PREVENTING CHRONIC DISEASE P U B L I C H E A L T H R E S E A R C H , P R A C T I C E , A N D P O LICY Volume 13, E103 AUGUST 2016 ORIGINAL RESEARCH Electronic Cigarette Use Among High School Students and Its Association With Cigarette Use And Smoking Cessation, North Carolina Youth Tobacco Surveys, 2011 and 2013 Li-Ling Huang, PhD, MPH; Sarah D. Kowitt, MPH; Erin L. Sutfin, PhD; Tanha Patel, MPH; Leah M. Ranney, PhD; Adam O. Goldstein, MD, MPH Suggested citation for this article:H uang LL, Kowitt SD, rent e-cigarette use was negatively associated with intention to Sutfin EL, Patel T, Ranney LM, Goldstein AO. Electronic quit cigarette smoking for good (relative risk ratio [RRR] = 0.51; Cigarette Use Among High School Students and Its Association 95% CI, 0.29–0.87) and with attempts to quit cigarette smoking in With Cigarette Use And Smoking Cessation, North Carolina the past 12 months (RRR = 0.69; 95% CI, 0.49–0.97). Current e- Youth Tobacco Surveys, 2011 and 2013. Prev Chronic Dis 2016; cigarette smokers were less likely than those who only smoked ci- 13:150564. DOI: http://dx.doi.org/10.5888/pcd13.150564. garettes to have ever abstained from cigarette smoking for 6 months (RRR = 0.42; 95% CI, 0.21–0.82) or 1 year (RRR = 0.21; 95% CI, 0.09–0.51) and to have used any kind of aids for smoking PEER REVIEWED cessation (RRR = 0.46; 95% CI, 0.29–0.74). Abstract Conclusion Public health practitioners and cessation clinic service providers Introduction should educate adolescents about the risks of using any nicotine- Although adolescent cigarette use continues to decline in the containing products, including e-cigarettes, and provide adequate United States, electronic cigarette (e-cigarette) use among adoles- tobacco cessation resources and counseling to adolescent tobacco cents has escalated rapidly. This study assessed trends and pat- users. terns of e-cigarette use and concurrent cigarette smoking and the relationships between e-cigarette use and smoking cessation inten- Introduction tions and behaviors among high school students in North Carolina. Electronic cigarettes (e-cigarettes) are devices that aerosolize li- Methods quid that contains nicotine, humectants, and flavoring agents and Data came from high school students who completed the school- mimic the experience of cigarette smoking. These devices are be- based, cross-sectional North Carolina Youth Tobacco Survey in ing aggressively marketed as smoking cessation aids and as 2011 (n = 4,791) and 2013 (n = 4,092). This study assessed healthy alternatives to cigarette smoking (1,2). Although e-cigar- changes in prevalence of e-cigarette and cigarette use from 2011 ettes are not approved by the US Food and Drug Administration through 2013, and cessation-related factors associated with those (FDA) as a cessation aid, they are perceived as healthier than ci- students’ current and past use of e-cigarettes in 2013. garettes by adolescents (3), young adults (4), and adults (5,6). Ad- olescent cigarette smokers report that one reason they try e-cigar- Results ettes is because they want to quit cigarettes (3). But, unlike adults’ The prevalence of current e-cigarette use (use in the past 30 days) reasons for using e-cigarettes, adolescents’ top reason is not a de- significantly increased from 1.7% (95% CI, 1.3%–2.2%) in 2011 sire to reduce cigarette smoking (6–10); for adolescents, curiosity, to 7.7% (95% CI, 5.9%–10.0%) in 2013. Among dual users, cur- appealing flavors, and peer influences rank as higher reasons (3). The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2016/15_0564.htm • Centers for Disease Control and Prevention 1 PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 Public health concerns about adolescent e-cigarette use have been between using e-cigarettes and cigarette smoking among adoles- raised because the adolescent’s developing brain is particularly cents and to test whether e-cigarette use is associated with inten- vulnerable to the negative effects of nicotine neurotoxin and nicot- tion to quit cigarette smoking, attempts to quit, and various quit ine dependence (11–13). Nicotine dependence may develop rap- methods. In addition, we studied trends in adolescents’ e-cigarette idly among at-risk youths who are still at relatively low levels of use over time. smoking, even before they progress to regular or daily smoking (14,15). Longitudinal evidence shows that early emerging depend- Methods ence symptoms in adolescence predict a greater predisposition for continued smoking behavior in young adulthood (16). High school