Factors Influencing The Use of E-Cigarettes

PROJECT
CALIFORNIA STATE UNIVERSITY SAN MARCOS
PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE
MASTER OF PUBLIC HEAL TH
TITLE: Factors Influencing the Use ofE-Cigarettes Among Adolescents and Young Adults
AUTHOR(S): Krupali Desai, Dipen Patel
DATE OF SUCCESSFUL DEFENSE: 11/19/2019
THE PROJECT HAS BEEN ACCEPTED BY THE PROJECT COMMITTEE IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF PUBLIC HEAL TH
Asherlev Santos May 4, 2020

COMMITTEE CHAIR SIGNATURE DATE
Kimberley Pulvers May 4, 2020

COMMITTEE MEMBER SIGNATURE DATE

Running Head: FACTORS INFLUENCING THE USE OF E-CIGARETTES AMONG 1
ADOLESCENTS AND YOUNG ADULTS
Title: FACTORS INFLUENCING THE USE OF E-CIGARETTES AMONG

ADOLESCENTS AND YOUNG ADULTS
Presented by
Krupali Girish Desai
Dipen M Patel
CSUSM
Thesis Chair Committee: Dr. AsherLev Santos

Thesis Committee Member: Dr. Kim Pulvers
FACTORS INFLUENCING THE USE OF E-CIGARETTES 2
Table of Contents
List of tables ............................................................................................................................................ 4
List of figures .......................................................................................................................................... 5
Chapter 1: Introduction of study .......................................................................................................... 6
Aim: ......................................................................................................................................................... 7
Goal 1:.................................................................................................................................................................. 7
Goal 2:.................................................................................................................................................................. 8
Chapter 2: Literature Review................................................................................................................ 9
Background .......................................................................................................................................................... 9
What are e-cigarette and its history? .................................................................................................................. 10
Prevalence of E-cigarette ................................................................................................................................... 12
Health effect due to e-cigarette smoking............................................................................................................ 14
Theory of Triadic Influence (TTI) ..................................................................................................................... 18
Awareness about Electronic Cigarettes and use ................................................................................................. 26
Chapter 3: National Youth Tobacco Survey - 2018 ........................................................................... 29
Introduction ........................................................................................................................................................ 29
Goal 1 ................................................................................................................................................................. 30
Specific Objectives ............................................................................................................................................ 30
Study Procedure and Sampling .......................................................................................................................... 31
Study method ..................................................................................................................................................... 32
Results ................................................................................................................................................................ 37
Discussion .......................................................................................................................................................... 43
Global Relevance ............................................................................................................................................... 46
Limitation ........................................................................................................................................................... 48
Chapter 4: California State University San Marcos Campus Survey ............................................. 49
Goal 2 ................................................................................................................................................................. 49
Hypothesis.......................................................................................................................................................... 49
Study Procedure and Study Population .............................................................................................................. 49
Study method ..................................................................................................................................................... 50
Results ................................................................................................................................................................ 53
Discussion .......................................................................................................................................................... 55
Global Relevance ............................................................................................................................................... 57
Limitation ........................................................................................................................................................... 58
