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Henraya McGruder, PhD, MS1; Kimp Walton, MS1; Saida Sharapova, MD, MPH1; Brian A. King, PhD, MPH1 (View author affiliations)

Suggested citation for this article: McGruder H, Walton K, Sharapova S, King BA. US Adults’ Perceptions About the Harms of Nicotine in Electronic Vapor Products on the Adolescent Brain, United States, 2016–2017. Prev Chronic Dis 2020;17:190391. DOI: http://dx.doi.org/10.5888/pcd17.190391external icon.

PEER REVIEWED

What is already known on this topic?

Electronic vapor products (EVP), including e-cigarettes, are the most commonly used tobacco products among US middle and high school students, and they typically contain nicotine, which is highly addictive and can harm the developing adolescent brain.

What is added by this report?

We assessed adults’ perceptions of the harms of nicotine on the adolescent brain and found that two-thirds of US adults agree that nicotine in EVP is harmful; however, variations in agreement were found across subpopulations.

What are the implications for public health practice?

Continued efforts are warranted to educate the public about the harmful effects of nicotine on the developing adolescent brain and about the risk of EVP use among adolescents.

Abstract

We used data from the 2016 and 2017 SummerStyles survey (N = 4,186 and 4,066, respectively) to assess US adults’ perceptions about the harms of nicotine in electronic vapor products (EVP) to the developing adolescent brain. Of respondents in 2016, 68.5% agreed exposure to nicotine in EVP was harmful, and of respondents in 2017, 62.6% agreed (P < .001). This agreement varied by several covariates. Continued efforts are warranted to educate the public about the risks of EVP use among youth, including the harmful effects of nicotine exposure on the developing adolescent brain.

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Objective

Electronic vapor products (EVP), including e-cigarettes, have been the most commonly used tobacco products among US middle and high school students since 2014 (1). EVP typically contain nicotine, which is highly addictive and can harm the developing adolescent brain (2,3). Adults serve a critical role in preventing youth tobacco product use (4). Therefore, it is important to educate adults, particularly those who are influencers of youth, about the harmful effects of youth EVP use. We assessed adults’ perceptions about the harms of nicotine in EVP to the adolescent brain by using data from cross-sectional internet surveys conducted in 2016 and 2017.

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Methods

We used data from 2016 (N = 4,186; response rate, 68%) and 2017 (N = 4,066; response rate, 74%) during June and July of both years from SummerStyles, an internet panel survey among adults aged 18 years or older fielded by Porter Novelli (Omnicon Group, New York, New York). Data were weighted to the US adult population based on sex, age, annual household income, race/ethnicity, household size, education, US region, metropolitan status, and internet access.

Perceptions about the harm of nicotine in EVP on the developing adolescent brain were assessed by the question, “Please indicate how much you agree or disagree with the following statement: Nicotine in electronic vapor products can harm a teenager’s developing brain.” Response options were “strongly disagree,” “somewhat disagree,” “neither agree nor disagree,” “somewhat agree,” and “strongly agree.”

Perceptions were assessed using point estimates and 95% confidence intervals; χ2 tests were used to determine significant (P < .05) differences. Assessed covariates were sex, age, race/ethnicity, educational attainment, annual household income, marital status, US region, children <18 years of age living in household, cigarette smoking status, and EVP use status.

Current cigarette smokers were defined as respondents who smoked at least 100 cigarettes in their lifetime, and smoked cigarettes “every day” or “some days” when surveyed. Former cigarette smokers were respondents who smoked at least 100 cigarettes in their lifetime, and who smoked “not at all” when surveyed. Never cigarette smokers had not smoked 100 cigarettes in their lifetime.

Current EVP users were defined as respondents who ever used an EVP (“e-cigarettes, e-cigars, e-pipes, vape pens, e-hookahs, and hookah pens, such as blu, NJOY, or Starbuzz”) even once and used EVP within the 30 days preceding the survey. Former EVP users were respondents who ever used an EVP, but not within the past 30 days. Never EVP users were respondents who reported never using an EVP, even just one time.

