The American Journal on Addictions, 24: 233–239, 2015 Copyright © American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/ajad.12206
Electronic Cigarettes in Adults in Outpatient Substance Use Treatment: Awareness, Perceptions, Use, and Reasons for Use Erica N. Peters, PhD,1,2 Paul T. Harrell, PhD,3 Peter S. Hendricks, PhD,4 Kevin E. O’Grady, PhD,5 Wallace B. Pickworth, PhD,1 Frank J. Vocci, PhD6 1
Battelle Memorial Institute, Health and Analytics, Baltimore, MD Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 3 Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida 4 Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama 5 Department of Psychology, University of Maryland, College Park, Maryland 6 Friends Research Institute, Baltimore, MD 2
Background and Objectives: Most studies on e-cigarettes have come from population-based surveys. The current research aimed to provide initial data on e-cigarette awareness, perceptions, use, and reasons for use among adults seeking substance use treatment. Methods: A survey was conducted among 198 participants 18 years old in a community-based outpatient substance use treatment program. Results: Of the 198 participants, 69% currently smoked cigarettes, 92% were aware of e-cigarettes, and 58% had ever used e-cigarettes. The proportion of the number of participants who had ever used ecigarettes to the number who currently smoked (89.7%) appeared higher than the corresponding proportion in the 2012–13 National Adult Tobacco Survey (78.3%). Almost half of the sample who reported ever using e-cigarettes endorsed quitting or reducing smoking as a reason for use, and 32% endorsed reasons for use relating to curiosity/experimentation. A greater likelihood of ecigarette ever-use was significantly associated with younger age (adjusted odds ratio [AOR] ¼ 0.94, 95%confidence interval [CI] ¼ 0.90, 0.98) and perceptions related to using e-cigarettes in public places where smoking cigarettes is not allowed (AOR ¼ 2.96, 95% CI ¼ 1.18, 7.42) but was not associated with primary drug of choice. Discussion and Conclusions: E-cigarette use in adults seeking substance use treatment appears higher than it is in the US general population of smokers. The high frequency of use may be due to curiosity/experimentation or attempts to quit or reduce smoking. Scientific Significance: Future research may consider how e-cigarettes interact with other substance use and affect high rates of nicotine and tobacco use in this population. (Am J Addict 2015;24:233–239)
Received August 4, 2014; revised December 30, 2014; accepted January 11, 2015. Address correspondence to Erica N. Peters, PhD, Principal Research Scientist, Battelle Memorial Institute, 6115 Falls Road, Suite 200, Baltimore, MD 21209. E-mail: [email protected]
INTRODUCTION Awareness and use of electronic nicotine delivery systems (also known as electronic cigarettes or e-cigarettes) have increased exponentially in the United States. Between 2009 and 2011, awareness of e-cigarettes increased from 16% to 58%, and ever-use increased from 1% to 6%.1 As of 2013, the prevalence of e-cigarette awareness and ever-use among adults was 86% and 14%, respectively.2,3 E-cigarette use has been consistently associated with current smoking,4–8 and has also been associated with younger age and Caucasian race.4,7,9 Individuals who use e-cigarettes have reported perceptions and reasons for use related to improved health, quitting and reducing smoking, avoiding smoking restrictions, cost savings, and less addictiveness.1 Findings on use of e-cigarettes in the United States have generally come from population-based surveys, with scant attention paid to adult populations that could be more likely to use e-cigarettes. Adults in substance use treatment could be one such population, for several reasons. First, cigarette smoking prevalence among individuals in substance use treatment is two to three times higher than in the general population.10 In light of the consistent association between smoking and e-cigarette use, plus the high rate of smoking among individuals in substance use treatment, it might be expected that rates of e-cigarette use would be higher in this population than in the general population. Second, individuals with substance use problems experience greater difficulty quitting smoking.11–14 Although e-cigarettes are not classified as an efficacious smoking cessation aid, many individuals who report use of e-cigarettes endorse using them to quit or reduce their cigarette use. Individuals in substance use treatment might report using e-cigarettes as a cessation or harm 233
reduction method if they have tried and failed to quit smoking using other methods. Third, the reinforcing effects of common substances of abuse (eg, alcohol, marijuana, cocaine, opioids) tend to be enhanced by nicotine.15–18 Putative mechanisms underlying the enhanced reinforcing effects associated with use of substances of abuse and nicotine include shared genetic liability, similar neuronal mechanisms of action, common route of administration, and concurrent or simultaneous use of substances. Although research has not yet studied how the reinforcing effects of substances of abuse are impacted by ecigarettes specifically, the active ingredient of nicotine in e-cigarettes supports the hypothesis that the reinforcing effects of substances of abuse would also be enhanced by these products. Thus, individuals who use substances of abuse may be especially likely to use e-cigarettes as a way of enhancing the subjective effects of substance use. The use of nicotine products, which include e-cigarettes, in adults in substance use treatment is significant because the health consequences of tobacco use and