Chapter 5: Discussion ........................................................................................................................... 59
Application of the Theory of Triadic Influence in Findings .............................................................................. 59
Chapter 6: Global Health Relevance .................................................................................................. 68
Chapter 7: Conclusion.......................................................................................................................... 71
Recommendation for future ............................................................................................................................... 73
Chapter 8: References .......................................................................................................................... 74
Appendix A............................................................................................................................................ 94
List of tables
Table 1: Application of Theory of Triadic Influence (TTI) model ............................................... 34
Table 2: Demographic Variables of the student population ......................................................... 37
Table 3: Various reasons and media channels advertisements among total population from NYTS-
2018 (n=19796)............................................................................................................................. 39
Table 4: Logistic regression .......................................................................................................... 41
Table 5: Dependent and Independent variables with application of Theory of Triadic Influence
(TTI), CSUSM survey. ................................................................................................................. 51
Table 6: Demographic characteristic of the study population, CSUSM survey-2019 (n=130) .... 53
Table 7: Descriptive frequencies of variables among the e-cigarette users from CSUSM survey-
2019 (n=47)................................................................................................................................... 54
List of figures
Figure 1: Parts and design of e-cigarettes. .................................................................................... 11
Figure 2: Types of e-cigarettes ..................................................................................................... 11
Figure 3: Prevalence of e-cigarette use among adolescents in the US ......................................... 13
Figure 4: Prevalence of e-cigarette use among adults in the US. ................................................. 13
Figure 5: Summary of positive, negative, and neutral symptoms and their associated systems .. 16
Figure 6: Theory of Triadic Influence .......................................................................................... 19
Figure 7: Application of TTI framework for factors influencing e-cigarette use. ........................ 19
Figure 8: Growth in e-cigarette market at a Compound Annual Growth Rate (CAGR). ............. 24
Figure 9: Estimated market growth rate by region from 2019-2024. ........................................... 26
Figure 10: Odds ratio of various media channels ads and covariates for e-cigarette use. ............ 42
Chapter 1: Introduction of study
Tobacco use has prevailed in our society for decades. Over the time it has been available
in various forms. The latest tobacco form trending in the society is as an electronic cigarette. E-
cigarettes are defined as battery-operated products that deliver nicotine without the burning of
tobacco (Glasser, et al., 2017). They are available in different shapes and forms, with a variety of
flavors (Electronic Cigarettes, 2019). The basic idea behind the introduction of e-cigarette was as
an alternative to conventional tobacco smoking and as a smoking cessation tool. E-cigarette has a
long history from 1927 to 2006. Joseph Robinson in 1927 came up with an idea of e-cigarette and
the first commercial e-cigarette was invented by Honk Lik in 2003 and was introduced to the
market in 2006 (Cummings et.al., 2014 and Historical Timeline of Electronic Cigarettes (n.d.)).
Within the first decade of introduction to the market, the e-cigarette use has increased
worldwide, especially among adolescents and young. According to the National Youth Tobacco
Survey (NYTS), in the United States 5.3 million youths use e-cigarettes. Of those 5.3 million
youths, 20.8% were in high school and 4.9% were in middle school. (CDC, Youth and Tobacco
Use 2019). According to 2018 National Health Interview Survey prevalence of e-cigarette use
among young adults in the US was 7.6% (Truth Initiatives, 2019). Surveys of students of Polish
schools and universities show prevalence of e-cigarette use is 23.5% for 15-19 years and 19% for
20-24 years old (Goniewicz & Zielinska-Danch, 2012). In a Mexico survey, prevalence of e-
cigarette trial was 7% among adolescents, 3% adult nonsmokers and 18% adult smokers (Zavala-
Arciniega, et al., 2018).
Sales of e-cigarettes have been increasing tremendously since 2007. Compound Annual
Growth Rate (CAGR) is a term used for the geometric progression ratio that provides a constant
rate of return over time and it is predicted that the e-cigarette market is expected to grow at a
CAGR of 21.4% rise from 2019 to 2024 reaching nearly USD 53.4 billion (Kumar K., 2019). With
this increased use and sales of e-cigarettes, there is still a question regarding the safety of e-
cigarette use. Advertising of e-cigarette portrays it to be safer than conventional tobacco and as a
smoking cessation tool, targeting a large adolescent and young adult population (Zhu, et al., 2014).
Various studies have been carried out giving cautious signal of it being harmful (Hua, Alfi,
& Talbot, 2013; Lerner, et al., 2015 & Sussan, et al., 2015). Effect of nicotine has a long-term
effect and e-cigarettes being new to market still studies need to be carried out, to determine the
pros and cons of its use.
