Epidemiology & Population Hlth

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Journal of Community Health (2022) 47:94–100 https://doi.org/10.1007/s10900-021-01027-7

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ORIGINAL PAPER

E‑cigarette Use Among Young Adult Patients: The Opportunity to Intervene on Risky Lifestyle Behaviors to Reduce Cancer Risk

Grace C. Hillyer1,2  · Meaghan Nazareth2 · Sarah Lima1 · Karen M. Schmitt2,3 · Andria Reyes2 · Elaine Fleck3 · Gary K. Schwartz2,4 · Mary Beth Terry1,2

Accepted: 19 August 2021 / Published online: 27 August 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract Use of e-cigarettes and other electronic nicotine delivery systems (ENDS) is on the rise. We administered a health needs survey via email to 804 adult primary care and oncology patients at a large urban academic medical center in 2019. We examined differences in e-cigarette use by smoking status, personal history of cancer, alcohol use, and second-hand tobacco smoke exposure. Of the 804 participants, 90 (11.2%) reported ever using e-cigarettes. E-cigarette use was more prevalent in young adults (risk ratio [RR] for 18–24 years: 4.58, 95% confidence interval [95% CI] 2.05, 10.26), current smoking (RR 4.64, 95% CI 1.94, 11.07), very often/often binge drinking (RR 3.04, 96% CI 1.38, 6.73), and ≥ 1 smokers in the home (RR 3.90, 95% CI 2.10, 7.23). Binge alcohol consumption and tobacco smoking are associated with increased risk cancer. Inquiries about e-cigarette use among adults 25–40 years present providers the opportunity to also counsel young adult about reducing cancer risk.

Keywords E-cigarettes · Electronic nicotine delivery systems · Binge alcohol consumption · Tobacco smoking · Young adults

Introduction

In the 56 years since the seminal Surgeon General report linking tobacco smoking to lung cancer, extensive cumula- tive evidence has demonstrated that inhaling the complex mixture of 7000 toxicants that include at least 69 known carcinogens in tobacco smoke causes harm to nearly every organ in the body and results in both short and long-term health effects [1]. The overall prevalence of tobacco smoking in the United States has declined steadily from 42% in 1964

to 13.7% among adults aged 18 years or older in 2018 [2]. However, among certain groups, tobacco smoking preva- lence remains high particularly among non-Hispanic Ameri- can Indians/Alaska Natives (22.6%), individuals of mixed racial heritage (19.1%) [3] and those with lower socioeco- nomic status, the less educated, and individuals with mental health and substance abuse issues [4]. The adverse health effects of smoking are a consequence of DNA damage, inflammation, and oxidative stress [1] and the risk and sever- ity of the negative outcomes caused by smoking are directly related to level and duration of tobacco smoke exposure and sustained, long-term exposures to nicotine in tobacco smoke that have powerfully addicting effects on nicotinic receptors in the brain [5].

Many changes to cigarettes have been made over the past decades to keep smokers smoking. In the early 1950’s, fil- tered cigarettes were introduced to reduce exposure to tar and nicotine in response to mounting scientific evidence implicating cigarette smoking in the development of heart, respiratory, and neoplastic disease [6]. Other changes in the succeeding decades included the use of flavors, treatments to reduce the smell and appearance of tobacco smoke, con- trolled nicotine dosing, and the introduction of new filters

* Grace C. Hillyer [email protected]

1 Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W. 168th Street, Room 1611, New York, NY 10032, USA

2 Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY 10032, USA

3 Division of Community and Population Health, New York Presbyterian Hospital, New York, NY 10032, USA

4 Department of Hematology and Oncology, Columbia University Irving Medical Center, New York, NY 10032, USA

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and tobacco blends. “Light” brands with low nicotine con- tent and the first generation of e-cigarettes were brought to market in the late 1980’s. None of these “enhancements” designed by the tobacco industry to undermine public health efforts aimed at prevention and cessation, however, were found to reduce death and disease associated with tobacco smoking [7] supporting the premise that there is no safe level of cigarette smoke exposure.