substance use are synergistic.19 Investigating the frequency and patterns of e-cigarette use among adults in substance use treatment is a first step toward understanding how use of e-cigarettes may impact the health of this population. The primary aim of the current research was to provide initial data on e-cigarette awareness, perceptions, use, and reasons for use among adults in substance use treatment. A secondary aim was to examine the associations of e-cigarette use with demographic variables, smoking characteristics, perceptions of e-cigarettes, and substance use, with the goal of informing future research on e-cigarette use in the context of substance use treatment. Based on prior studies in the US general population,4,7,9 it was hypothesized that e-cigarette ever use and current use would be associated with younger age and Caucasian race. Further, it was hypothesized that e-cigarette use would be associated with marijuana as primary drug of choice. In the absence of prior literature to support a hypothesis regarding the association of e-cigarette use and type of substance use, the hypothesized association of e-cigarette use and marijuana use was based on the theory of the common route of administration, which posits that substances that are ingested in the same manner are often coused (ie, both e-cigarettes and marijuana can be inhaled into the lungs, and there have been reports that THC oil can be added to e-cigarettes).20–21
METHODS Participants Participants were recruited from all three locations of one community-based outpatient substance use treatment program in Baltimore County, Maryland. Participants were recruited through clinic staff at the time of treatment sessions. Criteria for participation were being an adult (ie, >18 years old) and currently enrolled in treatment. The study was deemed exempt by the Friends Research Institute’s Institutional Review Board. 234
Measures The survey included 17 author-constructed items, did not collect any personally identifying information, was selfadministered via pen and paper, and was administered over a 4-week span in February of 2014. Participants were not compensated for survey completion. Participants identified their primary drug of choice as alcohol, marijuana, cocaine, opiates, or other. Smoking history items were lifetime smoking of >100 cigarettes (yes/no), and past 30-day frequency of cigarette smoking (every day, some days, have not smoked) and number of cigarettes smoked on smoking days (0–9; 10–19; 20–29; 30þ). The e-cigarette awareness question was: “Have you ever heard of an e-cigarette or electronic cigarette, a cigarette-looking electronic device that delivers nicotine vapor when you puff it?” (yes/no). E-cigarette perceptions items were: (1) e-cigarettes are less harmful than cigarettes; (2) e-cigarettes are less addictive than cigarettes; (3) people should be allowed to use e-cigarettes in public places where smoking cigarettes is not allowed; and (4) e-cigarettes can help people stop their drug or alcohol use; response options were strongly disagree, disagree, neutral, agree, and strongly agree. E-cigarette use questions were: (1) “Have you ever tried an e-cigarette, even just one time?” (yes/no); and (2) “How many days have you used an e-cigarette in the past 30 days?” (every day, some days, have not used). The e-cigarette reasons for use question was: what were your reasons for using an ecigarette (to quit smoking, to cut down on my smoking, to use in places where I was not allowed to smoke cigarettes; other [with an opportunity for a write-in response]; response options were not mutually-exclusive). Analysis Frequencies for participants who reported that they currently (ie, past 30 days) smoked cigarettes on a non-daily basis and participants who indicated that they formerly smoked were relatively low (n ¼ 31 and n ¼ 20 [15.7% and 10.1% of the total sample], respectively). Classification of participants as currently smoking on a daily basis, currently smoking on a non-daily basis, formerly smoking, or never smoking as four separate smoking status categories yielded wide confidence intervals surrounding odds ratio estimates in logistic regression models (see below). Thus, current daily and non-daily smoking categories were collapsed into one category of “currently smoking cigarettes” and former and never smoking categories were collapsed into another category of “not currently smoking cigarettes.” For similar reasons, primary drug of choice response categories of opiates (n ¼ 35; 17.7% of the total sample), cocaine (n ¼ 7; 3.5%), and other (n ¼ 5; 2.5%) were collapsed into one category of “other” drugs. Chi-square tests of independence and one-way analysis of variance compared characteristics between participants in the three clinic locations, between participants who did and did not report ever-use of e-cigarettes, and between participants who did and did not report current (ie, past 30 days) use of e-cigarettes. Separate multivariate logistic regression models, with clinic location and smoking status as
E-Cigarettes Substance Use
April 2015
covariates, evaluated the association of e-cigarette ever-use and e-cigarette current use with demographic characteristics, perceptions related to e-cigarette use, and primary drug of choice. Only variables that had a univariate association (p .10) with the dependent variable were included in the logistic regression model. Although smoking quantity was considered for inclusion in the models, it was not included because it significantly correlated with cigarette smoking status (r ¼ .6, p < .001) and did not have a significant unadjusted association with e-cigarette ever-use or current use. Data were analyzed using SPSS 19.