This project seeks to understand the factors contributing to e-cigarette use among
adolescents and young adults. The data showing increased prevalence among youth, and the
potential health impacts is the basis for our project. Our project primary aim and related goals and
objectives are as follows:
Aim: To assess factors contributing to the use of e-cigarette
Goal 1: Review the National Youth Tobacco Survey-2018.
Specific Objective:
Objective 1: To determine if there is variation for e-cigarette use by age groups
Objective 2: To analyze if there is a difference among gender for e-cigarette use.
Objective 3: To determine if there is difference among different grade levels for e-
cigarette use.
Objective 4: To analyze e-cigarette use among different races.
Objective 5: To analyze various reasons influencing the use of e-cigarette among
the users
Objective 6: To determine the influence of media channels advertisements among
e-cigarette users
Goal 2: Survey California State University San Marcos students
Specific Objectives:
Objective 1: To analyze if media has higher influence for e-cigarette use
compared to other factors.
Objective 2: To determine whether internet media has higher influence for e-
cigarette use compared to other media channels .

Chapter 2: Literature Review
Background
Smoking is one of the major epidemics prevailing globally. Smoking is one of the leading
causes of preventable diseases, affecting overall morbidity and mortality rate. According to World
Health Organization (WHO), around 8 million people die due to tobacco use every year. Of those
8 million, 7 million people die due to direct tobacco use and 1.2 million people die due to
secondhand smoke (WHO, Tobacco, 2019). The life expectancy of smokers decreases by 10 years.
Over time the forms of tobacco has been changing and are available as cigarettes, bidis,
hookah, cigars, water pipes, e-cigarettes etc. in the market. According to global smoking statistics
6.5 trillion cigarettes are sold every year, which comprises approximately 18 billion cigarettes sold
per day (Martin, 2019). Around 80% of 1.1 billion smokers estimated worldwide are from low-
and middle-income countries (WHO, Tobacco, 2019).
If we look for smoking data in the US, daily 2000 people below the age of 18 try their first
cigarette and around 300 become addicted to daily smoking. If this rate of smoking continues at
the same level, it is estimated that in the US, 5.6 million youths, younger than 18 years will die
prematurely in the US (CDC, Smoking & Tobacco Use, 2019). In the United States 480,000 people
die every year due to smoking and 41,000 die due to secondhand smoke exposure (CDC, Smoking
& Tobacco Use, 2019). Nine out of ten cigarette smokers try their first cigarette before the age of
18 (CDC, Youth and Tobacco Use, 2019).
There is a detrimental effect on the overall biological systems of the body. The effect of
smoking is not immediate, but in the long term it causes harm. Tobacco use can cause lung cancer
and affect various vital organs of the body such as the oral laryngeal, esophageal, stomach, liver,
kidney, bladder, pancreas, pharyngeal (Tao et.al., 2013). A cardiovascular disease (CVD) which
is one of the leading causes of death worldwide is interrelated to smoking (Prasad et.al., 2009).
From the study it was found that tobacco use can lead to sudden heart collapse, coronary artery
spasm, and cardiac arrhythmias and reduced capacity of blood to deliver oxygen. Smoking also
affects pregnancy leading to low birth rate, affecting the neurodevelopment of child (Wehby GL
et al., 2012; Inoue et al., 2017). Due to smoking, there is risk for abdominal obesity in females due
to increased testosterone levels and it also reduces attractiveness in females (Polkki et al., 2009).
E-cigarettes are the latest form of tobacco, and are advertised as being less harmful and a
smoking cessation tool. Within the decade of introduction of e-cigarette to the market, the use has
increased tremendously. It has gained popularity especially among adolescents and young adults.
E-cigarettes advertisements have played a vital role in bringing popularity. Media advertisement
is used as a platform to reach millions of adolescents and young adults and has played a crucial
role in bringing increased awareness regarding e-cigarettes. E-cigarette advertisements appear in
various media such as television, magazines, retail shops, and internet. Although few studies have
explored various factors influencing e-cigarette use among adolescents and young adults, the
existing data are lacking to understand the various factors influencing e-cigarette and see if media
is related to those factors for increased use of e-cigarettes among adolescents and young adults.