Data source students who are exposed to nicotine in early adolescence are also The NCYTS is a voluntary, anonymous, school-based survey of at higher risk for becoming highly nicotine dependent than are middle and high school students administered biannually since those exposed to nicotine later in adolescence, leading to more dif- 1999. The NCYTS survey uses a 2-stage cluster probability ficulty quitting (15). Having a better understanding of the relation- sampling design to produce a representative sample of students in ship between e-cigarette use and smoking cessation intentions and grades 6 through 12 (21). Our study consisted of public high behaviors among adolescents can inform FDA regulatory efforts school students only (grades 9–12) because adolescents of high on adolescent e-cigarette use, including communicating harmful school age are more vulnerable than younger adolescents to exper- health effects of e-cigarette use to youths, correcting mispercep- imenting with risky behaviors, including dual use of cigarette and tions about their role in smoking cessation and nicotine addiction, e-cigarettes, The Centers for Disease Control and Prevention fun- and providing adolescents with adequate cessation resources. ded and approved the NCYTS, which is conducted to evaluate Little data exists on how adolescents use e-cigarettes in an at- state tobacco control efforts. Our study, which used secondary tempt to quit cigarette smoking. Recent cross-sectional data show data analysis, was reviewed by the Office of Human Research Eth- that e-cigarette use among US adolescents was associated with ics at the University of North Carolina, Chapel Hill, which de- lower odds of abstinence from cigarette use for 30 days or more termined that the study did not constitute human subjects research (17). Planning to quit smoking cigarettes within the next year was as defined under federal regulations 45 CFR 46.102 (d or f) and 21 positively associated with ever using e-cigarettes, but not with cur- CFR 56.102(c)(e)(l) and did not require institutional review board rently using e-cigarettes, and attempts to quit smoking were not approval. associated with ever using or currently using e-cigarettes (17). An- Measurement other US study of adolescent smokers reported that ever using e- cigarettes was not associated with an intention to quit smoking Use of e-cigarettes and cigarettes. To assess cigarette smoking, we (18). In a study of Korean adolescents, e-cigarette use was associ- asked students whether they had ever tried cigarette smoking, even ated with higher odds of ever having attempted to quit smoking in 1 or 2 puffs; when the last time was they smoked a cigarette, even the past 12 months among current cigarette smokers and lower 1 or 2 puffs; and how many days they smoked cigarettes during odds of smoking cigarettes in the past 30 days among youths who the past 30 days. Students who reported that they had ever smoked had ever smoked cigarette, suggesting some youths may be using cigarettes, but not in the past 30 days, were categorized as “past e-cigarettes as a cessation aid (19). These studies showed that cur- users.” Those who reported smoking cigarettes at least 1 day in the rent e-cigarette users were significantly less likely to have ab- past 30 days were categorized as “current users.” Current and past stained from smoking cigarettes in the past 30 days; nevertheless, use of e-cigarettes was assessed by 2 questions: “In the past 30 the relationships between e-cigarette use and intentions or at- days, which of the following tobacco products have you used on at tempts to quit cigarettes were mixed. Recent evidence supports the least one day?” and “Which of the following tobacco products efficacy of psychosocial interventions for smoking cessation have you ever tried, even just one time?” Students who responded among adolescents, and some findings support the efficacy of they had used “electronic cigarettes or e-cigarettes, such as Ruyan nicotine replacement treatments (20). However, there is insuffi- or NJOY” on at least 1 of the past 30 days were categorized as cient evidence to determine the efficacy of pharmacological treat- current users. Those who said they had ever used e-cigarettes, but ments among adolescents (20). not in the past 30 days, were categorized as past users. Students who never tried cigarettes or e-cigarettes were categorized as We used cross-sectional data from the 2011 and 2013 North Caro- “never users.” Students who both smoked cigarettes and used e-ci- lina Youth Tobacco Survey (NCYTS) to examine relationships garettes in the past 30 days were categorized as current users of both. Students were also asked about their intention to try e-cigar- ettes with the question (asked in the 2013 survey only), “In the The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2016/15_0564.htm PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 next year, which of the following tobacco products do you think stated otherwise. We used χ2 tests to compare sample characterist- you will try?” Students who responded “electronic cigarettes or e- ics and to examine descriptive statistics for each covariate. Multi- cigarettes, such as Ruyan or NJOY” were considered as intending nomial logistic regression analyses were conducted to examine as- to try e-cigarettes. sociations between predictors (ie, cigarette use, quit intention, quit attempt, length of last abstinence period) and use of 3 outcome tToh aedseju dste mfoor gsreaxp, hgirca dvea r(i9atbhl–e1s2 wth)e,r aen uds eradc ea/se tchonviacritiyat e(ws hinit ea,n balaycskis, tceadte rgeolraiteivs:e n reisvke rr,a ptiaosst, (aRnRd Rcsu)r rwenetr e -ccaiglcaurleatte du sine irne f2e0re1n3c. eA tdoj uths-e Hispanic, and other). base group (ie, never e-cigarette users). Separate models were Intention to quit cigarette smoking. Intention to quit cigarette used for each cessation-related predictor because of collinearity smoking was measured with the question “Do you want to stop between the predictors. All models were adjusted for sociodemo- smoking cigarettes for good?” with response options “Yes,” “No,” graphic variables. and “I do not smoke now.” Quit attempts for cigarette smoking were measured with the question “During the past 12 months, how Results many times have you stopped smoking for 1 day or longer be- E-cigarette prevalence. Participants in the current study were cause you were trying to quit smoking cigarettes for good?” Stu- 4,791 students from 90 high schools who participated in the 2011 dents who chose 1 or more times (possible responses were 1 time, NCYTS and 4,092 students from 83 high schools who particip- 2 times, 3–5 times, 6–9 times, and ≥10 times) were categorized as ated in the 2013 NCYTS. The overall response rates combining having tried to quit smoking; those who chose “did not try to quit school and student levels were 78.2% in 2011 and 67.8% in 2013. smoking cigarettes” were categorized as not having tried to quit Of the high school students in the 2011 and 2013 surveys, about smoking; those who reported not smoking cigarettes during the half were male and more than 50% were non-Hispanic white (Ta- past 12 months were categorized as not smoking cigarettes. ble 2). The prevalence of current e-cigarette use among North Car- Length of last period of abstinence from cigarette smoking was olina high school students increased significantly, from 1.7% based on responses to the question “When you last tried to quit for (95% CI, 1.3%–2.2%) in 2011 to 7.7 (95% CI, 5.9%–10.0%) in good, how long did you stay off cigarettes?” Response options 2013 while current cigarette use declined from 15.1% (95% CI, were “less than 30 days,” “30 days,” “6 months,” and “1 year.” 13.7%–16.7%) to 13.1% (95% CI, 11.6%–14.7%) (Table 2). A Students were asked, “In the past 12 months, did you do any of the notable increase occurred in the proportion of current e-cigarette following to help you quit using tobacco of any kind for good?” users who had never smoked cigarettes from 2011 (n = 7, 7.8%; Students could select 1 or more of the following responses (Table 95% CI, 6.6%–8.6%) to 2013 (n = 26, 11.6%; 95% CI, 1): “attended a program at my school,” “attended a program in the 8.3%–16.0%). Among students who reported in the 2013 survey community,” “called a telephone help line or telephone quit line,” that they thought they would try e-cigarettes in the next year, 20% “used nicotine gum,” “used nicotine patch,” “used any medicine to had never smoked cigarettes. Concurrent use of cigarettes and e- help quit,” “visited an Internet quit site,” “got help from family or cigarettes was 4.4% (95% CI, 3.3–5.8) among students surveyed friends,” “used another method such as hypnosis or acupuncture,” in 2013, which was 3 times more than concurrent use of both “tried to quit on my own or quit cold turkey,” “I did not try to quit products in 2011 (1.3%; 95% CI, 1.0%–1.8%). Multinomial logist- during the past 12 months,” and “I did not use tobacco of any kind ic regression analysis for both 2011 and 2013 confirmed that cur- during the past 12 months.” A variable