daily or on some days in the past 30 days, and 11 (6%) had used them daily in the past 30 days. Thus, the majority (70%) of participants who had ever used e-cigarettes were not currently using them. Participants who were currently smoking cigarettes were significantly more likely to have ever used e-cigarettes than participants who were not currently smoking (73% vs. 38%; chi-square[1] ¼ 20.2, p < .01). The proportion of the number of individuals who had ever used e-cigarettes to the number of individuals who were currently smoking cigarettes (89.7%) appeared higher than the corresponding proportion in the 2012–13 National Adult Tobacco Survey (78.3%).
RESULTS
E-Cigarette Perceptions Relative to participants who had never used e-cigarettes, participants who reported that they had ever used e-cigarettes were significantly more likely to agree or strongly agree that ecigarettes are less harmful than cigarettes (68% vs. 44%, chisquare[1] ¼ 10.4, p < .01) and that people should be allowed to use e-cigarettes in public places (73% vs. 46%, chi-square[1] ¼ 12.3, p
Electronic Cigarettes in Adults in Outpatient Substance Use Treatment: Awareness, Perceptions, Use, and Reasons for Use Erica N. Peters, PhD,1,2 Paul T. Harrell, PhD,3 Peter S. Hendricks, PhD,4 Kevin E. O’Grady, PhD,5 Wallace B. Pickworth, PhD,1 Frank J. Vocci, PhD6 1
Battelle Memorial Institute, Health and Analytics, Baltimore, MD Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 3 Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida 4 Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama 5 Department of Psychology, University of Maryland, College Park, Maryland 6 Friends Research Institute, Baltimore, MD 2
Background and Objectives: Most studies on e-cigarettes have come from population-based surveys. The current research aimed to provide initial data on e-cigarette awareness, perceptions, use, and reasons for use among adults seeking substance use treatment. Methods: A survey was conducted among 198 participants 18 years old in a community-based outpatient substance use treatment program. Results: Of the 198 participants, 69% currently smoked cigarettes, 92% were aware of e-cigarettes, and 58% had ever used e-cigarettes. The proportion of the number of participants who had ever used ecigarettes to the number who currently smoked (89.7%) appeared higher than the corresponding proportion in the 2012–13 National Adult Tobacco Survey (78.3%). Almost half of the sample who reported ever using e-cigarettes endorsed quitting or reducing smoking as a reason for use, and 32% endorsed reasons for use relating to curiosity/experimentation. A greater likelihood of ecigarette ever-use was significantly associated with younger age (adjusted odds ratio [AOR] ¼ 0.94, 95%confidence interval [CI] ¼ 0.90, 0.98) and perceptions related to using e-cigarettes in public places where smoking cigarettes is not allowed (AOR ¼ 2.96, 95% CI ¼ 1.18, 7.42) but was not associated with primary drug of choice. Discussion and Conclusions: E-cigarette use in adults seeking substance use treatment appears higher than it is in the US general population of smokers. The high frequency of use may be due to curiosity/experimentation or attempts to quit or reduce smoking. Scientific Significance: Future research may consider how e-cigarettes interact with other substance use and affect high rates of nicotine and tobacco use in this population. (Am J Addict 2015;24:233–239)
Received August 4, 2014; revised December 30, 2014; accepted January 11, 2015. Address correspondence to Erica N. Peters, PhD, Principal Research Scientist, Battelle Memorial Institute, 6115 Falls Road, Suite 200, Baltimore, MD 21209. E-mail: [email protected]
INTRODUCTION Awareness and use of electronic nicotine delivery systems (also known as electronic cigarettes or e-cigarettes) have increased exponentially in the United States. Between 2009 and 2011, awareness of e-cigarettes increased from 16% to 58%, and ever-use increased from 1% to 6%.1 As of 2013, the prevalence of e-cigarette awareness and ever-use among adults was 86% and 14%, respectively.2,3 E-cigarette use has been consistently associated with current smoking,4–8 and has also been associated with younger age and Caucasian race.4,7,9 Individuals who use e-cigarettes have reported perceptions and reasons for use related to improved health, quitting and reducing smoking, avoiding smoking restrictions, cost savings, and less addictiveness.1 Findings on use of