What are e-cigarette and its history?
Electronic cigarettes are known as e-cigarettes, e-vaporizers or electronic nicotine delivery
systems (ENDS) and alternative nicotine delivery system (ANDS). They are battery operated
devices which contains nicotine, flavoring agents and other chemicals. They may look similar to
traditional cigars, cigarettes and pipes and may resemble pens and USB memory sticks. The
appellation names are e-cigs, e-hookahs, hookah pens, vapes, vape pens and mods (customizable,
more powerful vaporizers). Resembling in different shapes and sizes, e-cigarettes have four main
components: the first component is a cartridge or reservoir, which holds liquid solution and
encloses nicotine in fluctuating amount, flavoring agents and other chemicals. Second component
is the heating element (atomizer), third component is the power source which is usually battery
and fourth component is the mouthpiece which is used for inhalation by an individual (Electronic
Cigarettes, 2019).
Figure 1: Parts and design of e-cigarettes.
Shows various parts and design of e-cigarettes. Adapted from Electronic Cigarette Fires and Explosions in the United
States 2009 - 2016 (p. 3) by FEMA, 2017. Copyrights 2017 by Usfa.fema.gov
Figure 2: Types of e-cigarettes
Various types of e-cigarettes, including a disposable e-cigarette, a rechargeable e-cigarette, a medium-size tank device,
large-size tank devices, an e-cigar, and an e-pipe. Adapted from Various electronic cigarette by CDC, 2015.
Copyrights 2019 by Centers for Disease Control and Prevention
E-cigarettes were introduced as a quit-smoking therapy and an alternative for smoking
tobacco. The idea of e-cigarette has a long history since 1927. Joseph Robinson was the first to
crop up the concept of e-cigarette. In 1963 Herbert Gilbert came up with an idea of vaping, and in
1965 he patented “a smokeless non-tobacco cigarette”. There was no nicotine present in it and
contained only flavored steam, but it was not commercialized. 1979-80 Phil Ray, along with
physician Norman Jacobson designed the first commercialized e-cigarette with nicotine delivery,
but technologically it was not promising. In 2003, Honk Lik, 52-year-old pharmacist, inventor and
smoker, successfully launched first commercial electronic cigarette. In 2006 e-cigarettes were
introduced in Europe, 2007 in the US and then spread internationally (Cummings et.al., 2014 &
Historical Timeline of Electronic Cigarettes (n.d.)).
Prevalence of E-cigarette
In this section we will look at the global rate of e-cigarette prevalence in the society. There's
a tremendous increase in the use of e-cigarette since its introduction in the market. According to
the data from the National Youth Tobacco Survey (NYTS), the e-cigarette use among youths in
2018, in the US was 3.6 million and it increased to 5.3 million youths in 2019, making the
difference of 1.5 million youths. High school showed higher prevalence (20.8%) of e-cigarette use
than middle school students (4.9%), and the use of e-cigarette was highest compared to any other
tobacco product (CDC, Youth and Tobacco Use. 2019). The significant increase in e-cigarette use
among adolescents was found between 2011 and 2012 which rose to 6.8% from 3.3% and
specifically for high school students, it increased up to 10% (Carroll et.al., 2014). The dual use of
both e-cigarette and conventional form of tobacco smoking increased to 1.6%, in 2013 from 2012.
