108Electronic cigarettes, or e-cigarettes,” are de-vi.docx

108
E
lectronic cigarettes, or “e-cigarettes,” are de-
vices that consist of a battery-operated ele-
ment which heats a mixture of propylene gly-
col, vegetable glycerin, liquid nicotine and flavor-
ings for the user to inhale. Whereas their overall
safety, as well as their role in smoking cessation, is
the topic of ongoing debate,1 there is no doubt that
the prevalence of e-cigarette use has increased rap-
idly among all age groups.2,3 Among adolescents,
nationally-representative estimates indicate that
past 30-day use for e-cigarettes is higher than con-
ventional cigarettes, and a considerable proportion
of e-cigarette users are dual users of cigarettes.4
That is, a nontrivial number of adolescents—2.2%
of 8th graders, 4.3% of 10th graders and 7.3% of
12th graders— reported using both e-cigarettes and
cigarettes in the past 30 days.4 Several e-cigarette
product features are raising concerns about the
potential to appeal to youth. For example, charac-
teristics such as candy flavorings and easy access
have been implicated as reasons for youth experi-
mentation.5 E-cigarettes also are marketed heavily
on the Internet. A content analysis of e-cigarette
retail websites found frequent appeals to youth
such as use by celebrities, enhanced social activ-
ity, and romance.6

Adolescent Dual Product Use
Increasingly, youth who use tobacco products
are using more than one type of product.7,8 Be-
tween 2002 and 2011, rates of poly-tobacco use
increased significantly among users under age 26.9
According to estimates from the National Youth To-
bacco Survey, the majority of current tobacco us-
ers in middle and high school report use of more
than one tobacco product.10,11 Thus, use of mul-
tiple tobacco products by youth is more common
than exclusive use of one product alone. As such,
it is important to understand the correlates asso-
ciated with and characteristics of adolescent us-
ers of multiple tobacco products. To date, evidence
Maria Cooper, Post-doctoral Fellow, Kathleen R. Case, Pre-
doctoral Fellow, MeLisa R. Creamer, Faculty Associate, and
Cheryl L. Perry, Professor and Regional Dean, University of
Texas Health Science Center at Houston, School of Public
Health, Austin Regional Campus, Austin, TX. Alexandra Lou-
kas, Professor, University of Texas at Austin, Department of
Kinesiology and Health Education, Austin, TX.
Contact Dr Loukas; [email protected]
E-cigarette Dual Users, Exclusive Users
and Perceptions of Tobacco Products
Maria Cooper, PhD; Kathleen R. Case, MPH; Alexandra
Loukas, PhD;
MeLisa R. Creamer, PhD; Cheryl L. Perry, PhD
Objectives: We examined differences in
the characteristics of youth non-users,
cigarette-only, e-cigarette-only, and dual
e-cigarette and cigarette users. Methods:
Using weighted, representative data, lo-

gistic regression analyses were conducted
to examine differences in demographic
characteristics and tobacco use behav-
iors across tobacco usage groups. Multi-
ple linear regression analyses were con-
ducted to examine differences in harm
perceptions of various tobacco products
and perceived peer use of e-cigarettes by
tobacco usage group. Results: Compared
to non-users, dual users were more likely
to be white, male, and high school stu-
dents. Dual users had significantly higher
prevalence of current use of all products
(except hookah) than e-cigarette-only us-
ers, and higher prevalence of current use
of snus and hookah than the cigarette-
only group. Dual users had significantly
lower harm perceptions for all tobacco
products except for e-cigarettes and hoo-
kah as compared to e-cigarette-only us-
ers. Dual users reported higher peer use
of cigarettes as compared to both exclu-
sive user groups. Conclusion: Findings
highlight dual users’ higher prevalence of
use of most other tobacco products, their
lower harm perceptions of most tobacco
products compared to e-cigarette-only us-
ers, and their higher perceived peer use
of cigarettes compared to exclusive users.
Key words: tobacco use; adolescents;
electronic cigarettes
Am J Health Behav. 2016;40(1):108-116
DOI: http://dx.doi.org/10.5993/AJHB.40.1.12

Cooper et al
Am J Health Behav.™ 2016;40(1):108-116 109 DOI:
http://dx.doi.org/10.5993/AJHB.40.1.12
suggests that, in general, adolescents who use 2
or more tobacco products are demographically dis-
tinct from those who use one product. Dual prod-
uct users (in particular, those who use cigarettes
and smokeless tobacco) are more likely to be male
and white than female and non-white.7,12 In ad-
dition, current cigarette/smokeless tobacco dual
product users are more likely to be in high school
than middle school,13 and current cigar/cigarette
dual users are more likely to have a lower grade
point average as compared to non-users.14 Howev-
er, the demographic characteristics of adolescent
dual product e-cigarette and cigarette users are
largely unknown.
The literature describes the deleterious effects of
multiple tobacco product use among adolescents,
including increased nicotine dependence, as well
as increased risk for substance use disorders.7,15,16
However, to date, there is limited research exam-
ining the characteristics of adolescents who use
e-cigarettes and at least one other tobacco prod-
uct. Some studies have explored youth e-cigarette
use with a focus on the prevalence of concomi-
tant cigarette use, motivations for e-cigarette use,
abstinence from cigarettes and intentions to use
other tobacco products,17-20 but with a limited fo-
cus on social-cognitive risk factors. An exception

is a study by Wills et al21 that examined current e-
cigarette and cigarette use among high school stu-
dents in Hawaii. The researchers assessed differ-
ences in risk factors and protective factors among
students reporting no tobacco use, exclusive cur-
rent e-cigarette or cigarette use, and dual use.
Findings indicated that risk status varied across
usage groups, with dual users of e-cigarettes and
cigarettes reporting the most risk factors and the
fewest protective factors, and e-cigarette-only us-
ers representing an intermediate category between
non-users and dual users.
Perceptions of Harm and Peer Use of
E-cigarettes
According to the theory of planned behavior, in-
dividuals’ perceptions, including their attitude to-
ward a behavior, normative beliefs, and perceived
control, influence their decision to take part in a
particular behavior.22 Consistent with this theory,
adolescents who use tobacco products are expect-
ed to be less likely to perceive risks from their use
than non-users.23 Therefore, users of multiple to-
bacco products are likely to hold the lowest harm
perceptions as compared to users of only one to-
bacco product and non-users of tobacco; this re-
lationship has been demonstrated already.24 More-
over, adolescent ever smokers who believe it is safe
to smoke are more likely than their peers to use
tobacco products other than cigarettes (smokeless
tobacco, cigars, and bidis).25 However, few studies
have examined harm perceptions as they relate
to adolescents’ use of e-cigarettes, and even fewer
have focused on adolescents who use e-cigarettes
with at least one other tobacco product. This is

particularly important given the controversies
around the harmful effects of e-cigarette use,1 and
the need for more substantive research to docu-
ment the potentially harmful effects of e-cigarette
use in adolescence.26
To our knowledge, only 3 studies assess harm
perceptions of e-cigarettes in an adolescent popula-
tion. Amrock et al27 found that several characteris-
tics were associated with adolescents’ perceptions
of e-cigarettes as relatively safer than cigarettes:
being white, using other tobacco products, and
having family members who used tobacco. In ad-
dition, adolescents who had ever used e-cigarettes
perceived them as less harmful than cigarettes,
as compared to those who had never used e-ciga-
rettes. Ambrose et al28 found that whereas one in 3
adolescents believed e-cigarettes were less harm-
ful than cigarettes, the majority of current smokers
(54%) held this belief as compared to fewer of the
ever smokers (41%) and never smokers (25%). Ad-
ditionally, ever use of an e-cigarette had a strong
relationship with perceiving e-cigarettes as less
harmful than cigarettes. In particular, dual users
of e-cigarettes with cigarettes were more than twice
as likely to perceive e-cigarettes as less harmful
compared to exclusive cigarette smokers, and ado-
lescents who used e-cigarettes alone had a 6-fold
increase in their likelihood of perceiving e-ciga-
rettes as less harmful than cigarettes, compared
to adolescents who had never used either product.
Wills et al21 found that current e-cigarette-only us-
ers were more likely to report that e-cigarettes were
a healthy alternative to cigarettes as compared to
non-users, but no differences were found between

exclusive e-cigarette and cigarette user groups or
between exclusive e-cigarette and dual use groups.
As stated in the theory of planned behavior, nor-
mative beliefs are influenced by perceptions about
whether others in an individual’s social network
perform the behavior of interest.22 Prior research
demonstrates that peers have a strong influence
on both adolescents’ initiation and escalation in
cigarette use.29 Interestingly, perceived prevalence
of smoking rather than actual prevalence of peer
smoking is associated with an increased risk of
smoking among youth.30 There are few published
articles, however, that describe peer use in relation
to youth use of tobacco products other than ciga-
rettes. The limited evidence suggests that having
peers who used other tobacco products or expo-
sure to peer smoking are both significant predic-
tors of adolescent use of alternative tobacco prod-
ucts such as cigars, smokeless tobacco, bidis and
kreteks.25,12 Wills et al21 reported that among high
school students, perceptions of peer smoking dif-
fered according to tobacco usage group. Perceived
peer smoking was higher among exclusive e-cig-
arette users as compared to non-users as well as
higher among dual users as compared to exclusive
e-cigarette users. No differences were found for
peer smoking between e-cigarette-only and ciga-
rette-only groups.
E-cigarette Dual Users, Exclusive Users and Perceptions of
Tobacco Products
110

According to the Campaign for Tobacco-free Kids,
Texas ranks 32nd out of 50 US states in prevalence
of conventional cigarette smoking among high
school students.31 Additionally, our 2015 paper
showed that e-cigarette use was higher in Texas
than both national estimates and those document-
ed in other states.32 Furthermore, Texas receives
more tobacco industry marketing dollars than
any other state except California33 and ranks 40th
among states in spending for tobacco prevention.34
Therefore, youth in Texas, who represent 9.6% of
all US youth,35 are a vulnerable population, mak-
ing the state an important backdrop to understand
characteristics and perceptions associated with to-
bacco use in adolescents.
The purpose of the current study was to exam-
ine Texas adolescents’ harm perceptions of various
tobacco products and perceived peer use of e-cig-
arettes based on usage group. There were 3 aims.
First, we examined pairwise differences among 4
usage groups—non-cigarette and non-e-cigarette
users, cigarette-only users, e-cigarette-only users
and dual users—in their demographic character-
istics and tobacco use behaviors. Second, we ex-
amined pairwise differences among the 4 usage
groups in perceptions about the harms of various
tobacco products and alcohol use, as well as per-
ceived peer use of tobacco products. Third, we ex-
amined differences in cigarette harm perceptions
and e-cigarette harm perceptions by usage group.
We hypothesized that dual users would more likely
be older, white, and male as compared to other us-
age groups. We also hypothesized that dual users
would have higher rates of perceived peer use as

well as lower reported rates of perceived harm for
all tobacco products. This study furthers under-
standing of perceptions of tobacco products and
peer use among both exclusive and dual users of
e-cigarettes and cigarettes.
METHODS
Participants
Participants were 13,602 6th through 12th grade
students attending 69 public schools in 27 coun-
ties in Texas; 49.9% were female; 43.9% were non-
Hispanic Whites, 5.8% were African Americans,
41.1% were Hispanics, and 9.2% reported another
ethnicity.
Procedure
Data were drawn from the 2014 Texas Youth To-
bacco Survey, which sampled students from pub-
lic school districts across the state. Recruitment of
schools occurred in one of 2 ways: (1) school dis-
tricts in 12 “coalition” counties involved in a state-
funded tobacco prevention and control project
were recruited to participate in the study; of the 65
school districts in these counties, 23 participated
(N = 52 schools); and (2) proportional probability
sampling (recruitment probability is proportional
to size of the school) was used to recruit an ad-
ditional 17 schools from 15 additional counties.
The school response rate was 25%, whereas stu-
dent participation rate was 87%. In spring 2014,
13,602 students voluntarily completed the 38-item
anonymous survey, either via paper-and-pencil (N
= 59 schools) or online (N = 10 schools), in their

