Daily E-Cigarette Use Increasing Among Young Adult Americans

Michael J. Blaha, MD, MPH

Current e-cigarette use has slightly decreased among young Americans in recent years, according to a new study. However, in the same observed time period, daily e-cigarette use increased among adults in their 20s, suggesting a rise in nicotine dependence among users.

In new data from a team of investigators at Johns Hopkins University School of Medicine and the American Heart Association (AHA), a trend of significant increase in proportion of persons using e-cigarettes daily was observed from 2017 to 2020, signifying a greater rate of habitual use among young Americans.

The findings, from a team led by Michael J. Blaha, MD, MPH, from the Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, emphasize the need for greater monitoring of increased daily e-cigarette use among young American adults, and investigation into its clinical impact.

Blaha and colleagues had conducted a repeated cross-sectional analysis of nationally-representative data from the Behavioral Risk Factor Surveillance System in 2017, 2018 and 2020. The team sought to interpret recent years’ patterns in current and daily e-cigarette use among US adults.

“Previous studies examining patterns in e-cigarette use among US adults from 2016 to 2018 reported an increased prevalence of current and daily e-cigarette use, with the most substantial increase observed among young adults aged 18 to 24 years,” they wrote. “Of public health concern, the prevalence of e-cigarette use among individuals who have never used combustible cigarettes also increased significantly over the same period.”

The team used data from 994,307 adults living in US states and territories who provided data on e-cigarette use in 2017, 2018, and 2020. They sought a primary outmode of weighted prevalence of current and daily e-cigarette use estimates for each observed year, as well as changes in prevalence from 2017 to 2020, both by patient characteristics and within states. Current e-cigarette use was defined as the past 30 days.

Approximately 52% of observed individuals for each year of the national assessment were female. Adults aged 18-24 years old comprised 12.6%, 11.8% and 11.9% of survey participants in 2017, 2018 and 2020, respectively. Nearly two-thirds (65.1%) of all survey participants were White, followed by Hispanic (15.1%) then Black (12.2%).

Current e-cigarette increased from 4.4% (95 CI, 4.3 - 4.5) to 5.5% (95% CI, 5.4 - 5.7) over 2017 to 2018. It then decreased to 5.1% (95% CI, 4.9 - 5.3) in 2020. The decrease was primarily observed among young adults aged 18-20 years old—a 3.3 percentage point decrease over those 2 years. This same age group reported an increase in daily e-cigarette use from 1.5% to 2.3% in that time.

Current e-cigarette use among adults aged 21-24 years old was insignificant from 2018 (13.5%) to 2020 (14.5%), but daily use significantly increased in this population (4.4% to 6.6%; P <.001).

Overall, the proportion of current e-cigarette users who reported daily use increased from 34.5% (95% CI , 33.1 - 36.0) in 2017 to 44.4% (95% CI, 42.5 - 46.3) in 2020.

Combustible cigarette smoking prevalence was 16.3% (95% CI, 16.1 - 16.6) in 2017 but decreased to 14.8% (95% CI, 14.5 - 15.1) in 2020 among states with available data. The decrease was predominantly observed among younger adults—a 3.4 percentage point decrease in ages 18-20 and a 4.3 percentage point decrease in ages 21-24.

Blaha and colleagues stressed the possibility of unaccounted factors that may have driven the decrease in current e-cigarette use in 2020.

“With the rapidly evolving e-cigarette language and the increasing market share of disposable e-cigarettes (such as the Puff Bar brand, it is unclear whether BRFSS survey questions fully captured these newer products,” they wrote. “A recent study found that querying about general e-cigarette use (as in most surveys) rather than specific e-cigarette devices or brands, may underestimate the true prevalence of use.”

Regarding the increase of daily use among adults aged 21-24 years, the investigators wrote the rising rate may imply that “more e-cigarette users are becoming regular rather than experimental users.”

Taken together with the recent reduction in current e-cigarette use, this finding could mean that the decrease in current e-cigarette use is more reflective of quitting among experimental but not regular users,” they wrote. “However, because of the cross-sectional nature of this study, we were unable to assess these transitions.”

Nonetheless, the team concluded the findings indicate a need for greater national monitoring of e-cigarette trends, assessment into clinical risks associated with daily use among younger adults, and “importantly regulatory implications.”

“Continued surveillance and stricter enforcement of the Tobacco-21 legislation, the e-cigarette flavor ban, and marketing restrictions are warranted,” investigators wrote. “Among young adults aged 21 to 24 years, regulations and policy interventions that make e-cigarette use less appealing to this age group, such as extending the flavor ban to all non–tobacco flavored e-cigarettes and increasing the excise tax on these products, may be considered.”

The study, “Assessment of Patterns in e-Cigarette Use Among Adults in the US, 2017-2020,” was published online in JAMA Network.