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Results

In 2017, 62.6% of adults agreed (“strongly agree” = 35.7% and “somewhat agree” = 26.9%) that nicotine in EVP harmed the developing adolescent brain; 3.7% somewhat disagreed, 4.4% strongly disagreed, and 29.3% neither agreed nor disagreed (Table 1). Prevalence of agreement was higher among women (65.2%) than men (59.9%) (P < .05), and ranged from 61.1% among 25- to 44-year-olds to 65.0% among adults aged 65 years or older (Table 2). By race/ethnicity, agreement ranged from 55.1% among non-Hispanic blacks to 64.5% among non-Hispanic whites. Prevalence of agreement generally increased with greater educational attainment and annual household income. Prevalence of agreement was higher among married adults (64.2%) than single adults (58.9%). By region, prevalence of agreement ranged from 60.5% in the South to 66.0% in the Midwest. Prevalence of agreement was higher among those who lived in households with children (64.4%) compared with those who did not (62.0%). Prevalence of agreement was 42.6% among current smokers, 60.2% among former smokers, and 68.9% among never smokers. Additionally, prevalence of agreement was 34.9% among current EVP users, 50.4% among former EVP users, and 65.4% among never EVP users.

The prevalence of agreement that nicotine harms the adolescent developing brain was higher in 2016 (68.5%) than 2017 (62.6%, P < .001) (Table 2). By covariates, prevalence of agreement was higher in 2016 compared with 2017 among males (65.5% to 59.9%; P = .002), females (71.2% to 65.2%; P < .001), 25- to 44-year-olds (68.1% to 61.1%; P = .001), and 45- to 64-year-olds (67.0% to 62.5%; P = .02). Differences in the prevalence of agreement also existed by education, annual household income, marital status, US region, children living in the household, cigarette smoking status, and EVP use status between 2016 and 2017.

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Discussion

We found that approximately two-thirds of adults in the United States agree that nicotine in EVP is harmful to the developing adolescent brain. However, variations in agreement exist across subpopulations, with lower prevalence among current and former smokers and e-cigarette users.

In 2016, the Surgeon General concluded that the use of products containing nicotine in any form among youth, including in e-cigarettes, is unsafe (2). At that time, the Surgeon General released a Public Service Announcement warning about these risks (5). Subsequently, several states and communities developed educational and media materials to reflect the growing body of scientific evidence on this issue (6). Such information is important given that current e-cigarette use increased 78% among US high school students during 2017–2018 alone (7); this increase was likely because of the recent popularity of newer e-cigarettes such as JUUL, which can be used discreetly, have a high nicotine content, and come in youth appealing flavors (4).

Prevalence of agreement varied between 2016 and 2017, both overall and across subpopulations. This difference could be due to multiple factors, including differences in exposure to media campaigns and education about the risks of nicotine among youth, or differences in respondent characteristics or sample size between the 2 surveys.

This study has limitations. First, the survey was internet-based and may not be fully representative of the US adult population; however, data were weighted to US Current Population survey proportions. Second, data were self-reported, which could lead to recall bias.

In conclusion, about one-third of adults do not agree that nicotine harms the developing brain, which continues to develop through adolescence and into young adulthood (4). Continued efforts are warranted at the national, state, and local levels to educate the public about the risks of EVP use among youth, specifically related to the risks of nicotine exposure (2–4).

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Acknowledgments

No funding was secured for this study. The authors have no financial relationships relevant to this article and no conflicts of interest to disclose. No copyrighted surveys, instruments, or tools were used in this secondary data analysis. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Author Information

Corresponding Author: Henraya F. McGruder, PhD, MS, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS S107-7, Atlanta, GA 30341. Telephone: 770-488-8266. Email: [email protected].

Author Affiliations: 1Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

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References

  1. Arrazola RA, Singh T, Corey CG, Husten CG, Neff LJ, Apelberg BJ, et al. ; Centers for Disease Control and Prevention (CDC). Tobacco use among middle and high school students — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2015;64(14):381–5. PubMedexternal icon
  2. Office of the Surgeon General. E-cigarette use among youth and young adults: a report of the Surgeon General. Washington (DC): US Department of Health and Human Services, Centers for Disease Control and Prevention; 2016.
  3. England LJ, Aagaard K, Bloch M, Conway K, Cosgrove K, Grana R, et al. Developmental toxicity of nicotine: a transdisciplinary synthesis and implications for emerging tobacco products. Neurosci Biobehav Rev 2017;72:176–89. CrossRefexternal icon PubMedexternal icon
  4. Office of the Surgeon General. Surgeon General’s advisory on e-cigarette use among youth. https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf. Accessed July 31, 2019.
  5. Office of the Surgeon General. Know the risks: e-cigarettes and young people: resources. https://e-cigarettes.surgeongeneral.gov/resources.html. Accessed July 31, 2019.
  6. US Centers for Disease Control and Prevention. Media Campaign Resource Center (MCRC). https://www.cdc.gov/tobacco/multimedia/media-campaigns/index.htm. Accessed July 31, 2019.
  7. Gentzke AS, Creamer M, Cullen KA, Ambrose BK, Willis G, Jamal A, et al. Vital Signs: tobacco product use among middle and high school students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019;68(6):157–64. CrossRefexternal icon PubMedexternal icon