e-cigarettes in the United States have generally come from population-based surveys, with scant attention paid to adult populations that could be more likely to use e-cigarettes. Adults in substance use treatment could be one such population, for several reasons. First, cigarette smoking prevalence among individuals in substance use treatment is two to three times higher than in the general population.10 In light of the consistent association between smoking and e-cigarette use, plus the high rate of smoking among individuals in substance use treatment, it might be expected that rates of e-cigarette use would be higher in this population than in the general population. Second, individuals with substance use problems experience greater difficulty quitting smoking.11–14 Although e-cigarettes are not classified as an efficacious smoking cessation aid, many individuals who report use of e-cigarettes endorse using them to quit or reduce their cigarette use. Individuals in substance use treatment might report using e-cigarettes as a cessation or harm 233
reduction method if they have tried and failed to quit smoking using other methods. Third, the reinforcing effects of common substances of abuse (eg, alcohol, marijuana, cocaine, opioids) tend to be enhanced by nicotine.15–18 Putative mechanisms underlying the enhanced reinforcing effects associated with use of substances of abuse and nicotine include shared genetic liability, similar neuronal mechanisms of action, common route of administration, and concurrent or simultaneous use of substances. Although research has not yet studied how the reinforcing effects of substances of abuse are impacted by ecigarettes specifically, the active ingredient of nicotine in e-cigarettes supports the hypothesis that the reinforcing effects of substances of abuse would also be enhanced by these products. Thus, individuals who use substances of abuse may be especially likely to use e-cigarettes as a way of enhancing the subjective effects of substance use. The use of nicotine products, which include e-cigarettes, in adults in substance use treatment is significant because the health consequences of tobacco use and substance use are synergistic.19 Investigating the frequency and patterns of e-cigarette use among adults in substance use treatment is a first step toward understanding how use of e-cigarettes may impact the health of this population. The primary aim of the current research was to provide initial data on e-cigarette awareness, perceptions, use, and reasons for use among adults in substance use treatment. A secondary aim was to examine the associations of e-cigarette use with demographic variables, smoking characteristics, perceptions of e-cigarettes, and substance use, with the goal of informing future research on e-cigarette use in the context of substance use treatment. Based on prior studies in the US general population,4,7,9 it was hypothesized that e-cigarette ever use and current use would be associated with younger age and Caucasian race. Further, it was hypothesized that e-cigarette use would be associated with marijuana as primary drug of choice. In the absence of prior literature to support a hypothesis regarding the association of e-cigarette use and type of substance use, the hypothesized association of e-cigarette use and marijuana use was based on the theory of the common route of administration, which posits that substances that are ingested in the same manner are often coused (ie, both e-cigarettes and marijuana can be inhaled into the lungs, and there have been reports that THC oil can be added to e-cigarettes).20–21
METHODS Participants Participants were recruited from all three locations of one community-based outpatient substance use treatment program in Baltimore County, Maryland. Participants were recruited through clinic staff at the time of treatment sessions. Criteria for participation were being an adult (ie, >18 years old) and currently enrolled in treatment. The study was deemed exempt by the Friends Research Institute’s Institutional Review Board. 234