In the past several years, electronic cigarette use has become more popular, particularly among youth. Electronic cigarettes, also known as e-cigs, e-hookah, vape pens and electronic nicotine delivery systems (ENDS) produce an aerosol by heating a liquid that usually contains nicotine, flavorings, and other additives [8]. Users inhale ultrafine particles, volatile organic compounds, carcinogens, and potentially heavy metals such as nickel, tin, and lead from the cartomizer/ atomizer part of the delivery device deep into their lungs [8, 9]. The Centers for Disease Control and Prevention (CDC) suggests that there may be benefits to vaping for adults who substitute e-cigarettes for conven- tional cigarettes but because of the toxic and highly addic- tive nature of the nicotine contained in many e-cigarettes, they are regarded as unsafe for youth, young adults, pregnant women, and those who do not currently use tobacco prod- ucts [8]. Without formal US Food and Drug Administration approval, many e-cigarette companies have promoted their devices as a means to assist conventional tobacco smokers with cessation [10] and as a result, many cigarette smok- ers have turned to e-cigarettes with the intention of cutting back on the use of traditional cigarettes or quitting smok- ing [11]. The American Cancer Society strongly asserts that e-cigarettes should not be used to quit smoking and current e-cigarette users should not concurrently smoke traditional cigarettes or revert to smoking if a former smoker [12].

In New York City, the overall prevalence of tobacco smoking among adults has declined markedly from 21.5% in 2002 to 13.4% in 2017 [13]. This drop in smoking is due in large part to the New York State Tobacco Control Plan that has driven legislation for a strong clean indoor air policy, high state tobacco taxes, restrictions to minor’s access to tobacco, and increased access to cessation services through a toll free quitline that offers free starter nicotine replacement therapy [14]. Less is known about e-cigarette and alternative sources of nicotine. A single assessment in 2017 through the Community Health Survey in New York City showed that 6.6% of adult respondents reported having used an e-cigarette in the past 12 months. When evaluating e-cigarette use by smoking status among New York City adults, however, 59.3% of current tobacco smokers reported having vaped in the past year compared to 17.5% of never smokers and 23.2% of former smokers [13]. As part of a larger health assessment in our primary care and oncology patients in a large urban cancer center in New York City, we

inquired about e-cigarette use and assessed demographic and lifestyle factors associated with the use of these products.

Methods

This study was conducted in patients from our primary care and oncology clinics between May and December in 2019. Patients in our catchment area can be characterized as (1) those dwelling in the communities of Washington Heights, the South Bronx, and Central Harlem immediately surrounding the Cancer Center who are predominantly His- panic, Black, and underprivileged and (2) those with access to greater resources who live beyond the neighborhood and travel to our institution for their cancer care. Thus, the patients receiving cancer care at our center are racially and ethnically diverse with dramatically different social and eco- nomic backgrounds.

To represent the many distinct groups within our catch- ment area, we recruited and enrolled adults from among three groups to conduct our survey: current and former patients diagnosed and/or treated for cancer at Columbia University Irving Medical Center (CUIMC), patients receiv- ing primary care through the New York Presbyterian (NYP) Ambulatory Care Network, and local community members who may be under-represented in federal and local area statistics.

Patients with cancer and those receiving primary care were sampled using a non-probability sampling method that involved the selection of patient electronic medical records. Included were records of adult patients aged 18 years and older with a valid (non-bogus) email address and excluded were records of patients known to be deceased. Surveys were emailed to oncology and primary care patients, with 32% and 19% response rates, respectively. Partial surveys were excluded; 1270 full surveys were analyzed. A total of 804 (63.3%, 563 oncology vs. 241 primary care) answered all questions related to tobacco and e-cigarette use (Table 1). Data collected from these records included name, race and ethnicity, street address including zip code, and telephone contact information in addition to email address. Upon com- pletion of the survey, all participants were offered a gift card valued at $10. For emailed surveys, those who provided their name, and an up-to-date street address were sent the gift card via U.S. postal mail. Gift cards were distributed in-person to community members at the time of survey completion.

