E-Cigarette Use Without a History of Combustible Cigarette Smoking Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016

Abstract

Background: Combustible cigarette smoking is the leading cause of preventable death in the United States (1). E-cigarettes remain the most controversial smoking cessation intervention, and public health authorities are concerned that e-cigarette uptake among tobacco-naive people might outstrip the potential utility of e-cigarettes as quit devices (2). Indeed, the newest generations of e-cigarettes (including JUUL) are designed and marketed to appeal to noncombustible cigarette smokers (3). Therefore, a description of sole e-cigarette users (defined as users who never smoked combustible cigarettes) is vital to understand determinants of e-cigarette use and for devising effective interventions and policies. Objective: We used the Behavioral Risk Factor Surveillance System (BRFSS) 2016 to examine age distribution, state-level prevalence, health perceptions, and behaviors of U.S. adults who were sole e-cigarette users. Methods: Details on the analytic approach are published elsewhere (4). All analyses applied BRFSS weights to account for the complex survey design, noncoverage, and nonresponse using STATA, version 13.1 (4). We included 261#541 never-smokers (<100 cigarettes/lifetime) in our analysis of the prevalence of current (including daily and occasional) sole e-cigarette use. To report the absolute projected number of sole e-cigarette users, we used U.S. census projections of the number of adults in 2016 (4). We used behavioral variables available in BRFSS 2016 to compare health perceptions, behaviors, and health care access of sole e-cigarette users versus nonusers. (Survey questions are available in the Appendix Table.) All frequencies of health behaviors, perceptions, and prevalence estimates are age standardized and presented as percentages (95% CIs). Appendix Table. List of Variables Collected by the Behavioral Risk Factor Surveillance System 2016 Codebook* Results: The prevalence of sole e-cigarette use in 2016 was 1.4% (95% CI, 1.3% to 1.5%), translating to about 1.9 million sole e-cigarette users. Among them, 17.7% (CI, 15.1% to 20.6%) were daily users. Prevalence of sole e-cigarette use was highest among persons aged 18 to 24 years (approximately 1.2 million users) (Figure). Compared with nonusers, a larger proportion of sole e-cigarette users were male (43.6% vs. 65.5%). Figure. State-specific, age-standardized prevalence of current sole e-cigarette use (top) and prevalence (95% CI), by age group (bottom), among adults who have never smoked combustible cigarettes. Behavioral Risk Factor Surveillance System 2016. The prevalence of sole e-cigarette use differed markedly across states, with the highest prevalence in Michigan (2.1% [CI, 1.5% to 2.9%]) and the lowest in Alaska (0.4% [CI, 0.2% to 1.1%]) (Figure). Binge drinking, high-risk lifestyle, and marijuana use were reported more frequently among sole e-cigarette users than nonusers (Table). The frequency of at least 1 day with mental distress was higher among sole e-cigarette users than nonusers (61.6% vs. 44.6%). Sole e-cigarette users were more likely to use the Internet but were less likely to use health care services than nonusers. Table. Age-Standardized Frequency of Health Perception, Health Behaviors, and Health Care Use Among E-Cigarette Users and Nonusers Who Had Never Smoked Combustible Cigarettes* Discussion: Our findings suggest that e-cigarette use has extended to never-smokers, with an estimated population of 1.9 million sole e-cigarette users. Of note, 60% of sole e-cigarette users were younger than 25 years. This observation contrasts with the assertion of the Royal College of Physicians that e-cigarettes have not attracted significant use among adult never-smokers in the United Kingdom or other countries (5). Our data may be relevant to the U.S. Food and Drug Administration s plan to reduce the nicotine concentration in combustible cigarettes, with deferred regulatory action in e-cigarettes (6). These sweeping changes may shift a substantial proportion of the population to seek nicotine by using e-cigarettes. Thus, our study serves as a benchmark snapshot for future studies (6). The notable magnitude of the population of sole e-cigarette users highlights the potential need to regulate sales and marketing of e-cigarettes to protect vulnerable populations, including young persons who have never smoked combustible cigarettes. We report that sole e-cigarette users have a higher prevalence of high-risk lifestyle factors and have worse self-rated mental and physical health than nonusers. The behavior characterization of sole e-cigarette users may help to target those who are at higher risk for initiation of e-cigarette use and may facilitate discussions about healthy lifestyles. Limitations of our study include self-report of tobacco use and other behavioral information and lack of biochemical confirmation of tobacco use. In addition, BRFSS is a cross-sectional data set; whether e-cigarettes prevented sole e-cigarette users from becoming combustible-cigarette smokers or placed a large population at risk for becoming combustible-cigarette smokers (gateway) cannot be inferred. In conclusion, our findings may guide researchers, health care providers, and regulators about the emergence of e-cigarette use among young never-smokers. Future studies are needed to explain reasons for state-level differences and to assess the implications of high-risk behaviors among sole e-cigarette users with regard to a potential gateway effect and other possible long-term health effects of e-cigarettes.