Prevalence of e-cigarette use and associations between e-cigarette use and cigarette cessation attempts and abstinence among Kansas adults Trevor Christensen,

Prevalence of e-cigarette use and associations between e-cigarette use and cigarette cessation attempts and

abstinence among Kansas adults

Trevor Christensen, MPH, Ericka Welsh, PhD, Babalola Faseru, MD, MPH

Background: up to speed

Images from http://www.trinketsandtrash.org

• 2010: court finds FDA cannot regulate e-cigarettes as pharmaceutical unless marketed as therapeutic

• 2010-2014: explosive growth in e-cigarette market

• Piecemeal state and local laws prohibiting sales to minors or use in indoor public places

• April 2014, FDA proposes deeming as tobacco product

• Report ingredients

• Review novel products

• No free samples

• Minimum age

• Health warnings

MethodsGoal: use surveillance data to describe population profile of e-cigarette use in Kansas, including its use during quit attempts and dual use with cigarettes

Data Sources• 2012a & 2013b BRFSS (ever e-cig use)

• Kansas Adult Tobacco Surveyc (Sept. 2012 – Sept. 2013)


MethodsAnalyses in SAS 9.3

Account for complex survey methodology

• Demographic profiles

• Prevalence and subpopulation prevalence estimates

• Crude and adjusted prevalence odds ratios via logistic regression

o Covariates: age (cont.), gender and annual household income category


Results: e-cigarette use in Kansas

Our Mission: To protect and improve the health and environment of all Kansans.

Adults

• Ever e-cigarette use rose from 8.6%a in 2012 to 14.3% in 2013b

• In 2013, 3.4% had used e-cigarettes in the past monthc

• Half (51.5%) current smokers have tried e-cigarettesb

• 76.5% of past-month e-cigarette users and 68.2% of ever e-cigarette users also currently smoke cigarettesc

Youth

• 2013/2014 High School: 13.2% have tried and 4.7% currently use e-cigarettes*

*Unweighted Kansas Youth Tobacco Survey

Current smoker (n=1,341)

Former smoker (n=2,593)

Never smoker (n=5,690)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

45.0%

10.5%

2.2%

14.4%

2.1%

0.5%

Adult ever and past-month e-cigarette use by cigarette smoking status, Kansas, 2013 ATS

Past-month e-cigarette useEver e-cigarette use

User differences between products

Our Mission: To protect and improve the health and environment of all Kansans.

Overall, e-cigarette use strongly associated with conventional cigarette smoking.

What about people who have only used one or the other product?

Tried E-cigarettes (and don’t smoke)

Vs.

Smoke cigarettes (never tried e-cigarettes)

Current Smoking Only

Ever E-Cigarette Use Only

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11.9%

30.6%

21.6%

27.1%

16.6%

16.7%

38.8%

20.5%

11.1%

5.1%

Age distributionc

18-24 years old 25-34 years old 35-44 years old45-64 years old 65+ years old

Kansans who only try e-cigarettes tend to be younger than those who only smoke cigarettes.

Kansans who only try e-cigarettes tend to be more affluent than those who only smoke cigarettes.



0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

18.4%

10.4%

26.1%

21.9%

14.1%

10.4%

15.0%

15.1%

26.4%

42.2%

Annual household income distributionc

Less than $15,000 $15,000-$24,999 $25,000-$34,999$35,000-$49,999 $50,000+

Kansans who only try e-cigarettes tend to be more educated than those who only smoke cigarettes.



0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

22.5%

12.3%

38.9%

26.5%

30.0%

41.3%

8.5%

19.8%

Education level distributionc

No high school diploma or GED Diploma or GEDAssociates, vocational or some college College degree

Kansans who only try e-cigarettes tend to live in more urban areas than those who only smoke cigarettes.



0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

20.6%

18.3%

20.3%

15.3%

48.1%

58.7%

Population density distributionc

Frontier Rural Densely-Settled RuralSemi-Urban Urban

Less than $15,000

$15,000-$24,999

$25,000-$34,999

$35,000-$49,999

$50,000+

0% 5% 10% 15% 20% 25%

Prevalence of current smoking only and having ever smoked e-cigarettes only by annual household income, KS

ATS 2013

Tried e-cigarettes, not current smokerCurrent smoking only

Product use prevalence

An

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al

ho

us

eh

old

in

co

me

Results: e-cigarettes and quitting• 30.5% of Kansas adults that made a quit attempt in the

past 12 months used nicotine replacement therapy or medication to help them quit smokingc

• 20% of Kansas adults that made a quit attempt in the past 12 months used smokeless tobacco or e-cigarettes to help them quit smokingc


Results: e-cigarette use associated with quit attempts

Prevalence of e-cigarette use among current smokers by past-year quit attempt statusc

Made a quit attempt

Did not make a quit attempt

Prevalence Ratio (95% CI)

Ever e-cigarette use 57.5% 36.8% 1.56 (1.34-1.81)

Past-month e-cigarette use 22.1% 9.2% 2.39 (1.70-3.37)

Results: association persists after adjustment

Prevalence odds ratio of ever e-cigarette use by past-year quit attempt statusc

POR quit attempt (95% CI)

Adj. POR quit attempt (95% CI)

Did not make a quit attempt (ref) 1.00 1.00

Made a quit attempt 2.32 (1.74-3.08) 2.12 (1.55-2.89)

Adjusted on age, gender and income group.

