Adolescent awareness and use of electronic cigarettes: A review of emerging trends and

findings

Richard Greenhill, MResa

Lynne Dawkins, PhDb
Caitlin Notley, PhDc
Mark Finn, PhDa
John J. D. Turner, PhDa

a
School of Psychology, University of East London, London, United Kingdom
b
Division of Psychology, London South Bank University, London, United Kingdom
c
Norwich Medical School, University of East Anglia, Norwich, United Kingdom

Corresponding author: Richard Greenhill, School of Psychology, University of East

London, Stratford Campus, Water Lane, London, E15 4LZ
Telephone: 0208 223 4391
Email: r.greenhill@uel.ac.uk

Acknowledgements: This work is supported by Cancer Research UK grant C50882/A20492.

The funding source had no role or involvement at any stage of the literature review.
 Abstract

Adult electronic cigarette use is increasing globally and early studies have suggested that

similar trends may be observed among the adolescent population, albeit at lower levels. The

current literature review presents data collected since 2014 from 21 cross-sectional studies

and one cohort study that were all published in English. In particular, it focuses on awareness,

ever-use, past 30 day use and regular use of e-cigarettes. The article suggests that adolescents

are nearing complete awareness of e-cigarettes. Furthermore, in relation to ever-use and past

30 day use, higher prevalence rates continue to be reported across time, especially in the US.

Nonetheless, reported regular use of e-cigarettes remains much lower than past 30 day use,

although conclusions are limited due to inconsistencies with measurement and consequent

lack of cross-cultural applicability. The majority of studies do not report whether adolescents

use non-nicotine electronic cigarettes. There is a current absence of longitudinal studies that

explore any association between electronic cigarettes and tobacco use, and little qualitative

data that may illuminate how and why adolescents use electronic cigarettes. Through

addressing these methodological limitations, future research will be able to inform healthcare

and policy more effectively.

Keywords: electronic cigarettes, e-cigarettes, vaping, nicotine, adolescents

 Implications and Contribution

This article provides a rapid review of upwards trends in adolescent awareness and use of e-

cigarettes. Current research priorities include surveying the extent of non-nicotine e-cigarette

use and establishing the direction of any associations between e-cigarette and tobacco use

longitudinally. Health practitioner priorities include promoting education strategies regarding

what e-cigarettes are and their possible health implications.

Introduction

Electronic cigarettes (e-cigarettes; also known as electronic nicotine delivery systems or

electronic vaporising devices) are battery-operated handheld devices that deliver nicotine

vapour to the user. Since their introduction to the Chinese market in 2004, e-cigarettes have

grown in popularity worldwide. In the UK, adult e-cigarette use has more than tripled from

700,000 users in 2012 to 2.6 million users in 20151. Likewise, adult e-cigarette use in the US

grew from 1.8% to 13.0% between 2010 and 20132. Evidence suggests that e-cigarette vapour

contains some toxic substances albeit at much lower levels than in tobacco cigarettes3 and

they may have the same efficacy as currently recommended smoking cessation medications

(e.g. nicotine replacement therapies)4 5 6. However, there is continued debate around the

potential harm and efficacy of e-cigarettes7 and the Cochrane review of this area is clear

about the need for more robust evidence, prior to making definitive recommendations3.

Concerns regarding adolescent e-cigarette use stem from studies examining the effects of

nicotine on the adolescent brain have primarily been carried out on rodents, although some

studies have used human subjects8 9 10. These studies suggest that nicotine use may potentially
have deleterious effects. Relative to tobacco smoking, there are substantially lower health

risks associated with nicotine consumption (e.g. through nicotine replacement therapies)11.

Nonetheless, it is conceivable that use of nicotine delivered through e-cigarettes may be

associated with a spectrum of adolescent risk taking behaviours, such as tobacco use or

substance misuse. For an in-depth discussion of e-cigarette constituents, associated health

risks and adolescent healthcare practitioner advice, please see Hildick-Smith, Pesko, Shearer

et al.’s review12.

In a previous review of adolescent e-cigarette use, Durmowicz presented data collected from

14 studies published between 2011 and January 201413. The studies were carried out in

France, Hungary, Lithuania, South Korea, Poland and the US. According to the review,

adolescent awareness of e-cigarettes across this time period and within these countries ranged

from 10.2% to 67%. Adolescent ever-use of e-cigarettes ranged from 0.5% to 23.5%, while

adolescent past 30 day use of e-cigarettes ranged from 0.6% to 13%. Durmowicz emphasises

the increased prevalence rates across time, in particular citing a study that suggests that e-

cigarette ever and past 30 day use in US adolescents doubled between 2011 and 2012.

Likewise, Chapman and Wu’s similar review14 covered the same studies as Durmowicz and

therefore presented similar data. Both of these reviews are limited by the relatively low

number of studies reporting awareness and use rates.

While both of these reviews were comprehensive in their scope when published, e-cigarettes

are a rapidly developing product, the use of which among adults is rising and becoming more

ubiquitous1. In addition, their safety and efficacy as smoking cessation devices continues to

be widely discussed, both in the academic literature and mainstream media. The circulation

of moral and medical discourse is likely to affect potential users’ decisions on whether to
ultimately use e-cigarettes, as well as adolescent awareness and use patterns. As such, we feel

that it is important to maintain an up-to-date review of the literature specifically focused on

adolescent e-cigarette awareness and use. In the current literature review we aim to explore

new trends of awareness and use among adolescents, as well as to identify any novel

findings. In doing so, we aim to highlight limitations of current studies and make

recommendations for future research.

