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2013-29255-002.pdf
Smokers Who Try E-Cigarettes to Quit Smoking: Findings From a Multiethnic Study in Hawaii Pallav Pokhrel, PhD, MPH, Pebbles Fagan, PhD, MPH, Melissa A. Little, PhD, MPH, Crissy T. Kawamoto, BS, and Thaddeus A. Herzog, PhD
Electronic cigarettes, or e-cigarettes, are battery-powered devices that generate vapor- ized nicotine or non-nicotine vapor that may be inhaled orally in the manner in which con- ventional cigarettes are smoked. E-cigarettes deliver the vapor when a cartridge containing nicotine solution is heated. Because e-cigarettes are likely to contain lower levels of toxins or carcinogens than combustible tobacco prod- ucts,1 e-cigarettes are commonly promoted as safer alternatives to regular cigarettes and even as smoking cessation aids.2,3 Currently, the US Food and Drug Administration (FDA) lacks regulations for e-cigarettes as therapeutic drug delivery devices and intends to regulate them as tobacco products.3
Whether e-cigarettes deserve consideration as possibly effective cessation aids is a subject of ongoing debate.1,4 Much of the debate has been fueled by the uncertainties regarding the public health risks and benefits of e-cigarette use.5,6 The FDA has maintained that most available e-cigarettes lack quality control, tend to deliver inconsistent levels of nicotine (which at higher doses can be lethal), and may not be entirely free of toxins or carcinogens.3 More- over, the FDA is concerned that e-cigarette use may facilitate tobacco use initiation and in- creased nicotine addiction among youths and young adults.3 Recently, however, researchers have drawn attention to the promising aspects of e-cigarettes as cessation or harm reduction devices.4,7---10
E-cigarettes appear promising as cessation aids because e-cigarettes not only deliver nic- otine in the manner in which nicotine replace- ment therapy does but also closely simulate the experience of smoking combustible to- bacco. Moreover, e-cigarettes may have a com- parative advantage over current FDA-approved cessation aids in terms of user satisfaction be- cause e-cigarettes seem better suited to address both the pharmacological and the sensorimotor aspects of smoking.7,11 However, at present the research examining the efficacy of e-cigarettes
as cessation aids is in its early stages. In a study involving 40 non---treatment-seeking daily smokers who were assigned to use a particular brand of e-cigarette with the purpose of helping them quit or reduce smoking, 22.5% of par- ticipants showed sustained abstinence at 24- week follow-up and an additional 32.5% were found to have reduced their cigarette con- sumption by half.12 In another study, a group of first-time purchasers of a brand of e-cigarettes were contacted 6 months after the purchase date.13 Of the 4.5% of potential participants who responded, 31% reported point prevalence ab- stinence. Thus, the studies that have suggested that e-cigarettes are likely to be effective as cessation aids have been nonexperimental and based on convenience samples. In addition, although studies have tended to agree that e-cigarettes reduce craving and withdrawal symptoms in abstinent smokers,14---16 whether e-cigarettes are efficient as nicotine delivery de- vices is not clear.14,15,17,18 Hence, the usefulness of e-cigarettes as cessation aids is not certain.
However, the popularity of e-cigarettes has continued to soar in the United States and elsewhere.19---22 According to a recent study, approximately 6% of all adults and 21% of adult current daily smokers in the United States report ever using e-cigarettes.19 Although the majority of current e-cigarette users seem to report smoking cessation or reduction as the primary motive for e-cigarette use,11,23---24
limited evidence currently exists regarding smokers’ use of e-cigarettes as cessation aids, especially in the United States.22 Moreover, limited or no data are available on how smokers’ sociodemographic characteristics, nicotine dependence, smoking behavior, moti- vation and self-efficacy to quit, quit attempts, and use of FDA-approved cessation aids are related to the likelihood of having ever used e-cigarettes as cessation aids. We addressed these gaps in the literature. Specifically, we examined the prevalence of use of e-cigarettes as cessation aids in a multiethnic sample of adult current daily smokers from Hawaii and
Objectives. We characterized smokers who are likely to use electronic or
“e-”cigarettes to quit smoking.
Methods. We obtained cross-sectional data in 2010–2012 from 1567 adult daily
smokers in Hawaii using a paper-and-pencil survey. Analyses were conducted
using logistic regression.
