INTRODUCTION

For at least the past 5 years, e-cigarettes have been the most commonly used tobacco product among youth¹. In 2019, more than a third of US middle and high students had ever used e-cigarettes and one fifth were current users². Although e-cigarettes have been marketed as healthier alternatives to conventional cigarettes, their long-term health effects are not well documented, especially for youth users, and there is no consensus regarding their utility for smoking cessation³. Preventing youth tobacco uptake and established use are public health concerns that tend to garner more attention than promoting cessation, and e-cigarette use rates demonstrate their appeal to this population^4–7. Because e-cigarettes normally contain nicotine, youth users are at risk for the harms associated with nicotine consumption, such as epigenetic changes to the brain making them prone to future substance use⁸. Thus, better understanding factors that influence e-cigarette use in youth is important in preventing future use and its associated health implications, especially for youth vulnerable to tobacco use.

Appalachian youth are disproportionately exposed to tobacco. The Appalachian region has a history of tobacco culture from tobacco production to acceptance of tobacco use and celebrating this heritage (e.g. tobacco festivals)⁹. As a result, youth in Appalachia have higher smoking prevalence than youth residing in other parts of the US¹⁰. In addition to culture, rurality and poverty are associated with increased tobacco use^11,12, possibly contributing to higher rates of use among Appalachia youth. Accordingly, Appalachian youth are at risk for tobacco use, including the use of e-cigarettes.

Studies have linked youth e-cigarette use to viewing e-cigarettes as less harmful or less addictive than combustible cigarettes^5–7. Additional evidence suggests that youth perceive e-cigarettes as less harmful than other tobacco products, such as cigars and smokeless tobacco¹³. Although a relationship between perceiving e-cigarettes as less harmful or less addictive and e-cigarette use has been documented with some youth samples^5–7, research on Appalachian youth is limited. One study found that Appalachian youth perceived e-cigarettes as causing fewer health problems and less addiction than conventional tobacco products¹⁴. Our study extends prior research by examining specific e-cigarette-related harms, such as whether e-cigarettes cause breathing and oral health problems, as well as whether these perceptions differ by tobacco use.

METHODS

RESULTS

About two-thirds (66.1%) of participants were never users, one-tenth (10.5%) were non-e-cigarette users, and one-fourth (23.4%) were e-cigarette users. The distribution of descriptive characteristics by tobacco use is provided in Supplementary file Table S2. More non-e-cigarette users were female (60.2%), and more e-cigarette users were male (53.4%). Both use groups were older than never users, and frequencies of non-e-cigarette and e-cigarette use varied by state.

Prevalence of e-cigarette harm perceptions by tobacco use is presented in Table 1. Never users strongly agreed at higher proportions that e-cigarettes cause health problems (34.5%), breathing problems (34.1%), and oral health problems (32.7%) as well as are addictive (37.3%) and difficult to quit (34.1%), compared to non-e-cigarette users and e-cigarette users. Non-e-cigarette users strongly agreed (25.7%) and agreed (29.2%) at higher proportions than never users that e-cigarettes are healthier than smoking traditional cigarettes; however, e-cigarette users most often strongly agreed (32.3%). Compared to never and non-e-cigarette users, a higher proportion of e-cigarette users strongly disagreed that e-cigarettes cause health problems (10.4%), breathing problems (9.6%), and oral health problems (11.6%) and are difficult to quit (12.0%). The distribution of harm perceptions differed between never users and e-cigarette users (p<0.05). However, when comparing never users to non-e-cigarette users, harm perceptions differed only for e-cigarettes cause health problems (p=0.020) and are difficult to quit (p=0.002). Comparisons between non-ecigarette users and e-cigarettes users were not statistically significant. Additionally, sensitivity analysis results suggest that age did not play a significant role in associations between harm perceptions and e-cigarette use.

Results from regression analyses can be found in Table 2, and values of OR with 95% CI are reported below. Compared to never users, e-cigarette users had greater odds of strongly disagreeing (OR=6.12; 95% CI: 3.16–11.90) and disagreeing (OR=4.78; 95% CI: 2.71–8.41) that e-cigarettes cause health problems. Also, compared to never users, non-e-cigarette users had greater odds of disagreeing (OR=2.30; 95% CI: 1.11–4.75) that e-cigarettes cause health problems. E-cigarette users also had more than fourfold odds of strongly disagreeing (OR=4.40; 95% CI: 2.26–8.56) and over threefold odds of disagreeing (OR=3.14; 95% CI: 1.76–5.60) that e-cigarettes cause breathing problems, compared to never users; no associations were found for non-e-cigarette users. Similarly, e-cigarette users (OR=6.01; 95% CI: 3.16–11.44) and non-e-cigarette users (OR=3.34; 95% CI: 1.37–8.15) had greater odds of strongly disagreeing that e-cigarettes cause oral health problems, compared to never users. Both e-cigarette and non-e-cigarette users had elevated odds of strongly disagreeing or disagreeing that e-cigarettes are addictive and difficult to quit. Associations for e-cigarettes being difficult to quit were similar with both groups having at least threefold odds of strongly disagreeing or disagreeing compared to never users.

DISCUSSION

Compared to never users, Appalachian youth e-cigarette users and non-e-cigarette users perceive e-cigarettes to be less harmful, less addictive and less difficult to quit, with harm-related associations stronger for e-cigarette users. E-cigarette users disagreed that problems with breathing and oral health were caused by e-cigarette use, despite recent evidence of a potential link between e-cigarette use and respiratory disease¹⁵. Associations were less clear for non-e-cigarette users, illustrating ways that perceptions vary by type of health issue and use pattern. Among e-cigarette users, associations appear to be stronger for health-related harms, and addiction-related harms were similar among non-e-cigarette and e-cigarette users.

Our findings corroborate previous research that reports associations between perceiving e-cigarettes as less harmful or less addictive and tobacco use among youth^5,6. Specifically, among youth never cigarette users, perceiving e-cigarettes as less harmful was associated with e-cigarette use⁵. Similarly, among a sample of Florida youth, perceiving e-cigarettes as easy to quit was associated with more e-cigarette use including concurrent use of e-cigarettes and other tobacco products⁶. In our study, Appalachian youth views on whether e-cigarettes are harmful or addictive varied by tobacco use patterns. Although e-cigarette users indicated less concern about harms than did non-e-cigarette users, results for the latter group, who already use tobacco, suggest risk for e-cigarette uptake.

To combat e-cigarette use, health campaigns must inform youth of the associated harms and potential for addiction. Given evidence that perceiving e-cigarettes as less harmful predicts subsequent use among never users⁷, efforts must better explicate factors that predict youth susceptibility to trying e-cigarettes. Further, targeted messaging to e-cigarette users, who tend to perceive e-cigarettes as less dangerous, is needed to raise awareness and increase understanding, as these youth are especially vulnerable to continued use.

CONCLUSIONS

Compared to never users, Appalachian youth non-ecigarette and e-cigarette users perceive e-cigarettes as less harmful, with associations greater in magnitude for e-cigarette users. These users disagree that e-cigarettes are harmful, cause oral health problems, are addictive, and are difficult to quit. Our findings, which support previous work indicating that perceiving e-cigarettes as less harmful or less addictive is associated with e-cigarette use, provide insights on Appalachian youth tobacco views and use. Health communication messaging should address increasing youth understanding of the health dangers of these products, especially for vulnerable youth.