Method

For the period January 2014 to January 2016, we undertook a rapid review by searching three

reference databases (PubMed, Scopus, EBSCOhost) with keywords relevant to the review

(see Figure 1). For example, we searched for “electronic cigarette”, “e-cigarette”, “electronic

nicotine delivery system”, “electronic vaporising device”, “vaping”, “adolescent”, “child”,

“teen” and “youth”, and used Boolean Operators to refine our search. In order to be

considered for inclusion, articles had to be: (i) peer-reviewed journal articles; (ii) published in

English; (iii) published during the period January 2014 to January 2016; (iv) about the

awareness and/or use of e-cigarettes; and (v) partly or exclusively about children (i.e. people

aged 18 years old or younger). If studies surveyed children at schools where the leaving age

was 19 years old (e.g. in some Canadian provinces), they were included. If studies were

published online ahead of print in 2016, they were also included. If studies were published

during 2014, but had already been included in the aforementioned review12, they were

excluded. Finally, if studies dealt with both children and adults, but did not differentiate

between the two in their results, they were excluded. Once we had identified relevant studies

that met the inclusion criteria, we searched their reference lists for any further studies that

also fulfilled the inclusion criteria.

Measuring e-cigarette use: terminology and clarifications

The terminology used to define e-cigarette use differs across the reviewed studies (see Table

1). The majority of studies report e-cigarette use that has either occurred “at least once”

and/or “in the past 30 days”. We describe these definitions under the terms “ever-use” and

“past 30 day use” respectively. In addition, a small number of studies report on “frequency”

of e-cigarette use, rather than use that has occurred “in the past 30 days”. We describe these

definitions under the term “regular use”.

Results

22 relevant studies met the inclusion criteria (see Table 2). The findings of these studies can

be divided into four categories: (i) awareness of e-cigarettes; (ii) ever-use of e-cigarettes; (iii)

past 30 day use of e-cigarettes; and (iv) regular use of e-cigarettes.

Awareness of e-cigarettes

Seven studies15-21 reported on the awareness of e-cigarettes among adolescents. Awareness of

e-cigarettes was reported at 50.3%, 77.3% and 90.1% in the US15 18 19. It was reported at

76.6% in Canada, 83.2%, in the UK, 85.3% in Finland and 89.6% in Ireland16 17 20 21.

Use of e-cigarettes

All of the studies reported on the use of e-cigarettes among adolescents. 17 studies reported

ever-use of e-cigarettes, 11 studies reported past 30 day use of e-cigarettes and four studies

reported regular use of e-cigarettes.

Ever-use was generally defined as previous use of an e-cigarette on at least one occasion (see

Table 1). Ever-use of e-cigarettes ranged from 6.5% to 31% in the US15 18 19 22-27. In the UK,

ever-use was reported at 8.2% and 12.3%17 31 It was reported at 4.7% in Germany28, 14.6% in

Canada16, 16.6% in Greece35, 17.4% in Finland17, 20.0% in New Zealand29, 24.0% in

Ireland21 and 38.5% in Romania30.

Past 30 day use was generally defined as use of an e-cigarette at least once in the past 30 days

(see Table 1). Past 30 day use of e-cigarettes ranged from 2.0% to 14.0% in the US15 18 19 22-25
27 31
. It was reported at 7.2% in Canada32 and 1.1% in Hong Kong33.

Regular use was generally defined as use of an e-cigarette with regular frequency (i.e. at least

once per month; see Table 1). Regular use of e-cigarettes was reported at 1.5% in the UK34,

0.5% in Greece35 and 3.2% in Ireland21. In addition, it was reported at 24% in Switzerland a 36.

Discussion

Data from a variety of international studies suggests upward trends in adolescent awareness

and use of e-cigarettes. Awareness of e-cigarettes appears to be moving towards complete

awareness, with later studies reporting awareness among at least three-quarters of the

adolescents surveyed. Ever-use of e-cigarettes is also higher than in previous years. Among

US samples, it is not uncommon to find ever-use rates of at least 20% among adolescents.

Outside of the US ever-use is lower, but comparative studies still suggest that reported rates

have doubled or tripled in recent years. Past 30 day use of e-cigarettes remains lower than

ever-use, yet still seems to be on the rise in some regions. While past 30 day use was

a
The Swiss study grouped “several times” and “regularly” together in their analysis (see Table 1)
generally reported at under 10% of adolescents, it was higher among US samples with some

studies reporting similar rates to non-US ever-use. Regular use of e-cigarettes is lower still,

with reported rates of under 3.2% in nicotine e-cigarettes.

Awareness of e-cigarettes

Data around adolescent awareness of e-cigarettes in the previous literature is sparse, however

data from the South Korean 2008 Health Promotion Fund Project suggested rates of

awareness at 10.2%37 and a survey of a 2011 nationally representative US sample reported

awareness at 67%38. Although we do not have longitudinal data to base inferences on, the

current literature review would seem to suggest that adolescent awareness of e-cigarettes is

getting increasingly closer to absolute awareness. Indeed, a cross-sectional comparison of

British data indicates that awareness rose from 66.8% in 2013 to 83.2% in 201422, which may

reflect a wider trend.

Research has not directly addressed how awareness of e-cigarettes may be influenced and

why awareness may have increased among adolescents. However, one of the reviewed

studies reports that a 53.2% majority of North Carolina adolescents heard about e-cigarettes

from television advertisements15, which provides one possible outlet for awareness in

countries where e-cigarette advertisements are not prohibited. Elsewhere, it may be the case

that as e-cigarettes have become more popular among adults1 2, adolescents have become

increasingly exposed to their use, either directly through friends and family or indirectly on

the street. Nonetheless, awareness of e-cigarettes does not necessarily entail use. In both the

UK and US adult populations, there is near full awareness of e-cigarettes among smokers and

non-smokers, yet this does not mean that there is anywhere near full ever and/or past 30 day

use of e-cigarettes among adults1 2 38. Although awareness is usually a prerequisite for use, it
would be impossible to protect adolescents from exposure to these products and possibly

undesirable to completely limit access to a potentially less harmful alternative for adolescent

smokers.