Results. Of the participants, 13% reported having ever used e-cigarettes to quit
smoking. Smokers who had used them reported higher motivation to quit,
higher quitting self-efficacy, and longer recent quit duration than did other
smokers. Age (odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.97, 0.99)
and Native Hawaiian ethnicity (OR = 0.68; 95% CI = 0.45, 0.99) were inversely
associated with increased likelihood of ever using e-cigarettes for cessation.
Other significant correlates were higher motivation to quit (OR = 1.14; 95% CI =
1.08, 1.21), quitting self-efficacy (OR = 1.18; 95% CI = 1.06, 1.36), and ever using
US Food and Drug Administration (FDA)–approved cessation aids such as
nicotine gum (OR = 3.72; 95% CI = 2.67, 5.19).
Conclusions. Smokers who try e-cigarettes to quit smoking appear to be
serious about wanting to quit. Despite lack of evidence regarding efficacy,
smokers treat e-cigarettes as valid alternatives to FDA-approved cessation
aids. Research is needed to test the safety and efficacy of e-cigarettes as
cessation aids. (Am J Public Health. 2013;103:e57–e62. doi:10.2105/AJPH.2013.
301453)
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examined the associations of sociodemographic factors and smoking- and cessation-related characteristics with ever having used e-cigarettes for smoking cessation. Thus, the results of this study will help guide future research by quantifying the nature of the relationships between e-cigarette use for ces- sation and smokers’ characteristics, including their cessation-related attitudes and behavior. For example, knowledge about the extent of statistically significant associations of e-cigarette use with demographic and cognitive correlates will help guide the design and analytic aspects of future studies on the etiology of e-cigarette use among current smokers. In addition, the results of this study will help guide future studies testing the efficacy of e-cigarettes as cessation aids. For example, cessation-related variables found to be significant correlates of e-cigarette use for cessation may be tested as potential moderators of the efficacy of e-cigarettes as cessation aids. Thus, this study is likely to advance the research on e-cigarette use, especially among smokers.
METHODS
Our sample consisted of individuals who participated in the baseline survey completed between January 2010 and August 2012 as part of a longitudinal study being conducted in Hawaii to compare the alternative stage models of smoking cessation. Participants were recruited using advertisements in the newspa- per Midweek, which is distributed across the Hawaiian Islands and is available for free. Thus, eligible participants from all islands in Hawaii were welcome to participate in the study, even though the primary research site was located on the island of Oahu. Eligible participants:
1. were aged 18 years or older, 2. were able to read English, 3. had mailing addresses, 4. had smoked at least 100 cigarettes in their
lifetime, and 5. self-identified as smokers who consumed on
average at least 3 cigarettes per day.
Potential participants were screened for eligibility requirements over the telephone. After eligible potential participants provided
informed consent, they were mailed baseline questionnaires along with stamped and addressed return envelopes. Of those who re- ceived the questionnaire, 93% completed and returned the baseline survey (n = 1567). On receipt of completed questionnaires, participants were mailed $25 gift cards.
Measures
Sociodemographic variables. Sociodemo- graphic variables assessed included partici- pants’ age, gender, income, education, and ethnicity. To determine annual household in- come, participants were asked “What is the approximate total yearly income of your household?” Eleven response options were provided ranging from “$10,000 or less” (1) to “Over $100,000” (11). Education was deter- mined in terms of highest level of schooling completed. Participants chose from a list rang- ing from 8th grade or less (1) to postgraduate degree (8).
Ethnicity was determined on the basis of responses to the survey item “Please select the one ethnic group with which you most strongly identify.” The list of response options included Chinese, Filipino, Hawaiian or part Hawaiian, Japanese, Korean, White or Cau- casian, African American, and other. The “other” option provided space to fill in one’s ethnicity. Because the sample had relatively small numbers of Chinese (n = 36) and Ko- reans (n = 19), we combined these ethnicities with Filipinos (n = 102) and Japanese (n = 172) to form 1 Asian category. In the current sample, participants identifying themselves with ethnicities other than Asian, Hawaiian or part Hawaiian, or White or Caucasian were combined into a single “other” category be- cause of their small individual group sizes. The “other” category consisted mainly of African Americans, Hispanics, and Native Americans. Use of products for smoking cessation. To
measure ever use of e-cigarettes for smoking cessation, we asked a yes-or-no question: “Have you ever used electronic cigarettes when trying to quit smoking?” The same question was modified according to product to measure ever use of each of the following FDA-approved cessation products: nicotine gum, nicotine patch, bupropion (e.g., Zyban), and varenicline (e.g., Chantix).