classrooms during class time.
Measures
Tobacco use categories. To generate cat-
egories of current tobacco use, responses from 2
items adapted from the Centers for Disease Con-
trol and Prevention’s (CDC) 2013 National Youth
Tobacco Survey were analyzed: (1) “During the
past 30 days, on how many days did you use elec-
tronic cigarettes or e-cigarettes, such as Ruyan or
NJOY?” and (2) During the past 30 days, on how
many days did you smoke cigarettes?” From these
2 items, 4 usage groups were generated: non-users
of e-cigarettes or cigarettes; e-cigarette-only users;
cigarette-only users; and e-cigarette and cigarette
dual users. Participants who reported not using
either product during the past 30 days were clas-
sified as non-users of e-cigarettes or cigarettes,
participants who reported using e-cigarettes at
least one day during the past 30 days and re-
ported using cigarettes zero days during the past
30 days were classified as e-cigarette-only users,
participants who reported using e-cigarettes zero
days during the past 30 days and reported using
cigarettes on at least one day during the past 30
days were classified as cigarette-only users, and
participants who reported using both products on
at least one day during the past 30 days were clas-
sified as e-cigarette and cigarette dual users.
Other current and lifetime tobacco use. Cur-
rent and lifetime use of other tobacco products in-
cluding chew, snus, hookah and flavored tobacco
products also was analyzed. For each of the tobac-

co products, students reporting at least one day
of other tobacco product use in the past 30 days
were classified as current users, and those who
reported ever using a tobacco product were clas-
sified as lifetime users. Lifetime use of e-cigarettes
and of cigarettes also was included; thus, students
reporting ever using those products were classified
as lifetime users.
Harm perceptions of tobacco products and
alcohol. To measure harm perceptions for various
products, respondents are asked: “How dangerous
do you think it is for a person your age to use: (1)
Cigarettes; (2) Chewing tobacco, snuff, or dip, such
as Redman, Levi Garrett, Beechnut, Skoal, Skoal
Bandits, or Copenhagen; (3) Snus, such as Skoal,
General, Camel or Marlboro Snus; (4) Tobacco in a
hookah or a water pipe; (5) Electronic cigarettes or
e-cigarettes, such as Ruyan or NJOY; (6) Tobacco
products that are flavored; (7) Alcohol.” Response
options are given on a 4-point scale, and include:
“very dangerous, somewhat dangerous, not very
dangerous, and not dangerous at all.” Responses
were reverse coded from “not dangerous at all” (1)
to “very dangerous” (4).
Cooper et al
Perceived peer use of tobacco products. To
measure perceived peer use for various products,
respondents are asked: “About how many of your

closest friends: 1) Smoke cigarettes? (2) Use chew-
ing tobacco, snuff or dip such as Redman, Levi
Garrett, Beechnut, Skoal, Skoal Bandits, or Co-
penhagen? (3) Electronic cigarettes or e-cigarettes,
such as Ruyan or NJOY?“ Response options are
given on a 6-point scale, and include: “none, a few,
some, most, all, not sure.” Respondents who chose
“not sure” were removed from the analysis on peer
use. Therefore, responses ranged from “none” (0)
to “all” (4).
Data Analysis
Logistic regression analyses were used to ex-
amine differences in demographic characteristics,
grades in school, and tobacco use behaviors across
usage groups. Demographic characteristics, grades
in school, and tobacco use behaviors served as the
dependent variables, while usage group served
as the independent variable. All dependent vari-
Table 1
Demographic Characteristics in Usage Groups (Logistic
Regression
Analyses) — 2014 Texas Youth Tobacco Survey
Non-e-cigarette/
Cigarette Users
(N = 11,431)
E-cigarette-only Users
(N = 638)
Cigarette-only Users

(N = 474)
Dual Users
(N = 761)
Overall (%) 82.2 6.38 3.87 7.55
Sex
% Female 52.06 50.76 43.51 28.99a
% Male 47.94 49.24 56.49 71.01a
School Level
% Middle School 49.54 32.58 31.05a 19.36a,c
% High School 50.46 67.42 68.95a 80.64a,c
Race/Ethnicity
% White 42.22 47.11 44.71 58.12a,c
% Black 6.39 2.29 9.49 1.96
% Hispanic 43.12 35.36 33.10 27.08a,b
% Other 8.27 15.24 12.70 12.84
Mean Gradesd 3.14 3.13 2.52a,b 2.83a
Current Tobacco Use
% Chew 1.88 22.55a 41.12a 52.47a,b
% Snus 0.45 10.15a 15.20a 47.33a,b,c
% Hookah 1.86 45.40a 17.04 54.26a,c
% Flavored 1.67 38.23a 37.93a 64.82a,b
Lifetime Use
% E-cigarette 9.15 -- 55.03a --

% Cigarette 12.45 54.78a -- --
% Chew 7.12 30.81a 50.65a 60.61a,b
% Snus 2.56 21.41a 37.93a 53.88a,b
% Hookah 5.49 60.02a 32.32a 59.87a
% Flavored 6.86 56.64a 60.33a 76.74a
Note.
a Significantly different from Non-e-cigarette/Cigarette users,
p < .05
b Significantly different from E-cigarette-only users, p < .05
c Significantly different from Cigarette-only users, p < .05
d Measured on 0 to 4 scale, from “Mostly Fs” to “Mostly As”;
ANOVA conducted to determine differences in mean
grades
Tobacco Products
112
ables were dichotomized using dummy variables,
and separate regression models were conducted
for each of the dependent variables. Results were
adjusted to account for multiple comparisons us-
ing the Bonferroni correction. Additionally, one-
way analysis of variance (ANOVA) was conducted
to determine differences in mean grades in school
across the 4 usage groups. Multiple linear regres-
sion analyses were conducted to examine differ-
ences in harm perceptions and perceptions of peer
use by usage groups, adjusting for age, sex, and

race/ethnicity. Pairwise comparisons using the
Bonferroni correction were obtained post-estima-
tion to determine differences in harm perceptions
and perceived peer use between: (1) non-users of
e-cigarettes and cigarettes versus dual users; (2)
e-cigarette-only users versus dual users; and (3)
cigarette-only users versus dual users. Finally, to
examine differences in cigarette harm perceptions
and e-cigarette harm perceptions by usage group,
multiple linear regression analyses were conducted
to generate mean harm perceptions for each of the
usage groups. Multiple linear regression analyses
also were performed to determine the difference in
mean by each current usage group and to test if
the difference was significantly different from zero.
Analyses were adjusted for age, sex, and race/eth-
nicity.
All analyses were conducted using state sam-
pling weights, and school level clustering was ac-
counted for by including schools as the cluster
variable in regression models, thereby making the
study representative of schools in Texas. Whereas
the overall sample size was 13,602, the sample
sizes varied for each model due to missing data,
which ranged from 0.8% to 2.3% for the included
variables.
RESULTS
Differences across 4 Usage Groups in
Demographic Characteristics and Tobacco Use
Behaviors
The majority of participants (82.2%) were non-
users of either product. Nearly 8% were dual us-
ers, over 6% were e-cigarette-only users and close

to 4% were cigarette-only users. As Table 1 shows,
dual users were significantly more likely to be
male than non-users. The proportion of dual users
in high school was significantly higher than the
proportions of cigarette-only and non-user groups
in high school (versus middle school). Dual users
were more likely to be white than both the ciga-
rette-only and non-user groups. Non-users were
more likely to be Hispanic than dual users (but
not more likely than the e-cigarette-only or cig-
arette-only groups). In addition, differences were
Table 2
Adjusted Means (SE) for Variables across Usage Groups with
Regression
Coefficients from Multiple Linear Regression—2014 Texas
Youth Tobacco Survey
Non-e-cigarette/
Cigarette Users
(N = 11,431)
E-cigarette-
only Users
(N = 638)
Cigarette-
only Users
(N = 474)
Dual
Users
(N = 761)

Non-users
vs Dual
Users
E-cigarette-
only vs
Dual Users
Cigarette-
only vs.
Dual Users
Harm Perceptionsa
Cigarettes 3.59 (.02) 3.51 (.10) 2.84 (.05) 2.76 (.06) 0.83***
0.74*** 0.07
E-cigarettes 3.13 (.04) 2.11 (.06) 2.46 (.14) 1.91 (.07)
1.22*** 0.20 0.55***
Chew 3.57 (.02) 3.21 (.06) 2.91 (.13) 2.82 (.06) 0.75***
0.39*** .10
Snus 3.61 (.02) 3.36 (.10) 2.90 (.13) 2.83 (.06) 0.78***
0.53*** .07
Hookah 3.43 (.02) 2.47 (.17) 2.66 (.13) 2.50 (.09) 0.93*** -
0.03 0.16
General Tobacco 3.43 (.02) 2.77 (.06) 2.71 (.13) 2.54 (.05)
0.89*** 0.23** 0.17
Alcohol 3.42 (.03) 3.06 (.05) 2.91 (.06) 2.68 (.06) 0.74***
0.38** 0.23
Peer useb
Cigarettes 0.55 (.02) 1.01 (.13) 1.67 (.12) 2.11 (.05) -1.56***
-1.10*** -0.44*
E-cigarettes 0.73 (.04) 1.76 (.08) 1.57 (.25) 2.01 (.13) -
1.28*** 0.25 -0.44

Chew 0.58 (.02) 1.11 (.15) 1.60 (.26) 1.71 (.09) -1.13*** -
0.60 -0.11
*p < .05, **p < .01, ***p < .001
Note.
a Measured on a 1 to 4 scale from “not dangerous at all” to
“very dangerous”
b Measured on a 0 to 4 scale from “none” to “all”
Analyses adjusted for age, sex and race/ethnicity, using state
sampling weights and accounting for school-level clustering;
results adjusted for multiple comparisons using Bonferroni
adjustment
Cooper et al
found among usage groups for self-reported aca-
demic performance in the last school year. Both
non-users and e-cigarette-only users had higher
mean grades than the cigarette-only group, and
the non-user group had higher mean grades than
the dual user group.
Significant differences in prevalence of other
tobacco product use were found across all cate-
gories of products. Non-users differed from all 3
usage groups, and had the lowest prevalence of
current and lifetime use other tobacco products
with one exception being no significant difference
between non-users and cigarette-only users in
current hookah use. Current and lifetime use of

other products was not significantly different be-
tween e-cigarette-only and cigarette-only groups.
Dual users did not differ from cigarette-only users
on lifetime use of any tobacco product. However,
lifetime prevalence estimates for chew (60.6%) and
snus (53.9%) were higher among dual users than
e-cigarette-only users and non-users. Moreover,
dual users had higher prevalence of current use of
all products (except hookah) than e-cigarette-only
users, as well as significantly higher prevalence of
current use of snus (47.3%) and hookah (54.3%)
than the cigarette-only group.
Harm Perceptions and Peer Use across Usage
Groups
As Table 2 shows, significant differences were
found in the perceptions of harm of tobacco prod-
ucts and alcohol use among usage groups. Non-
users were significantly more likely to rate all
tobacco products and alcohol use as more harm-
ful than did the dual use group. The e-cigarette-
only group perceived cigarettes as more harmful,
when compared to the dual user group, and the
cigarette-only group rated e-cigarettes significantly
more harmful than the dual use group. There were
similar patterns of differences in perceptions of
harm for both chew and snus. The e-cigarette-only
group perceived both products as more harmful
than the dual use group, whereas no differences
were seen between the cigarette-only group and
the dual use group. No significant differences were
found between e-cigarette-only users or cigarette-
only users and dual users in their perceptions of
harm of hookah. Similar patterns also were seen

in perceptions of harm for general tobacco and al-
cohol. Whereas no differences were found between
the cigarette-only group and the dual user group,
e-cigarette-only users were more likely to rate both
general tobacco and alcohol use as more harmful
than the dual user group.
Regarding peer use, there were significant dif-
ferences between groups on perceived peer use of
cigarettes, e-cigarettes and chew (Table 2). Dual
users perceived higher peer use of all products as
compared to non-users. Dual users also perceived
higher peer use of cigarettes as compared to both
the e-cigarette-only and cigarette-only groups. No
differences were seen in perceived peer use of ei-
ther e-cigarettes or chew between dual users and
exclusive user group comparisons.
Comparisons in Harm Perceptions of
Cigarettes and E-cigarettes within Usage
Groups
Comparisons of cigarette and e-cigarette harm
perceptions by tobacco usage group are displayed
in Table 3.The mean harm perceptions score was
significantly higher for cigarettes than for e-ciga-
rettes among all usage groups. The difference in
mean harm perceptions between cigarettes and e-
cigarettes was 0.46 (p < .001) for non-users, 1.44
(p < .001) for e-cigarette-only users, 0.55 (p = .003)
for cigarette-only users, and 0.89 (p < .001) for
dual users.
Table 3
Comparison of Cigarette and E-cigarette Harm Perceptions by
Usage Group