Ever-use of e-cigarettes

Previous surveys have placed ever-use of e-cigarettes at 1%, 6.1%, and 10.0% in the US38 40
41
, 0.5% and 4.7% in South Korea37 45, 8.1% in France43 and 9.1% in Lithuania44. In the prior

literature, analysis of Polish data indicates exceptionally high rates of ever e-cigarette use at

23.5% in 201145. If we exclude the Polish data and consider that the lowest US figures are

from 2011 and 2012 data, then it is clear that in recent years ever-use of e-cigarettes has

shifted from under 10% of adolescents to anything between 4.7% and 38.5%. Even if we

include the Polish data, some US studies and the Romanian study still display higher ever-use

rates. The Romanian data displays particularly high ever-use and we would suggest that this

may result from a definition of ever-use that also includes past 30 day use. However, it is also

worth considering that Eastern European countries maintain higher tobacco smoking rates46,

which may also explain the high rate of e-cigarette use in Poland. This broad increase in ever

use of e-cigarettes is illuminated by a cross-sectional comparison in the New Zealand data,

where ever-use almost tripled from 7.0% in 2012 to 20.0% in 201429.

There is limited literature regarding why adolescents might ever-use e-cigarettes. In the

reviewed literature, one study suggested that 34.2% of all adolescents felt that e-cigarettes

were less harmful compared to tobacco cigarettes and that 71.8% of adolescent ever-users

were more likely to perceive e-cigarettes as less harmful15. Another study indicated that 60%

of all adolescents reported that e-cigarettes were safe or a minor health hazard and that 53.4%

viewed e-cigarettes as less harmful than tobacco cigarettes19. Both of these studies open up
the possibility that initial use of e-cigarettes is motivated by a relative lack of concern around

any potential health risks. Unfortunately, owing to the lack of longitudinal data, we are

unable to explore any relationships between ever and past 30 day use of e-cigarettes.

However, the former study also suggests that ever-users are more likely than never-users to

perceive e-cigarettes as less harmful15, which could lead to more regular use of e-cigarettes. If

these users have not previously been exposed to nicotine via tobacco, some have speculated

that the highly addictive nature of nicotine may lead to continued use with negative

developmental implications for the adolescent brain7-9. At the same time, it is possible that

ever-users are using non-nicotine e-cigarettes, which would pose a reduced risk. Either way,

as ever-use can include using an e-cigarette once across the lifetime, the extent of increased

nicotine exposure as a result of ever e-cigarette use is unclear. Indeed, longitudinal research

has previously suggested that adolescents may experiment with legal and/or illegal

substances without becoming regular users in the long-term47-49 and this pattern is likely to be

reflected in adolescent e-cigarette ever-users.

Past 30 day use of e-cigarettes

Previous surveys in the US have documented year-on-year increases in past 30 day use of e-

cigarettes in adolescents from 1.5% (2011) to 2.8% (2012)40, 1.9% (2011) to 5.9% (2013)41

and 0.9% (2010) to 2.3% (2011)50. Elsewhere, past 30 day use was reported at 4.7% in South

Korea42, 8.2% in Poland45 and 13% in Hungary44. Hong Kong appears to have maintained

lower levels than those countries previously examined. However, both the US and Canada

display increased past 30 day use of e-cigarettes at levels that are either comparable or higher

than in all previous studies. Although longitudinal data sets are missing from the literature, it

is notable that a 2011 survey of Connecticut youth suggested that 2.5% were past 30 day

users31, while a 2013 survey of the same state found that 9.4% were past 30 day users18. This
sharp increase in past 30 day use of e-cigarettes mirrors that found in earlier US studies and

may consequently represent an upwards trend in the US.

Once again, there is limited literature regarding why adolescents might be past 30 day users

of e-cigarettes. However, a number of the reviewed studies report on how past 30 day e-

cigarette users may use tobacco alongside e-cigarettes. Across the studies that surveyed

adolescents on both e-cigarette and tobacco cigarette use, significant positive associations

were regularly found between past 30 day e-cigarette use and all levels of tobacco cigarette

use14 15 19 24 26 27 29. In particular, past 30 day users of e-cigarettes appear to have the highest

use of other tobacco products. For example, in Texas 93.5% of past 30 day e-cigarette users

had ever-used any tobacco product compared to 22.5% of ever e-cigarette users22, in Ontario

and Alberta significantly more (75.5%) past 30 day e-cigarette users reported past 30 day use

of any tobacco, shisha, or nicotine product28 and in the UK 80% of regular e-cigarette users

had also smoked tobacco31. The direction of this association is not explored in the studies.

Furthermore, longitudinal evidence is lacking for adolescent patterns of past 30 day tobacco

use in the same samples across the same period. However, a recent meta-analysis indicates a

strong association between tobacco use and all levels of e-cigarette use in both adolescent and

adult populations51. As there are higher odds ratios of tobacco use among adolescent e-

cigarette users, it is possible that this may reflect the propensity for adolescents to engage in

sensation seeking and risky behaviours52 53. Alternatively, if we consider recent trends in the

decline of tobacco use among US adolescents reported in the 2014 Monitoring the Future

survey54, there is the tentative possibility that adolescent past 30 day e-cigarette users have

been regular tobacco smokers and are dual-using or switching entirely to e-cigarettes as a

means of harm reduction and/or cessation. Nonetheless, there is a clear need for future

research to examine the direction of this association between tobacco and e-cigarette use.
Regular use of e-cigarettes

It is notable that three of the reviewed studies21 34 35 reported lower rates than the majority of

the North American studies that measured past 30 day use. This indicates that adolescents

may be less likely to use e-cigarettes on a regular basis. Moreover, it is possible that there are

cultural differences between North America and other regions that have led to different

patterns of use among adolescents. Indeed, the Hong Kong study also reported low rates of

past 30 day use at 1.1%33. In the current literature review, significantly fewer studies

measured regular use of e-cigarettes. For example, none of the North American studies

measured regular use. As such, we recommend that future studies measure the temporal

regularity of e-cigarette use (e.g. monthly, weekly, daily), so that it is easier to discern the

possible impact of cultural differences on nicotine consumption habits.

Second, it is of interest that 24% of the Swiss sample had tried e-cigarettes several times or

regularly, which is higher than all of the studies that measured past 30 day use. It is entirely

possible that this is a result of the combination of two quite different measurements (i.e.