Comparing the dual use between high school and middle school students, the dual use increase
among middle school students was from 0.3% to 0.7% and among high school students was from
1.2% to 2.2%, from 2012 to 2013. 20.3% of students in middle school and 7.2% of students in
high school reported using e-cigarettes, although they were nonsmokers (Centers for Disease
Control and Prevention (CDC) 2013)
Figure 3: Prevalence of e-cigarette use among adolescents in the US
Prevalence of e-cigarette use among adolescents in the US. Adapted from E-cigarettes: Facts, stats and regulations by
truth initiative, 2019. Copyrights 2019 by Truth Initiative
According to current data, in the US, overall e-cigarette use among adults in 2018 was
3.2%. It was higher among young adults between 18-24 years (7.6%), followed by 4.2% among
adults between 25-44 years and least among older adults between 45-64 years (2.1%). The
population above 65 years of age had 0.8% of e-cigarette use prevalence (E-cigarettes: Facts, stats
and regulations, 2019).
Figure 4: Prevalence of e-cigarette use among adults in the US.
Shows prevalence of e-cigarette use among adults in the US. Reprinted from E-cigarettes: Facts, stats and regulations
by truth initiative, 2019. Copyrights 2019 by Truth Initiative
If we look at the global data for e-cigarette use among adolescents and young adults a study
was conducted among Polish high school and universities students. The sample size consisted of
20240 students and it was conducted between September 2010 and June 2011. It was analyzed that
for age between 15 to 19 years, 23.5% had ever used e-cigarettes and for universities age between
20 to 24 years, 19% had ever used e-cigarettes (Goniewicz and Zielinska 2012).
For another survey in Mexico among adolescents and adults, it was found that there is
increased awareness about e-cigarette in 2015 compared to 2012. The prevalence of e-cigarette
trial was 7% among adolescents, 3% among adult non-smokers and 18% among adult smokers.
Awareness about e-cigarette was higher among conventional smokers compared to non-smokers
and awareness was also high among older adolescents (16–17 years vs. 12 years) and young adults
(18-24 years vs. 25 years and above). Increased awareness was related to e-cigarette use (Zavala-
Arciniega et.al., 2018).
Another survey was conducted in Korea, among high and middle school students, to know
the e-cigarette use among adolescents. The sample size consisted of 2,369 for middle school
students with an average mean age of 14 years and 1,847 for high school students with a mean age
of 16.5 years. The overall response rate was 70.5%. It was analyzed that the use of e-cigarette was
0.5% (Cho et.al., 2011).
Health effect due to e-cigarette smoking
Just within a decade of the accessibility of e-cigarette in the market, the use has increased
tremendously and with increased use comes the concern for impact on health. There are mixed
views for e-cigarette use and impact on health, and discussions and studies are still going on
(Drummond and Upson., 2014). The article by Drummond and Upson, (2014) highlights through
various studies that vapor released through electronic cigarette use, contains nicotine in different
amounts and other harmful toxins, which are injurious to an individual's health (Drummond and
Upson., 2014). Even a 5 minute period of exposure to e-cigarette use, displays increased lung flow
resistance and increased heart rate (Eissenberg. 2010 & Vansickel and Eissenberg ., 2013).
According to the article by Bekki et.al., (2014), research was conducted for four years
between 2010 and 2014 to analyze the carbonyl compounds released from e-cigarettes.
Formaldehyde, acetaldehyde, acetone, acrolein, propanal, crotonaldehyde, butanal, glyoxal, and
methylglyoxal, were detected as the carbonyl compounds released from e-cigarette. These
compounds are harmful to an individual’s health. An experiment by was done on mice by Sussan
et.al (2015), to see if there is an impact on pulmonary response due to e-cigarette use. It was
revealed that there is impaired antibacterial defense due to a defect in macrophage function and
alveolar macrophage in response to S. pneumoniae. Also impaired antiviral defense was seen in
response to Influenza A virus. It was concluded that e-cigarette exposure affects the pulmonary
response and elicits impaired pulmonary anti-microbial defenses. Another experiment by Lerner
et.al. (2015) on mice with e-cigarette exposure, revealed that exposure to aerosol which is released
from e-cigarette use during vaping, leads to increased production of inflammatory cytokines and
decreased lung glutathione level in human airway epithelial cells. The e-cigarette use induces
oxidative reeducates indicating inhalation of oxidants (OX) or reactive oxidant species (ROS). The
study concludes that exposure to e-liquid/e-juices advances towards lung toxicity (Lerner et.al.,
2015).