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Tables

Table 1. Adult Perceptions About Whether Exposure to Nicotine in EVP Is Harmful to the Developing Adolescent Brain, SummerStyles Survey, United States, 2017
Characteristic No. Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly Agree
% (95% CI)
Overall 4,066 4.4 (3.7–5.1) 3.7 (3.1–4.4) 29.3 (27.8–30.9) 26.9 (25.4–28.5) 35.7 (34.1–37.4)
Sexa
Male 1,981 3.9 (2.9–5.0) 4.1 (3.2–5.3) 32.2 (29.8–34.5) 27.1 (24.9–29.4) 32.8 (30.4–35.2)
Female 2,085 4.8 (3.9–6.0) 3.2 (2.5–4.2) 26.7 (24.6–28.9) 26.8 (24.7–29.0) 38.4 (36.2–40.7)
Age, ya
18–24 259 3.6 (1.9–7.0) 3.8 (2.1–6.8) 28.9 (23.5–35.0) 31.3 (25.7–37.6) 32.4 (26.6–38.7)
25–44 1,335 5.5 (4.3–7.1) 4.7 (3.5–6.2) 28.7 (26.1–31.6) 27.4 (24.9–30.1) 33.6 (30.9–36.4)
45–64 1,707 3.7 (2.8–4.9) 3.5 (2.7–4.6) 30.2 (27.9–32.7) 24.6 (22.4–26.9) 38.0 (35.5–40.5)
≥65 765 3.9 (2.6–5.6) 2.2 (1.3–3.7) 29.0 (25.6–32.6) 27.6 (24.2–31.2) 37.4 (33.8–41.2)
Race/ethnicity
Non-Hispanic white 2,976 4.2 (3.4–5.1) 3.6 (2.9–4.4) 27.8 (26.1–29.6) 27.4 (25.7–29.2) 37.0 (35.2–38.9)
Non-Hispanic black 363 4.6 (2.6–7.9) 3.4 (1.9–6.1) 36.9 (31.6–42.5) 22.7 (18.4–27.6) 32.5 (27.4–38.0)
Hispanic 492 5.6 (3.7–8.3) 3.9 (2.4–6.1) 30.2 (25.9–34.8) 26.7 (22.6–31.4) 33.7 (29.2–38.4)
Non-Hispanic other 235 3.2 (1.5–6.9) 4.7 (2.5–8.6) 28.6 (22.4–35.7) 29.6 (23.3–36.8) 33.9 (27.3–41.2)
Educationa
<High school 256 6.8 (4.1–11.1) 4.4 (2.4–7.9) 35.9 (29.9–42.4) 24.1 (19.0–30.2) 28.9 (23.2–35.2)
High school diploma 1,276 4.0 (2.9–5.3) 3.3 (2.3–4.6) 33.4 (30.6–36.3) 25.1 (22.6–27.8) 34.4 (31.6–37.3)
Some college 1,217 3.7 (2.7–5.1) 4.0 (3.0–5.5) 30.7 (27.9–33.7) 28.4 (25.7–31.4) 33.1 (30.3–36.0)
College degree or more 1,317 4.4 (3.4–5.8) 3.5 (2.5–4.7) 21.8 (19.4–24.3) 28.4 (25.8–31.1) 42.0 (39.1–44.9)
Annual household income, $a