Results: never e-cigarette use associated with abstinence

Among former smokers who had their last cigarette in the past five years, prevalence odds of past-month cigarette abstinence by ever e-cigarette usec

POR cig. abstinence (95% CI)

Adj. POR cig. abstinence (95% CI)

Ever tried e-cigarettes 1.00 1.00Never tried e-cigarettes 2.35 (1.36-4.07) 2.31 (1.27-4.21)

Adjusted on age, gender and income group.

“The prevalence odds of past-month abstinence among those who have never had an e-cigarette is 2.3 times higher than those who have tried e-cigarettes.”

UHRCEC. Committee on Energy and Commerce, US House of Representative: E-Cigarette Flashbacks. 2014; http://democrats.energycommerce.house.gov/index.php?q=page/e-cigarette-flashbacks. Accessed April 29, 2014.

Discussion: history repeated

Cigarettes, 1958 E-Cigarettes, 2013

http://democrats.energycommerce.house.gov/index.php?q=page/e-cigarette-flashbacks


Discussion: new developmentsEnglish study found e-cigarettes were more strongly associated with cigarette abstinence than over-the-counter nicotine replacement therapy

Possible explanations…

- English study not of general population – limited to people using e-cigarettes for cessation

- English study notes rising e-cigarette popularity coincides with declining cigarette smoking – not the case in Kansas

- May indicate most e-cigarette users are not using e-cigarettes to aid cessation

Brown, Beard, Kotz, Michie, & West, 2014

In summation• E-cigarettes strongly associated with

cigarette smoking

• Comparisons have been drawn between historic cigarette advertising and current e-cigarette advertising

• Adults who have only tried e-cigarettes are younger and more affluent than those who only smoke cigarettes

• People are using e-cigarettes as cessation aids regardless of inconclusive evidence

• E-cigarette use among cigarette smokers is associated with quit attempts, but not using e-cigarettes is associated with abstinence


Limitations

• Data are cross-sectional

• Cannot describe temporal relationships such as transitions from one product to another

• Bias due to under or over reporting is unknown

• Data are from general surveillance tools – covariates critical for discussing addiction and cessation are lacking


Questions

Thanks to Trinkets and Trash for documenting artifacts of the tobacco epidemic.http://www.trinketsandtrash.org

References and further readingComparison of past cigarette and current e-cigarette advertising from US House of Representatives Committee on Energy and Commerce “E-Cigarette Flashbacks.” Now available at http://ecigflashbacks.strikingly.com/

1. Adkison SE, O'Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med. Mar 2013;44(3):207-215.

2. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. May 20 2014.

3. Brown J, West R, Beard E, Michie S, Shahab L, McNeill A. Prevalence and characteristics of e-cigarette users in Great Britain: Findings from a general population survey of smokers. Addictive Behaviors. 6// 2014;39(6):1120-1125.

4. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. Nov 16 2013;382(9905):1629-1637.5. Caponnetto P, Auditore R, Russo C, Cappello GC, Polosa R. Impact of an electronic cigarette on smoking reduction and cessation in schizophrenic smokers:

a prospective 12-month pilot study. Int J Environ Res Public Health. Feb 2013;10(2):446-461.6. Caponnetto P, Campagna D, Cibella F, et al. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-

month randomized control design study. PloS one. 2013;8(6):e66317.7. CDC. Notes from the field: electronic cigarette use among middle and high school students - United States, 2011-2012. MMWR Morb Mortal Wkly Rep. Sep 6

2013;62(35):729-730.8. Choi K, Forster JL. Authors' response. Am J Prev Med. Jun 2014;46(6):e58-59.9. de Andrade M, Hastings G, Angus K. Promotion of electronic cigarettes: tobacco marketing reinvented? BMJ. 2013;347:f7473.10. Dutra LM, Glantz SA. Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents: A Cross-sectional Study. JAMA pediatrics. Mar 6 2014.11. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. May 13 2014;129(19):1972-1986.12. Grana RA, Ling PM. "Smoking revolution": a content analysis of electronic cigarette retail websites. Am J Prev Med. Apr 2014;46(4):395-403.13. Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA internal medicine. May 2014;174(5):812-813.14. KDHE. Kansas Department of Health and Environment. Effectiveness of the Kansas Tobacco Quitline 2011;

http://www.kdheks.gov/tobacco/download/KSQLEffectiveness.pdf.15. KDHE. Kansas Department of Health and Environment. Technical notes. 2012; http://www.kdheks.gov/brfss/technotes.html. Accessed April 25, 2014.16. King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010-2011. Nicotine & tobacco

research : official journal of the Society for Research on Nicotine and Tobacco. Sep 2013;15(9):1623-1627.17. Lum KL, Polansky JR, Jackler RK, Glantz SA. Signed, sealed and delivered: "big tobacco" in Hollywood, 1927-1951. Tob Control. Oct 2008;17(5):313-323.18. Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction

and cessation: a prospective 6-month pilot study. BMC public health. 2011;11:786.19. Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am J Public Health. May 2013;103(5):923-930.20. UHRCEC. Committee on Energy and Commerce, US House of Representative: E-Cigarette Flashbacks. 2014;

http://democrats.energycommerce.house.gov/index.php?q=page/e-cigarette-flashbacks. Accessed April 29, 2014.21. USDHHS. Reducing the Health Consequences of Smoking: 25 Year of Progress. A Report of the Surgeon General. Atlanta, US Department of Health and

Human Services, Public Health Services, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 1989.

http://ecigflashbacks.strikingly.com/

http://ecigflashbacks.strikingly.com/

























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Prevalence of e-cigarette use and associations between e-cigarette use and cigarette cessation attempts and abstinence among Kansas adults Trevor Christensen,