Another survey by Hua, Alfi and Talbot (2013) was conducted to look for the positive and
negative effects of e-cigarette use on health. It was an online survey where participants self-
reported their symptoms due to the use of e-cigarettes. Basic division of symptoms was done
according to 12 biological systems of the body such as circulatory, digestive, cardiovascular,

neurological, respiratory etc. The health symptoms were associated with short term use of e-
cigarettes. At the end of survey, from the collected data it was evaluated that e-cigarette use has
effect on human biological systems and the most affected were respiratory and neurological system
(Hua, Alfi and Talbot, 2013). The figure below shows summary of all positive (green), negative
(red),and neutral (white) symptoms and their associated systems as reported by e-cigarette users
on the Electronic Cigarette Forum, from the study by Hua, Alfi and Talbot (2013).
Figure 5: Summary of positive, negative, and neutral symptoms and their associated systems
A summary of all positive (green), negative (red),and neutral (white) symptoms and their associated systems as
reported by e-cigarette users on the Electronic Cigarette Forum. Reprinted from Health-Related Effects Reported by
Electronic Cigarette Users in Online Forums. Journal of Medical Science). Copyrights 2013 by Hua, M., Alfi, M., &
Talbot P.
There are more than 7000 flavors available in the market and these flavors often contain
diacetyl. Diacetyl is connected to disease called “popcorn lungs”. A study by Joseph et.al. (2016)
aimed to analyze presence of diacetyl and two other priority flavoring agent 2,3-pentanedione and
acetoin present in e-cigarettes. 51 samples of different brands of e-cigarettes were taken and it was
inspected that among those 51 samples, 47 contained at least one flavoring agent and 39 had
diacetyl level above the laboratory limit. This outcome highlights that if prompt action is not taken
for e-cigarette use, future respiratory consequences can be severe as diacetyl is associated with
bronchiolitis and other respiratory diseases (Allen et.al., 2016 ).
E-cigarettes introduction to market is from last decade and the adverse health effect due to
nicotine exposure which is present in e-cigarette can be evaluated after a long term exposure. E-
cigarettes are available with varying amount of nicotine, claiming it to be less harmful than
traditional tobacco products. Just within the decade of its commercialization, the trend chart of e-
cigarette use has increased excessively, especially among adolescents and young adults. No such
studies, till now clarifies e-cigarettes to be completely safe, instead studies reveal that even short-
term use of e-cigarettes has an unfavorable effect on health. Hence laws should be made on its
availability in the market and use, as done for tobacco, until there are enough evidences to prove
the point of its existence as being less harmful than conventional smoking and advantageous as
smoking cessation tool.
Looking at these data of increased use of e-cigarette among adolescents and young adults,
and also an ongoing debate of it being less harmful than conventional smoking, it is necessary to
understand the factors that have influenced the use of e-cigarettes

Theory of Triadic Influence (TTI)
Theory of Triadic Influence (TTI) was developed to acknowledge numerous behavioral
influences and to provide structured and testable integrated theory. It proposes that theory have
different levels of causations. Few variables have direct effect on the behavior whereas some
variables are interlinked to other variables, which effects on behavioral outcome. This framework
integrates social, biological and environmental and is based on the concept that the entire factors
social, biological and environmental affect the behavior.
TTI theory has three main streams named Intrapersonal stream, Social stream and
Environmental stream (Flay and Petraitis., 1994; Flay et al., 2009). The first Intrapersonal stream
can be defined as the factors influenced due to an individual’s biological predispositions and self-
efficacy. Second, Interpersonal Social stream can be defined as; factors influenced due to
individuals social surroundings and situation that ultimately affect the behavioral outcome. And
the final, Environmental stream can be defined as factors influenced due to multiple sociocultural
surrounding that contributes towards attitude for specific behavior (Flay and Petraitis., 1994; Flay
et al., 2009).