“several times” and “regularly”) under the same category. However, it is also worth noting

that Switzerland is the only country in the current literature review where the sale of e-

cigarettes containing nicotine is entirely prohibited. This is reflected in the large number of

adolescents in this study who used non-nicotine e-cigarettes (74.6% of ever-users and 70.2%

of more regular users), which is significantly higher than in other studies that report on

nicotine content. As such, this anomaly in the reviewed literature may be attributed to the low

prevalence of nicotine e-cigarettes in Switzerland and may indicate that Swiss youth are not

using e-cigarettes as a means of nicotine consumption.

The nicotine content in e-cigarettes used by adolescents is rarely surveyed in the literature,

yet when it is surveyed nicotine e-cigarette use tends to be less prevalent. For example, in

Ontario 10.5% reported ever using a non-nicotine e-cigarette and 4.1% reported ever using a

nicotine e-cigarette16. Furthermore, those who had smoked tobacco in the past year were

more likely to use a nicotine e-cigarette. Similarly, in Connecticut, current cigarette smokers

were most likely to consistently use nicotine e-cigarettes (59.2%), followed by ever smokers

(31.9%) and never-smokers (11.4%)18. An exception is found in the Finnish data, where

65.7% of adolescent ever e-cigarette users had used nicotine e-cigarettes17. However, this

sample had a low rate (8.3%) of tobacco never smokers, which suggests that a number of

those using nicotine e-cigarettes may have previously used tobacco. As such, the above

studies support the argument that adolescent nicotine e-cigarette use is more likely among

those who are ever or current cigarette smokers. At the same time, some studies report that

20.4%, 34.3% and 61% of adolescents are unaware that e-cigarettes may contain nicotine18-20,

meaning that they may not be motivated by prior or current smoking habits. Either way,

future research should seek to expand our knowledge of nicotine e-cigarette use and

awareness by measuring it more widely.

Limitations

The current literature review is somewhat limited by possible differences in cultural

behaviours and regulations between countries. This is largely a result of the limited studies

that have been carried out in different countries to date. However, it may be useful for future

studies to review specific countries, or group together regions with similar cultural

behaviours and regulations. In addition, the regulatory environments for e-cigarettes are

constantly changing and developing. For example, the recent (May 2016) Tobacco Products

Directive (TPD) will change the ways in which e-cigarettes are advertised, sold and used
across the EU. As such, we highlight and recommend the need for regular literature reviews

of adolescent awareness and use of e-cigarettes, so that the research and practitioner

communities can remain up-to-date with this dynamic area.

Conclusions

To date, the literature has rarely examined patterns of nicotine and non-nicotine e-cigarette

use. If adolescents are ever using flavoured non-nicotine e-cigarettes, then this behaviour is

not necessarily problematic, aside from any potential risks posed by other constituents in the

vapour. On the other hand, although e-cigarettes may be less harmful than tobacco cigarettes,

if the user has never smoked tobacco then the use of nicotine e-cigarettes would involve

unnecessary exposure to nicotine. Limited data does indicate lower prevalence of e-cigarette

use among adolescent never smokers of tobacco. However, it also indicates that a small

proportion of e-cigarette users do not know whether their e-cigarettes contain nicotine or not.

Consequently, it may be important to explore health education strategies aimed at informing

adolescents about e-cigarettes and the possible risks involved with their use.

In addition, there is a need to investigate how past 30 day e-cigarette use may be associated

with tobacco abstinence, or a lack thereof. At present, it seems clear that past 30 day

adolescent users of e-cigarettes are more likely to use other tobacco products. However, the

nature of this association is unclear and it is important to discern whether regular use of e-

cigarettes is assisting adolescent smokers with tobacco abstinence or introducing adolescent

non-smokers to tobacco. As such, longitudinal studies that track the trajectory of use would

greatly aid our comprehension of how adolescents are using e-cigarettes in relation to

tobacco. Moreover, it is important for future studies to utilise qualitative methods as a means
of exploring in-depth how and why adolescents are using e-cigarettes. By answering these

questions in future research, we can move forward in understanding the extent to which e-

cigarettes pose either a risk to adolescent public health, or represent an opportunity to assist

with adolescent smoking prevention or cessation efforts.

Funding sources

This work is supported by Cancer Research UK grant C50882/A20492. The funding source

had no role or involvement at any stage of the literature review.

References

1. Use Of Electronic Cigarettes (Vapourisers) Among Adults In Great Britain. 2015.

Available at: http://www.ash.org.uk/files/documents/ASH_891.pdf. Accessed January 7,

2016.

2. McMillen R, Gottlieb M, Shaefer R, Winickoff J, Klein J. Trends in Electronic Cigarette

Use Among U.S. Adults: Use is Increasing in Both Smokers and Nonsmokers. Nicotine

& Tobacco Research. 2014;17(10):1195-1202. doi:10.1093/ntr/ntu213.

3. Goniewicz M, Knysak J, Gawron M et al. Levels of selected carcinogens and toxicants in

vapour from electronic cigarettes. Tobacco Control. 2013;23(2):133-139.

doi:10.1136/tobaccocontrol-2012-050859.

4. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes

when used to aid smoking cessation: a cross-sectional population study. Addiction.

2014;109(9):1531-1540. doi:10.1111/add.12623.
5. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking

cessation and reduction. Cochrane Database of Systematic Reviews. 2014.

doi:10.1002/14651858.cd010216.pub2.

6. Public Health England. E-Cigarettes: An Evidence Update; 2015.

7. Gornall J. Public Health England’s troubled trail. BMJ. 2015:h5826.

doi:10.1136/bmj.h5826.

8. Goriounova N, Mansvelder H. Short- and Long-Term Consequences of Nicotine Exposure

during Adolescence for Prefrontal Cortex Neuronal Network Function. Cold Spring

Harbor Perspectives in Medicine. 2012;2(12):a012120-a012120.

doi:10.1101/cshperspect.a012120.

