Yet for a good number of young Americans, in particular, the message that vaping can be bad for your health doesn't seem to be sinking in -- and that's troubling news for family physicians and other health care professionals who do their best to warn patients about the harms associated with e-cigarettes.
That's the essence of a recent nationwide survey(www.asco.org) of some 4,000 adults, the initial results of which were posted online last month. The survey, which was commissioned by the American Society of Clinical Oncology, found that more than 20% of young adults consider e-cigarettes to be both harmless and nonaddictive, a belief that seems to fly in the face of mounting evidence to the contrary.
"These beliefs among young adults about e-cigarettes parallel early misperceptions about tobacco products," said ASCO President Howard "Skip" Burris III, M.D., in a news release.(www.asco.org) "Education is crucial to correcting misinformation and preventing what could become a public health crisis."
- Results of a recent American Society of Clinical Oncology survey revealed that more than 20% of young Americans thought e-cigarettes were both harmless and nonaddictive.
- Many young Americans also thought flavored e-cigarettes were less harmful than nonflavored e-cigarettes.
- Family physicians are strongly encouraged to educate patients of all ages about the risks associated with e-cigarette use, as well as the risks of using combustible tobacco products.
Survey Methods and Findings
The 2019 National Cancer Opinion Survey was conducted online between July 9 and Aug. 10. A total of 4,001 U.S. adults 18 and older completed the survey, which asked participants a variety of questions on e-cigarette use, perceived risks and proposed regulations. Participants were categorized into five age groups:
- Generation Z (18-22),
- Millennials (23-38),
- Generation X (39-54),
- Boomers (55-72) and
- Silent (73 and older).
The survey revealed several important findings.
E-cigarette use. Thirteen percent of adults overall used e-cigarettes daily or recreationally. E-cigarette use by percentage was highest in Millennials (21%) and those in Generation Z (18%) and lowest in Boomers (5%) and members of the Silent generation (1%).
Among adults who were parents, 17% of those with children ages 9-17 said that their child had tried e-cigarettes, and 7% of those children were reported to be regular e-cigarette users.
Health risks. Although 71% of adults agreed that e-cigarettes cause cancer, they were less certain of other risks:
- 39% thought e-cigarettes were a healthier alternative to traditional e-cigarettes,
- 20% thought people couldn't become addicted to e-cigarettes, and
- 16% thought e-cigarettes were harmless.
Younger adults were significantly more likely than older adults to believe that e-cigarettes were nonaddictive and harmless. Twenty-four percent of Millennials and 20% of those in Generation Z thought e-cigarettes were harmless compared with just 10% of Boomers.
Younger adults also appeared less concerned about the risks associated with flavored e-cigarettes. Twenty-nine percent of Millennials and 27% of adults in Generation Z thought flavored e-cigarettes were less damaging to health than nonflavored e-cigarettes. Only 12% of Boomers held the same belief.
Policy actions. Overall, 71% of adults expressed support for having the FDA regulate the sale and manufacture of e-cigarettes, and 68% supported raising the legal age for purchasing e-cigarettes from 18 to 21.
Younger adults were much less likely to support these proposals, however. Just 60% of Millennials and 58% of those in Generation Z supported FDA regulation of these products, and only 59% of Millennials and 49% of those in Generation Z supported raising the purchase age.
Although the survey did not address how to raise awareness of the harms associated with vaping, Burris was adamant that physicians act to protect vulnerable patients.
"We should do everything in our power to prevent a generation of young people from becoming addicted to nicotine, regardless of how it is delivered," he said.
Burris also expressed concern that e-cigarettes could serve as a gateway to combustible tobacco products among youth, exposing them to additional health risks -- a concern supported by study findings from the National Academies of Science, Engineering and Medicine and others.
Similarly, Richard Schilsky, M.D., ASCO's chief medical officer, had a strong recommendation for adults who smoke.
"There is no doubt that quitting smoking is one of the best things you can do for your health," said Schilsky. If you are trying to quit, we recommend talking to your doctor about methods that are proven to work."
FP Expert's Perspective
Tom Houston, M.D., of Dublin, Ohio, a former chair of the AAFP Commission on Health of the Public and Science and of the Academy's now-dissolved Smoking Cessation Advisory Committee, told AAFP News he wasn't caught off guard by the survey's findings -- including some common misperceptions about the risks of e-cigarette use.
"Respondents incorrectly thought e-cigarettes were linked to cancer; this has yet to be proven," Houston said. "However, vaping has been shown to be a potential cause of heart and lung disease. The flavoring agents may also add to the harms of vaping."
"It is very worrisome that a significant number did not know (or were in denial) that e-cigarettes are addictive, just as conventional cigarettes are," Houston added. "While the number and concentration of toxins in e-cigarette 'vapor' are less than cigarette smoke, exposure to these chemicals is not harmless."
Houston said he's advised patients of all ages about using e-cigarettes.
"With younger patients, the first aim is prevention and counseling about never starting," he said. "Family physicians have a very important role in education for youth and their parents about the risk of addiction from vaping and the potential 'on-ramp' to conventional cigarettes."
On the other hand, older patients may be using e-cigarettes to quit smoking traditional cigarettes and may require a different approach.
"Counseling them about traditional, proven tobacco cessation methods is the place to begin, along with strong advice to completely switch to e-cigarettes if they resist using FDA-approved pharmacotherapy. After a period of complete abstinence from cigarettes, strategies to stop e-cigarettes can be undertaken," said Houston.
Regardless of patient age, Houston recommended that family physicians use the 5 As model for treating tobacco use and dependence(276 page PDF) established by the U.S. Public Health Service, which consists of
- asking patients whether they smoke,
- advising smokers to quit,
- assessing each patient's willingness to quit,
- assisting the patient in quitting and
- arranging for follow-up.
Houston also suggested that FPs include e-cigarette use when asking patients about smoking habits.
The Academy has a wealth of tobacco use and smoking cessation resources available for review. Houston recommended that AAFP members visit the Academy's Ask and Act page, which links to internal AAFP materials and external organizations, as a good starting point. He also suggested members read the American College of Cardiology's 2018 Expert Consensus Decision Pathway on Tobacco Cessation Treatment(www.onlinejacc.org) along with resources on youth and tobacco(www.aap.org) from the American Academy of Pediatrics Julius B. Richmond Center of Excellence.
Related AAFP News Coverage
CDC: THC Products Used in Most Vaping Illness Cases
Agency Updates Latest Findings, Including Demographics