Survey distribution

Emailed surveys were distributed between May and December 2019. A unique link to the consent form and Qualtrics survey was embedded in an introductory email written in both English and Spanish at the 6th grade

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reading level. Introductory letters were addressed to the patient by the Chief of Hematology and Oncology within the Department of Medicine at CUIMC for patients with cancer and the Associate Chief Medical Director of the Ambulatory Care Network of New York Presbyterian Hospital for primary care patients. Potential participants were instructed to click on the embedded link to access the consent form that would lead to either the English or Span- ish version of consent and survey. Within the informed

consent, permissions to access and review their electronic health records, to make contact in the future to inform them of research opportunities, and to add them to a con- tact list to receive information about cancer and research at our institution were additionally requested. Participants were free to select any, all, or none of the extra options. After the initial email, a total of four reminder emails at 2–4-week intervals was sent to encourage participation.

Table 1 Comparison of characteristics of e-cigarette users vs. non-e-cigarette users among primary care and oncology patients participating in a community health survey (May–December 2019)

E-cigarette use

Total (n = 804) Yes (n = 90, 11.2%) No (n = 714, 88.8%) P value

Participant type < 0.001  Primary care 241 (30.0) 49 (20.3) 192 (79.7)  Oncology 563 (70.0) 41 (7.3) 522 (92.7)

Smoking status < 0.001  Current smoker 36 (4.5) 20 (55.6) 16 (44.4)  Former smoker 210 (26.1) 26 (12.4) 184 (87.6)  Never smoker 558 (69.4) 44 (7.9) 514 (92.1)

Sociodemographics Age  18–24 91 (11.3) 22 (24.2) 69 (75.8) < 0.001  25–40 238 (29.6) 47 (19.7) 191 (80.3) < 0.001  40 + 475 (59.1) 21 (4.4) 454 (95.6) < 0.001

Sex 0.07  Male 266 (33.1) 22 (8.3) 244 (91.7)  Female 538 (66.9) 68 (12.6) 470 (87.4)

Sexual orientation 0.014  Heterosexual 736 (92.1) 77 (10.5) 659 (89.5)  LGBTQ + 63 (7.9) 13 (20.6) 50 (79.4)

Ethnicity < 0.001  Hispanic 341 (42.4) 60 (17.6) 281 (82.4)  Non-Hispanic 452 (56.2) 30 (6.6) 422 (93.4)

Race 0.001  White 429 (53.4) 30 (7.0) 399 (93.0)  Black/African American 125 (15.5) 16 (12.8) 109 (87.2)  Other 106 (13.2) 16 (15.1) 90 (84.9)  Don’t know 59 (7.3) 13 (22.0) 46 (78.0)

Education 0.62  < High school 38 (4.8) 6 (15.8) 32 (84.2)  High school 102 (12.8) 10 (9.8) 92 (90.2)   > High school 654 (82.4) 72 (11.0) 582 (89.0)

Personal history of cancer < 0.001  Yes 274 (34.2) 11 (4.0) 263 (96.0)  No 527 (65.8) 79 (15.0) 448 (85.0)

Binge alcohol consumption < 0.001  Very often/often 49 (6.1) 16 (32.7) 33 (67.3)  Occasionally/rarely/never 755 (93.9) 74 (9.8) 681 (90.2)

Smokers in the home < 0.001  None 684 (85.1) 55 (9.0) 629 (92.0)   ≥ 1 91 (11.3) 35 (38.5) 56 (61.5)

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Members of the community were recruited and enrolled using a convenience sampling method. Through partnerships with community organizations, we approached and surveyed community members not part of our CUIMC oncology patient or NYP primary care patient populations. These local sites within the catchment areas included food pantries, shel- ters, and community education centers. Surveys were con- ducted by bilingual (English/Spanish) research assistants.