(Multiple Linear Regression Analyses) —2014 Texas Youth
Tobacco Survey
Cigarette Harm
Perceptionsa
Mean (SE)
E-cigarette Harm
Perceptionsa
Mean (SE)
Differenceb
Mean (SE)
Use Behavior
Non- e-cigarette/Cigarette Users N = 11,020) 3.59 (.02) 3.13
(.04) 0.46 (.02) p < .001
E-cigarette-only Users (N = 611) 3.53 (.11) 2.09 (.08) 1.44
(.07), p < .001
Cigarette-only Users (N = 448) 3.03 (.06) 2.48 (.14) 0.55
(.18), p = .003
Dual Users (N = 729) 2.80 (.07) 1.91 (.07) 0.89 (.11) p <
.001
Note.
a measured on a 1 to 4 scale from “not dangerous at all” to
“very dangerous”
b Cigarette- e-cigarette Harm Perceptions
Analyses adjusted for age, sex and race/ethnicity, using state
sampling weights and accounting for school-level clustering
Means presented in Table 3 differ slightly from those is Table 2
as a result of differences in sample size due to missing data

Tobacco Products
114
DISCUSSION
The current study adds to the limited body of
literature describing patterns of e-cigarette use
among middle and high school students, percep-
tions of harm, and peer use for these relatively new
products whose prevalence of use is on the rise,
as well as other types of tobacco products. Find-
ings from the 2014 Texas Youth Tobacco Survey
confirm results from other studies on the emerging
patterns of e-cigarette use among youth, showing
that a large number of youth are using e-cigarettes
only, and many are using e-cigarettes in conjunc-
tion with conventional cigarettes.2,4
Findings highlight demographic differences
based on usage group. Interestingly, non-users
and e-cigarette-only users did not differ on any
of the sociodemographic characteristics we exam-
ined. Dual users had the most differences across
groups. They were more likely to be male, older,
white, and have lower mean grades than non-
users. They were also more likely to be older and
white compared to the cigarette-only group. Dual
users consistently had the highest prevalence of
other tobacco product use, except for lifetime hoo-
kah use, indicating that teens using both e-ciga-
rettes and cigarettes are more likely to use other
types of products, such as chew, snus and any fla-
vored product.
Across the various tobacco products, harm per-

ceptions differed among usage groups. For exam-
ple, e-cigarette-only users viewed conventional cig-
arettes as more harmful than the dual user group.
This is a novel finding that has not been reported
previously in the literature. The same pattern was
not seen for e-cigarettes, however. Interestingly,
there were no differences in how harmful the e-
cigarette-only and the dual user groups rated e-
cigarettes, however, the cigarette-only group rated
e-cigarettes as more harmful than the dual user
group. This study differs from one performed by
Wills et al21 in that it measures absolute harm of
e-cigarettes rather than relative harm compared
to cigarettes; our results follow similar trends. For
example, no differences in perceived harmfulness
of e-cigarettes were found between e-cigarette-
only and dual user groups. Findings also gener-
ally confirm results from studies by Amrock et al27
and Ambrose et al28 that found that adolescents
who use e-cigarettes perceive them as less harmful
than those who do not. Consistent with Ambrose
et al,28 dual users in our sample were more likely
to perceive e-cigarettes as less harmful compared
to exclusive cigarette smokers, and in terms of dif-
ferences between harm perceptions of e-cigarettes
and cigarettes, our results also generally align with
the finding that the highest risk of perceiving e-
cigarettes as less harmful than cigarettes was held
by the exclusive e-cigarette users. Specifically, al-
though the current study found that all 4 usage
groups rated cigarettes as more harmful than e-
cigarettes, the magnitude of the difference in harm
perceptions was greatest for the e-cigarette-only
users followed by the dual users. These findings
are consistent with the theory of planned behav-

ior.22 According to the theory, dual users would
perceive e-cigarettes to be less harmful than non-
users and cigarette-only users, which may be why
they would use them. Students who perceive e-cig-
arettes as more harmful would be less likely than
their counterparts to initiate use of these products.
Another striking finding was that harm percep-
tions for hookah followed the same pattern as that
of e-cigarettes in that, unlike all other tobacco
product comparisons, perceptions of harm did
not differ between e-cigarette-only and dual user
groups. Few studies offer explanation as to why
perceptions of harm may be similar for both prod-
ucts. One study, however, highlighted a connec-
tion between e-cigarette and hookah use, finding
that adolescent e-cigarette-only users were more
likely than cigarette smokers to use hookah.19
Given the limited evidence, we can only specu-
late that similar ratings of harmfulness between
e-cigarettes and hookah may be related to both
products having a multitude of available flavorings
or similarities between the sensation of inhaling
e-cigarette aerosol and hookah smoke which has
been cooled by the water pipe. For perceptions of
chew and snus, group comparisons were gener-
ally consistent with prior literature that has found
that perceived risk of harm for smokeless tobacco
varied by the tobacco product use groups, with a
higher proportion of nonsmokers perceiving great
risk of harm.36
Our results on perceived peer cigarette smoking
are consistent with Wills et al’s21 finding that dif-
ferences exist between exclusive e-cigarette users
and dual users. Perceived peer use of e-cigarettes

and chew differed only between non-users and
dual users, a finding that has not been reported
previously. Consistent with the theory of planned
behavior, students who perceive higher levels of
peer use are more likely to use tobacco products.22
These findings highlight the need to better under-
stand the role of peers in adolescents’ e-cigarette
use.
Limitations
This study is subject to at least 3 limitations.
First, the cross-sectional design precludes us from
making causal inferences about the findings. Sec-
ond, the study participants are limited to Texas
youth; therefore, findings may not be generalizable
to populations outside of the sample. Finally, the
survey item on flavored tobacco products does not
make a distinction between types of product. Fur-
thermore, it unknown whether adolescents con-
sider e-cigarettes to be tobacco products.
Conclusion
This study provides demographic characteristics
of adolescents who were exclusive e-cigarette us-
ers, exclusive cigarette users, and dual users of
cigarettes and e-cigarettes, a novel contribution to
Cooper et al

the field. Our findings confirm in many ways what
we know about harm perceptions and tobacco use,
that is, using a tobacco product is tied strongly
to believing that it is less harmful than those who
choose not to use the product. However, our find-
ings also offer a new understanding of how tobac-
co usage groups rate the harmfulness of various
tobacco products. Dual users were more likely to
have lower harm perceptions as compared to ex-
clusive e-cigarette users for all tobacco products
except for e-cigarettes and hookah, and they dif-
fered from the cigarette-only group only in their
harm perceptions of e-cigarettes, which they rated
as less harmful. Dual users also were more likely
to perceive higher peer use of cigarettes than the
non-users and both exclusive user groups. Within
the 4 tobacco usage groups, the e-cigarette-only
users had the largest difference in their percep-
tions of e-cigarettes as less harmful than ciga-
rettes.
Implications for Practice and Policy
The Family Smoking Prevention Tobacco Control
Act (2009) permitted the US Food and Drug Ad-
ministration (FDA) to regulate cigarettes, smoke-
less tobacco, and roll-your-own tobacco; however,
the FDA also has the authority to regulate other
products. In 2014, the FDA proposed to deem oth-
er tobacco products, including e-cigarettes, within
its purview. Findings in this study indicate that
other tobacco products, including e-cigarettes, are
popular among youth, and provide additional sci-
entific evidence to support the need for these prod-
ucts to be regulated by the FDA. Our study’s re-
sults also provide important implications for pub-

lic health practice. Interventions should include
the full spectrum of tobacco products as students
in our sample who used e-cigarettes were more
likely to perceive e-cigarettes as less harmful and
more likely to think their peers used e-cigarettes
and smokeless tobacco. Therefore, interventions
should provide information regarding the harm-
fulness of e-cigarettes and focus on changing the
normative beliefs associated with these products.
Human Subjects Statement
This study’s procedures have been approved by
Texas A&M University’s Institutional Review Board
- Human Subjects in Research.
Conflict of Interest Disclosure Statement
None of the authors has any competing interests.
Acknowledgements
The authors acknowledge the investigators and
staff members at Texas A&M University’s Public
Policy Research Institute who conducted the Tex-
as Youth Tobacco Survey in conjunction with the
Texas Department of State Health Services. Study
authors were supported by grant number [1 P50
CA180906-01] from the National Cancer Insti-
tute at the National Institutes of Health and the
Food and Drug Administration, Center for Tobacco
Products (CTP). The content is solely the responsi-
bility of the authors and does not necessarily rep-
resent the official views of the National Institutes of
Health or the Food and Drug Administration.

References
1. Cobb NK, Byron MJ, Abrams DB, Shields PG. Novel nico-
tine delivery systems and public health: the rise of the
“e-cigarette.” Am J Public Health. 2010;100(12):2340-
2342.
2. Arrazola R, Singh T, Corey CG, et al. Tobacco use among
middle and high school students- United States, 2011-
2014. MMWR Morb Mortal Wkly Rep. 2015;64(14):381-
385.
3. King BA, Patel R, Nguyen KH, Dube SR. Trends in aware-
ness and use of electronic cigarettes among U.S. adults,
2010-2013. Nicotine Tob Res. 2015;17(2):219-227.
4. Monitoring the Future 2014. National Results on Adoles-
cent Drug Use: Overview of Key Findings. Ann Arbor, MI:
Institute for Social Research, The University of Michigan;
2015.
5. Kong G, Morean ME, Cavallo DA, et al. Reasons for elec-
tronic cigarette experimentation and discontinuation
among adolescents and young adults. Nicotine Tob Res.
2015;17(7):847-854.
6. Grana RA, Ling PM. “Smoking revolution”: a content
analysis of electronic cigarette retail websites. Am J Prev
Med. 2014;46(4):395-403.
7. Everett SA, Malarcher AM, Sharp DJ, et al. Relationship
between cigarette, smokeless tobacco, and cigar use,
and other health risk behaviors among U.S. high school
students. J School Health. 2000;70(6):234-240.
8. Soldz S, Huyser DJ, Dorsey E. Characteristics of users

of cigars, bidis, and kreteks and the relationship to ciga-
rette use. Prev Med. 2003;37(3):250-258.
9. Fix BV, O’Connor RJ, Vogl L, et al. Patterns and correlates
of polytobacco use in the United States over a decade:
NSDUH 2002-2011. Addict Behav. 2014;39(4):768-781.
10. Apelberg BJ, Backinger CL, Curry SJ. Enhancing youth
tobacco surveillance to inform tobacco product regula-
tion: findings from the 2012 National Youth Tobacco
Survey. Am J Prev Med. 2014;47(2 Suppl 1):S1-S3.
11. Nasim A, Blank MD, Cobb CO, et al. Patterns of alter-
native tobacco use among adolescent cigarette smokers.
Drug Alcohol Depend. 2012;124(1-2):26-33.
12. Tercyak K. Psychosocial correlates of alternate tobac-
co product use during early adolescence. Prev Med.
2002;35(2):193-198.
13. Tomar SL, Alpert HR, Connolly GN. Patterns of dual
use of cigarettes and smokeless tobacco among US
males: findings from national surveys. Tob Control.
2010;19(2):104-109.
14. Brooks A, Larkin EM, Kishore S, et al. Cigars, cigarettes,
and adolescents. Am J Health Behav. 2008;32(6):640-
649.
15. Post A, Gilljam H, Rosendahl I, et al. Symptoms of nico-
tine dependence in a cohort of Swedish youths: a com-
parison between smokers, smokeless tobacco users and
dual tobacco users. Addiction. 2010;105(4):740-746.
16. Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, et al. Youth
tobacco use type and associations with substance use

disorders. Addiction. 2014;109(8):1371-1380.
17. Dutra LM, Glantz SA. Electronic cigarettes and conven-
tional cigarette use among US adolescents: a cross-sec-
tional study. JAMA Pediatr. 2014;168(7):610-617.
18. Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions
to smoke cigarettes among never-smoking U.S. middle
and high school electronic cigarette users, National
Youth Tobacco Survey, 2011-2013. Nicotine Tob Res.
2015;17(2):228-235.
Tobacco Products
116
19. Camenga DR, Kong G, Cavallo DA, et al. Alternate to-
bacco product and drug use among adolescents who use
electronic cigarettes, cigarettes only, and never smokers.
J Adolesc Health. 2014;55(4):588-591.
20. Camenga DR, Delmerico J, Kong G, et al. Trends in use
of electronic nicotine delivery systems by adolescents.
Addict Behav. 2014;39(1):338-340.
21. Wills TA, Knight R, Williams RJ, et al. Risk factors for
exclusive e-cigarette use and dual e-cigarette use and
tobacco use in adolescents. Pediatrics. 2015;135(1):e43
-e51.
22. Montaño D, Kasprzyk D. Theory of reasoned action, the-
ory of planned behavior, and the integrated behavioral
model. In Glanz K, Rimer BK, Viswanath K, eds. Health

