• Research Delivers Mixed News on E-cigarettes

    Awareness of Harms, Risks Has Increased, but So Has Use

    June 24, 2021, 12:56 p.m. Michael Devitt — More middle school and high school students than ever know that e-cigarettes are addictive and harmful, but such knowledge hasn’t stopped many American youth from using the products.

    young man using e-cigarette

    That’s the primary finding of a recent study in the American Journal of Preventive Medicine. The authors determined that the use of combustible cigarettes among American youth declined steadily between 2015 and 2019. Their research also showed, however, that a significant increase in awareness of the harms and addiction risks of e-cigarettes was accompanied over the same span by a significant increase in the percentage of young individuals using these products.

    “While teenagers may be aware of some risks of e-nicotine use, they may not fully appreciate the impact of the high dose of nicotine that is efficiently delivered in e-nicotine products on their developing brains,” said Kristina Gracey, M.D., M.P.H., an assistant professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School, Worcester. “There is a potential role for family physicians to engage in conversations with patients and families about the lifelong dependence that may result from early and high-dose exposure to e-nicotine products.”

    According to a 2019 Morbidity and Mortality Weekly Report Surveillance Summary, e-cigarettes are the most commonly used tobacco product among American youth. More than 27% of high school students and 10.5% of middle school students — about 5.3 million young people — reported using e-cigarettes in 2019. Additional information from the 2020 National Youth Tobacco Survey indicated that more than 80% of youth who use e-cigarette products reported using flavored e-cigarettes.

    Methods and Analysis

    The AJPM study reviewed five consecutive years of National Youth Tobacco Survey data, beginning in 2015. The nationwide survey, which is maintained by the CDC, is administered each spring to middle school and high school students in public and private schools.

    Story Highlights

    The survey asked students whether they had used e-cigarettes or combustible cigarettes in the past 30 days. It also asked them to give their opinions on the harms of both combustible cigarettes and e-cigarettes, and on the addictiveness of e-cigarettes compared with combustible cigarettes. More than 83,000 students completed the survey between 2015 and 2019.


    The study’s authors noted a steady increase in the perceived harm of e-cigarette use over the study period. In 2015, for example, just over 14% of youth thought that there was no harm in using e-cigarettes; by 2019, less than 6% of youth still had the same opinion. Similarly, in 2015, less than 24% thought that e-cigarettes caused a lot of harm; by 2019 more than 32% thought that e-cigarettes were very harmful.

    Respondents’ perceptions of the addictiveness of e-cigarettes also changed considerably over the study period. In 2015, more than 29% of surveyed youth thought e-cigarettes were less addictive than combustible cigarettes, and slightly more than 7% thought they were more addictive. In 2019, only about 18% of youth thought e-cigarettes were less addictive, while more than 26% thought they were more addictive.

    Yet despite this heightened awareness regarding the harms and risks of e-cigarettes, use of these products increased sharply in the last two years reviewed by the authors. In 2015, less than 11% of those surveyed reported using e-cigarettes in the past 30 days. While usage rates declined in each of the following two years, they jumped to 13.4% in 2018; in 2019, 19.8% of youth reported using e-cigarettes.

    In comparison, use of combustible cigarettes declined steadily in each year of the survey, from 5.78% in 2015 to 3.93% in 2019.

    Although the study’s authors found some of the survey results encouraging, they expressed concerned about data that “clearly show that a substantial proportion of adolescents do not attribute harm or addictive properties to e-cigarettes.” They further stated that “these devices threaten to dangerously undermine previous public health efforts to minimize and eliminate tobacco use in children and adolescents.”

    To address this disconnect, the authors called for more concerted public health efforts to make youth more aware of the dangers associated with e-cigarettes. They noted that, while gaps in existing federal regulations still allow for the sale of flavored e-cigarette products in the United States, some European nations have implemented stronger controls on certain types of tobacco products, causing youth e-cigarette rates to plateau or increase at slower rates than in the U.S.

    Family Physician Perspective

    Gracey, who also serves as a faculty member at Barre Family Health Center in Barre, Mass., said that other factors such as advertising and use of e-cigarettes by youth peers likely contributed to the increased use of e-cigarettes during the study period. She told AAFP News that family physicians can advocate for tighter regulations and limits on e-cigarette ads and participate in middle- and high school education programs that help students, families and educators understand the risks of these products.

    Gracey also provided some advice for discussing e-cigarette use with young patients based on her own clinical experience.

    “I built into my regular practice talking with adolescents about their health behaviors, including e-nicotine use,” Gracey said. “This is done best with adequate time allocated for these visits. Asking the parent to give permission to speak with the adolescent alone, or asking if it is OK to call after the visit to speak with the adolescent, can help create space for the adolescent to speak.

    “Asking open-ended questions of the adolescent and starting by asking if any friends use e-nicotine products can help an adolescent to talk about their own experiences and concerns,” Gracey continued. “Nonjudgmental approaches and nonverbal communication promoting a comfortable environment help.”

    Gracey added that it is important to understand why and when youth began using e-cigarettes.

    “Understanding and addressing the root causes for e-nicotine use requires taking the time, listening patiently, and building a relationship of trust,” Gracey said. “Partnering with our behavioral health clinicians to address the reasons for use has helped me, as a clinician, ensure I am comprehensively addressing the behavioral reasons for e-nicotine use. It can be particularly challenging to address time limitations in visits in primary care, but a team-based approach can ensure patients get all the care they need.”

    Using AAFP Resources to Change Youth Perceptions

    Earlier this month, the Academy — with support from the CVS Health Foundation — published a group of seven tobacco cessation resources to assist family physicians in helping their patients quit using tobacco products. Five of these pertain directly to e-cigarettes. They are

    The new resources are the product of the Academy’s Reimagining Ask and Act Office Champions Project, which kicked off in July 2019.

    Gracey, who worked on Reimagining Ask and Act for the Academy, suggested that young patients may be more receptive to using smartphone apps to track their health patterns and recommended several additional products, including