9. Goriounova N, Mansvelder H. Nicotine exposure during adolescence alters the rules for

prefrontal cortical synaptic plasticity during adulthood. Front Syn Neurosci. 2012;4.

doi:10.3389/fnsyn.2012.00003.

10. Dwyer J, McQuown S, Leslie F. The dynamic effects of nicotine on the developing brain.

Pharmacology & Therapeutics. 2009;122(2):125-139.

doi:10.1016/j.pharmthera.2009.02.003.

11. Nice.org.uk. Smoking: harm reduction | Guidance and guidelines | NICE. 2013.

Available at: https://www.nice.org.uk/guidance/ph45. Accessed June 7, 2016.

12. Hildick-Smith G, Pesko M, Shearer L et al. A Practitioner's Guide to Electronic

Cigarettes in the Adolescent Population. Journal of Adolescent Health. 2015;57(6):574-

579. doi:10.1016/j.jadohealth.2015.07.020.

13. Durmowicz E. The impact of electronic cigarettes on the paediatric population. Tobacco
 Control. 2014;23(Supplement 2):ii41-ii46. doi:10.1136/tobaccocontrol-2013-051468.

14. Carroll Chapman S, Wu L. E-cigarette prevalence and correlates of use among

adolescents versus adults: A review and comparison. Journal of Psychiatric Research.

2014;54:43-54. doi:10.1016/j.jpsychires.2014.03.005.

15. Amrock S, Zakhar J, Zhou S, Weitzman M. Perception of E-Cigarette Harm and Its

Correlation With Use Among U.S. Adolescents. Nicotine & Tobacco Research.

2014;17(3):330-336. doi:10.1093/ntr/ntu156.

16. Hamilton H, Ferrence R, Boak A et al. Ever Use of Nicotine and Nonnicotine Electronic

Cigarettes Among High School Students in Ontario, Canada. Nicotine & Tobacco

Research. 2014;17(10):1212-1218. doi:10.1093/ntr/ntu234.

17. Kinnunen J, Ollila H, El-Amin S, Pere L, Lindfors P, Rimpelä A. Awareness and

determinants of electronic cigarette use among Finnish adolescents in 2013: a

population-based study. Tobacco Control. 2014;24(e4):e264-e270.

doi:10.1136/tobaccocontrol-2013-051512.

18. Krishnan-Sarin S, Morean M, Camenga D, Cavallo D, Kong G. E-cigarette Use Among

High School and Middle School Adolescents in Connecticut. Nicotine & Tobacco

Research. 2014;17(7):810-818. doi:10.1093/ntr/ntu243.

19. Anand V, McGinty K, O'Brien K, Guenthner G, Hahn E, Martin C. E-cigarette Use and

Beliefs Among Urban Public High School Students in North Carolina. Journal of

Adolescent Health. 2015;57(1):46-51. doi:10.1016/j.jadohealth.2015.03.018.

20. Eastwood B, Dockrell M, Arnott D et al. Electronic cigarette use in young people in Great

Britain 2013-2014. Public Health. 2015;129(9):1150-1156.

doi:10.1016/j.puhe.2015.07.009.
21. Babineau K, Taylor K, Clancy L. Electronic Cigarette Use among Irish Youth: A Cross

Sectional Study of Prevalence and Associated Factors. PLOS ONE.

2015;10(5):e0126419. doi:10.1371/journal.pone.0126419.

22. Dutra L, Glantz S. Electronic Cigarettes and Conventional Cigarette Use Among US

Adolescents. JAMA Pediatrics. 2014;168(7):610.

doi:10.1001/jamapediatrics.2013.5488.

23. Gilreath T, Leventhal A, Barrington-Trimis J et al. Patterns of Alternative Tobacco

Product Use: Emergence of Hookah and E-cigarettes as Preferred Products Amongst

Youth. Journal of Adolescent Health. 2016;58(2):181-185.

doi:10.1016/j.jadohealth.2015.10.001.

24. Bostean G, Trinidad D, McCarthy W. E-Cigarette Use Among Never-Smoking California

Students. Am J Public Health. 2015;105(12):2423-2425. doi:10.2105/ajph.2015.302899.

25. Cooper M, Case K, Loukas A. E-cigarette use among Texas youth: Results from the 2014

Texas Youth Tobacco Survey. Addictive Behaviors. 2015;50:173-177.

doi:10.1016/j.addbeh.2015.06.034.

26. Wills T, Sargent J, Knight R, Pagano I, Gibbons F. E-cigarette use and willingness to

smoke: a sample of adolescent non-smokers. Tobacco Control. 2015:tobaccocontrol-

2015-052349. doi:10.1136/tobaccocontrol-2015-052349.

27. Barnett T, Soule E, Forrest J, Porter L, Tomar S. Adolescent Electronic Cigarette Use:

Associations With Conventional Cigarette and Hookah Smoking. American Journal of

Preventive Medicine. 2015;49(2):199-206. doi:10.1016/j.amepre.2015.02.013.

28. Hanewinkel R, Isensee B. Risk factors for e-cigarette, conventional cigarette, and dual

use in German adolescents: A cohort study. Preventive Medicine. 2015;74:59-62.

 doi:10.1016/j.ypmed.2015.03.006.

29. White J, Li J, Newcombe R, Walton D. Tripling Use of Electronic Cigarettes Among

New Zealand Adolescents Between 2012 and 2014. Journal of Adolescent Health.

2015;56(5):522-528. doi:10.1016/j.jadohealth.2015.01.022.

30. Nădăşan V, Foley K, Pénzes M et al. Use of electronic cigarettes and alternative tobacco

products among Romanian adolescents. International Journal of Public Health. 2016.

doi:10.1007/s00038-015-0774-8.

31. Camenga D, Kong G, Cavallo D et al. Alternate Tobacco Product and Drug Use Among

Adolescents Who Use Electronic Cigarettes, Cigarettes Only, and Never Smokers.

Journal of Adolescent Health. 2014;55(4):588-591.

doi:10.1016/j.jadohealth.2014.06.016.