Behavior: Theory, Research, and Practice. 5th ed. San
Francisco, CA: Jossey-Bass; 2015:95-124.
23. Benthin A, Slovic P, Severson H. A pyschometric study of
adolescent risk perception. J Adolesc. 1993;16:153-168.
24. Latimer LA, Batanova M, Loukas A. Prevalence and harm
perceptions of various tobacco products among college
students. Nicotine Tob Res. 2014;16(5):519-526.
25. Gilpin EA, Pierce JP. Concurrent use of tobacco products
by California adolescents. Prev Med. 2003;36(5):575-
584.
26. Durmowicz EL. The impact of electronic cigarettes on the
paediatric population. Tob Control. 2014;23 Suppl 2:ii41-
46.
27. Amrock SM, Zakhar J, Zhou S, et al. Perception of e-
cigarettes’ harm and its correlation with use among U.S.
adolescents. Nicotine Tob Res. 2015;17(3):330-336.
28. Ambrose BK, Rostron BL, Johnson SE, et al. Perceptions
of the relative harm of cigarettes and e-cigarettes among
U.S. youth. Am J Prev Med. 2014;47(2 Suppl 1):S53-S60.
29. Li C, Pentz MA, Chou CP. Parental substance use as a
modifier of adolescent substance use risk. Addiction.
2002;97:1537-1550.
30. Ellickson PL, Bird CE, Orlando M. Social context and
adolescent health behavior: does school-level smoking
prevalence affect students’ subsequent smoking behav-
ior? J Health Soc Behav. 2003(44):525–535.

31. Campaign for Tobacco-free Kids. Toll of tobacco in the
United States. Available at: http://www.tobaccofreekids.
org/what_we_do/state_local/. Accessed September 17,
2015.
32. Cooper M, Case KR, Loukas A. E-cigarette use among
Texas youth: results from the 2014 Texas Youth Tobacco
Survey. Addict Behav. 2015;50:173-177.
33. Campaign for Tobacco-free Kids. State-specific estimates
of tobacco company marketing expenditures, 1998-
2012. Available at: https://www.tobaccofreekids.org/
research/factsheets/pdf/0271.pdf. Accessed September
17, 2015.
34. Campaign for Tobacco-Free Kids. Spending on tobacco
prevention: Texas. Available at: https://www.tobacco-
freekids.org/microsites/statereport2015/texas.html.
Accessed September 17, 2015.
35. The Annie E. Casey Foundation. KIDS COUNT data cen-
ter. Available at: datacenter.kidscount.org. Accessed
September 17, 2015.
36. Tomar SL, Hatsukami DK. Perceived risk of harm from
cigarettes or smokeless tobacco among U.S. high school
seniors. Nicotine Tob Res. 2007;9(11):1191-1196.
Copyright of American Journal of Health Behavior is the
property of PNG Publications and
its content may not be copied or emailed to multiple sites or
posted to a listserv without the
copyright holder's express written permission. However, users
may print, download, or email

articles for individual use.
Refer to the below table, The number of health plans with an
“excellent” rating, the significance of an “excellent” rating, and
the accreditations for the plans.
Do you think that health plan report cards are valuable? Why or
why not?
Your Search Results -
Maryland, Medicaid, Medicare
Why is my plan not listed?
14 results match your search
A health plan may not be listed on this site for any of these
reasons:
1. Plans use many different names in the different areas they
serve. If your plan is not listed, be sure to review the list of
additional names your health plan may use to see if it is
included under a different name on our report card. Additional
plan names are listed under the plan name on the search results

page.
2. Some health plans choose not to participate in NCQA’s
programs. Enrolling in an NCQA Accredited plan is one of the
best ways to ensure that you and your family will get the care,
service and consideration you need, when you need it. Contact
your plan to see if they have applied for and received NCQA
Accreditation. If a plan chooses not to be reviewed by NCQA,
you should ask: Why not?
If you receive health care coverage through your employer, talk
with them about offering NCQA-accredited plans. Health plans
are more likely to focus on quality and seek accreditation if
encouraged to do so by health plan members and employers who
make decisions about which plans to choose.
[Close this window]
Plan name is the name of the organization that provides health
care coverage to individuals and families.
[Close this window]
The Accreditation Type is the type of NCQA Accreditation the
health plan has received. Types include First, Interim, Renewal
(Health Plan Accreditation 2013), and Health Plan Accreditation
(Before 2013).
[Close this window]
Indicates whether this Accreditation is scored based on HEDIS
results.
[Close this window]
Indicates whether this Accreditation is scored based on CAHPS
results.
[Close this window]
The Plan Type refers to a specific plan that is designed to

provide health care coverage to a certain population or group of
people. NCQA divides plan type by Commercial, Medicare, and
Medicaid.
[Close this window]
An Accredited Product is the type of health plan offered by
different health care organizations. NCQA divides Accredited
Product by HMO, POS and PPO.
[Close this window]
Overall Accreditation Status refers to the level of NCQA
Accreditation a plan has received. NCQA Accreditation is a
thorough and rigorous evaluation of a health plan for quality
measurement and continuous quality improvement by NCQA.
What’s new about accreditation scoring?
A change to NCQA’s accreditation scoring methodology that we
began making July 1, 2011, will—slowly over five years—make
it harder for health plans to reach the highest levels of
accreditation (Excellent or Commendable).
The change is the elimination of the "sampling variation scoring
adjustment." That is NCQA’s practice from 1999 (when we
incorporated performance measurement into accreditation) of
adding five extra points to HEDIS and CAHPS results. Given
that we have added more measures over time and the
performance on those measures has become more stable, we
announced that we no longer need this scoring adjustment. We
also note that health plans have raised their performance over
time. By phasing out the scoring adjustment, NCQA is raising
the bar in order to drive further improvement. For more
information visit www.ncqa.org/Accreditation_Scoring.
[Close this window]
A health plan may not be listed on this site for any of these
reasons:
1. Plans use many different names in the different areas they
serve. If your plan is not listed, be sure to review the list of
additional names your health plan may use to see if it is
included under a different name on our report card. Additional
plan names are listed under the plan name on the search results

page.
2. Some health plans choose not to participate in NCQA’s
programs. Enrolling in an NCQA Accredited plan is one of the
best ways to ensure that you and your family will get the care,
service and consideration you need, when you need it. Contact
your plan to see if they have applied for and received NCQA
Accreditation. If a plan chooses not to be reviewed by NCQA,
you should ask: Why not?
If you receive health care coverage through your employer, talk
with them about offering NCQA-accredited plans. Health plans
are more likely to focus on quality and seek accreditation if
encouraged to do so by health plan members and employers who
make decisions about which plans to choose.
[Close this window]
Select
All
Plan Name ?
Accreditation Type ?
Organization Type ?
Product ?
Scored on HEDIS? ?
Scored on CAHPS? ?
Overall Accreditation
Status ?
AMERIGROUP Maryland, Inc.
Amerigroup Maryland
Health Plan Accreditation
Medicaid
HMO

Yes
Yes
Commendable
Jai Medical Systems Managed Care Organization, Inc.
Inc.;Jai Medical Systems Managed Care Organization
Medicaid
HMO
Yes
Yes
Excellent
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
HealthChoice;HealthChoice (Maryland Medicaid)
Medicaid
HMO
Scheduled
Maryland Care Inc., d/b/a/ Maryland Physicians Care
Maryland Physicians Care
Medicaid
HMO
No
No
Interim
MedStar Family Choice, Inc.
MedStar Family Choice
Medicaid
HMO

Yes
Yes
Commendable
Priority Partners MCO
Medicaid
HMO
Yes
Yes
Commendable
Riverside Health of Maryland, Inc.
Riverside Health of Maryland
Medicaid
HMO
No
No
Interim
UnitedHealthcare of the Mid-Atlantic, Inc. - Medicaid
United Healthcare Community Plan
Medicaid
HMO
Yes
Yes
Accredited
Aetna Health Inc. (Pennsylvania) - Maryland
Aetna Medicare Plan (HMO)
Medicare
HMO
Yes

Yes
Accredited
Aetna Life Insurance Company (MD/DC)
Aetna MedicareSM Plan (PPO)
Medicare
PPO
Yes
Yes
Commendable
Cigna-HealthSpring Mid-Atlantic, Inc.
Achieve/Achieve Plus;Bravo Achieve;Bravo Choice;Bravo
Classic;Bravo Gold;Bravo Premier Plus;Bravo Select;Bravo
Traditions;Preferred/Preferred Plus;TotalCare;Traditions
Medicare
HMO
Yes
Yes
Accredited
Humana Insurance Company (Ohio)
Humana Insurance Company
Medicare
PPO
Yes
Yes
Commendable
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
KP Medicare Plus (Cost) Plan;KP Medicare Plus Plan;Signature
Medicare

HMO
Yes
Yes
Excellent
UnitedHealthCare Insurance Company (IN)
AARP MedicareComplete Choice (PPO);AARP
MedicareComplete Choice Plan 2 (PPO);UnitedHealthcare
Group Medicare Advantage (PPO)
Medicare
PPO
Yes
Yes
Commendable
Bottom of Form
Original investigatiOn
e-Cigarette awareness, Use, and Harm Perceptions in
italy: a national representative survey
Silvano Gallus ScD1, Alessandra Lugo ScD2, Roberta Pacifici
ScD3, Simona Pichini PhD3,
Paolo Colombo ScD4, Silvio Garattini MD1, Carlo La Vecchia,
MD2
1Department of Epidemiology, IRCCS – Istituto di Ricerche
Farmacologiche Mario Negri, Milan, Italy; 2Department of

Clinical
Sciences and Community Health, Università degli Studi di
Milano, Milan, Italy; 3Department of Therapeutic Research and
Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy;
4Istituto DOXA, Worldwide Independent Network/Gallup
International Association, Milan, Italy
Corresponding Author: Silvano Gallus, ScD, Department of
Epidemiology, IRCCS – Istituto di Ricerche Farmacologiche
Mario Negri, Via G. La Masa 19, 20159 Milan, Italy.
Telephone: 390239014657; Fax: 390233200231; E-mail:
[email protected]
marionegri.it
Received December 12, 2013; accepted June 21, 2014
abstraCt
introduction: Only a few studies have provided information on
awareness, use, and harm perceptions of e-cigarettes in Europe.
We fill the knowledge gap in Italy.
Methods: We used data from a face-to-face survey conducted in
2013 of a sample of 3,000 individuals, representative of the
Italian population aged ≥15 years (51.1 million inhabitants).
results: Awareness of e-cigarettes was 91.1%; it was lowest
among women (87.8%), the elderly (78.4%), those with less
education (84.1%), and never-smokers (89.0%). Ever e-cigarette
use was 6.8% overall and was inversely related to age, whereas
no significant difference was observed according to sex. With
regard to smoking status, 2.6% of never-smokers, 7.0% of ex-
smokers, and 20.4% of current smokers tried the e-cigarette at
least once. Regular e-cigarette use was 1.2% overall, 1.5%
among
men, and 0.9% among women, and it was highest among young

