Prevalence and Factors Associated with Electronic Cigarette Use Among Young Adult Cancer Survivors Using Behavioral Risk Factor Surveillance System,2016–2018

Introduction

Electronic cigarettes (e-cigarettes) are battery-powered nicotine delivery systems marketed in various shapes and forms. ¹ Following their introduction into the United States market over a decade ago, there has been a surge in the use of e-cigarettes by youths and young adults.^2–4 Age at initiation of e-cigarette use has been reported to be as low as 7 years, with aggressive and tactical marketing of these products directed at the young and vulnerable population. ⁵ In addition, e-cigarette use has been associated with increased concurrent use of conventional cigarettes and other tobacco products among youths.^6–8

In 2012, over three-quarters of youths who were current e-cigarette users in the United States reported concurrent smoking of conventional cigarettes. ⁹ Although promoted as a safer alternative to conventional cigarettes, e-cigarettes contain several toxins and carcinogens with current evidence suggesting a possible link with various forms of cancers. ¹⁰

Young adult cancer survivors have been reported to have a higher prevalence of current smoking compared to those without cancer. ¹¹ A recent study showed that they are more likely to report both lifetime and current use of e-cigarettes relative to their counterparts without a cancer history. ¹² This population has the worst morbidity and mortality outcomes when compared to cancer survivors at either extreme of age.^11,13 In recent times, the prevalence of both lifetime and current use of e-cigarettes among adolescents and young adults in the United States have been increasing. Current e-cigarette use increased from 11.7% in 2017 to almost 30% in 2019 among high school students and increased by almost 20-fold over the same period among middle school students, increasing from 0.6% in 2017 to 10.5% in 2019. ¹⁴ Since some substances in the e-cigarette vapor have been shown to increase the risk of cancer, young adult cancer survivors who use e-cigarettes may be at risk for other cancers with attendant health and economic burden on the survivors, their families, caregivers, and the community.

Various factors have been linked to e-cigarette use. A recent population-based study revealed an association between e-cigarette use and depression. ¹⁵ Using the Behavioral Risk Factor Surveillance System (BRFSS) data, researchers found that current and former e-cigarette users were 2 times and 1.6 times more likely, respectively, to report a diagnosis of clinical depression compared to never users. ¹⁵ In addition, alcohol consumption is associated with increased lifetime and current e-cigarette use.^16–18 However, there is a paucity of studies assessing the factors associated with e-cigarette use in young adult cancer survivors. The diagnosis and treatment of cancer are traumatizing and associated with the emotional and psychological impact on these survivors.^19,20 Sociodemographic factors such as race/ethnicity, gender, and urbanicity have been studied and linked with e-cigarette use in young adults with cancer. ¹²

However, no research to the best of our knowledge has explored the relationship between modifiable factors such as depression, binge drinking, and the use of conventional cigarettes and e-cigarette use in this population. Given that young adult cancer survivors are at risk for another cancer and poorer health outcomes, understanding factors associated with e-cigarette use could inform behavioral modifications to improve the quality of life of these survivors. Using a population-based study, we examined the prevalence of lifetime and current e-cigarette use among young adult cancer survivors and compared these to the prevalence among young adults without a cancer history in the United States between 2016 and 2018. In addition, we assessed the association between conventional cigarette use, binge drinking, and depression and how these relate to lifetime and current e-cigarette use among young adult cancer survivors. We also explored other factors that may be associated with e-cigarette use in this population.