32. Czoli C, Hammond D, Reid J, Cole A, Leatherdale S. Use of Conventional and

Alternative Tobacco and Nicotine Products Among a Sample of Canadian Youth.

Journal of Adolescent Health. 2015;57(1):123-125.

doi:10.1016/j.jadohealth.2015.03.006.

33. Wang M, Ho S, Leung L, Lam T. Electronic cigarette use and its association with

smoking in Hong Kong Chinese adolescents. Addictive Behaviors. 2015;50:124-127.

doi:10.1016/j.addbeh.2015.06.037.

34. Moore G, Hewitt G, Evans J et al. Electronic-cigarette use among young people in Wales:

evidence from two cross-sectional surveys. BMJ Open. 2015;5(4):e007072-e007072.

doi:10.1136/bmjopen-2014-007072.

35. Fotiou A, Kanavou E, Stavrou M, Richardson C, Kokkevi A. Prevalence and correlates of

electronic cigarette use among adolescents in Greece: A preliminary cross-sectional

 analysis of nationwide survey data. Addictive Behaviors. 2015;51:88-92.

doi:10.1016/j.addbeh.2015.07.021.

36. Surís J, Berchtold A, Akre C. Reasons to use e-cigarettes and associations with other

substances among adolescents in Switzerland. Drug and Alcohol Dependence.

2015;153:140-144. doi:10.1016/j.drugalcdep.2015.05.034.

37. Cho J, Shin E, Moon S. Electronic-Cigarette Smoking Experience Among Adolescents.

Journal of Adolescent Health. 2011;49(5):542-546.

doi:10.1016/j.jadohealth.2011.08.001.

38. Pepper J, Reiter P, McRee A, Cameron L, Gilkey M, Brewer N. Adolescent Males'

Awareness of and Willingness to Try Electronic Cigarettes. Journal of Adolescent

Health. 2013;52(2):144-150. doi:10.1016/j.jadohealth.2012.09.014.

39. King B, Patel R, Nguyen K, Dube S. Trends in Awareness and Use of Electronic

Cigarettes Among US Adults, 2010-2013. Nicotine & Tobacco Research.

2014;17(2):219-227. doi:10.1093/ntr/ntu191.

40. Corey C, Wang B, Johnson S et al. Electronic Cigarette Use Among Middle and High

School Students - United States, 2011-2012. Morbidity and Mortality Weekly Report.

2013;62:729-730.

41. Bunnell R, Agaku I, Arrazola R et al. Intentions to Smoke Cigarettes Among Never-

Smoking US Middle and High School Electronic Cigarette Users: National Youth

Tobacco Survey, 2011-2013. Nicotine & Tobacco Research. 2014;17(2):228-235.

doi:10.1093/ntr/ntu166.

42. Lee S, Grana R, Glantz S. Electronic Cigarette Use Among Korean Adolescents: A

Cross-Sectional Study of Market Penetration, Dual Use, and Relationship to Quit

 Attempts and Former Smoking. Journal of Adolescent Health. 2014;54(6):684-690.

doi:10.1016/j.jadohealth.2013.11.003.

43. Dautzenberg B, Birkui P, Noël M, Dorsett J, Osman M, Dautzenberg M. E-Cigarette: A

New Tobacco Product for Schoolchildren in Paris. OJRD. 2013;03(01):21-24.

doi:10.4236/ojrd.2013.31004.

44. German Cancer Research Center. Electronic Cigarettes - An Overview. Heidelberg; 2013.

Available at: https://www.dkfz.de/en/presse/download/RS-Vol19-E-Cigarettes-EN.pdf.

Accessed January 7, 2016.

45. Goniewicz M, Zielinska-Danch W. Electronic Cigarette Use Among Teenagers and

Young Adults in Poland. Pediatrics. 2012;130(4):e879-e885. doi:10.1542/peds.2011-

3448.

46. Bogdanovica I, Godfrey F, McNeill A, Britton J. Smoking prevalence in the European

Union: a comparison of national and transnational prevalence survey methods and

results. Tobacco Control. 2010;20(1):e4-e4. doi:10.1136/tc.2010.036103.

47. Perkonigg A, Lieb R, Hofler M, Schuster P, Sonntag H, Wittchen H. Patterns of cannabis

use, abuse and dependence over time: incidence, progression and stability in a sample of

1228 adolescents. Addiction. 1999;94(11):1663-1678. doi:10.1046/j.1360-

0443.1999.941116635.x.

48. Parker H, Williams L, Aldridge J. The Normalization of 'Sensible' Recreational Drug

Use: Further Evidence from the North West England Longitudinal Study. Sociology.

2002;36(4):941-964. doi:10.1177/003803850203600408.

49. Sweeting H, West P. Drug use over the youth–adult transition in a west of Scotland

cohort: Prevalence, pathways and socio-demographic correlates. Addiction Research &

 Theory. 2008;16(5):474-494. doi:10.1080/10929080802028729.

50. Camenga D, Delmerico J, Kong G et al. Trends in use of electronic nicotine delivery

systems by adolescents. Addictive Behaviors. 2014;39(1):338-340.

doi:10.1016/j.addbeh.2013.09.014.

51. Wang M, Wang J, Cao S, Wang H, Hu R. Cigarette Smoking and Electronic Cigarettes

Use: A Meta-Analysis. International Journal of Environmental Research and Public

Health. 2016;13(1):120. doi:10.3390/ijerph13010120.

52. Steinberg L. Risk Taking in Adolescence: New Perspectives From Brain and Behavioral

Science. Current Directions in Psychological Science. 2007;16(2):55-59.

doi:10.1111/j.1467-8721.2007.00475.x.

53. Steinberg L. A social neuroscience perspective on adolescent risk-taking. Developmental

Review. 2008;28(1):78-106. doi:10.1016/j.dr.2007.08.002.