(2.4%) and current smokers (3.7%). Among 36 e-cigarette regu-
lar users, 22.0% did not change their smoking habit, 67.7%
reduced traditional cigarette consumption, and 10.4% quit
smoking.
Conclusions: After fewer than 3 years from the opening of the
first Italian e-cigarette shop, more than 45 million Italians have
heard about e-cigarettes, 3.5 million have tried e-cigaretts, and
more than 600,000 Italians regularly use e-cigarettes. Three out
of 4 e-cigarette users reported to have favorably modified their
smoking habit; however, 90% of users did not quit smoking as a
consequence of starting vaping e-cigarettes. Almost 900,000
Italian never-smokers, particularly young never-smokers, have
tried
this new and potentially addictive product at least once.
intrOdUCtiOn
Approximately, one decade ago, the electronic nicotine delivery
system, also known as electronic cigarette or e-cigarette, was
first introduced into the market in China by the Beijing com-
pany Ruyan (Dawkins, Turner, Roberts, & Soar, 2013; Dockrell,
Morrison, Bauld, & McNeill, 2013; Pauly, Li, & Barry, 2007).
The e-cigarette is a product that allows the inhalation of a
chem-
ical mixture including propylene glycol, nicotine, and flavors
(Kuehn, 2009; Pauly et al., 2007; World Health Organization
[WHO], 2013). Given the shape, the method of inhalation, the
taste, and the possible content of nicotine, the e-cigarette gives
to its consumer (known as “vaper”) a sensation which is similar
to that experienced by inhaling the tobacco smoke of a tradi-
tional cigarette (Sugerman, 2014; WHO, 2013).
Over the last few years, e-cigarette rose in popular-
ity (Ayers, Ribisl, & Brownstein, 2011) and since October

2010, the e-cigarette spread in the Italian market, also given
the persistent promotion of this product on several media. In
various advertisements, e-cigarette manufacturers state that
the use of e-cigarette improves smoking cessation, decreases
smoking consumption, does not produce adverse effects on
health (given the lack of tobacco combustion during inhala-
tion), and is socially and legally accepted in public or private
places (Richardson, Ganz, Stalgaitis, Abrams, & Vallone,
2014; Richardson, Ganz, & Vallone, 2014; Sugerman, 2014).
Consequently, many current smokers were likely induced to
e-cigarette consumption. Thus, the number of shops selling
exclusively e-cigarettes has appreciably grown over the last
2 years, and today more than 1,500 retailers of e-cigarettes are
available throughout Italy.
A debate recently grew whether e-cigarette can be consid-
ered a safe alternative to tobacco smoking (Borland, 2011;
Etter, 2013; Wagener, Siegel, & Borrelli, 2012) or another
© The Author 2014. Published by Oxford University Press on
behalf of the Society for Research on Nicotine and Tobacco.
All rights reserved. For permissions, please e-mail:
[email protected]
doi:10.1093/ntr/ntu124
Advance Access publication July 31, 2014
nicotine & tobacco research, volume 16, number 12 (december
2014) 1541–1548
1541
e-cigarette awareness, use, and harm perceptions in italy
way to make nicotine addiction socially acceptable (Chapman,

2013). Although there is a broad consensus that e-cigarette
vapor is much less toxic than cigarette smoke (Benowitz
& Goniewicz, 2013), most of the public health experts and
tobacco control activists, the FDA and the WHO itself, warned
the public against this new emerging phenomenon, given (a)
the paucity of clinical studies analyzing safety of the liquid
or the vapor inhaled in the lungs of vapers, (b) the inadequate
evidence that e-cigarettes are effective to let smokers quit or
reduce traditional cigarette consumption, and (c) the lack of
a legislative regulation for this new product (Bains, Agombar,
Clarke, & Patel, 2012; Bauld, 2012; Benowitz & Goniewicz,
2013; Chapman, 2013; Etter, Bullen, Flouris, Laugesen, &
Eissenberg, 2011; Flouris & Oikonomou, 2010; Hampton,
2014; Kuehn, 2009; Pauly et al., 2007; Popova & Ling, 2013;
Sugerman, 2014; WHO, 2013; Yamin, Bitton, & Bates, 2010).
Moreover, various cartridges of e-cigarettes contain a liquid
which substantially vary in the amount of different chemicals,
including nicotine, and purchasers have often no adequate
information to understand the real content and composition
of the refills (Benowitz & Goniewicz, 2013; Cameron et al.,
2013; Cheah, Chong, Tan, Morsed, & Yee, 2012; Flouris &
Oikonomou, 2010; Goniewicz, Kuma, Gawron, Knysak, &
Kosmider, 2013; Trtchounian & Talbot, 2011; WHO, 2013;
Williams & Talbot, 2011). Of concerns is also the fact that fla-
vors can be particularly attractive to adolescents, who could
consequently start e-cigarette use as a gateway to tobacco
smoking (Benowitz & Goniewicz, 2013; Choi, Fabian, Mottey,
Corbett, & Forster, 2012; Hampton, 2014; Sugerman, 2014;
WHO, 2013).
Only a limited number of studies, mostly from the United
States, have been conducted so far to understand awareness,
use,
and harm perception in representative surveys of adults (Pepper
& Brewer, 2013). To our knowledge, within Europe, only one
study on adults from the United Kingdom (Dockrell et al.,

2013),
three studies on smokers from the United Kingdom (Adkison
et al., 2013) and the Czech Republic (Kralikova, Kubatova,
Truneckova, Kmetova, & Hajek, 2012; Kralikova, Novak,
West, Kmetova, & Hajek, 2013), and one study on adolescents
and young adults from Poland (Goniewicz & Zielinska-Danch,
2012) have been published. We therefore fill the knowledge gap
in Italy, a country where smoking prevalence was 20.8% in
2012
(Gallus, Lugo, Colombo, Pacifici, & La Vecchia, 2013), and
where a comprehensive legislation came into force in 2005 to
ban smoking in workplaces and all indoor public places, includ-
ing restaurants and pubs (Gallus et al., 2006).
The objective of the present study is therefore to quan-
tify the proportion of awareness, use, and harm perception of
e-cigarettes using data from a representative population-based
survey conducted in Italy.
MetHOds
Data were collected through a survey on smoking conducted
in Italy during February–May 2013 by DOXA, the Italian
branch of the WIN/GIA (Worldwide Independent Network/
Gallup International Association). The overall sample con-
sisted of 3,000 individuals aged ≥15 years (1,442 men and
1,558 women), representative of the general Italian population
aged 15 years and over (51.1 million inhabitants), in terms of
sex, age, geographic area, and socioeconomic characteristics.
Participants were selected through a representative multi-
stage sampling. The first stage was used to select municipali-
ties (the smallest Italian administrative division) in all of the
20 Italian regions (the largest Italian administrative division)
in order to be representative of the geographic areas sampled.
Thus, taking as criteria two characteristics, region and size of

municipality, we identified 116 municipalities, providing a
reproduction of the Italian universe of municipalities (method
known as proportional stratified sample). In the second stage,
in each municipality, an adequate number of electoral wards
was randomly extracted (each ward corresponding to a given
district of the municipalities), so that the various types of more
or less affluent areas of the municipality were represented in
the right proportions (i.e., central and suburban districts, out-
skirts and isolated houses). In the third stage, individuals were
randomly sampled from electoral rolls, within strata defined
by sex and age group, in order to be representative of the
demographic structure of the population. For adolescents aged
15–17 years, we used the same sampling approach for the first
two stages. For the third stage, adolescents, whose names are
not included in the electoral lists, were selected, among neigh-
bors of adult respondents, by means of a “quota” method (by
sex and exact age).
Field substitution was used as the preferred strategy to deal
with nonrespondence (Baldissera et al., 2014). Therefore, non-
respondents, including potential participants refusing to partici-
pate, unavailable (i.e., units nonresponding up to three attempts
of direct contact) and ineligible participants (e.g., hospitalized,
deceased, prisoners or moved away units), were substituted by
their neighbors (living in the same floor/building/street) with
the same sex and age group. In the phase of processing the data,
statistical weights were also generated to balance the sample
with its universe, and therefore to assure representativeness of
the Italian population aged 15 years or over.
Ad hoc trained interviewers conducted interviews in Italian
using a structured questionnaire in the context of a computer-
assisted personal in-house interview. Besides general informa-
tion on sociodemographic characteristics, data were collected
on smoking status (never/ex-/current smokers). Ever smokers
(current and ex-smokers) were participants who had smoked

100 or more cigarettes in their lifetime. Ex-smokers were par-
ticipants who had quit smoking since at least 1 year, and cur-
rent smokers were individuals continuing smoking or having
stopped since less than 1 year. Current smokers were asked
if they had an intention to quit within the next 6 months and
whether they had made at least one quit attempt. Ex-smokers
were asked to report the time since quitting. A specific section
of the questionnaire focused on e-cigarettes. Participants were
asked about their awareness and use of e-cigarettes using the
following single question: “Have you ever heard about e-ciga-
rettes, have you ever tried them or do you have the intention to
try them?” Participants were admitted to answer only one of the
following choices: (a) I have never heard about e-cigarettes; (b)
I heard about e-cigarettes, I have never tried them, and I have
no intention to try them; (c) I heard about e-cigarettes, I have
never tried them, and I have intention to try them; and (d)
I heard about e-cigarettes and I tried them. Participants report-
ing they “have heard about e-cigarettes and have tried them”
were labeled as “ever users” of e-cigarettes. Ever users were
further asked: “Do you regularly use e-cigarettes?” Moreover,
regular e-cigarette users were asked about the features of their
e-cigarettes, including the type of e-cigarette most frequently
1542
nicotine & tobacco research
used, and about the characteristics of use, including the number
of e-cigarettes (sessions of consumption) per day (using the
question: “How many times per day do you use e-cigarettes?”)
and the consequence of e-cigarette use on smoking behavior.
All participants were asked about their opinion (true or false)
on seven different statements concerning e-cigarettes; they (a)
are not harmful for health; (b) are less harmful than traditional

cigarettes because they do not contain nicotine; (c) are less
harmful because there is no tobacco combustion; (d) are less
harmful because they contain only nicotine; (e) are more harm-
ful than traditional cigarettes; (f) are an efficient tool to quit
smoking; and (g) allow smoking even where it is forbidden.
Participants were also asked about their attitudes toward the
ban of e-cigarette use in (a) public indoor places (e.g., bars,
restaurants, shops) and (b) on trains (four-item score: strongly
in favor, moderately in favor, moderately against, and strongly
against).
Data Analysis
Multivariate p values for awareness of e-cigarettes and their
regular use were computed through unconditional multiple
logistic regression models adjusted for sex, age, level of educa-
tion, smoking status, and geographic area. Odds ratios (OR)
for use of e-cigarettes (“ever users” vs. “never users”) and the
corresponding 95% confidence intervals (CI) were derived
using the same unconditional multiple logistic regression mod-
els. All the analyses were performed with SAS version 9.2
statistical package (SAS Institute). All the estimates provided
are weighted for statistical weights.
resUlts
Table 1 shows the distribution of 3,000 Italians aged ≥15 years
according to their awareness and use of e-cigarettes. Overall,
8.9% (95% CI = 7.8%–9.9%) of survey participants had never
heard about e-cigarettes, 84.4% (95% CI = 83.1%–85.7%)
had heard about them but had never tried (74.3% without any
intention to try and 10.1% with an intention to try), 5.6% (95%
CI = 4.8%–6.5%) had tried without a regular use, and 1.2%
(95% CI = 0.8%–1.6%; 36 participants) reported a regular use
of e-cigarettes. Men more frequently heard about e-cigarettes

(94.8%) than women (87.8%; multivariate p < .001). Awareness
of e-cigarettes increased with decreasing age (p for trend <
.001) and increasing level of education (p for trend < .001).
Compared to never-smokers (89.0%), awareness of e-cigarettes
was significantly higher among current (96.0%; p = .002) and
ex-smokers (94.3%; p = .004). Compared to southern Italy
(88.7%), awareness of e-cigarettes was significantly higher in
northern (92.1%; p = .004) and central Italy (93.1%; p = .004).
Regular e-cigarette use was similar in men (1.5%) and
women (0.9%; multivariate p = .910) and in various categories
of education (p for trend = .504). E-cigarettes were more fre-
quently used by the young (prevalence of regular use was 2.4%
in 15–24 years old individuals, 1.6% in 25–44, 1.0% in 45–64
table 1. Awareness and Use of E-cigarettes on the Overall
Samplea, by Selected Characteristics: Italy 2013
Awareness of e-cigarettes (%)b
N
No awareness of
e-cigarettes (%)b
Never tried without
intention to try
Never tried with
intention to try
Tried but no
regular use Regular use
Total 3,000 8.9 74.3 10.1 5.6 1.2
Sex
Men 1,442 5.2 74.6 11.8 6.9 1.5

