A Comparative Analysis of E-cigarette Users and State-Specific Prevalence Change in the United States Between 2017 and 2018

Introduction Despite states’ regulatory efforts, e-cigarettes are gaining popularity, which poses a public health concern. The study objective is to compare demographic and state prevalence changes in e-cigarette use from 2017 to 2018. Methods A retrospective analysis was conducted using publicly available data from the Behavioral Risk Factor Surveillance System survey (2017-2018). The prevalence of current e-cigarette use was analyzed with direct age-adjustment based on the 2010 United States Census population. Results The overall use of e-cigarettes increased from 4.3% in 2017 to 5.4% in 2018. Although most demographics reported increased prevalence from 2017 to 2018, the most significant change was observed in younger adults (18-24), males, Hispanics, college graduates, non-smokers, marijuana non-users, and heavy alcoholics. Oklahoma (9.8%), Hawaii (7.8%), Arkansas (7.7%), and Colorado (7.3%) greater prevalence in 2018. Significant inclining prevalence was observed in Alaska, Connecticut, and Massachusetts, while Illinois reported a sharp decline. California, the District of Columbia, and Puerto Rico consistently reported the lowest prevalence. Idaho, Maine, Michigan, North Dakota, and Oregon are transitioning to a higher prevalence of e-cigarette use from 2017 to 2018. Conclusion The rising prevalence of e-cigarettes across demographics warrants a holistic approach to behavioural change interventions, health awareness and education, and regulatory efforts.


Introduction
The most frequently published data on substance use in recent times remain pertinent to electronic cigarettes (vaping) and cannabis (marijuana) use in addition to tobacco smoking and alcohol abuse among young [1,2]. The paucity of evidence proposing a clear risk and benefits of mainly using e-cigarettes merits for contemporary data to screen population remaining at higher risk of polysubstance use with potentially greater health risk. We sought to assess the age-adjusted prevalence of current e-cigarette use between 2017 and 2018 in a diverse subset of the population. Concomitantly we report comparative state-specific prevalence in 2017 and 2018 with state-wise effective dates on laws related to e-cigarettes.

Materials And Methods
A retrospective analysis was conducted using the publicly available data from the Behavioral Risk Factor Surveillance System (BRFSS) survey (2017)(2018). The BRFSS is the largest telephone-based annual population survey of United States adult residents conducted by the Centers for Disease Control and Prevention (CDC) on health-related risk behaviours, chronic health conditions, and preventive services utilization [3]. The prevalence of current e-cigarette use was analyzed with direct age-adjustment based on the 2010 US Census population. Data were collected from main and all available optional modules with information on e-cigarette use. Current e-cigarette use was assessed using the following two BRFSS questions: (1)"Have you ever used an e-cigarette or other electronic vaping products, even just one time, in your entire life?" and (2)"Do you now use e-cigarettes or other vaping products every day, some days, or not at all?" Respondents who answered yes to the first question were classified as current users if they used ecigarettes daily or some days in the second question. The demographics and behavioural characteristics of ecigarette users were selected based on previously published studies from the same database [1,4,5]. The information on state-wise e-cigarette regulations as of July 2020 was gathered from publicly available sources [6,7].
Baseline characteristics for the current e-cigarette use were compared using row frequencies with appropriate BRFSS survey weights and developed methodology [8,9]. Analyses were conducted using Stata-16.1, and maps were created using ArcGIS-10.7.1.

Discussion
Recent reports on the prevalence of e-cigarette use showed varied rates in the United States adult population representing diverse geographic, ethnic, and socioeconomic strata [1]. Consistently, we observed Caucasians dominating the study cohort; however, all age, sex, and racial/ethnic groups reported increased e-cig use during the study period. The most pronounced increase was noted among the young (18-24 years) participants, males, and Hispanics. Education and employment status also showed an impact on the frequency of e-cigarettes. Low education among participants (less than high school, 4.5% & 5.2%) and those who were either unable to work (6.9% & 9.4%) or were unemployed (6% & 6.7%) reported a high frequency of using e-cigarettes. Expectedly, current cigarette smoking was associated with a higher frequency (15.1%) of concomitant e-cigarette smoking as compared to former cigarette smoking. This finding is corroborative of earlier reports suggesting concerning behavioural patterns in youth indicating polysubstance use. While the prevalence of e-cigarette use during the last two years was also evident in heavy alcohol users, marijuana users, current smokers, the greatest inclining was observed among marijuana non-users and nonsmokers. This rising frequency of e-cigarettes use is concerning as numerous reports starting suggested potential severe adverse healthcare effects of using e-cigarettes, including cardio-cerebrovascular and lunginjury [4,10,11].
Furthermore, we found interesting differences in terms of the state-wise prevalence of e-cigarette use during the study period. Looking at higher incremental use of e-cigarettes in states including Arkansas, Colorado, Florida, Indiana, Oklahoma, and Wyoming, call for attention from policymakers especially any conclusive evidence showing beneficial effects of e-cigarettes over combustible cigarette smoking over a long period whereas numerous reports suggesting acute healthcare effects in young individuals using e-cigarettes [4,10,12]. Reassuringly, a few states including Arizona, Illinois, New Mexico, and South Carolina, showed a steep decline in the use of e-cigarettes which could be hypothesized due to improved awareness regarding the ill effects of vaping among the general public and physicians. However, it would be interesting to see if these states would be able to continue to control the vaping epidemic until clear, conclusive evidence and guidelines endorse the use of e-cigarette use and its benefits over combustible cigarette use. Interestingly, California, the District of Columbia, and Puerto Rico have shown consistently lower prevalence during 2017-18. One possible explanation could be laws taxing e-cigarettes and strict e-smoking regulations, including required retail licensure imposed before the study period [6,7,13]. In contrast, states such as Idaho, Michigan, North Dakota, and Oregon without requirements for retail licensure and excise tax showed increasing prevalence from 2017 to 2018. Future studies should look at the longitudinal effects of states' policy efforts in regulating e-cigarette use and changing prevalence in the population.
Although the survey design is limited in terms of self-reported information and identifying the duration, mode, and sequential use of the e-cigarette, combustible cigarette, and marijuana, it remains important to highlight the alarming rate at which polysubstance abuse has been increasing since the last few years. While it is early to conclude the relationship between e-cigarette, smoking, and marijuana, it is essential to assess ongoing trends between 2019 and 2020 especially with enormous scientific evidence highlighting the severe health impacts of both substances.

Conclusions
The study provides essential information on a recent increase in the overall use of e-cigarette and concomitant rising prevalence of polysubstance use. The most pronounced rise in e-cigarette use between 2017 and 2018 was noted in young, male, and Hispanic survey participants. A few states like California and the District of Columbia showed an encouraging decline in e-cigarette use. In contrast, states like Arkansas, Colorado, and Florida showed a steep rise and call for attention from physicians and policymakers to spread awareness among young adults about the adverse effects of e-cigarette use. Whether state regulation efforts have any influence on e-cigarette prevalence is inconclusive, these findings open a door for debate on reevaluating states' current smoking policies and public health efforts.