Measures The survey included 17 author-constructed items, did not collect any personally identifying information, was selfadministered via pen and paper, and was administered over a 4-week span in February of 2014. Participants were not compensated for survey completion. Participants identified their primary drug of choice as alcohol, marijuana, cocaine, opiates, or other. Smoking history items were lifetime smoking of >100 cigarettes (yes/no), and past 30-day frequency of cigarette smoking (every day, some days, have not smoked) and number of cigarettes smoked on smoking days (0–9; 10–19; 20–29; 30þ). The e-cigarette awareness question was: “Have you ever heard of an e-cigarette or electronic cigarette, a cigarette-looking electronic device that delivers nicotine vapor when you puff it?” (yes/no). E-cigarette perceptions items were: (1) e-cigarettes are less harmful than cigarettes; (2) e-cigarettes are less addictive than cigarettes; (3) people should be allowed to use e-cigarettes in public places where smoking cigarettes is not allowed; and (4) e-cigarettes can help people stop their drug or alcohol use; response options were strongly disagree, disagree, neutral, agree, and strongly agree. E-cigarette use questions were: (1) “Have you ever tried an e-cigarette, even just one time?” (yes/no); and (2) “How many days have you used an e-cigarette in the past 30 days?” (every day, some days, have not used). The e-cigarette reasons for use question was: what were your reasons for using an ecigarette (to quit smoking, to cut down on my smoking, to use in places where I was not allowed to smoke cigarettes; other [with an opportunity for a write-in response]; response options were not mutually-exclusive). Analysis Frequencies for participants who reported that they currently (ie, past 30 days) smoked cigarettes on a non-daily basis and participants who indicated that they formerly smoked were relatively low (n ¼ 31 and n ¼ 20 [15.7% and 10.1% of the total sample], respectively). Classification of participants as currently smoking on a daily basis, currently smoking on a non-daily basis, formerly smoking, or never smoking as four separate smoking status categories yielded wide confidence intervals surrounding odds ratio estimates in logistic regression models (see below). Thus, current daily and non-daily smoking categories were collapsed into one category of “currently smoking cigarettes” and former and never smoking categories were collapsed into another category of “not currently smoking cigarettes.” For similar reasons, primary drug of choice response categories of opiates (n ¼ 35; 17.7% of the total sample), cocaine (n ¼ 7; 3.5%), and other (n ¼ 5; 2.5%) were collapsed into one category of “other” drugs. Chi-square tests of independence and one-way analysis of variance compared characteristics between participants in the three clinic locations, between participants who did and did not report ever-use of e-cigarettes, and between participants who did and did not report current (ie, past 30 days) use of e-cigarettes. Separate multivariate logistic regression models, with clinic location and smoking status as
E-Cigarettes Substance Use
April 2015
covariates, evaluated the association of e-cigarette ever-use and e-cigarette current use with demographic characteristics, perceptions related to e-cigarette use, and primary drug of choice. Only variables that had a univariate association (p .10) with the dependent variable were included in the logistic regression model. Although smoking quantity was considered for inclusion in the models, it was not included because it significantly correlated with cigarette smoking status (r ¼ .6, p < .001) and did not have a significant unadjusted association with e-cigarette ever-use or current use. Data were analyzed using SPSS 19.
daily or on some days in the past 30 days, and 11 (6%) had used them daily in the past 30 days. Thus, the majority (70%) of participants who had ever used e-cigarettes were not currently using them. Participants who were currently smoking cigarettes were significantly more likely to have ever used e-cigarettes than participants who were not currently smoking (73% vs. 38%; chi-square[1] ¼ 20.2, p < .01). The proportion of the number of individuals who had ever used e-cigarettes to the number of individuals who were currently smoking cigarettes (89.7%) appeared higher than the corresponding proportion in the 2012–13 National Adult Tobacco Survey (78.3%).
RESULTS
E-Cigarette Perceptions Relative to participants who had never used e-cigarettes, participants who reported that they had ever used e-cigarettes were significantly more likely to agree or strongly agree that ecigarettes are less harmful than cigarettes (68% vs. 44%, chisquare[1] ¼ 10.4, p < .01) and that people should be allowed to use e-cigarettes in public places (73% vs. 46%, chi-square[1] ¼ 12.3, p