54. Johnston, LD, O'Malley, PM, Miech, RA, Bachman, JG, & Schulenberg, JE. Monitoring

the Future National Survey Results on Drug Use: 1975-2014: Overview, Key Findings

on Adolescent Drug Use. Ann Arbor; Institute for Social Research, The University of

Michigan; 2015.
Table 1: Definitions of ever-use, past 30 day use and regular use
in identified studies
Citation Ever-use of e-cigarette
Amrock SM, Those who responded “electronic cigarettes
Zakhar J, Zhou S, or e-cigarettes, such as Ruyan or NJOY” to
& Weitzman M the question “Which of the following
(2014) tobacco products have you ever tried, even
just one time?”
Camenga DR, Those who chose <1 day in response to
Kong G, Cavallo question: “In the past 30 days have you
DA et al. (2014) used any of the following tobacco
products?” Choices included e-cigarettes
(an electronic cigarette that is filled with
liquid nicotine and emits “smoke” vapor).
Dutra LM & Those who responded “electronic cigarettes
Glantz SA (2014) or e-cigarettes, such as Ruyan or NJOY,” to
the question “Which of the following
tobacco products have you ever tried, even
just 1 time?”
Hamilton HA, Those who reported smoking an e-cigarette
Ferrence R, Boak with nicotine or smoking an e-cigarette
A, Schwartz R et al without nicotine in response to the question
(2014) “Electronic cigarettes, or e-cigarettes, are
electronic devices made in the shape of
cigarettes that create an inhaled mist
without odour. Have you ever smoked at
least one puff from an electronic
Past 30 day use of e-cigarette Regular use of e-cigarette
Those who reported that they had N/A
used e-cigarettes on at least one of the
past 30 days.
Those who chose ≥1 day in response N/A
to question: “In the past 30 days have
you used any of the following tobacco
products?” Choices included e-
cigarettes (an electronic cigarette that
is filled with liquid nicotine and emits
“smoke” vapor).
Those who responded “e-cigarettes” N/A
to the question “During the past 30
days, which of the following tobacco
products did you use on at least 1
day?”
N/A N/A
 cigarette?”

Kinnunen JM, Those who responded “I have tried once or N/A N/A
Ollila H, El-Amin twice”, “I have tried 20 times or less”, or “I
SET, Pere LA et al. have tried more than 20 times” to the
(2014) question “Have you ever tried electronic
cigarettes? How many times altogether?”

Krishnan-Sarin S, Those who reported that they had tried an Those who reported use in the past 30 N/A
Morean M, e-cigarette in response to the question days in response to the question
Camenga D, “Have you tried e-cigarettes?” “Have you tried e-cigarettes?”
Cavallo DA et al.
(2014)

Anand V, McGinty Results differentiate between “ever use” Results differentiate between “ever N/A
KL, O'Brien K, and “past 30 day use”. use” and “past 30 day use”.
Guenthner G et al.
(2015) Those who reported “I have tried an e- N/A Those who reported “I smoke an
cigarette once or twice but don’t use one e-cigarette at least once a month”,
Babineau K, regularly” or “I used to smoke e-cigarettes “I smoke an e-cigarette at least
Taylor K & but have given up” in response to being once a week” or “I smoke an e-
Clancy, L (2015) asked to describe themselves. cigarette every day” in response to
being asked to describe
themselves.
Barnett TE, Soule Those who responded “Yes” to the question Those who responded “Yes” to the N/A
EK, Forrest JR, “Have you ever tried, even once, using an question “During the past 30 days,
Porter, L et al. electronic cigarette?” have you used an electronic
(2015) cigarette?”

Bostean G, Those who reported that they had used e- Those who reported that they had N/A
Trinidad DR, & cigarettes at least once in their lifetime. used e-cigarettes at least once in the
McCarthy WJ past 30 days.
(2015)

Cooper M, Case Those who responded “Yes” to the question Those who reported use on at least N/A
KR, & Loukas A “Have you ever tried using electronic one day in response to the question
(2015) cigarettes or e-cigarettes, such as Ruyan or “During the past 30 days, on how
NJOY?” many days did you use electronic
cigarettes or e-cigarettes, such as
Ruyan or NJOY?”

Czoli CD, N/A Those who responded “E-cigarettes” N/A

Hammond D, Reid in response to the question ““In the
JL, Cole AG et al. last 30 days, did you use any of the
(2015) following?”

Eastwood B, Those who reported “I have tried them once N/A N/A
Dockrell MJ, or twice”, “I use them sometimes”, or “I
Arnott D, Britton J use them often” in response to being asked
et al. (2015) to describe their experience of e-cigarettes.

Fotiou A, Kanavou Those who responded “Yes, only 1–2 N/A Those who responded “Yes, more
E, Stavrou M, times” or “Yes, more than twice, but I don't than twice and I use it now” to the
Richardson C et al. use it now” to the question “Have you ever question “Have you ever used
(2015) used electronic cigarettes?” electronic cigarettes?”

Gilreath TD, Those who reported an age of first use, but Those who reported an age of first use N/A
Leventhal A, no use in the past 30 days. and use in the past 30 days.
Barrington-Trimis
JL, et al. (2016)

Hanewinkel R, & Those who responded “Yes” to the question N/A N/A
Isensee B (2015) “Have you ever used an electronic
cigarette?”
Moore G, Hewitt Those who responded “I have used e- N/A Those who responded “I regularly
G, Evans J, cigarettes on a few occasions (1–5 times)” use e-cigarettes (at least once a
Littlecott HJ et al. to being asked if they had ever used an e- month)” to being asked if they had
(2015) cigarette. ever used an e-cigarette.

Those who responded “yes” for “e- N/A N/A

Nădăşan V, Foley cigarettes” to the question “Which of the
KL, Pénzes M et al. following products have you ever tried?”
(2016)

Surís JC, Those who responded “Only once” to the N/A Those who responded “Several
Berchtold A, & question “Have you ever tried e- times” or “Regularly” to the
Akre C (2015) cigarettes?” question “Have you ever tried e-
cigarettes?”

Wang MP, Ho SY, Those who responded “No” to a question Those who responded “Yes” to a N/A
Leung LT, & Lam on e-cigarette use in the past 30 days. question on e-cigarette use in the past
TH (2015) 30 days.