Smoking, nicotine dependence, and quitting attitudes and behaviors. We measured cigarette consumption by asking participants the num- ber of cigarettes they smoked per day on average in the past 7 days. Participants who reported smoking 10 or fewer cigarettes on average per day were classified as light smokers.25,26 Participants were classified as heavy smokers if they reported smoking more than 10 cigarettes per day. We assessed nico- tine dependence using the Fagerstrom Test of Nicotine Dependence.27
We assessed past quit attempts by asking participants to state the number of lifetime quit attempts that had lasted 24 hours or longer. Duration of most recent quit attempt was measured with a single item on a 6-point scale (ranging from 0 = “Never attempted quitting” to 5 = “1 year or more”). Motivation to quit smoking was assessed using 2 measures: a 5-item Motivation to Quit Scale28 and the Contemplation Ladder.29 The Motivation to Quit Scale contains items on cessation intention and planning (e.g., “Do you intend to quit smoking?”) that are assessed on a 5-point scale ranging from 1 = “No definitely not” to 5 = “Yes definitely” (Cronbach a = .85). Using a numbered image of a ladder, the Contem- plation Ladder asks participants to rate their readiness to quit (ranging from 0 = “No thought of quitting” to 10 = “Taking action to quit”). We assessed quitting self-efficacy using 2 items that asked participants to indicate their confidence about quitting smoking “some- day” and “in the next 6 months” on a 5-point scale ranging from 1 (“Not at all confident”) to 5 (“Extremely confident”).
Data Analysis
We analyzed the data using SAS version 9.2 (SAS Institute, Cary, NC). First, we computed descriptive statistics of key study variables separately by e-cigarette use status. The mean or proportion pertaining to each study variable was compared across e-cigarette user and nonuser groups using the t or v2 test. Next, to test the associations of sociodemographic and smoking- and cessation-related variables with ever having used e-cigarettes for cessation, we used multivariate logistic regression. This par- ticular analytic approach enabled assessment of the effects of independent variables on ever having used e-cigarettes in terms of odds ratios,
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which in turn helped explain the nature and strength of the effects. We conducted regres- sion analyses in 2 sets. First, we tested the association of each demographic variable (i.e., age, gender, ethnicity, education, and in- come) with e-cigarette use, adjusting for other demographic variables as covariates. Second, we tested the association of each smoking cessation---related variable with e-cigarette use, adjusting for all demographic variables as covariates. Statistically significant associations were determined at P < .05 (2-tailed).
RESULTS
Most participants (98%) were from Oahu. Approximately 13% of participants (n = 202) reported having tried e-cigarettes when trying to quit cigarettes. The sample consisted of equal numbers of each gender. The ethnic distribution of the sample matched the ethnic distribution of smokers in Hawaii.30 Moreover, consistent with national-level data regarding current daily smokers,31 the majority of the participants tended to be of lower socioeco- nomic status. That is, 40% of the sample had a high school diploma, general equivalency degree, or less education, and 61% reported an annual household income of $20 000 or less. The majority of the participants were heavy smokers (68%). On average, participants had been smoking for 27 years and had attempted to quit almost 12 times in their lifetime. Table 1 summarizes the participant characteristics by e-cigarette use status. Smokers who had used e-cigarettes when trying to quit smoking were significantly younger and had been smoking for fewer years than those who had not. Moreover, smokers who had tried e-cigarettes for cessation help were significantly more motivated to quit smoking and reported higher quitting self-efficacy, longer recent quit dura- tion, and greater likelihood of having used FDA-approved smoking cessation products.