Figure 6: Theory of Triadic Influence
Theory of Triadic Influence. Reprinted from the Theory of Triadic Influence (p. 458), by Flay, Snyder, Petriatis, John
Wiley & Sons. Copyright 2009 by Emerging Theories in Health Promotion Practice and Research
Application of Theory of Triadic Influence (TTI) for factors influencing e-cigarette use
Figure 7: Application of TTI framework for factors influencing e-cigarette use.

Intrapersonal Influences
For the first stream Intrapersonal, we will explain various factors influencing e-cigarette
use such as the gender, age, quit smoking/cessation tool for smoking, and available in various
flavors.
Gender:
Males shows higher prevalence of e-cigarette than females. To support this, the cross-
sectional study by Perialathan et. al. (2018) was carried out in seven public hospitals and health
clinics in Malaysia; and it was found that males showed 18.1% higher prevalence of e-cigarette
use, compared to females (Perialathan et al., 2018). Another online survey by Pineiro et.al. (2016)
was done to know the gender difference for e-cigarette use. There were total 1,815 e-cigarette users
and from those 1,815 participants 1212 were male participants and 603 were female participants
who were e-cigarette users (Pineiro et.al., 2016). For the electronic search in PubMed, EMBASE,
and Google Scholar databases, a study was conducted by Perikelous et.al. (2018), and it was found
that gender affects the use of e-cigarette. From the study it was concluded that males show higher
use of e-cigarettes compared to females (Perikelous et.al., 2018). Through meta-analysis of various
studies, it can be said that males show higher rates of e-cigarette use than females.
Age:
Age factor plays a vital role for e-cigarette use. High school students showed higher
prevalence compared to middle school students, as they have more knowledge and easy
accessibility to e-cigarettes (Perikelous et.al., 2018). The study conducted in school in Paris,
France, it was identified that age is associated with the use of e-cigarette. (Dautzenberg et al.,
2015). From NYTS data, adolescents and young adult’s shows higher prevalence of e-cigarette
use compared to others (CDC, Youth and Tobacco Use. 2019). Also according to the secondary
analysis conducted in Canada by using Canadian Tobacco, Alcohol and Drugs Survey (CTADS),
males and females didn't show higher variation in smoking but if we glance through age it was
higher among youth and young adults. Among the ever e-cigarette use, it was analyzed that 25-44
years of age group showed the higher prevalence (Reid et al., 2015). Adolescents and young adults
show higher prevalence of e-cigarette use.
Quit smoking:
The basic idea for invention of the e-cigarette was for smoking cessation or as a smoking
cessation tool. The belief it is safer compared to conventional cigarette, has led to its increased use
compared to other forms of smoking cessation therapy. To support this, a study was conducted in
Hawaii. The main objective of the study by Pokhrel et al. was to know whether the use of e-
cigarette is for smoking cessation or some other reason and also collect information whether it is
effective tool for smoking cessation or not (Pokhrel & Herzog, 2014). There were total 1988
participants and the result was that 14.7% had ever tried e-cigarette for smoking cessation, 5.6%
had tried e-cigarettes but not nicotine replacement therapy (NRT: another alternative for quit
smoking); 9.1% had tried both e-cigarettes and NRT; and 27.3% had tried NRT but not e-
cigarettes. It was found that younger age population, higher income and lower nicotine dependence
were more likely to use e-cigarettes. The reformed users who switched to e-cigarette from
conventional smoking also revealed other aspects of its use. The other reasons were price and odor.
It was also found that those who have stopped conventional smoking, still continues to use e-
cigarettes (Pokhrel & Herzog, 2014).
Available in various flavors:
According to one study more than 7,700 flavors are available for e-cigarette in the market
(Zhu et al., 2014). One of the main reasons for e-cigarette use is its availability in different flavors.