Survey instrument

The full assessment consisted of a core set of questions pro- moted by the National Cancer Institute and supplementary constructs of interest to our site. Core questions were derived from multiple sources and were related to demographics, healthcare access, social determinants of health, cancer screening and lifestyle behaviors that included tobacco and e-cigarette use, personal and family cancer history, and can- cer beliefs. The full survey was designed to take approxi- mately 30–40 min to complete.

For the current study, we examined type of participant (primary care patient vs. oncology patient), tobacco use, sociodemographic characteristics, personal of cancer, binge alcohol consumption, and second-hand tobacco smoke expo- sure. E-cigarette use was ascertained using a single question “New types of cigarettes are now available called electronic cigarettes or e-cigarettes (also known as vape-pens, hookah pens, e-hookahs, or e-vaporizers). These products deliver nicotine through a vapor. Have you ever used an e-cigarette, even one or two times?” [15]. To assess tobacco used we asked participants if they had ever smoked more than 100 cigarettes in their lifetime and whether they currently smoke cigarettes [15]. Those who stated they had smoked more than 100 cigarettes in their lifetime and were currently smok- ing were categorized as current smokers. Sociodemographic questions included age (18–39, 40–64, and 65 +), sex and sexual orientation (heterosexual/straight vs. LGBTQ +), race (white, black/African American, and other) ethnicity (Hispanic vs. Non-Hispanic), and education (< high school, high school, > high school). Participants were asked if they had ever been diagnosed with cancer to determine personal history of cancer. Binge drinking was assessed by inquir- ing about how often in the past 12 months the participant consumed 5 or more drinks, if male, or 4 or more drinks, if female, containing any kind of alcohol within a 2-h period. Responses 3–7  days/week were coded as “very often”, 1–2 days/week as “often”, 1–3 days/month as “occasion- ally,” 1–11 days/year as “rarely,” and “never/do not drink alcohol.” Second-hand smoke exposure was categorized as none vs. 1 or more smokers in the home. All study proce- dures were reviewed and approved by the Columbia Uni- versity Institutional Review Board (CU IRB AAAS0395).

Data analysis

Analysis was performed in 2020. We conducted univari- able analyses to evaluate differences between ever e-cig- arette users and non-e-cigarette users by participant type, smoking status, sociodemographic characteristics (age, sex, sexual orientation, ethnicity, race, and education), personal history of cancer, binge drinking behavior, and smokers in the home using the Chi square test. Statisti- cally significant covariates were tested with univariable and multivariable logistic regression models. Age was recoded as 18–39 years vs. 40 + years and binge drinking as very often/often vs. occasionally/rarely/never. Relative risk ratios and 95% confidence intervals were reported. All analyses used sampling weights based on demographics from the US Census. All analyses were performed using IBM SPSS version 27 [16].