was derived from answers rent cigarette use was strongly associated with both current and to this question to classify students into 4 groups: “used any quit past e-cigarette use after adjusting for sociodemographic variables aid” for those who used any aid but not quit cold turkey, “quit cold (RRR=18.68; 95% CI, 12.95–26.93 for current e-cigarette use in turkey only” for those who answered “tried to quit on my own or 2013; RRR = 46.17; 95% CI, 28.98–73.55 for past e-cigarette use quit cold turkey” only, “did not attempt to quit,” or “did not use in 2013) (Table 3). tobacco.” Smoking cessation behaviors and e-cigarette use. The number of Statistical analysis adolescents who got tobacco cessation help was low. Among those who responded that they used any method to quit tobacco for good NCYTS data are statistically weighted to reflect the likelihood of in the past 12 months (n = 517), the majority (n = 357; 70.1%) re- sampling each student and to reduce bias by compensating for dif- ported trying to quit on their own or “quit cold turkey” (Table 1). fering patterns of nonresponse. Data were analyzed by using Among those who reported using cessation aids, nicotine gum STATA version 13.1 (STATA Corp) survey procedures to ac- (8.7%) and “help from family or friends” (8.3%) were the most count for the complex survey design and sampling weights unless common methods reported by students, followed by “attended a The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2016/15_0564.htm • Centers for Disease Control and Prevention 3 PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 program” at their school or community. More than half of adoles- rapidly from 2011 to 2013, consistent with national data (17,22). cents who reported that they used only “quitting cold turkey” (n = Given that e-cigarettes have recently become the leading form of 317) were either current e-cigarette users (24.1%) or past e-cigar- tobacco used by US adolescents (22), the rapid increase in e-cigar- ette users (33.1%). Fewer of those who reported using at least one ette use among North Carolina cigarette “never smokers” is also cessation aid to help them quit than those who reported using only concerning. Longitudinal research began to monitor the relation- “quit cold turkey,” reported current e-cigarette use (15.5%) or past ship between e-cigarette use and initiating cigarette smoking over e-cigarette use (16.2%) (data not shown). time and demonstrated that e-cigarette use leads to cigarette smoking, which could potentially become the initial source of Correlates of current e-cigarette use.Table 4 shows factors signi- nicotine exposure and create a new generation of adolescents with ficantly associated with current and past e-cigarette use in 2013. nicotine addiction (23,24). Overall, adolescents who were male, older (in higher grades), non- Hispanic white or Hispanic (compared with non-Hispanic black), Our finding illustrated that North Carolina adolescent cigarette had no intention to quit smoking cigarettes, or made no attempt to smokers who intended to quit or made any attempt to quit smoking quit smoking cigarettes were more likely to be current e-cigarette cigarettes in the past 12 months were less likely to be current e-ci- users. Adolescents who had ever abstained from cigarette smoking garette users. Such results are not surprising given that cessation is for long periods and used cessation aids were less likely to be cur- a far less commonly cited reason to use e-cigarettes among adoles- rent e-cigarette users than those who made no quit attempt in the cents than adults (3). The relationship between e-cigarette use and past 12 months. For example, compared with students who did not intention and attempts to quit cigarette smoking were mixed across want to stop smoking for good, those who did want to stop studies of US adolescents and Korean youths (17–19). The dis- smoking were 0.51 times more likely than nonusers to be current crepant findings on quit intentions and attempts among the cur- e-cigarette users (RRR = 0.51; 95% CI, 0.29–0.87). Current e-ci- rent and previous studies may be explained by several factors. garette use was negatively associated with trying to quit smoking Reasons for trying e-cigarettes may vary significantly by smoking cigarettes in the past 12 months (RRR = 0.69; 95% CI, 0.49–0.97) cessation intentions and frequency of e-cigarette use, thereby mak- and ever abstinence from cigarette smoking for 6 months (RRR = ing an association between cessation intentions and the use pat- 0.42; 