Women 1,558 12.2 73.9 8.5 4.5 0.9
Age (years)
15–24 349 5.2 70.9 12.3 9.2 2.4
25–44 994 4.6 74.2 13.0 6.7 1.6
45–64 948 5.2 77.0 10.4 6.5 1.0
≥65 709 21.6 72.4 4.4 1.3 0.3
Level of education
Low 1,193 15.9 72.1 7.8 3.2 1.0
Intermediate 1,362 4.2 73.8 11.8 8.6 1.6
High 445 4.1 81.4 11.0 3.1 0.5
Smoking status
Never-smoker 1,992 11.0 80.3 6.1 2.5 0.1
Ex-smoker 392 5.7 82.7 4.6 4.3 2.8
Current smoker 616 4.0 49.3 26.3 16.6 3.7
Geographic area
Northern Italy 1,380 7.9 74.9 10.2 6.0 0.9
Central Italy 596 6.9 76.6 11.5 4.7 0.3
Southern Italy and islands 1,024 11.3 72.0 9.0 5.6 2.1
aSample of 3,000 Italians aged ≥15 years, representative of the
general Italian population in terms of sex, age, geographic
area, and socioeconomic characteristics. All the estimates in
the table were derived using statistical weights to reassure
sample
representativeness.
bRow percentages.
1543
and 0.3% in ≥65 year old adults; p for trend = .001). Compared
to never-smokers (0.1%), regular use of e-cigarette was higher
in current (3.7%; p < .001) and ex-smokers (2.8%; p < .001),

while, compared to central Italy (0.3%), regular use was higher
in southern Italy (2.1%; p = .018) and similar in northern Italy
(0.9%; p = .132).
Among 36 regular users, 95.5% reported to use e-cigarettes
with nicotine and only 4.5% used e-cigarettes with vapor and
flavors only (without nicotine). Regular users reported to use
e-cigarettes from 1 to 70 times per day (mean: 10.0 overall,
10.8 among men and 8.7 among women). As a consequence of
starting using e-cigarettes, 78.0% of regular users reported to
have modified their smoking behavior, 67.7% having reduced
traditional cigarette consumption and 10.4% having quit smok-
ing (Table 2).
Table 3 shows the distribution of participants by lifetime
use of e-cigarettes (“ever users” vs. “never users”) according to
selected characteristics, overall and among current smokers.
The
proportion of participants reporting to have ever tried e-
cigarettes
was 6.8% (95% CI = 5.9%–7.7%; n = 205). E-cigarette trial was
inversely related to age, the ORs compared to participants aged
15–24 years being 0.56 for 25–44, 0.49 for 45–64, and 0.16 for
≥65 years (p for trend < .001). Individuals with intermediate
compared to low education reported to have tried e-cigarettes
more frequently (OR = 1.91), whereas no significant difference
was observed according to sex and geographic area. Overall,
2.6% (95% CI = 1.9%–3.3%; n = 52) of never-smokers, 7.0%
(95% CI = 4.5%–9.6%; n = 28) of ex-smokers, and 20.4% (95%
CI = 17.2%–23.6%; n = 126) of current smokers tried at least
once
e-cigarettes. Compared to never-smokers, the OR for ex-
smokers
was 3.79 and that of current smokers was 9.20. The pattern of
cur-
rent smokers largely reflects that of the overall population.

Trial of e-cigarettes was more common in current smokers
with an intention to quit smoking within the following 6 months
(36.0%), compared to those with no plans to quit (15.5%; p <
.001) and in smokers who had made at least one quit attempt
(29.3%) compared to those who had not made a quit attempt
(16.5%; p < .001). Among ex-smokers who tried the e-ciga-
rette, 92.6% had quit smoking in the previous 3 years.
The majority of Italians believe that e-cigarettes allow smok-
ing even where it is forbidden (71.9%), they are less harmful
than traditional cigarettes since there is no tobacco combustion
(64.7%) and they are a useful tool to quit smoking (57.3%).
Overall, 47.7% of Italians believe that e-cigarettes are less
harmful because they contain only nicotine, 32.4% that they
are not harmful for health, but 23.1% that they are more harm-
ful than traditional cigarettes. Similar patterns were observed
according to different smoking status.
Figure 1 shows the prevalence of participants who moder-
ately or strongly support banning e-cigarettes in public places.
The proportion of Italians aged ≥15 years in favor of a com-
plete ban of e-cigarette use in public indoor places (including
bars, restaurants, and shops) was 64.8% overall, 70.4% among
never-smokers, 60.0% among ex-smokers, and 50.4% among
current smokers. The prevalence of participants supporting the
ban of e-cigarettes on trains was 64.0% overall, 69.4% among
never-smokers, 59.9% among ex-smokers, and 49.7% among
current smokers. After exclusion of the few participants who
were unaware of e-cigarettes, estimates on perceptions and atti-
tudes did not substantially change.
disCUssiOn
According to this representative sample, more than 45 million
Italians (91.1% of Italians aged ≥15 years) have heard about the

e-cigarettes, 3.5 million (6.8%) have already tried, and more
than 600,000 Italians (1.2%) regularly use it.
According to awareness, in Italy, we found the highest pro-
portion of the adult population having heard about e-cigarettes
(Pepper & Brewer, 2013). This may be due in part to a time
effect, but certainly also to the persistent promotion of e-cig-
arettes on several media in Italy. Our proportion among cur-
rent smokers (96%) was similar only to that observed among
smokers in the Czech Republic in 2012 (97%) (Kralikova et al.,
2013). All the studies providing data on the trend of awareness
of e-cigarettes systematically showed a substantial increase
with calendar period. Thus, in the United States, the number of
table 2. Characteristic of Regular E-cigarettes Users: Italy 2013
Total
N % (95% CI)
36 100.0
Type of e-cigarette most frequently used
With nicotine 34 95.5 (87.7–100.0)
Only vapor (without nicotine) 0 0.0
Vapor and flavor (without nicotine) 2 4.5 (0.0–11.3)
Number of e-cigarettes per day
<5 10 27.4 (12.8–42.0)
5–14 19 54.5 (38.2–70.9)
≥15 7 18.1 (5.5–30.7)
Consequences on smoking behaviors
Started smoking manufactured cigarettes
(from never-smoker to current smoker)
0 0.0

Did not change my smoking habit 8 22.0 (8.4–35.6)
Slightly reduced number of cigarettes smoked per day 16 44.5
(28.1–60.8)
Drastically reduced number of cigarettes smoked per day 8 23.2
(9.3–37.0)
Quitted smoking 4 10.4 (0.4–20.4)
Note. CI = confidence interval.
1544
adults having heard about e-cigarettes doubled between 2009
(16%) and 2010 (32%) (Regan, Promoff, Dube, & Arrazola,
2013) and markedly increased between 2010 (40%) and 2011
(58%) (King, Alam, Promoff, Arrazola, & Dube, 2013). In
the United Kingdom, smokers who heard about e-cigarettes
increased from 60% in 2010 to 77% in 2012 (Dockrell et al.,
2013). Also in Italy, we observe such a trend. In fact, awareness
of e-cigarettes was 72% among current and ex-smokers in a
companion survey conducted by DOXA in 2012 (Gallus et al.,
2013; OSSFAD, 2012). This estimate increased to more than
95% among ever smokers in 2013. In our study, awareness of
e-cigarette was highest among current smokers, men, young-
est, and highly educated subjects. This is in broad agreement
with previous studies (Adkison et al., 2013; Choi & Forster,
2013; King et al., 2013; Regan et al., 2013).
Ever use of e-cigarette also substantially increased in Italy
in 1 year only. In fact, ever smokers having tried e-cigarettes
were 7.3% in 2012 (OSSFAD, 2012) and 15.2% in 2013. In
agreement with several other studies (Adkison et al., 2013;

Choi & Forster, 2013; Pearson, Richardson, Niaura, Vallone,
table 3. Distribution of the Overall Sample and the Sample of
Current Smokers by Lifetime Use of E-Cigarettes
(Ever vs. Never Users), by Selected Characteristics: Italy 2013
Overall sample Current smokers
E-cigarette use, N (%)a ORb for e-cigarette ever
users vs. never
users (95% CI)
E-cigarette use, N (%)a ORb for e-cigarette
ever users vs. never
users (95% CI)Ever users Never users Ever users Never users
Total 205 (6.8) 2795 (93.2) – 126 (20.4) 491 (79.6) –
Sex
Men 121 (8.4) 1321 (91.6) 1c 76 (20.2) 301 (79.8) 1c
Women 84 (5.4) 1475 (94.6) 0.89 (0.65–1.22) 49 (20.6) 190
(79.4) 0.96 (0.64–1.45)
Age (years)
15–24 40 (11.6) 309 (88.4) 1c 23 (32.6) 48 (67.4) 1c
25–44 82 (8.2) 912 (91.8) 0.56 (0.36–0.86) 49 (20.3) 194
(79.8) 0.55 (0.30–0.99)
45–64 71 (7.5) 877 (92.5) 0.49 (0.31–0.78) 47 (20.4) 184
(79.6) 0.59 (0.32–1.08)
≥65 11 (1.6) 698 (98.4) 0.16 (0.08–0.33) 6 (8.7) 65 (91.4) 0.26
(0.10–0.72)
Level of education
Low 50 (4.2) 1143 (95.8) 1c 35 (15.1) 198 (84.9) 1c
Intermediate 139 (10.2) 1223 (89.8) 1.95 (1.35–2.81) 77 (25.0)

230 (75.0) 1.70 (1.06–2.73)
High 16 (3.6) 429 (96.4) 0.71 (0.39–1.29) 14 (17.9) 63 (82.1)
1.15 (0.57–2.34)
Smoking status
Never-smokers 52 (2.6) 1940 (97.4) 1c
Ex-smokers 28 (7.0) 365 (93.0) 3.79 (2.30–6.27)
Current smokers 126 (20.4) 491 (79.6) 9.20 (6.47–13.07)
Geographic area
Northern Italy 94 (7.0) 1283 (93.0) 1c 55 (19.7) 225 (80.3) 1c
Central Italy 30 (5.0) 566 (95.0) 0.68 (0.43–1.06) 18 (14.8) 104
(85.2) 0.69 (0.38–1.24)
Southern Italy and islands 78 (7.7) 946 (92.3) 1.07 (0.76–1.49)
52 (24.4) 162 (75.6) 1.33 (0.85–2.06)
Note. OR = odds ratio; CI = confidence interval.
aRow percentages.
bORs were estimated using unconditional multiple logistic
regression models after adjustment for sex, age, level of
education,
smoking status, and geographic area.
cReference category.
Figure 1. Percent distribution and corresponding 95%
confidence interval of never, current, and ex-smokers according
to support
of a ban of e-cigarettes in selected areas (Italy 2013). Overall,
14% to 17% of subjects had no opinion on the statements and
were
therefore excluded by the present analysis.
1545