Table 2 presents the point estimates and corresponding 95% confidence intervals for adjusted odds ratios representing the associa- tions between smoker characteristics and use of e-cigarettes for cessation help. Older age was significantly related to lower likelihood of using e-cigarettes to quit smoking and, relative to Whites, Native Hawaiians were significantly less likely to have used e-cigarettes as cessation
aids. No other demographic variable showed a significant effect on e-cigarette use. How- ever, all cessation-related variables, except
number of past quit attempts, were signifi- cantly associated with ever having used e-cigarettes for cessation help. For example,
TABLE 1—Demographic and Smoking- and Cessation-Related Characteristics of Study
Participants (n = 1567) by E-Cigarette Use Status: Hawaii, January 2010–August 2012
Characteristics
E-Cigarette Users (n = 202),
Mean 6SE or % (95% CI)
E-Cigarette Nonusers (n = 1365),
Mean 6SE or % (95% CI)
Age,*** y 42.3 61.02 45.6 60.35
Gender
Male 45.5 (38.9, 52.7) 50.6 (47.9, 53.3)
Female 54.5 (47.6, 61.3) 49.4 (46.7, 52.0)
Ethnicity
White 36.1 (29.5, 43.2) 34.1 (31.6, 36.7)
Asiana 25.3 (19.4, 31.8) 20.4 (18.2, 22.5)
Native Hawaiian 26.2 (20.3, 32.9) 31.8 (29.3, 34.3)
Other 12.4 (8.2, 17.7) 13.8 (12.9. 15.6)
Education
College degree 16.4 (11.3, 21.5) 16.4 (14.4, 18.3)
Some college 40.8 (34.0, 47.6) 37.9 (35.4, 40.5)
High school diploma or GED 34.3 (27.8, 40.9) 35.1 (32.6, 37.8)
< high school 8.5 (4.6, 12.3) 10.6 (8.9, 12.2)
Annual income, $
> 40 000 17.7 (12.4, 23.0) 17.7 (15.6, 19.8)
20 001–40 000 24.2 (18.3, 30.2) 20.5 (18.3, 22.6)
£ 20 000 58.1 (51.2, 65.0) 61.9 (59.3, 64.5) Light or heavy smoker
Light smokerb 33.7 (27.2, 40.6) 32.1 (29.5, 34.5)
Heavy smoker 66.3 (59.8, 72.9) 68.0 (65.4, 70.5)
Cigarettes/d 17.8 60.71 18.3 60.31
Nicotine dependencec 4.95 60.16 5.07 60.06
Years of smoking** 23.9 61.03 27.02 60.36
Motivation to quit
MQS d, *** 17.81 60.29 15.6 60.14
CL e, *** 5.97 60.17 4.84 60.08
Quitting self-efficacyf
Next 6 mo** 2.42 60.07 2.24 60.03
Someday*** 3.20 60.07 2.92 60.03
Past quit attempts (lifetime)g 12.4 61.75 11.4 61.39
Recent quit duration h, *** 2.43 60.09 1.81 60.04
Ever use of nicotine gum***
No 55.8 (48.9, 62.8) 79.5 (77.3, 81.6)
Yes 44.2 (37.2, 51.1) 20.5 (18.4, 22.8)
Ever use of nicotine patch***
No 55.1 (48.1, 62.0) 73.5 (71.1, 75.8)
Yes 44.9 (38.0, 51.9) 26.5 (24.2, 28.9)
Ever use of bupropion
No 87.8 (83.2, 92.3) 93.3 (92.0, 94.7)
Yes 12.2 (7.7, 16.8) 6.7 (5.4, 8.2)
Continued
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a unit increase in motivation to quit was associated with 10% to 14% greater likeli- hood of having used e-cigarettes in the past for quitting purposes (P < .001). In addition, those who had used nicotine replacement gum, patch, bupropion, or varenicline were 2 to 4 times more likely to have used e-cigarettes as cessation aids.