95% CI, 0.21–0.82) or 1 year (RRR = 0.21; 95% CI, tern of e-cigarettes nonsignificant. Research, including our study, 0.09–0.51). No association existed between reported ever abstain- often defines current e-cigarette use as any reported use in the past ing for less than 6 months and current e-cigarette use. Students 30 days; thus, current e-cigarette users may include experimenters, who reported using any kind of cessation aid to quit using tobacco unlike frequent users, who usually have different reasons for us- in the past 12 months, including medication and family and friend ing e-cigarettes and will persist in using e-cigarettes (25). The support, were less likely to be current e-cigarette users (RRR = definitions of quit intentions and attempts also vary across studies. 0.46; 95% CI, 0.29–0.74). Marked variation across studies in the measurement of adolescent e-cigarette use makes results difficult to interpret (26). Future re- Correlates of past e-cigarette use. Similar to current e-cigarette search needs to use consistent and validated measures to assess use, older, non-Hispanic white, and Hispanic students were more quit intentions and attempts and to examine reasons for using e-ci- likely to be past e-cigarette users (Table 4). However, past e-cigar- garette by e-cigarette use frequency. ette use was not associated with adolescent intentions to quit cigar- ette smoking for good (RRR = 0.83; 95% CI, 0.50–1.36, P = .45), Similar to the findings of quit intentions and quit attempts, adoles- trying to quit smoking cigarettes in the past 12 months (RRR = cent cigarette smokers who had ever abstained from cigarette 1.10; 95% CI, 0.68–1.80, P = .68), or ever abstinence from cigar- smoking for 6 months or more were less likely to be current e-ci- ette smoking. Students who quit cold turkey without any other ces- garette users. Future research should examine adolescents’ reas- sation aids were more likely to be past e-cigarette users (RRR = ons for using cigarettes to determine whether they use e-cigarettes 1.72; 95% CI, 1.21–2.45). Students who used cessation aids to to quit smoking cigarettes, whether they did not want to quit help them quit tobacco were less likely to have used e-cigarettes in smoking entirely but sought a healthier alternative, or whether the past, but this association was moderate (RR = 0.58; 95% CI, they simply experimented or used e-cigarettes for recreational 0.33–1.02, P = .06). reasons rather than for cessation reasons. Longitudinal research is needed to determine the causal relationship between e-cigarette Discussion use and cessation outcomes by tracking the patterns of cessation behaviors and e-cigarette use and examining reasons for using e- The prevalence of e-cigarette use and concurrent use of e-cigar- cigarettes over time. ettes and cigarettes among North Carolina adolescents increased The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2016/15_0564.htm PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 The majority of adolescent tobacco users reported that they either Acknowledgments had tried to quit cold turkey or did not try to quit at all in the past 12 months. These adolescents may have felt invulnerable to This work was supported by the National Cancer Institute at the health-threatening behaviors, felt optimistic about their chances of National Institutes of Health and the Center for Tobacco Products avoiding harm compared with adults’ chances, believed they were at the Food and Drug Administration (P50CA180907); and the less addicted to smoking, and believed quitting would be easy Centers for Disease Control and Prevention (DP 14-1415). The (27,28). Our results also found that adolescents who reported they content is solely the responsibility of the authors and does not ne- had used any cessation aids were less likely to be current e-cigar- cessarily represent the official views of the National Institutes of ette users; on the other hand, those adolescents who tried quitting Health, the Food and Drug Administration, or the Centers for Dis- on their own were more likely to have used e-cigarettes in the past. ease Control and Prevention. The authors declare no conflicts of It is unclear whether these adolescents experimented with e-cigar- interest. ettes out of curiosity, or used e-cigarettes as a cessation aid or a healthier alternative. Future research should understand the role of Author Information e-cigarette use in adolescents’ cessation behaviors by examining adolescents’ reasons for using e-cigarettes and distinguish between Corresponding