Results

Of 804 respondents, 69.4% reported never smoking tobacco, 66.9% were female, and 42.4% were Hispanic. Ninety respondents (11.2%) stated that they had ever used an e-cigarette. Primary care patients more often were e-cigarette users (20.3% vs. 7.3%, P < 0.001) than were oncology patients. Current smokers compared to former and never smokers, more often reported using e-cigarettes (55.6% vs. 12.4% and 7.9%, P < 0.001) as did younger (18–24 and 25–40 years) compared to respondents 40 + years of age (24.2% and 19.7%, respectively vs. 4.4%, P < 0.001), LGBTQ + compared to heterosexual/straight patients (20.6% vs. 10.5%, P = 0.014), and Hispanic vs. non-Hispanic patients (17.6% vs. 6.6%, P < 0.001). Reported e-cigarette use was also higher among those with no personal history of cancer compared to those who were diagnosed with cancer (15.0% vs. 4.0%, P < 0.001), patients who very often/often engaged in binge alcohol drinking behavior vs. occasionally/rarely/never (32.7% vs. 9.8%, P < 0.001), and patients who lived with one or more tobacco smokers in the home (38.5% vs. 9.0%, P < 0.001). Results of the multivariable logistic regression analysis demonstrated that e-cigarette use was associated with being a current tobacco smoker vs. a former/never smoker (risk ratio [RR] 4.64, 95% confidence interval [95% CI] 1.94, 11.07), being between the ages of 18–24 years and 25–40 years of age compared to 40 + years (RR 4.58, 95% CI 2.05, 10.26 and RR 3.28, 95% CI 1.69, 6.38, respec- tively); very often/often binge alcohol drinking compared to occasionally/rarely/never (RR 3.04, 95% CI 1.38, 6.73) and living with one or more smokers in the home (RR 3.90, 95% CI 2.10, 7.23) (Table 2).

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Discussion

Our study examined e-cigarette use among primary care and oncology patients attending a large urban medical center in New York City and found that among the 804 patients surveyed, 11.2% reported ever using e-cigarettes. Respond- ents aged 25–40 years adults were nearly as likely as those 18–24 years (RR 3.28, 95% CI 1.69, 6.38 vs. RR 4.58, 95% CI 2.05, 10.26) to have ever used e-cigarettes compared to adults 40 years and older. E-cigarette use was also strongly associated with current tobacco use vs. former and never smoking, very often/often binge alcohol drinking behaviors and being exposed to smokers in the home—all factors that contribute to increased cancer risk.

With more than 3.6 million U.S. middle and high school students reporting using e-cigarettes in the past 30 days and the potential impact of nicotine toxicity on the developing brain [8, 17], much research is focused on e-cigarette initia- tion [18], prevention [19, 20], and, more recently, e-cigarette cessation strategies [21] among youth less than 25 years of age. For both youth and adults, e-cigarettes are considered a gateway to conventional tobacco smoking [22], and the

dual use of e-cigarettes with conventional tobacco use [23, 24], smokeless tobacco, illicit drugs, and cannabinoids [17]. In our study, we found that 24.2% of youth younger than 25 years of age reported ever using e-cigarettes but also found that nearly as many (19.7%) of those 25–40 years ever used e-cigarettes. In multivariable analysis, patients aged 25–40 in our study were more than three times as likely to ever use e-cigarettes as those older than 40. Few others have examined e-cigarette use in adults in this age range. In a recent analysis of National Health and Nutrition Examina- tion Survey (NHANES), Stallings-Smith et al. reported the odds of e-cigarette use among ages 18–34 years of 4.77 (95% CI 3.63, 6.27) and 2.16 (95% CI 1.49, 3.14) among ages 35–54 [25]. Motivation to use e-cigarettes in this age group my likely be related to attempts to quit using conventional tobacco cigarettes as 55.6% of e-cigarette users in our cohort were current tobacco smokers.

Our findings also highlight the association between binge episodes of alcohol consumption, dual use of tobacco smok- ing, exposure to indoor pollution generated by others in the home smoking cigarettes and ever use of e-cigarettes, which raises serious concerns for increasing cancer risk. Although the co-use e-cigarettes, conventional tobacco cigarettes and binge drinking has been reported among adolescents [26, 27] and adults in general [28, 29], the relationship with increased cancer risk has not been the focus when discouraging these behaviors. Our findings present yet another important reason for providers to inquire about e-cigarette use, particularly among the 25–39-year-old group for which there is a paucity of research related to e-cigarette use. A recent study at the Mayo Clinic tracking the prevalence of e-cigarette use after the implementation of questions to record this information in their electronic health record, found that of the 638,804 outpatients, use of e-cigarettes was recorded for only 6% of patients [30]. Among those patients, 2.7% reported cur- rent e-cigarette use, 2.5% were former e-cigarettes users, and 94% were never users. Clearly, consistent recording of e-cigarette use is presently underutilized when available and the results of this study indicate that e-cigarette use is far more prevalent than what is currently being documented. Considering our observation that risky behaviors extend beyond e-cigarette use, routine inquiry and documentation of e-cigarette use may serve to guide patient counseling in ways to decrease risk of future cancer in addition to reducing harms associated with these risky behaviors individually.