We conducted post hoc analyses to compare the levels of motivation to quit and quitting self-efficacy between smokers who had tried e-cigarettes to quit smoking (n = 202) and smokers who had tried nicotine replacement gum or patch, bupropion, or varenicline but not e-cigarettes (n = 483). We found that motiva- tion to quit, as measured by the Motivation to Quit Scale,28 was marginally significantly higher among those who had tried e-cigarettes: The mean motivation to quit among those who had ever used e-cigarettes was 17.81 (SD = 4.18) versus 17.09 (SD = 4.52) among those who had tried gum, patches, bupropion, or varenicline (t = –1.92; df=679; P = .05). We found no statistically significant difference be- tween the groups on the Contemplation Lad- der: The mean readiness to quit among those who had ever used e-cigarettes was 5.96 (SD = 2.36) versus 5.71 (SD = 2.69) among smokers who had tried gums, patches, bupropion, or varenicline (t = –1.15; df=679; P = .25). We found no significant difference between the groups in either measure of quitting self- efficacy. For example, the mean next-6-month quitting self-efficacy for smokers who had tried e-cigarettes was 3.20 (SD = 1.00) versus 3.16 (1.06) among smokers who tried cessation aids but not e-cigarettes.
DISCUSSION
In this study, we attempted to show that use of e-cigarettes as cessation aids is prevalent among current daily smokers. In addition, we attempted to characterize smokers who are likely to use e-cigarettes when trying to quit by examining the associations of sociodemo- graphic and smoking- and cessation-related characteristics with the likelihood of ever hav- ing used e-cigarettes to quit smoking. We found that 13% of the current smokers had tried e-cigarettes to quit smoking, which is compa- rable to the rates of e-cigarette use among current smokers reported in previous stud- ies,19,20,22 although previous studies lacked information on what percentage of current smokers had tried e-cigarettes to quit smoking. We found age and Native Hawaiian ethnicity to be inversely associated with the use of e-cigarettes, even after controlling for gender, income, and education. Native Hawaiians showed lower odds of e-cigarette use for cessation than did Whites. However, gender, income, education, smoking frequency and in- tensity, years of smoking, past quit attempts, and nicotine dependence were not significantly associated with e-cigarette use for help with smoking cessation.
Some of these findings are consistent with some of the findings in the literature concern- ing e-cigarette users in the United States.22 For example, the present finding concerning the inverse association between Native Hawaiian ethnicity and e-cigarette use parallels the previous finding concerning the inverse asso- ciation between African American ethnicity
TABLE 1—Continued
Ever use of varenicline
No 86.7 (81.9, 91.1) 94.4 (93.2, 95.7)
Yes 13.3 (8.6, 18.1) 5.6 (4.4, 6.9)
Note. CI = confidence interval; CL = Contemplation Ladder; GED = general equivalency diploma; MQS = Motivation to Quit Scale. a Asian ethnicity included Japanese (52%), Filipino (31%), Chinese (11%), and Korean (6%). b Light smokers smoked £ 10 cigarettes on average daily. cFagerstrom Test of Nicotine Dependence (range = 0–10). dRange = 5–25. eRange = 0–10 (0 = no thought of quitting to 10 = taking action to quit). f Confidence in quitting (1 = not at all confident to 5 = extremely confident). g Lifetime number of having quit for 24 hours or longer. h Length of time most recent quit attempt lasted (0 = never attempted to 5 = 1 year or more). **P < .01; ***P < .001; All P values were 2-tailed.
TABLE 2—Adjusted Odds Ratios of
E-Cigarette Use for Cessation Help
Among Current Smokers (n = 1567):
Hawaii, January 2010–August 2012
Characteristics AOR (95% CI)
Age 0.98*** (0.97, 0.99)
Gender
Male (Ref) 1.00
Female 1.26 (0.92, 1.71)
Ethnicitya
White (Ref) 1.00
Asian 1.13 (0.76, 1.68)
Native Hawaiian 0.68* (0.45, 0.99)
Other 0.82 (0.50, 1.34)
Education
College degree (Ref) 1.00
Some college 1.03 (0.65, 1.61)
High school diploma
or GED
0.89 (0.55, 1.46)
< high school 0.82 (0.42, 1.58)
Income, $
> 40 000 (Ref) 1.00
20 001–40 000 1.16 (0.72, 1.87)
£ 20 000 0.95 (0.62, 1.46) Light or heavy smoker
Light smoker (Ref) 1.00
Heavy smoker 0.95 (0.69, 1.32)
Cigarettes/d 0.99 (0.98, 1.01)
Nicotine dependence 0.99 (0.93, 1.06)
Years of smoking 0.99 (0.98, 1.01)
Motivation to quit
MQS 1.10*** (1.06, 1.14)
CL 1.14*** (1.08, 1.21)
Quitting self-efficacy
Next 6 mo 1.18** (1.03, 1.36)
Someday 1.19** (1.03, 1.36)
Past quit attempts (lifetime) 1.00 (0.99, 1.01)
Recent quit duration 1.32** (1.19, 1.45)