Author: Li-Ling Huang, PhD, MPH, Center for e-cigarette motivated users (eg, quitting smoking as a goal-ori- Regulatory Research on Tobacco Communication, Lineberger ented reason) and e-cigarette experimenters (eg, curiosity as a non- Comprehensive Cancer Center, University of North Carolina, goal-oriented reason) (9). Chapel Hill, Chapel Hill, NC 27599. Telephone: 919-966-2994. Email: PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 4. Choi K, Forster J. Characteristics associated with awareness, 18. Park J-Y, Seo D-C, Lin H-C. E-Cigarette use and intention to perceptions, and use of electronic nicotine delivery systems initiate or quit smoking among US youths. Am J Public Health among young US Midwestern adults. Am J Public Health 2016;106(4):672–8. 2013;103(3):556–61. 19. Lee S, Grana RA, Glantz SA. Electronic cigarette use among 5.Dockrell M, Morrison R, Bauld L, McNeill A. E-cigarettes: Korean adolescents: a cross-sectional study of market prevalence and attitudes in Great Britain. Nicotine Tob Res penetration, dual use, and relationship to quit attempts and 2013;15(10):1737–44. former smoking. J Adolesc Health 2014;54(6):684–90. 6.Adkison SE, O’Connor RJ, Bansal-Travers M, Hyland A, 20. Simon P, Kong G, Cavallo DA, Krishnan-Sarin S. Update of Borland R, Yong H-H, et al. Electronic nicotine delivery adolescent smoking cessation interventions: 2009–2014. Curr systems: international tobacco control four-country survey. Am Addict Rep 2015;2(1):15–23. J Prev Med 2013;44(3):207–15. 21. Proescholdbell SK, Summerlin-Long SK, Goldstein AO. 7. Etter J-F, Bullen C. Electronic cigarette: users profile, Declining tobacco use among North Carolina middle and high utilization, satisfaction and perceived efficacy. Addiction school students: 1999–2007. N C Med J 2009;70(3):205–12. 2011;106(11):2017–28. 22.Arrazola RA, Singh T, Corey CG, Husten CG, Neff LJ, 8.Vickerman KA, Carpenter KM, Altman T, Nash CM, Apelberg BJ, et al.;Centers for Disease Control and Prevention Zbikowski SM. Use of electronic cigarettes among state (CDC). Tobacco use among middle and high school students tobacco cessation quitline callers. Nicotine Tob Res 2013; — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 15(10):1787–91. 2015;64(14):381–5. 9. Pepper JK, Ribisl KM, Emery SL, Brewer NT. Reasons for 23. Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. starting and stopping electronic cigarette use. Int J Environ Res Progression to traditional cigarette smoking after electronic Public Health 2014;11(10):10345–61. cigarette use among US adolescents and young adults. JAMA 10.Rahman MA, Hann N, Wilson A, Worrall-Carter L. Electronic Pediatr 2015;169(11):1018–23. cigarettes: patterns of use, health effects, use in smoking 24. Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, cessation and regulatory issues. Tob Induc Dis 2014;12(1):21. Sussman S, Riggs NR, et al. Association of electronic cigarette 11. Slotkin TA. Cholinergic systems in brain development and use with initiation of combustible tobacco product smoking in disruption by neurotoxicants: nicotine, environmental tobacco early adolescence. JAMA 2015;314(7):700–7. smoke, organophosphates. Toxicol Appl Pharmacol 2004; 25.Amato MS, Boyle RG, Levy D. How to define e-cigarette 198(2):132–51. prevalence? Finding clues in the use frequency distribution. 12.Walley SC, Jenssen BP;Section on Tobacco Control. Tob Control 2016;25(e1,e1):e24–9. Electronic nicotine delivery systems. Pediatrics 2015; 26. Echevarria C, Sinha IP. Heterogeneity in the measurement and 136(5):1018–26. reporting of outcomes in studies of electronic cigarette use in 13.McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. adolescents: a systematic analysis of observational studies. Tob Electronic cigarettes for smoking cessation and reduction. Control 2016;tobaccocontrol-2015-052881. Published online Cochrane Database Syst Rev 2014;12(12):CD010216. Apr 29, 2016 14.DiFranza JR, Savageau JA, Fletcher K, O’Loughlin J, Pbert L, 27.Amos A, Wiltshire S, Haw S, McNeill A. Ambivalence and Ockene JK, et al. Symptoms of tobacco dependence after brief uncertainty: experiences of and attitudes towards addiction and intermittent use: the Development and Assessment of Nicotine smoking cessation in the mid-to-late teens. Health Educ Res Dependence in Youth-2 study. Arch Pediatr Adolesc Med 2006;21(2):181–91. 2007;161(7):704–10. 28.Cohn LD, Macfarlane S, Yanez C, Imai WK. Risk-perception: 15.Mermelstein R. Teen smoking cessation. Tob Control 2003; differences between adolescents and adults. Health Psychol 12(90001,Suppl 1):i25–34. 