Frequency of E-cigarette Use, Health Status, and Risk and Protective Health Behaviors in Adolescents

Published in: Journal of Addiction Medicine, v. 11, no. 1, Jan/Feb 2017, p. 55-62. doi:10.1097/ADM.0000000000000272

Posted on on March 16, 2017

by Michael Stephen Dunbar, Joan S. Tucker, Brett Ewing, Eric R. Pedersen, Jeremy N. V. Miles, Regina A. Shih, Elizabeth J. D'Amico

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Research Questions

  1. How does health status (physical and mental) and behavior (risky and protective) differ among adolescents who use electronic cigarettes (e-cigarettes), regular cigarettes, both, or neither?
  2. How does frequency of e-cigarette use correlate with health status and protective health behaviors?


E-cigarettes (ECs) are increasingly popular among adolescents, who perceive them as “safer” than cigarettes. Although research has examined risk factors for adolescent EC use, little is known about how EC use correlates with health status and protective health behaviors.


In all, 2488 adolescents (mean age = 17.31 years, SD = 0.67; 46% male) completed a survey on EC and cigarette use, physical and mental health, physical activity, diet, sleep, and alcohol and other drug (AOD) use. Logistic regression compared EC-only users to dual EC/cigarette users, cigarette-only users, and nonusers on these health factors. Among EC-only users, separate ordinary least-squares regression models assessed the effects of health status/behavior variables on frequency of past-year EC use, controlling for demographics and smokeless tobacco use.


User groups were similar on physical health and engagement in protective health behaviors (physical activity, sleep duration/quality, healthy diet), but EC-only users reported fewer mental health symptoms and less AOD use than dual or cigarette-only users. Among EC-only users, AOD use (all P < 0.0001) predicted more frequent EC use; healthy diet predicted less frequent use (P < 0.01).


EC-only use is associated with lower engagement in risky behaviors, but not better health status or higher engagement in protective health behaviors, compared with cigarette smoking. Dual EC/cigarette users may represent a particularly high-risk group due to their greater AOD use and cigarette consumption. Among “intermediate-risk” EC-only users, AOD use and unhealthy diet correlated with heavier use, and may be important targets for preventing escalation to more harmful tobacco use.

Key Findings

  • Although they are not a homogenous group, adolescents who only used e-cigarettes reported less alcohol and drug use, and fewer mental health symptoms, than those who smoked cigarettes.
  • E-cigarette only users, however, were not in better physical health and did not engage more in protective health behaviors than those who used other forms of cigarettes.
  • Over 90 percent of adolescents who smoked cigarettes in addition to using e-cigarettes reported using alcohol or other drugs in the past year, indicating they are at particularly high risk for negative health outcomes.
  • Among e-cigarette only users, alcohol and drug use correlated with more frequent e-cigarette use; healthy diet correlated with less frequent use.
  • Participants who only used e-cigarettes were younger than others in the study; it is unknown whether their lower rate of engagement in risky behaviors will change as they age.
  • Screening for e-cigarette use among adolescents could help catch youth before they transition to smoking tobacco and other risky behavior.

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