Ever use of nicotine gum
No (Ref) 1.00
Yes 3.72*** (2.67, 5.19)
Ever use of nicotine patch
No (Ref) 1.00
Yes 2.51*** (1.82, 3.46)
Ever use of bupropion
No (Ref) 1.00
Yes 2.29*** (1.38, 3.79)
Continued
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and e-cigarette use.22 Previous studies have shown that non-White racial/ethnic groups, including Native Hawaiians, are less likely to report use of cessation aids.28,32---34 Pearson et al.22 found that African Americans reported lower levels of e-cigarette awareness and use and higher levels of harm perception. Only future research can answer questions pertain- ing to e-cigarette use awareness and harm perception among Native Hawaiians. Most existing studies on e-cigarette use have used predominantly White samples. Our study is one of the few to examine e-cigarette use in a sample that is not predominantly White and the first study to report e-cigarette use among Native Hawaiians. Clearly, more studies are needed to better understand the possible eth- nic differences in e-cigarette use and e-cigarette use correlates.
Moreover, studies have shown that e-cigarette use in general increases as age decreases22 and that younger individuals are more likely to perceive e-cigarettes to be less harmful than cigarettes.35 In addition, techno- logically savvy individuals, who tend to be younger, are more likely to be drawn toward e-cigarettes because of the technological in- novativeness that e-cigarettes may represent for them.1 Our finding that younger smokers are more likely to use e-cigarettes to quit smoking emphasizes the need to test both the abuse liability and the efficacy of e-cigarettes as cessation aids among younger adults. If e-cigarettes are ineffective as cessation aids and are potentially risky, strategies need to be developed to help younger smokers find ef- fective cessation aids. Conversely, if e-cigarettes are found to be relatively safer and effective as cessation aids, the appeal that they have for younger adults should be used to enhance
smoking cessation among younger smokers. On the basis of our findings, smoking charac- teristics such as smoking rate, light or heavy smoker status, and nicotine dependence appear not to be associated with e-cigarette use for cessation help. Although previous studies have found a similar lack of association,20,22 future studies need to continue examining the relation- ships between smoking characteristics and e-cigarette use to better understand whether certain types of smokers are more likely to be drawn to e-cigarette use for cessation than others.
We found that smokers who had tried e-cigarettes to quit smoking tended to report significantly higher motivation to quit than other smokers. On 1 measure of motivation to quit (i.e., the Motivation to Quit Scale), smokers who had tried e-cigarettes to quit smoking scored higher than smokers who had tried FDA-approved pharmacotherapies. We also found statistically significant associations be- tween higher motivation to quit, quitting self- efficacy, and duration of recent quit attempt and e-cigarette use for cessation help. In addi- tion, we found the use of e-cigarettes as cessation aids to be strongly and significantly associated with past use of FDA-approved cessation products. Taken together, these find- ings suggest that smokers who report having used e-cigarettes when trying to quit smoking appear to be motivated to quit smoking and consider e-cigarettes to be valid cessation aids. Also, our findings lend support to the recent observation21 that e-cigarettes may be com- peting with FDA-approved cessation products in the market.
However, we should note that this study assessed e-cigarette use in terms of trying to quit smoking; thus, on the basis of our data no conclusion may be drawn regarding motivation to quit among smokers who use e-cigarettes for other reasons. Research is needed to better understand how motivation to quit or quitting self-efficacy compares among smokers who opt for e-cigarettes to quit smoking versus those who choose mainstream cessation products. In the current analyses, we did not find statisti- cally significant differences between the 2 groups in self-efficacy and on 1 measure of motivation to quit (i.e., Contemplation Ladder). Pursuing this line of investigation further is important to determine whether smokers who
are highly motivated to quit may choose to use e-cigarettes instead of mainstream cessation products. Moreover, research is needed to un- derstand the sequence of use of e-cigarettes and mainstream cessation products among smokers who try various cessation products.