& Abrams, 2012; Popova & Ling, 2013), we observed a higher
prevalence of e-cigarette users among the youngest age group,
where 11.6% had tried at least once an e-cigarette. Of concern
is also the non-negligible proportion of adolescents having tried
the e-cigarette in our sample (7.4%; 95% CI = 2.2%–12.6%,
based on 99 adolescents aged 15–17 years). We found more-
over that e-cigarette users had most frequently an intermedi-
ate level of education, in line with a U.S. study (McMillen,
Maduka, & Winickoff, 2012). Current smokers with an inten-
tion to quit within the next 6 months more frequently reported
e-cigarette use, in agreement with one study from the United
States (Pearson et al., 2012). However, at least other three stud-
ies did not find any relation between e-cigarette use and inten-
tion to quit tobacco smoking (Adkison et al., 2013; Popova &
Ling, 2013; Sutfin, McCoy, Morrell, Hoeppner, & Wolfson,
2013).
Our study adds knowledge on the harm perception of the
Italian adult population; while the majority of Italians (65%)
believe that e-cigarettes are less harmful than traditional cig-
arettes because of the lack of tobacco combustion in e-ciga-
rette, 23% of adults still believe that e-cigarettes may be even
more harmful than traditional ones. Finally, the large majority
of Italians, but also half of current smokers, are favorable to
ban e-cigarettes not only on trains, where a regulation ban-
ning smoking only in selected wagons is available since 1975
(Legge 584, 1975), but also in all indoor public places, regu-
lated by a total ban since 2005 (Gallus et al., 2006).
A limitation of the present survey is the relatively small
number of e-cigarette users, which makes estimates unstable.
Another limitation is that the questionnaire on e-cigarettes was
not validated, and some questions on regular use, intensity
of use of e-cigarettes, and its consequences on smoking sta-

tus may have been misinterpreted by survey participants. The
strengths of this study include the face-to-face survey design
and the national representativeness of the sample.
In conclusion, we observe a diffuse awareness of e-ciga-
rette—and an increasing diffusion of its use as well—in Italy
in less than 3 years from the constitution of the first Italian
shop selling e-cigarettes. On the one hand, our data suggest that
e-cigarettes may be an alternative to tobacco smoking, since
three out of four users reported to have favorably modified
their smoking habit (68% reduced smoking consumption and
10% quitted smoking completely) after starting e-cigarette use.
On the other hand, 90% of e-cigarette users did not quit smok-
ing as a consequence of starting vaping e-cigarettes, and the
majority of e-cigarette users remain therefore current smok-
ers. This raises concerns on dual use, since decreasing cigarette
consumption confers clearly less health benefit than quitting
smoking completely (Chapman, 2013). More importantly,
almost 900,000 Italian never smokers, particularly the young,
have tried at least once this new and potentially addictive
product. This suggests that e-cigarette use may be a gateway
to nicotine addiction and consequently to tobacco smoking
(Benowitz & Goniewicz, 2013; Choi et al., 2012; WHO, 2013).
There is substantial heterogeneity in the composition of
various types of e-cigarettes (Benowitz & Goniewicz, 2013;
Cameron et al., 2013; Cheah et al., 2012; Flouris & Oikonomou,
2010; Goniewicz, Kuma, et al., 2013; Trtchounian & Talbot,
2011; WHO, 2013; Williams & Talbot, 2011), and each of these
should be monitored on a toxicological and, in principle, epi-
demiological level. In particular, the release of nicotine tends
to be limited by e-cigarettes but is highly variable (Cameron
et al., 2013; Cheah et al., 2012). Flavors may also release toxic
substances, but no adequate data have been published to date.
More in general, there is a broad issue of safety and of effi-

cacy also in comparative terms with other nicotine releasing
devices (chewing gums, patches). A randomized clinical trial
administered to quantify the efficacy of e-cigarette to support
smoking cessation was conducted in New Zealand (Bullen
et al., 2013). Randomizing 657 smokers to (a) e-cigarette with
nicotine, (b) nicotine patch, and (c) e-cigarette without nicotine
(placebo), no significant differences in smoking cessation rates
at 6 months were observed among the three groups. Cessation
rates were 7.3% among users of e-cigarette, 5.8% among those
with nicotine patch, and 4.1% among placebo users (Bullen
et al., 2013; Hampton, 2014). At least other two population-
based longitudinal studies showed that e-cigarettes have no
effect on smoking cessation (Grana, Popova, & Ling, 2014;
Vickerman, Carpenter, Altman, Nash, & Zbikowski, 2013).
Despite the increasing number of studies on e-cigarettes
(Bullen et al., 2010; 2013; Caponnetto et al., 2013; Chen,
2013; Goniewicz, Knysak et al., 2013; Pellegrino et al., 2012;
Siegel, Tanwar, & Wood, 2011; Vardavas et al., 2012;
Williams,
Villarreal, Bozhilov, Lin, & Talbot, 2013; Zhang, Sumner, &
Chen, 2013), questions raised over 5 years ago (Pauly et al.,
2007) on the safety of the e-cigarette use and the efficacy of the
e-cigarette as a substitute to tobacco smoking have not been
adequately elucidated, yet. Only providing answers to those
questions it will be possible to understand any risk-benefit bal-
ance of e-cigarette on a population level.
FUnding
The work of SG and CLV was partially supported by the Italian
League Against Cancer (Milan) and the Italian Foundation for
Cancer Research (FIRC).
deClaratiOn OF interests

None declared.
aCknOwledgMents
The survey was conducted with the contribution of the Italian
Ministry of Health.
reFerenCes
Adkison, S. E., O’Connor, R. J., Bansal-Travers, M., Hyland,
A., Borland, R., Yong, H. H., … Fong, G. T. (2013).
Electronic nicotine delivery systems: International tobacco
control four-country survey. American Journal of Preventive
Medicine, 44, 207–215. doi:10.1016/j.amepre.2012.10.018
Ayers, J. W., Ribisl, K. M., & Brownstein, J. S. (2011).
Tracking the rise in popularity of electronic nicotine deliv-
ery systems (electronic cigarettes) using search query sur-
veillance. American Journal of Preventive Medicine, 40,
448–453. doi:10.1016/j.amepre.2010.12.007
Bains, M., Agombar, H., Clarke, E., & Patel, R. (2012). Time
for NHS policy on electronic cigarettes. British Medical
Journal, 345, e6587. doi:10.1136/bmj.e6587
Baldissera, S., Ferrante, G., Quarchioni, E., Minardi, V.,
Possenti, V., Carrozzi, G., … Salmaso, S. (2014). Field
substitution of nonresponders can maintain sample size
1546
and structure without altering survey estimates - The expe-

rience of the Italian behavioral risk factors surveillance
system (PASSI). Annals of Epidemiology, 24, 241–245.
doi:10.1016/j.annepidem.2013.12.003
Bauld, L. (2012). Commentary on Wagener et al. (2012):
E-cigarettes: Room for cautious optimism. Addiction, 107,
1549–1550. doi:10.1111/j.1360-0443.2012.03904.x
Benowitz, N. L., & Goniewicz, M. L. (2013). The regulatory
chal-
lenge of electronic cigarettes. Journal of the American Medical
Association, 310, 685–686. doi:10.1001/jama.2013.109501
Borland, R. (2011). Electronic cigarettes as a method of tobacco
control. British Medical Journal, 343, d6269. doi:10.1136/
bmj.d6269
Bullen, C., Howe, C., Laugesen, M., McRobbie, H., Parag, V.,
Williman, J., & Walker, N. (2013). Electronic cigarettes for
smoking cessation: A randomised controlled trial. Lancet,
382, 1629–1637. doi:10.1016/S0140-6736(13)61842-5
Bullen, C., McRobbie, H., Thornley, S., Glover, M., Lin, R.,
& Laugesen, M. (2010). Effect of an electronic nicotine
delivery device (e-cigarette) on desire to smoke and with-
drawal, user preferences and nicotine delivery: Randomised
cross-over trial. Tobacco Control, 19, 98–103. doi:10.1136/
tc.2009.031567
Cameron, J. M., Howell, D. N., White, J. R., Andrenyak, D. M.,
Layton, M. E., & Roll, J. M. (2013). Variable and potentially
fatal amounts of nicotine in e-cigarette nicotine solutions.
Tobacco Control. doi:10.1136/tobaccocontrol-2012-050604
Caponnetto, P., Campagna, D., Cibella, F., Morjaria, J. B.,
Caruso, M., Russo, C., & Polosa, R. (2013). EffiCiency and

Safety of an eLectronic cigAreTte (ECLAT) as tobacco ciga-
rettes substitute: A prospective 12-month randomized con-
trol design study. PLoS One, 8, e66317. doi:10.1371/journal.
pone.0066317
Chapman, S. (2013). Should electronic cigarettes be as freely
available as tobacco cigarettes? No. British Medical Journal,
346, f3840. doi:10.1136/bmj.f3840
Cheah, N. P., Chong, N. W., Tan, J., Morsed, F. A., & Yee, S.
K.
(2012). Electronic nicotine delivery systems: regulatory and
safety challenges: Singapore perspective. Tobacco Control,
23, 119–125. doi:10.1136/tobaccocontrol-2012-050483
Chen, I. L. (2013). FDA summary of adverse events on elec-
tronic cigarettes. Nicotine and Tobacco Research, 15, 615–
616. doi:10.1093/ntr/nts145
Choi, K., Fabian, L., Mottey, N., Corbett, A., & Forster, J.
(2012). Young adults’ favorable perceptions of snus, dis-
solvable tobacco products, and electronic cigarettes:
Findings from a focus group study. American Journal
of Preventive Medicine, 102, 2088–2093. doi:10.2105/
AJPH.2011.300525
Choi, K., & Forster, J. (2013). Characteristics associated with
awareness, perceptions, and use of electronic nicotine deliv-
ery systems among young US Midwestern adults. American
Journal of Preventive Medicine, 103, 556–561. doi:10.2105/
AJPH.2012.300947
Dawkins, L., Turner, J., Roberts, A., & Soar, K. (2013).
‘Vaping’ profiles and preferences: An online survey of
electronic cigarette users. Addiction, 108, 1115–1125.
doi:10.1111/add.12150

Dockrell, M., Morrison, R., Bauld, L., & McNeill, A. (2013).
E-Cigarettes: Prevalence and attitudes in Great Britain. Nicotine
and Tobacco Research, 15, 1737–1744. doi:10.1093/ntr/ntt057
Etter, J. F. (2013). Should electronic cigarettes be as freely
available as tobacco? Yes. British Medical Journal, 346,
f3845. doi:10.1136/bmj.f3845
Etter, J. F., Bullen, C., Flouris, A. D., Laugesen, M., &
Eissenberg, T. (2011). Electronic nicotine delivery sys-
tems: A research agenda. Tobacco Control, 20, 243–248.
doi:10.1136/tc.2010.042168
Flouris, A. D., & Oikonomou, D. N. (2010). Electronic ciga-
rettes: Miracle or menace? British Medical Journal, 340,
c311. doi:10.1136/bmj.c311
Gallus, S., Lugo, A., Colombo, P., Pacifici, R., & La Vecchia,
C. (2013). Smoking prevalence in Italy 2011 and 2012, with
a focus on hand-rolled cigarettes. Preventive Medicine, 56,
314–318. doi:10.1016/j.ypmed.2013.02.009
Gallus, S., Zuccaro, P., Colombo, P., Apolone, G., Pacifici, R.,
Garattini, S., & La Vecchia, C. (2006). Effects of new smok-
ing regulations in Italy. Annals of Oncology, 17, 346–347.
doi:10.1093/annonc/mdj070
Goniewicz, M. L., Knysak, J., Gawron, M., Kosmider, L.,
Sobczak, A., Kurek, J., … Benowitz, N. (2013). Levels of
selected carcinogens and toxicants in vapour from electronic
cigarettes. Tobacco Control, 23, 133–139. doi:10.1136/
tobaccocontrol-2012–050859
Goniewicz, M. L., Kuma, T., Gawron, M., Knysak, J., &
Kosmider, L. (2013). Nicotine levels in electronic cigarettes.