<25,000 406 5.0 (3.1–8.2) 3.8 (2.1–6.5) 38.4 (33.4–43.7) 21.9 (17.8–26.6) 30.9 (26.2–36.1)
25,000–49,999 921 2.8 (1.9–4.2) 4.7 (3.3–6.6) 30.7 (27.4–34.1) 25.6 (22.6–28.9) 36.1 (32.8–39.6)
50,000–99,999 1,343 4.7 (3.5–6.1) 3.3 (2.4–4.6) 29.8 (27.2–32.6) 28.5 (25.9–31.3) 33.7 (31.0–36.5)
≥100,000 1,387 4.7 (3.6–6.1) 3.3 (2.5–4.5) 23.6 (21.3–26.2) 28.7 (26.1–31.4) 39.7 (36.9–42.6)
Marital status
Married/living with partner 2,813 4.1 (3.3–4.9) 3.7 (3.0–4.5) 28.1 (26.3–30.0) 26.7 (24.9–28.5) 37.5 (35.5–39.4)
Single 713 5.0 (3.4–7.2) 4.1 (2.7–6.0) 32.0 (28.4–35.9) 28.1 (24.6–31.9) 30.8 (27.2–34.7)
Divorced/widowed/separated 540 4.7 (3.0–7.3) 2.9 (1.7–4.9) 30.2 (26.1–34.7) 26.0 (22.0–30.4) 36.2 (31.8–40.8)
US region
Northeast 779 4.4 (3.0–6.4) 4.4 (3.1–6.3) 28.9 (25.4–32.6) 26.7 (23.3–30.4) 35.6 (32.0–39.4)
Midwest 887 4.7 (3.2–6.7) 3.1 (2.0–4.8) 26.3 (23.1–29.7) 29.0 (25.8–32.5) 36.9 (33.5–40.5)
South 1,480 4.3 (3.2–5.6) 4.3 (3.2–5.6) 31.0 (28.4–33.7) 25.1 (22.7–27.6) 35.5 (32.8–38.2)
West 920 4.2 (3.0–5.9) 2.7 (1.8–4.1) 29.7 (26.5–33.2) 28.3 (25.1–31.7) 35.1 (31.7–38.6)
Children <18 y living in householda
Yes 1,335 5.8 (4.3–7.6) 4.1 (3.0–5.6) 25.7 (23.0–28.6) 27.1 (24.5–29.9) 37.2 (34.4–40.2)
No 2,723 3.7 (3.0–4.6) 3.5 (2.8–4.4) 30.7 (28.8–32.7) 26.9 (25.1–28.8) 35.1 (33.2–37.1)
Cigarette smoking statusa,b
Never 2,319 4.2 (3.4–5.3) 2.9 (2.3–3.8) 23.9 (22.0–25.9) 28.5 (26.4–30.6) 40.5 (38.2–42.7)
Former 1,090 4.1 (2.9–5.8) 4.8 (3.5–6.6) 31.0 (28.0–34.1) 28.1 (25.2–31.1) 32.1 (29.2–35.2)
Current 523 5.4 (3.5–8.3) 4.5 (2.9–7.0) 47.5 (42.6–52.3) 21.5 (17.9–25.7) 21.1 (17.3–25.4)
EVP use statusa,c
Never 3,471 4.2 (3.5–5.1) 3.1 (2.5–3.8) 27.3 (25.7–29.0) 26.9 (25.2–28.6) 38.5 (36.7–40.3)
Former 461 4.7 (2.8–7.7) 6.0 (3.8–9.1) 38.9 (34.1–44.0) 29.1 (24.6–34.1) 21.3 (17.4–25.8)
Current 121 6.4 (2.9–13.5) 10.9 (6.1–18.8) 47.8 (38.0–57.9) 21.5 (14.3–30.9) 13.4 (8.0–21.7)