Methods

Results

Among 2074 young adult cancer survivors who reported lifetime use of e-cigarettes, 31.8% were between age 30 and 34 years, while 29.7% were between 35 and 39 years. Furthermore, the majority of lifetime users of e-cigarettes were female (71.6%), non-Hispanic whites (66.3%) with some college degree (38.0%), earning less than $25,000 (48%) (Table 1). On the contrary, out of 82,418 young adults without a cancer history who reported lifetime use of e-cigarettes, 39.8% were aged 18–24 years, while 23.3% were between 25 and 29 years. Although majority of young adults without a cancer history were male (60.9%), the distribution of other sociodemographic characteristics was similar to that of young adult cancer survivors (Table 2). There were significant differences between young adult cancer survivors and young adults without a cancer history by sociodemographic characteristics, e-cigarette use, and other variables included in the analyses (Supplementary Table S2). The sample distribution for young adult cancer survivors across the years was 37.7% in 2016, 37.2% in 2017, and 25.0% in 2018 and this was similar to the distribution of young adults without a cancer history. The prevalence of lifetime e-cigarette use among cancer survivors increased steadily from 40.1% in 2016 to 44.0% in 2017 and 47.4% in 2018. Among young adults without a cancer history, the prevalence of lifetime e-cigarette use was 34.3% in 2016, 32.7% in 2017, and 38.1% in 2018 (Fig. 1a). On the contrary, the prevalence of current e-cigarette use among young adult cancer survivors was 25.5% in 2016, decreased to 21.0% in 2017, and then increased to 28.4% in 2018, while the prevalence in those without cancer increased from 20.7% in 2016 to 22.3% in 2017 and 25.9% in 2018 (Fig. 1b).

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FIG. 1.

Prevalence of (a) lifetime and (b) current e-cigarette use. e-cigarette, electronic cigarette. Color images are available online.

Results of bivariate analyses of lifetime e-cigarette use showed that former smokers were 5.16 times more likely to be lifetime users of e-cigarettes relative to never smokers (unadjusted odds ratio [OR]: 5.16, 95% confidence interval [CI]: 3.55–7.52) while current smokers were 15.58 times more likely to be lifetime users of e-cigarettes compared to never smokers (unadjusted OR: 15.58, 95% CI: 11.9–20.35). Those who reported a history of binge drinking were 2.18 times more likely to be lifetime users of e-cigarettes (unadjusted OR: 2.18, 95% CI: 1.71–2.78). Young adult cancer survivors with a clinical history of depression were 2.50 times more likely to report lifetime use of e-cigarettes relative to those without a clinical history of depression (unadjusted OR: 2.50, 95% CI: 1.98–3.16). Survivors between 25 and 29 years had a 52% higher odds of lifetime e-cigarette use compared to those between ages 18–24 years (unadjusted OR: 1.52, 95% CI: 1.05–2.20) (Table 3).

In the adjusted analyses of associations with lifetime e-cigarette use, we found that former smokers were 5.47 times more likely to be lifetime users of e-cigarettes compared to never smokers (adjusted odds ratio [AOR]: 5.47, 95% CI: 3.48–8.61), while current smokers were 16.50 times more likely to be lifetime users of e-cigarettes compared to never smokers (AOR:16.50, 95% CI: 11.59–23.57). Furthermore, young adult cancer survivors with a history of binge drinking reported 52% higher odds of e-cigarette use relative to those without a history of binge drinking (AOR: 1.52, 95% CI: 1.13–2.04). Similarly, those with a clinical history of depression were 50% more likely to report lifetime use of e-cigarettes relative to those without a clinical history of depression (AOR: 1.50, 95% CI: 1.09–2.06). In addition, we found that young adult cancer survivors were significantly less likely to be lifetime e-cigarette users with each increasing age category. Young adult cancer survivors between 30 and 34 years were 40% less likely to report lifetime use of e-cigarettes (AOR: 0.60, 95% CI: 0.37–0.98) when compared to those between 18 and 24 years. Similarly, those between 35 and 39 years were 54% less likely to report lifetime use of e-cigarettes (AOR: 0.46, 95% CI: 0.27–0.76) (Table 3; Fig. 2a).

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FIG. 2.

Adjusted odds of (a) lifetime and (b) current e-cigarette use. Color images are available online.

