this article, the ACS, ADA, and AHA review strategies for the prevention and early detection of cancer, cardiovascular disease, and diabetes, as the beginning of a new collaboration among the three organizations. The goal of this joint venture is to stimulate substantial improvements in primary prevention and early detection through collaboration between key organizations, greater public awareness about healthy lifestyles, legislative action that results in more funding for and access to primary prevention programs and research, and reconsideration of the concept of the periodic medical checkup as an effective platform for prevention, early detection, and treatment.