Limitations
This study has some limitations. First, al- though the sample was similar to smokers in Hawaii in terms of ethnic distribution, they were recruited using newspaper advertise- ments and did not represent a random sample of smokers in Hawaii, which may limit the generalizability of the current findings to some extent. However, we should note that the sample seems comparable to adult US smokers in terms of socioeconomic status and smoking- related indicators.36 Second, this study was cross-sectional; hence, no causal inferences may be made on the basis of the present findings. E-cigarette use was measured using a single item. Use of multiple items to assess different aspects of e-cigarette use, related or unrelated to cessation, would permit more nuanced analyses. For example, the item used to assess use of e-cigarettes as cessation aids—“Have you ever tried e-cigarettes when trying to quit cigarettes?”—may be subject to multiple interpretations (e.g., tried e-cigarettes “during quit attempt” or “to quit smoking”), even though both interpretations suggest use for help with cessation. Inclusion of multiple items would thus improve measurement reliability. Addi- tionally, measurement of e-cigarette use for reasons other than cessation would inform knowledge of the rates of prevalence of differ- ent motives for e-cigarette use among current smokers. Last, although we collected detailed data on race/ethnicity, because of small sample sizes, we were unable to disaggregate several racial/ethnic groups (e.g., African American, Hispanic) for analyses.
Conclusions
Despite the limitations, this study makes a strong case in favor of rigorously testing e-cigarettes for safety and cessation effective- ness. First, this study’s results suggest that smokers who try e-cigarettes to quit smoking are likely to show higher average motivation to quit and quitting self-efficacy and longer average recent quit duration than other
TABLE 2—Continued
Ever use of varenicline
No (Ref) 1.00
Yes 2.94*** (1.77, 4.89)
Note. AOR = adjusted odds ratio; CI = confidence interval; CL = Contemplation Ladder; GED = general equivalency diploma; MQS = Motivation to Quit Scale. The odds ratios are adjusted for all demographic covariates (i.e., age, gender, ethnicity, education, and income). aAsian ethnicity included Japanese (52%), Filipino (31%), Chinese (11%), and Korean (6%). *P < .05; **P < .01; ***P < .001.
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smokers. Second, this study shows that younger age, higher motivation to quit smoking and quitting self-efficacy, and longer recent quit duration are significant concurrent predictors of ever having used e-cigarettes as cessation aids among current smokers. Third, this study suggests that e-cigarettes may be perceived as valid cessation aids similar to FDA-approved cessation aids. Clearly, more research is needed to learn whether e-cigarettes are displacing some or most of the FDA-regulated cessation products or whether smokers who are moti- vated to quit are trying various cessation products concurrently. Despite the lack of firm evidence regarding safety or effectiveness, e-cigarettes appear to have become cessation aids of choice for some smokers who appear to show a relatively higher motivation to quit smoking. Thus, this study confirms the impor- tance of promptly developing appropriate e-cigarette regulations that address smokers’ use of e-cigarettes as cessation products. j
About the Authors Pallav Pokhrel, Pebbles Fagan, Melissa A. Little, Crissy T. Kawamoto, and Thaddeus A. Herzog are with the Univer- sity of Hawaii Cancer Center, University of Hawaii Manoa, Honolulu. Correspondence should be sent to Pallav Pokhrel,
University of Hawaii Cancer Center, B-4, 701 Illalo Street, Honolulu, HI 96813 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted May 14, 2013.
Contributors P. Pokhrel and T. A. Herzog designed the study. P. Pokhrel led article preparation, data analysis, and re- vision. P. Fagan, M. A. Little, and C. T. Kawamoto assisted with conceptual development of the article as well as with data analysis and interpretation. T. A. Herzog pro- vided guidance at various stages of article preparation.
Acknowledgments This research was supported by the National Cancer Institute (grant 5R01CA120799-05 to T. A. Herzog). M.A. Little was supported during the work on this project by a postdoctoral fellowship on grant R25 CA90956 from the National Cancer Institute to the University of Hawaii Cancer Center.
Human Participant Protection This research was approved by the University of Hawaii Manoa institutional review board.
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RESEARCH AND PRACTICE
e62 | Research and Practice | Peer Reviewed | Pokhrel et al. American Journal of Public Health | September 2013, Vol 103, No. 9
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