The current study was embedded within a larger assess- ment of the health needs of patients (primary care and oncology) seeking care at our urban medical center. The single question about use of ever e-cigarette use does not allow us to examine ongoing use, frequency and duration of use, or details about the type of e-cigarette used but demonstrates that use among young adults is relatively higher among patients vs. young adults in the general

Table 2 Factors associated with e-cigarette use among primary care and oncology patients participating in a community health survey (May–December 2019)

Crude RR (95% CI) Adjusted RR (95% CI)

Smoking status  Former/never smoker 1.00 1.00  Current smoker 12.45 (6.18, 25.15) 4.64 (1.94, 11.07)

Age  40 + 0.17 (0.10, 0.29) 1.00  25–40 2.99 (1.92, 4.67) 3.28 (1.69, 6.38)  18–24 3.02 (1.76, 5.20) 4.58 (2.05, 10.26)

Sexual orientation  Heterosexual 1.00 1.00  LGBTQ + 2.23 (1.16, 4.28) 1.40 (0.64, 3.07)

Ethnicity  Non-Hispanic 1.00 1.00  Hispanic 3.00 (1.89, 4.78) 1.37 (0.77, 2.45)

Personal history of cancer

 No 1.00 1.00  Yes 0.24 (0.12, 0.45) 0.60 (0.27, 1.34)

Binge alcohol con- sumption

 Occasionally/rarely/ never

1.00 1.00

 Very often/often 4.46 (2.35, 8.49) 3.04 (1.38, 6.73) Smokers in the home  None 1.00 1.00

 ≥ 1 7.15 (4.32, 11.84) 3.90 (2.10, 7.23)

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population. This finding presents opportunities for health- care intervention on this and other risky health behaviors that are known to contribute to the future development of cancer. Ours was an observational study with a relatively small number of individuals reporting e-cigarette use but, in this group, we observed e-cigarette prevalence nearly as high among patients 25–39 years old as among those 18–25 years (19.7% vs. 24.2%). We also report on e-ciga- rette use among patients in an urban area where the patient population was very racially and ethnically diverse (42.4% Hispanic, 15.5% black/African American, and 13.2% race other than black or white) which may not be representa- tive of other patient populations across the country but is nonetheless informative.

Although the effects of e-cigarette use on an individu- al’s future health and cancer risk are not fully understood at this time, the impact of binge alcohol drinking, and tobacco smoking are. Conversations discouraging use of e-cigarettes present an opportunity to providers to discuss co-use of binge alcohol consumption and the potential of initiating tobacco smoking and the cancer-related hazards of these co-related behaviors. Young adults aged 25–40 years have received little attention regarding e-cigarette use and represent a group in which cancer prevention edu- cation is likely to have a real and lasting impact on reduc- ing risk of developing cancer in the future.

Authors contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by GCH, MN, SL, KMS, AR, and MBT. The first draft of the manuscript was written by GCH and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding This work was supported by a grant from the National Cancer Institute (P30CA013696) to MBT.

Data availability The data that support the findings of this study are available from the corresponding author upon request.

Declarations

Conflict of interest The authors have no relevant financial or non-fi- nancial interests to disclose.

Ethical approval This study was approved by the Columbia University Institution Review Board (CU IRB AAAS0395).

Consent to participate Informed consent was obtained from all human subjects participating in this study.

Consent for publication All authors have provided consent for pub- lication.

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