Results of bivariate analysis of current e-cigarette use showed that former smokers of conventional cigarettes were 1.86 times more likely to be current users of e-cigarettes relative to never smokers (unadjusted OR: 1.86, 95% CI: 1.15–3.02), while current smokers of conventional cigarettes were 2.29 times more likely to be current users of e-cigarettes compared to never smokers (unadjusted OR: 2.29, 95% CI: 1.43–3.68). Similarly, those who reported a history of binge drinking were 63% more likely to be current users of e-cigarettes relative to those without a history of binge drinking (unadjusted OR: 1.63, 95% CI: 1.07–2.48). Young adult cancer survivors with a clinical history of depression were 74% more likely to report current use of e-cigarettes relative to those without a clinical history of depression (unadjusted OR: 1.74, 95% CI: 1.21–2.49) (Table 4).

In the adjusted analyses of associations with current e-cigarette use, former smokers of conventional cigarettes were 90% more likely to be current users of e-cigarettes compared to never smokers (AOR: 1.90, 95% CI: 1.12–3.23), while current smokers of conventional cigarettes were 2.10 times more likely to be current users of e-cigarettes compared to never smokers (AOR: 2.10, 95% CI: 1.24–3.57). We found no association between current e-cigarette use and binge drinking or clinical history of depression. However, our results revealed an association between different age categories and current use of e-cigarettes, we found that those 30–34 years of age were 47% less likely to be current e-cigarette users (AOR: 0.53, 95% CI: 0.33–0.86), while those of 35–39 years were 58% less likely to be current e-cigarette users (AOR: 0.42, 95% CI: 0.24–0.71) relative to those 18–24 years of age (Table 4; Fig. 2b).

Discussion

This study highlights a rising prevalence in lifetime e-cigarette use between 2016 and 2018 from 40.1% in 2016 to 47.4% in 2018, indicating over a three-fold increase compared to the 12.6% reported in 2014 among United States adults, 13.4% reported among middle and high school students in the United States and 14.8% reported among United States cancer survivors.^3,27,28 However, our finding is similar to the prevalence of lifetime e-cigarette use recently reported by another study in the same population and is explained by previous findings in the literature, which state that young adults with a cancer history participate more frequently in high-risk health behaviors than their healthy counterparts.^11,12,29 Majority of lifetime and current e-cigarette users in our study were females. This finding may be related to the higher proportion of females in our study at baseline and, hence, may not be reflective of true population rates. We also found that current e-cigarette users are significantly more likely to be males. This association is no different from what has been previously reported.^30,31 While males generally describe more reasons for e-cigarette use such as social facilitation and increased energy, females report the use of e-cigarettes mostly for weight control. ³² This may explain the reduced incentive for e-cigarette use among female cancer survivors since the progression of cancer diagnosis and subsequent treatment is commonly accompanied by weight loss. However, male adolescent cancer survivors are likely to be involved in other externalizing behaviors, including substance use, which may further worsen their already compromised health state and worsen their risk for a second cancer. ³³ Furthermore, male cancer survivors are at risk of having fertility problems from cancer treatment, and the recent study suggesting a link between e-cigarette use and infertility highlights the need to address the issue.^34–36 Our study also reveals an association between age and e-cigarette use. Younger cancer survivors are more likely to ever use or currently use e-cigarettes compared to those in the older age categories. This finding is not surprising as it is similar to previous reports indicating that the glamorized marketing of e-cigarettes is strategically designed to appeal to the most vulnerable younger population. Peer pressure, curiosity, flavorings, and low perceived harm are some of the reasons encouraging the use of e-cigarettes in this population. ³⁰ These underscore the need for gender and age-specific interventions directed at youth, young adults, and especially, young adult cancer survivors before they initiate e-cigarette use. There is also a need for health care providers and other advocacy groups involved in cancer care and management to re-educate young adults, particularly young adult cancer survivors on the dangers of e-cigarette use.