White J, Li J, Those who responded “Yes” to the question N/A N/A

Newcombe R, & “Have you ever tried electronic cigarettes?”
Walton D (2015)

Wills TA, Sargent Those who reported 1–2 times, 3–4 times, N/A N/A
JD, Knight R, yearly, monthly, weekly or daily use in
Pagano I et al. response to the question “Which of the
(2015) following is most true for you about
smoking electronic cigarettes (E-cigarettes,
Volcanos)?”
Table 2: Identified studies examining adolescent awareness and/or use of e-cigarettes
Citation Data source Country Sample size Age group Study type Awareness and/or use

Amrock SM, Zakhar J, 2012 National Youth US 24,658 12-17 years Cross- 50.3% had heard of e-cigarettes
Zhou S, & Weitzman M Tobacco Survey sectional 6.8% were ever-users
(2014)
2.1% were past 30 day users

Camenga DR, Kong G, 2011 survey US 1556 14-18 years Cross- 2.5% were past 30 day users
Cavallo DA et al. (2014) (Connecticut) sectional

Dutra LM & Glantz SA 2011 & 2012 National US 17,353 12-17 years Cross- Ever-use increased from 3.1%
(2014) Youth Tobacco Survey (2011) sectional (2011) to 6.5% (2012)
22,529 Past 30 day use increased from
(2012) 1.1% (2011) to 2.0% (2012)

Hamilton HA, Ferrence 2013 Ontario Student Canada 2892 11-19 years Cross- 62% had heard of e-cigarettes
R, Boak A, Schwartz R Drug Use and Health (Ontario) sectional 14.6% were ever-users
et al (2014) Survey

Kinnunen JM, Ollila H, 2013 Adolescent Health Finland 3535 12-18 years Cross- 85.3% were aware of e-cigarettes
El-Amin SET, Pere LA and Lifestyle Survey sectional 17.4% were ever-users
et al. (2014)

Krishnan-Sarin S, 2013 survey US 4780 11-18 years Cross- 92.0% had heard of e-cigarettes
Morean M, Camenga D, (Connecticut) sectional 20.0% were ever-users
Cavallo DA et al. (2014)
9.4% were past 30 day users

Anand V, McGinty KL, 2013 survey US 2769 14-18 years Cross- 77.3% were aware of e-cigarettes
O'Brien K, Guenthner G (North Carolina) sectional 15.2% were ever-users
et al. (2015) 7.4% were past 30 day users

Babineau K, Taylor K & 2014 survey Ireland 821 16-17 years Cross- 89.6% were aware of e-cigarettes
Clancy, L (2015) sectional 24.0% were ever-users
3.2% were regular users

Barnett TE, Soule EK, 2013 Florida Youth US 12,615 11-18 years Cross- 8.7% were ever-users
Forrest JR, Porter, L et Tobacco Survey sectional 3.9% were past 30 day users
al. (2015) (Florida)

Bostean G, Trinidad DR, 2013-14 California US 482,179 11-18 years Cross- 24.4% were ever-users
& McCarthy WJ (2015) Healthy Kids Survey (California) sectional 12.9% were past 30 day users

Cooper M, Case KR, & 2014 Texas Youth US 13,602 11-18 years Cross- 23.6% were ever-users
Loukas A (2015) Tobacco Survey (Texas) sectional 14.0% were past 30 day users

Czoli CD, Hammond D, 2013-14 COMPASS Canada 44,163 14-18 years Cross- 7.2% were past 30 day users
Reid JL, Cole AG et al. survey (Ontario & Alberta) sectional
(2015)

Eastwood B, Dockrell 2013 & 2014 YouGov UK 2062 (2013) 11-18 years Cross- Awareness increased from 66.8%
MJ, Arnott D, Britton J survey 1952 (2014) sectional (2013) to 83.2% (2014)
et al. (2015) Ever-use increased from 4.6%
(2013) to 8.2% (2014)

Fotiou A, Kanavou E, 2014 Health Behaviour Greece 1320 15 years Cross- 16.6% were ever-users
Stavrou M, Richardson in School-aged Children sectional 0.5% were regular users
C et al. (2015) Survey
Gilreath TD, Leventhal 2014 Southern California US 2091 16-18 years Cross- 14.4% were ever-users
A, Barrington-Trimis Children’s Health Study (Southern sectional 9.6% were past 30 day users
JL, et al. (2015) California)

Hanewinkel R, & Isensee 2010, 2012 & 2014 Germany 3444 (2010) 10-14 years Cohort 4.7% were ever-users
B (2015) Eigenständig werden (Bremen, Hesse, 2693 (2014) study
study North Rhine-
Westphalia,
Schleswig-Holstein)

Moore G, Hewitt G, 2014 Health Behaviour UK 9055 11-18 years Cross- 12.3% were ever-users
Evans J, Littlecott HJ et in School-aged Children (Wales) sectional 1.5% were regular users
al. (2015)

Nădăşan V, Foley KL, 2014 ASPIRE-Romania Romania 1835 14-15 years Cross- 38.5% were ever-users
Pénzes M et al. (2016) sectional

Surís JC, Berchtold A, & 2014 ado@internet.ch Switzerland 621 16 years Cross- 19% were ever-users
Akre C (2015) survey (French-speaking) sectional 24% were regular users

Wang MP, Ho SY, 2012-13 survey Hong Kong 45,128 12-17 years Cross- 1.1% were past 30 day users
Leung LT, & Lam TH sectional
(2015)

White J, Li J, Newcombe 2012 & 2014 Youth New Zealand 3017 (2012) 14-15 years Cross- Ever-use increased from 7.0%
R, & Walton D (2015) Insights Survey 2855 (2014) sectional (2012) to 20.0% (2014)

Wills TA, Sargent JD, 2013-14 survey US 2309 14-18 years Cross- 31% were ever-users
Knight R, Pagano I et al. (Oahu, Hawaii) sectional
(2015)
Figure 1: Study selection flow diagram