Abbreviations: CI, confidence interval; EVP, electronic vapor products.
a Significant χ2 test (P < .05) across favorability categories within the specified characteristic.
b Current smoking was defined by having smoked at least 100 cigarettes and currently smoking “some days” or “every day.” Former smoking was defined by having smoked at least 100 cigarettes and currently smoking “not at all.” Never smoking was defined as not having smoked 100 cigarettes.
c EVP use was defined as “Electronic vapor products (eg, e-cigarettes, e-hookahs, e-cigars, e-pipes, hookah pens, vape pens, or some other electronic vapor product).” Ever EVP use was defined as ever trying EVP, even just once; current use was any use in the past 30 days; former use was defined as ever use and no use in the last 30 days; and never use was defined as never trying.

Table 2. Adult Perceptions About Whether Exposure to Nicotine in EVP Is Harmful to the Developing Adolescent Brain, SummerStyles Survey, United States, 2016 and 2017
Characteristic 2016 2017 P Valueb
No. % Agree (95% CI)a No. % Agree (95% CI)a
Overall 4,186 68.5 (66.7–70.1) 4,066 62.6 (61.0–64.3) <.001
Sex
Male 1,984 65.5 (62.9–67.9) 1,981 59.9 (57.4–62.3) .002
Female 2,202 71.2 (68.8–73.5) 2,085 65.2 (62.9–67.5) <.001
Age, y
18–24 263 71.3 (65.0–76.9) 259 63.7 (57.4–69.5) .08
25–44 1,212 68.1 (64.9–71.1) 1,335 61.1 (58.1–64.0) .001
45–64 1,757 67.0 (64.3–69.6) 1,707 62.5 (60.0–65.0) .02
≥65 954 69.9 (66.3–73.2) 765 65.0 (61.2–68.6) .06
Race/ethnicity
Non-Hispanic white 3,093 68.5 (66.5–70.4) 2,976 64.5 (62.5–66.3) .004
Non-Hispanic black 422 63.4 (57.8–68.7) 363 55.1 (49.5–60.7) .04
Hispanic 465 68.6 (63.3–73.4) 492 60.4 (55.5–65.1) .02
Non-Hispanic other 206 75.6 (67.7–82.0) 235 63.5 (56.2–70.2) .02
Education
<High school 276 62.3 (55.7–68.5) 256 53.0 (46.4–59.5) .047
High school 1,242 62.9 (59.7–66.0) 1,276 59.4 (56.4–62.4) .12
Some college 1,269 70.7 (67.6–73.6) 1,217 61.5 (58.4–64.6) <.001
College degree or more 1,399 74.4 (71.5–77.0) 1,317 70.3 (67.6–73.0) .04
Annual household income, $
<25,000 719 57.9 (53.3–62.4) 406 52.8 (47.4–58.1) .15
25,000–49,999 1,002 68.1 (64.5–71.5) 921 61.8 (58.2–65.2) .01
50,000–99,999 1,343 69.9 (66.9–73.8) 1,352 62.2 (59.3–65.0) <.001
≥100,000 1,122 73.6 (70.4–76.5) 1,387 68.4 (65.6–71.0) .01
Marital status
Married/living with partner 2,616 71.3 (69.2–73.3) 2,813 64.2 (62.2–66.1) <.001
Single 801 65.1 (61.2–68.9) 713 58.9 (54.9–62.9) .03
Divorced/widowed/separated 769 63.5 (59.0–67.7) 540 62.2 (57.5–66.6) .68
US region
Northeast 777 66.9 (62.8–70.7) 779 62.3 (58.4–66.0) .10
Midwest 1,023 66.5 (62.9–69.9) 887 66.0 (62.3–69.4) .83
South 1,494 66.5 (63.6–69.4) 1,480 60.5 (57.7–63.3) .004
West 892 74.6 (71.0–77.9) 920 63.3 (59.7–66.8) <.001
Children <18 y living in household
Yes 1,391 72.2 (69.0–75.2) 1,335 64.4 (61.3–67.4) <.001
No 2,791 66.9 (64.8–68.9) 2,723 62.0 (60.0–64.0) <.001
Cigarette smoking statusc
Never 2,401 74.3 (72.1–76.4) 2,319 68.9 (66.8–71.0) <.001
Former 1,172 65.2 (62.0–68.3) 1,090 60.2 (56.8–63.4) .03
Current 511 47.2 (42.0–52.4) 523 42.6 (37.9–47.5) .20
EVP use statusd
Never 3,609 70.8 (69.0–72.6) 3,471 65.4 (63.6–67.2) <.001
Former 450 59.4 (53.9–64.7) 461 50.4 (45.3–55.6) .02
Current 117 31.9 (22.4–43.1) 121 34.9 (26.0–45.0) .68

Abbreviations: CI, confidence interval; EVP, electronic vapor products.
a Agree was defined as “somewhat agree” and “strongly agree” responses.
b Significant χ2 test (P < .05).
c Current smoking was defined by having smoked at least 100 cigarettes and currently smoking “some days” or “every day.” Former smoking was defined by having smoked at least 100 cigarettes and currently smoking “not at all.” Never smoking was defined as not having smoked 100 cigarettes.
d EVP use was defined as “Electronic vapor products (eg, e-cigarettes, e-hookahs, e-cigars, e-pipes, hookah pens, vape pens, or some other electronic vapor product).” Ever EVP use was defined as ever trying EVP, even just once; current use was any use in the past 30 days; former use was defined as ever use and no use in the last 30 days; and never use was defined as never trying.

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Source of original article: Centers for Disease Control and Prevention (CDC) / Preventing Chronic Disease (tools.cdc.gov).
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