Nicotine and Tobacco Research, 15, 158–166. doi:10.1093/
ntr/nts103
Goniewicz, M. L., & Zielinska-Danch, W. (2012).
Electronic cigarette use among teenagers and young
adults in Poland. Pediatrics, 130, e879–885. doi:10.1542/
peds.2011-3448
Grana, R. A., Popova, L., & Ling, P. M. (2014). A longitudi-
nal analysis of electronic cigarette use and smoking cessa-
tion. JAMA Internal Medicine, 174, 812–813. doi:10.1001/
jamainternmed.2014.187
Hampton, T. (2014). Experts call for research plus regulation of
e-cigarettes. Journal of the American Medical Association,
311, 123–124. doi:10.1001/jama.2013.285292
King, B. A., Alam, S., Promoff, G., Arrazola, R., & Dube, S.
R. (2013). Awareness and ever use of electronic cigarettes
among U.S. adults, 2010–2011. Nicotine and Tobacco
Research, 15, 1623–1627. doi:10.1093/ntr/ntt013
Kralikova, E., Kubatova, S., Truneckova, K., Kmetova, A., &
Hajek, P. (2012). The electronic cigarette: What proportion of
smokers have tried it and how many use it regularly? Addiction,
107, 1528–1529. doi:10.1111/j.1360-0443.2012.03916.x
Kralikova, E., Novak, J., West, O., Kmetova, A., & Hajek, P.
(2013). Do e-cigarettes have the potential to compete with
conventional cigarettes? A survey of conventional cigarette
smokers’ experiences with e-cigarettes. Chest, 144, 1609–
1614. doi:10.1378/chest.12-2842
Kuehn, B. M. (2009). FDA: Electronic cigarettes may be risky.
Journal of the American Medical Association, 302, 937.
doi:10.1001/jama.2009.1245

Legge 584. (1975). Divieto di fumare in determinati locali e
su mezzi di trasporto pubblico. Gazzetta Ufficiale n. 322.
Retrieved from May 13, 2014, www.normattiva.it/ricerca/
semplice
McMillen, R., Maduka, J., & Winickoff, J. (2012). Use of
emerging tobacco products in the United States. Journal
of Environmental and Public Health, 2012, 989474.
doi:10.1155/2012/989474
OSSFAD. (2012). DOXA: Il fumo in Italia. Retrieved from
December 10, 2013, www.iss.it/binary/fumo4/cont/
Indagine_DOXA2012.pdf
Pauly, J., Li, Q., & Barry, M. B. (2007). Tobacco-free
electronic
cigarettes and cigars deliver nicotine and generate concern.
Tobacco Control, 16, 357. doi:10.1136/tc.2006.019687
Pearson, J. L., Richardson, A., Niaura, R. S., Vallone, D. M.,
& Abrams, D. B. (2012). e-Cigarette awareness, use, and
harm perceptions in US adults. American Journal of Public
Health, 102, 1758–1766. doi:10.2105/AJPH.2011.300526
Pellegrino, R. M., Tinghino, B., Mangiaracina, G., Marani,
A., Vitali, M., Protano, C., … Cattaruzza, M. S. (2012).
Electronic cigarettes: An evaluation of exposure to
1547
chemicals and fine particulate matter (PM). Annali di Igiene,

24, 279–288.
Pepper, J. K., & Brewer, N. T. (2013). Electronic nicotine
deliv-
ery system (electronic cigarette) awareness, use, reactions
and beliefs: A systematic review. Tobacco Control. [Epub
ahead of print]. doi:10.1136/tobaccocontrol-2013-051122
Popova, L., & Ling, P. M. (2013). Alternative tobacco prod-
uct use and smoking cessation: A national study. American
Journal of Public Health, 103, 923–930. doi:10.2105/
AJPH.2012.301070
Regan, A. K., Promoff, G., Dube, S. R., & Arrazola, R. (2013).
Electronic nicotine delivery systems: Adult use and aware-
ness of the ‘e-cigarette’ in the USA. Tobacco Control, 22,
19–23. doi:10.1136/tobaccocontrol-2011-050044
Richardson, A., Ganz, O., Stalgaitis, C., Abrams, D., &
Vallone,
D. (2014). Noncombustible tobacco product advertising:
How companies are selling the new face of tobacco. Nicotine
and Tobacco Research, 16, 606–614. doi:10.1093/ntr/ntt200
Richardson, A., Ganz, O., & Vallone, D. (2014). Tobacco on
the web: Surveillance and characterisation of online tobacco
and e-cigarette advertising. Tobacco Control. [Epub ahead of
print]. doi:10.1136/tobaccocontrol-2013-051246
Siegel, M. B., Tanwar, K. L., & Wood, K. S. (2011). Electronic
cigarettes as a smoking-cessation: Tool results from an
online survey. American Journal of Preventive Medicine, 40,
472–475. doi:10.1016/j.amepre.2010.12.006
Sugerman, D. T. (2014). JAMA patient page. e-Cigarettes.
Journal of the American Medical Association, 311, 212.

doi:10.1001/jama.2013.279164
Sutfin, E. L., McCoy, T. P., Morrell, H. E., Hoeppner, B. B.,
& Wolfson, M. (2013). Electronic cigarette use by college
students. Drug and Alcohol Dependence, 131, 214–221.
doi:10.1016/j.drugalcdep.2013.05.001
Trtchounian, A., & Talbot, P. (2011). Electronic nicotine deliv-
ery systems: Is there a need for regulation? Tobacco Control,
20, 47–52. doi:10.1136/tc.2010.037259
Vardavas, C. I., Anagnostopoulos, N., Kougias, M.,
Evangelopoulou, V., Connolly, G. N., & Behrakis, P. K.
(2012). Short-term pulmonary effects of using an electronic
cigarette: Impact on respiratory flow resistance, imped-
ance, and exhaled nitric oxide. Chest, 141, 1400–1406.
doi:10.1378/chest.11–2443
Vickerman, K. A., Carpenter, K. M., Altman, T., Nash, C. M.,
& Zbikowski, S. M. (2013). Use of electronic cigarettes
among state tobacco cessation quitline callers. Nicotine and
Tobacco Research, 15, 1787–1791. doi:10.1093/ntr/ntt061
Wagener, T. L., Siegel, M., & Borrelli, B. (2012). Electronic
cigarettes: Achieving a balanced perspective. Addiction, 107,
1545–1548. doi:10.1111/j.1360-0443.2012.03826.x
Williams, M., & Talbot, P. (2011). Variability among electronic
cigarettes in the pressure drop, airflow rate, and aerosol pro-
duction. Nicotine and Tobacco Research, 13, 1276–1283.
doi:10.1093/ntr/ntr164
Williams, M., Villarreal, A., Bozhilov, K., Lin, S., & Talbot,
P. (2013). Metal and silicate particles including nanopar-
ticles are present in electronic cigarette cartomizer fluid
and aerosol. PLoS One, 8, e57987. doi:10.1371/journal.

pone.0057987
World Health Organization (WHO). (2013). Questions and
answers on electronic cigarettes or electronic nicotine deliv-
ery systems (ENDS). Tobacco Free Initiative. Retrieved
from December 10, 2013, www.who.int/tobacco/communi-
cations/statements/eletronic_cigarettes/en/index.html
Yamin, C. K., Bitton, A., & Bates, D. W. (2010).
E-cigarettes: A rapidly growing Internet phenom-
enon. Annals of Internal Medicine, 153, 607–609.
doi:10.7326/0003-4819-153-9-201011020-00011
Zhang, Y., Sumner, W., & Chen, D. R. (2013). In vitro particle
size distributions in electronic and conventional cigarette
aerosols suggest comparable deposition patterns. Nicotine
and Tobacco Research, 15, 501–508. doi:10.1093/ntr/
nts165
1548
Copyright of Nicotine & Tobacco Research is the property of
Oxford University Press / USA
and its content may not be copied or emailed to multiple sites or
posted to a listserv without
the copyright holder's express written permission. However,
users may print, download, or
email articles for individual use.
Am J Health Behav.™ 2015;39(3):361-371 361

T
here is an upsurge in tobacco industry ad-
vertising to encourage cigarette smokers to
use electronic cigarettes (e-cigarettes) in no-
smoking areas and as an aid to smoking cessation.
E-cigarettes are devices that include a battery-pow-
ered heating element designed to heat and aerosol-
ize liquids containing varying levels of nicotine, fla-
voring agents, a number of unknown components,
and in some cases tobacco itself.1 Aerosolized nic-
otine in e-cigarettes contains glycerine to mimic
smoke of conventional cigarettes while supposedly
delivering lower toxin levels than those found in a
conventional cigarette.2-5 Vaporizers (or vape-pens)
are similar to e-cigarettes, but typically contain a
larger battery with variable heat settings to heat a
refillable tank with a wick for liquid nicotine or a
compartment for vaporizing THC oil or even can-
nabis buds. Vaporizers are more expensive than e-
cigarettes, and their higher heat levels can deliver
a larger dose of nicotine vapor. The nicotine can be
purchased in varying concentrations and flavors.
There is a dearth of information on the perceptions
and use of e-cigarettes among older adults.
Prevalence and Impact of Smoking in Older
Adults
Older smokers initiated smoking when it was
ubiquitous and they were most impacted by indoor
smoking bans. Disparities in tobacco use among
adults continue to exist by race/ethnicity, educa-
tion, income, and mental health status.6 In the last
decade, smoking prevalence has declined in all age

groups in the US except for older smokers. In fact,
smoking prevalence for adults over 65 actually has
increased. In 2011, smoking prevalence for 45-
64 year-olds was 19.5%, higher than the national
average of 18%.7 These statistics reflect both the
marginalization of older smokers by society and
tobacco research funding,8 and the fact that older
smokers are targeted by an aggressive tobacco in-
dustry.9 Older smokers frequently face economic
and social disadvantages; yet, they are often ig-
nored in discussions of marginalized populations
impacted by tobacco.10-13
Because older smokers underestimate both the
risks of smoking and the benefits of cessation, they
are the least likely to quit of any age group.13 Older
adults have the greatest smoking related health
burden.14 However, quitting smoking, at any age,
decreases cardiovascular risk and provides sig-
nificant health benefits and quitting by age 50 re-
duces the risk of lung cancer by half.15 Yet, older
adults (45-64 year-olds) are often unaware of these
benefits.16 A primary reason for these mispercep-
Janine K. Cataldo, Associate Professor, University of Cali-
fornia, San Francisco School of Nursing, San Francisco, CA.
Anne Berit Petersen, Doctoral Candidate, University of Cali-
fornia, San Francisco School of Nursing, San Francisco, CA.
Mary Hunter, Doctoral Student, University of California, San
Francisco School of Nursing, San Francisco, CA. Julie Wang,
Postdoctoral Fellow, University of California, San Francisco,
Center of Tobacco Control, Research, and Education, San
Francisco, CA. Nicolas Sheon, University of California, San
Francisco, Department of Medicine, San Francisco, CA.
Correspondence Dr Cataldo; [email protected]
E-cigarette Marketing and Older Smokers:

Road to Renormalization
Janine K. Cataldo, RN, PhD, FAAN; Anne Berit Petersen, RN,
MS, MPH; Mary Hunter, MN;
Julie Wang, MPH, PhD; Nicolas Sheon, PhD
Objectives: To describe older smokers’
perceptions of risks and use of e-cigarettes,
and their responses to marketing and
knowledge of, and opinions about, regula-
tion of e-cigarettes. Methods: Eight 90-min-
ute focus groups with 8 to 9 participants
met in urban and suburban California to
discuss topics related to cigarettes and al-
ternative tobacco products. Results: Older
adults are using e-cigarettes for cessation
and as a way to circumvent no-smoking
policies; they have false perceptions about
the effectiveness and safety of e-cigarettes.
They perceive e-cigarette marketing as a
way to renormalize smoking. Conclusions:
To stem the current epidemic of nicotine
addiction, the FDA must take immediate
action because e-cigarette advertising pro-
motes dual use and may contribute to the
renormalization of smoking.
Key words: older smokers; e-cigarettes;
marketing; perception; use
Am J Health Behav. 2015;39(3):361-371
DOI: http://dx.doi.org/10.5993/AJHB.39.3.9

E-cigarette Marketing and Older Smokers: Road to
Renormalization
362
tions is the tobacco industry’s aggressive targeting
of older smokers8 in the marketing of both con-
ventional and emerging tobacco products, such
as e-cigarettes and vaporizers.17-19 Tobacco com-
panies encourage tobacco use through marketing
that reduces perceptions of harm associated with
tobacco use and increases perceptions of social ac-
ceptability.20-22 Previous analyses have shown that
the tobacco industry has targeted older adults and
marketed “light” and “low-tar” cigarettes as alter-
natives to quitting with the false implication that
they were healthier choices.8 Using a similar strat-
egy, the tobacco industry has expanded its adver-
tising of smokeless tobacco and e-cigarettes as
alternative products for use in no-smoking areas
and as aides to decrease smoking.23,24
The Emergence of E-cigarette Use in Older
Adults
In the US, the prevalence of e-cigarette use is
rising; in one study, 3.3% of adults in 2010 and
6.2% in 2011 had ever used an e-cigarette.25 In ad-
dition, awareness of these products among adults
increased from 40.9% in 2010 to 57.9% in 2011.25
Current cigarette smokers are more likely to use
e-cigarettes than former or never smokers25 and in
2012, 76.3% of current e-cigarette users reported
concurrent use of conventional cigarettes.26-29

108Electronic cigarettes, or e-cigarettes,” are de-vi.docx

108Electronic cigarettes, or e-cigarettes,” are de-vi.docx

Recommended

Recommended

More Related Content

Similar to 108Electronic cigarettes, or e-cigarettes,” are de-vi.docx

Similar to 108Electronic cigarettes, or e-cigarettes,” are de-vi.docx (20)

More from hyacinthshackley2629

More from hyacinthshackley2629 (20)

Recently uploaded

Recently uploaded (20)

108Electronic cigarettes, or e-cigarettes,” are de-vi.docx