1995;14(3):217–22. 16.Dierker L, Hedeker D, Rose J, Selya A, Mermelstein R. Early 29.Wagoner KG, Cornacchione J, Wiseman KD, Teal R, Moracco emerging nicotine dependence symptoms in adolescence KE, Sutfin EL. E-cigarettes, hookah pens and vapes: predict daily smoking in young adulthood. Drug Alcohol adolescent and young adult perceptions of electronic nicotine Depend 2015;151:267–71. delivery systems. Nicotine Tob Res; 2016. Epub Mar 30, 2016. 17.Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among U.S. adolescents: a cross-sectional study. JAMA Pediatr 2014;168(7):610–7. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2016/15_0564.htm PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 30. Food and Drug Administration. FDA takes significant steps to protect Americans from dangers of tobacco through new regulation. Accessed May 5, 2016. http://www.fda.gov/ N ew s E v e n t s / N ew s r o om / P r e s s A n n o u n c em e n t s / ucm499234.htm. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2016/15_0564.htm • Centers for Disease Control and Prevention 7 PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 Tables Table 1. Smoking Cessation Methods Attempted by Study Sample of Participants (N = 517)a in Relation to E-Cigarette Use, 2013 North Carolina Youth Tobacco Sur- vey Used E-Cigarettes? Cessation Method NTo (t%al)ab Never (n = 3,405), n (%) In Past (n = 397), n (%) Currently (n = 290), n (%) Attended a program at my school 33 (6.6) 23 (66.5) 6 (20.0) 4 (13.5) Attended a program in the community 36 (6.9) 32 (90.2) 3 (5.7) 1 (4.1) Called a telephone help line or telephone quit line 22 (3.8) 18 (85.2) 2 (5.7) 2 (9.1) Used nicotine gum 39 (8.7) 22 (62.4) 8 (18.7) 9 (18.9) Used nicotine patch 22 (3.8) 16 (73.7) 1 (7.5) 5 (18.8) Used any medicine to help quit 10 (1.7) 4 (42.5) 2 (10.0) 4 (47.5) Visited an Internet quit site 6 (1.1) 2 (32.5) 2 (27.6) 2 (40.0) Got help from family or friends 50 (8.3) 22(46.2) 16 (27.8) 12 (26.0) Used another method such as hypnosis or acupuncture 4 (0.5) 3 (84.4) 1 (15.6) 0 (0.0) Tried to quit on my own or quit cold turkey 357 (70.1) 163 (42.9) 106 (32.1) 88 (25.1) a Study participants could choose all quit methods tried; therefore, number of responses (579) exceeds number of study respondents (517). b The percentages are weighted data based on the total of 517 participants. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 8 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2016/15_0564.htm PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 Table 2. Sociodemographic Characteristics of Participants in the 2011 (N = 4,791) and 2013 (N = 4,092) North Carolina Youth Tobacco Survey, by E-Cigarette Use 2011 2013 E-Cigarette User E-Cigarette User Full Sample Full Sample (n = 4,791), Never (n = Past (n = Current (n = (n = 4,092), Never (n = Past (n = Current (n = n (% [95 % 4,492), n (% 204), n (% 95), n (% [95 n (% [95 % 3,405), n (% 397), n (% 290) n (% Sample Characteristics CI]) [95 % CI]) [95 % CI]) % CI]) CI]) [95 % CI]) [95 % CI]) [95 % CI]) Smoked cigarettes? 4,791 (100.0) 4,492 (94.1 204 (4.2 95 (1.7 4,092 (100.0) 3,405 (82.2 397 (10.1 290 (7.7 [93.0–95.0]) [3.5–5.1]) [1.3–2.2]) [78.0–85.7]) [8.2–12.5]) [5.9–10.0]) Never 2,878 (61.3 2,863 (64.7 8 (5.8 7 (7.8 2,544 (63.2 2,449 (73.5 69 (18.5 26 (11.6 [58.2–64.3]) [61.8–67.5]) [2.3–14.0]) [6.6–8.6]) [61.2–65.2]) [70.5–76.3]) [13.6–24.7]) [8.3–16.0]) In the past 1,149 (23.6, 1,060 (23.2, 73 (36.4 16 (14.6 1,007 (23.8 716 (19.9 197(49.0 94 (31.1 21.6–25.8]) 20.9–25.7]) [26.7–47.4]) [8.0–25.2]) [22.2–25.4]) [18.2–21.9]) [42.7–55.4]) [26.4–36.2]) Currently 764 (15.1 569 (12.1 123 (57.8 72 (77.6 541 (13.1, 240 (6.5 131 (32.5 170 (57.3 [13.7–16.7]) [10.9–13.5]) [47.2–67.8]) [65.8–86.1]) 11.6–14.7]) [5.3–8.1 ]) [27.4–38.0]) [51.0–63.3]) Sex Female 2,577 (49.3 2,461 (50.4 88 (35.1 28 (23.5 2,195 (48.9 1,909 (51.0 189 (47.8 97 (27.9 [46.1–52.4]) [47.0–53.7]) [26.6–44.7]) [16.2–32.9]) [46.0–51.8]) [48.0–54.1]) [40.5–44.8]) [20.9–36.1]) Male 2,211 (50.7 2,208 (49.6 116 (64.9 67 (76.5 1,893 (51.1 1,493 (49.0 207 (52.2 193 (72.1 [47.6–53.9]) [46.3–53.0]) [55.3–73.4]) [67.1–83.8]) [48.2–54.0]) [45.9–52.0]) [44.8–59.5]) [63.9–79.1]) Race/ethnicity Non-Hispanic black 1,063 (32.2, 1,041 (33.5 17 (11.8 5 (10.2 1,132 (27.3 1,028 (30.2 67 (17.9 37 (8.8 25.3–40.0]) [26.3–41.5]) [6.2–21.3]) [4.1–23.1]) [23.9–31.0]) [26.4–34.3]) [13.4–23.5]) [5.1–14.6]) Non-Hispanic white 2,880 (55.9 2,644 (54.5 162 (79.7 74 (73.8 2,113 (54.0 1,650 (50.1 258 (67.7 205 (78.1 [48.3–63.2]) [46.6–62.1]) [70.0–87.9]) [61.5–83.2]) [48.6–59.4]) [44.9–55.2]) [61.9–73.1]) [66.1–86.7]) Non-Hispanic other 232 (3.9 215 (3.9 11 (3.8 6 (4.5 224 (7.5 192 (8.1 19 (4.5 13 (4.7 [3.1–4.9]) [3.1–50.0]) [1.7–8.0]) [1.5–12.6]) [5.4–10.3]) [6.2–10.9]) [1.9–10.2]) [2.1–10.4]) Hispanic 597 (8.0 574 (8.1 13 (4.7 10 (11.5 607 (11.2 519 (11.6 53 (9.9 35 (8.4 [7.0–9.2]) [7.0–9.4]) [2.1–9.8]) [5.0–24.4]) [9.2–13.5]) [9.6–13.9]) [7.3–13.2]) [4.9–14.2]) Grade 9th 1,463 (29.9 1,395 (30.7 46 (14.9 22 (18.9 1,193 (28.8 1,069 (31.5 72 (16.8 52 (15.4 [23.3–37.4]) [23.9–38.5]) [9.2–23.3]) [10.4–31.6]) [22.4–36.2]) [25.3–38.5]) [11.1–24.6]) [8.7–25.8]) 10th 1,269 (26.0 1,201 (26.0 46 (28.4 22 (20.9 931 (25.9 790 (25.7 89 (30.0 52 (22.1 [21.9–30.6]) [21.8–30.7]) [21.3–36.8]) [12.6–32.6]) [21.1–31.3]) [21.4–30.5]) [19.5–43.0]) [14.3–32.5]) 11th 1,081 (23.3 1,010 (23.2 53 (27.4 18 (23.2 957 (23.4, 759 (22.1 110 (28.0 88 (32.0 [19.0–28.3]) [18.8–28.2]) [18.4–38.6]) [14.4–35.1]) 19.0–28.5]) [17.7–27.2]) [22.6–34.1] [23.7–41.4]) 12th 970 (20.8 878 (20.1 59 (29.3 33 (37.1 1,000 (21.9 776 (20.7 126 (25.2 98 (30.6 [17.3–24.6]) [16.8–23.9]) [21.1–39.1]) [24.8–51.3]) [18.3–26.1]) [16.9–25.2]) [16.6–36.4]) [23.7–38.5]) Quit-smoking intention Do not want to stop smoking 425 (8.6 316 (6.9 66 (31.8 43 (49.3 317 (8.5 136 (4.1 74 (20.2 107 (38.8 cigarettes for good [7.6–9.8]) [6.0–7.9]) [23.6–41.3]) [36.2–62.4]) [7.4–9.9]) [3.4–5.0]) [16.2–24.9]) [33.0–44.9]) Want to stop smoking cigarettes 355 (7.2 275 (5.9 59 (29.2 21 (24.8 253 (5.9 129 (3.4 65 (15.2 59 (18.6 for good [6.1–8.5]) [5.0–6.9]) [21.7–38.0]) [14.6–39.0]) [4.8–7.2]) [2.6–4.5]) [9.6–23.1]) [13.9–24.5]) Do not smoke cigarettes now 3,889 (84.2 3,787 (87.3 76 (39.1 26 (25.9 3,355 (85.6 2,990 (92.4 246 (64.6 119 (42.6 [82.4–85.9]) [85.7–88.6]) [29.4–49.6]) [16.8–37.9]) [84.1–87.0]) [90.6–93.9]) [57.1–71.5]) [37.1–48.4]) Attempted to quit in the past 12 months Did not try to quit smoking 431 (8.5 340 (7.2 51 (23.5 40 (47.9 304 (7.7 136 (4.0 69 (19.4 99 (32.1 cigarettes [7.4–9.9]) [6.1–8.4]) [17.0–31.7]) [36.2–57.9]) [6.3–9.4]) [3.4–4.6]) [13.9–26.5]) [28.2–36.3]) Tried to quit smoking cigarettes 631 (13.1 499 (11.0 98 (49.0 34 (36.7 481 (11.9 230 (6.6 140 (34.6 111 (38.4 for good [11.4–14.9]) [9.6–12.6]) [38.3–57.8]) [26.0–48.9]) [10.6–13.4]) [5.2–8.4]) [25.9–44.6]) [33.0–44.0]) Did not smoke cigarettes 3,630 (78.4 3,562 (81.8 53 (27.5 15 (15.4 3,200(80.4 2,950 (89.4 178 (46.0 71 (29.5 [76.1–80.1]) [79.8–83.6]) [19.7–36.9]) [8.0–27.7]) [78.4–82.1]) [87.4–91.2]) [39.7–52.3]) [23.6–36.2]) (continued on next page) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2016/15_0564.htm • Centers for Disease Control and Prevention 9 PREVENTING CHRONIC DISEASE VOLUME 13, E103 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2016 (continued) Table 2. Sociodemographic Characteristics of Participants in the 2011 (N = 4,791) and 2013 (N = 4,092) North Carolina Youth Tobacco Survey, by E-Cigarette Use 2011 2013 E-Cigarette User E-Cigarette User Full Sample Full Sample (n = 4,791), Never (n = Past (n = Current (n = (n = 4,092), Never (n = Past (n = Current (n = n (% [95 % 4,492), n (% 204), n (% 95), n (% [95 n (% [95 % 3,405), n (% 397), n (% 290) n (% Sample Characteristics CI]) [95 % CI]) [95 % CI]) % CI]) CI]) [95 % CI]) [95 % CI]) [95 % CI]) Abstinence from cigarette use Never tried to quit 469 (9.6 386 (8.4 45 (21.9 38 (48.7 333 (8.5 168 (4.8 73 (20.5 92 (32.3 [8.3–11.1]) [7.1–9.8]) [15.2–30.6]) [39.7–57.7]) [7.2–9.9]) [4.1–5.6]) [15.8–26.3]) [27.0–38.2]) <30-day abstinence 383 (7.7 285 (6.1 74 (34.4 24 (27.0 301 (7.2 158 (4.5 67 (15.2 76 (26.1 [6.3–9.2]) [4.9–7.6]) [25.8–44.1]) [25.8–44.1]) [6.3–8.3]) [3.6–5.7]) [10.9–20.8]) [21.6–31.2]) 30-day abstinence 151 (2.9 132 (2.7 14 (8.5 5 (3.3 107 (2.8 47 (1.5 39 (9.6 21 (8.6 [2.4–3.6]) [2.2–3.2]) [5.5–12.7]) [1.2–8.5]) [2.1–3.8]) [0.9–2.3]) [5.8–15.4]) [5.0–14.2]) 6-month abstinence 105 (2.1 82 (1.7 19 (9.0 4 (2.9 96 (2.1 53 (1.4 30 (6.8 13 (4.1 [1.6–2.6]) [1.3–2.3]) [5.3–14.8]) [1.0–7.8]) [1.6–2.9]) [1.0–2.0]) [4.0–11.3]) [2.2–7.8]) 1-year abstinence 234 (4.7 207 (4.5 22 (10.1 5 (4.2 187 (4.6 123 (3.4 143 (13.3 21 (5.8 [4.0–5.5]) [3.7–5.4]) [5.8–16.9]) [1.3–12.2]) [3.8–5.4]) [2.6–4.3]) [10.2–17.3]) [2.9–11.2]) Never smoked cigarettes 3,350 (73.1 3,310 (76.6 27 (16.2 13 (14.0 2,954 (74.8 2,770 (84.5 129 (34.6 55 (23.1 [70.2–75.7]) [74.0–79.1]) [10.3–24.4]) [7.7–24.0]) [72.8–76.7]) [82.0–86.8]) [28.0–41.9]) [17.5–30.0]) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 10 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2016/15_0564.htm