We found an association between lifetime e-cigarette use and depression among young adult cancer survivors. This finding supports a previous report which showed an association between e-cigarette use and depression in the general United States population. ¹⁵ Cancer survivors are known to be at increased risk of depressive episodes from the diagnosis and management of their condition. Furthermore, young adults with cancer have substantially higher rates of unique psychological problems and depression when compared to older adults. ³⁷ This may make them more vulnerable to tobacco messaging designed to increase youth uptake of e-cigarettes. On the contrary, the increased lifetime use of e-cigarette use may explain the increased likelihood of clinical depression reported by young adult cancer survivors. It is known that individuals with mental health conditions and cancer diagnoses are more likely to have used e-cigarettes compared to those without this health conditions.^12,38 Our study revealed no association between current e-cigarette use and the clinical diagnosis of depression. A clinical diagnosis of cancer and/or depression is often followed by multiple hospital visits, increasing contact between the patients and their health care providers. This potentially exposes them to more counseling and anti-tobacco messaging from health providers and reiterates why physicians are vital in providing accurate health information to cancer patients. Cancer survivors trust their health care providers and are more likely to seek health information from them rather than not.^39,40 This relationship allows providers the opportunity to counsel and educate their patients about the harmful effects of tobacco and e-cigarette use on health outcomes, including second cancers.

Our results revealed that young adult cancer survivors who reported binge drinking were more likely to report lifetime e-cigarette use. This is similar to what has been previously reported on binge drinking and e-cigarette use in the general population. ³¹ Our study also supports what is currently known about the association between e-cigarette use and conventional cigarettes. Several studies have reported that young adults who smoke conventional cigarettes are more likely to use e-cigarettes.^8,30,41,42 Concurrent use of e-cigarettes and conventional cigarettes put cancer survivors at increased risk of exposure to high levels of toxins and carcinogens. We found over a 5- and 16-fold increase in the odds of former or current conventional cigarette use, respectively, among young adult cancer survivors with lifetime e-cigarette use. This may suggest that while the rates of e-cigarette use increase in young adult cancer survivors, the tobacco epidemic remains pervasive in this population and calls for stricter policies and heightened regulations to control this menace. Efforts to control e-cigarette use among young adult cancer survivors need to be multipronged, simultaneously addressing other harmful practices such as binge drinking and the use of conventional cigarettes.

Our study is novel in describing the association between e-cigarette use (lifetime and current) and depression, binge drinking, and conventional cigarette use among young adult cancer survivors using a population-based study. In addition, our research uses data that are nationally representative of the noninstitutionalized United States population, making our findings generalizable to the United States population of young adult cancer survivors. However, the study has several limitations. First, this is a cross-sectional study, and as such, we are unable to prove causality. Also, we are unable to rule out reverse causality. For example, we do not know if depression or binge drinking in young adult cancer survivors is causing a surge in e-cigarette use or vice versa. Furthermore, since this was a self-reported study, there is potential for recall bias. Nonetheless, most of the questions asked in the survey were difficult to obtain through other means. The study is also prone to random error from missing data which may affect the precision of our estimates and our conclusions. However, weighting procedures, sampling techniques, and multiple imputation were used to address low response rates and missing data. Our classification of e-cigarette use is different from the conventional reporting of rates of current drug use. Still, our definition is used in published literature to reflect current use of e-cigarettes since participants who are allowed to respond to the question on current use are limited to respondents who report ever use of e-cigarettes. While a greater proportion of the young adult cancer survivors in our study population were older and female, majority of young adults without a cancer history were younger and male. This variation in our comparison group may explain some of the differences in prevalence we noted across the years. Furthermore, this study is prone to potential confounding from unmeasured factors such as marijuana use and other tobacco-related factors such as age at tobacco initiation and state-specific differences in smoke-free protections and tobacco pricing.

In conclusion, we found a higher prevalence of lifetime and current e-cigarette use in young adult cancer survivors compared to young adults without cancer and young adults in general. Our findings also revealed an increasing trend in the prevalence of lifetime and current e-cigarette use among young adult cancer survivors. Furthermore, we found that conventional cigarette use, binge drinking, depression, age, and gender are associated with e-cigarette use in young adult cancer survivors. There is an urgent need for strong policy and regulations to curb the e-cigarette epidemic in this population as well as longitudinal studies to confirm our findings.