According to the data by Population Assessment of Tobacco and Health (PATH) 2013-14, 81% of
youth and 86% of young adults had their first e-cigarette to be flavored. Flavor outstands to be the
primary reason for e-cigarette use and was preferred over plain form (Villanti et al., 2017). In an
article by Schneller et al., (2019), secondary analysis from PATH study concluded that 51.6% of
youth reported using one flavor of e-cigarette and 45.5% of youths reported using two or more
flavors of e-cigarette. 66.6% of adults reported using one flavor of e-cigarette and 32.1% of adults
reported using more than two flavors of e-cigarette (Schneller et al., 2019). According to the study
by Virginia Commonwealth University, addition of flavors in e-cigarettes, gives a pleasant
satisfaction and enjoyment, by suppressing the harshness of nicotine. It also enhances the taste and
induces inhalation, compared to non-flavor e-cigarettes. It was also found that e-cigarettes benefit
in weight loss by suppressing hunger craving and smells good leaving clothes, hair and body
smelling without smoke (Soule et al., 2016).
Social influences
For second stream Social, we will discuss parents and close family members, and role
models as influencing factors.
Parents and close family:
Parents and close family members who include siblings, uncles, aunts and cousins, play a vital role
in the child's life, especially during adolescence and young adult period. A smoking habit within
family increases the chances of child smoking behavior for initiating and continuing in the future
(Langton and Berger. 2011). For one study conducted among Korean middle and high school
students, it was analyzed that e-cigarette smoking had higher prevalence among students who had
a history of parents and close relative smoking (Cho et al., 2011). Furthermore, to support relation
between parental smoking and e-cigarette use, a cross sectional school-based survey was
conducted in the city of Paris, France in 2013. It was concluded that 17.9% of children had tried
an e-cigarette in comparison to 9.8% in 2012. The use of e-cigarettes among school students
showed significant association between parental, peer and sibling smoking status (Dautzenberg et
al., 2015). The study conducted by Goniewicz et al., (2012) among Polish students indicated that
those who had parental smoking showed a higher risk of current e-cigarettes use.
Role models:
Not many studies and surveys are done on the influence of e-cigarette use and role models.
Duke et al., (2014) from Nielson data, illustrates that expenditure for e-cigarette advertisements
has increased and the majority of advertisements were displayed with film actors conveying a
message to viewers about the benefits of e-cigarette use. Still studies need to be conducted because
for traditional smoking, role model do influence the use (Green et.al., 2008).
Environmental influences
For the third stream environmental, we will explain media advertisement as an influencing
factor for e-cigarette use and a brief overview of various medias. Since the introduction of e-
cigarettes in society in 2007, the marketing has grown rapidly. In the United States according to
data, in 2011 the expenditure for marketing of e-cigarettes was $6.4 million and in 2012 it was
$18.3 million, a significant increase of nearly three times (Kim, Arnold, & Makarenko, 2014).
Also, if we see global data of e-cigarette marketing, according to one research study, the market is
expected to grow at a Compound Annual Growth Rate (CAGR) of 21.4% rise from 2019 to 2024
reaching nearly USD 53.4 billion (Kumar K., 2019). The most familiar sources of advertising are
Television (TV), magazines and newspaper, and internet, targeting youths and young adults.
Figure 8: Growth in e-cigarette market at a Compound Annual Growth Rate (CAGR).
The estimated growth in e-cigarette market at a Compound Annual Growth Rate (CAGR). Reprinted from E - cigarette
Market by vynzresearch, 2019. Copyrights 2019 by vynzresearch
TV Advertisement:
There are currently restrictions on advertising e-cigarettes on TV in the US, unless it is
advertised in a way directed by US Food and Drug Administration regulations. According to
Nielsen data, exposure to TV advertisements in the US has seen rise of 256% among youths and
321% among young adults from 2011 to 2013. This targeted about 24 million youths and if the
same trend of advertising continues than there can be a marked increase in the awareness about e-
cigarette among youths and young adults leading to increased use of e-cigarette (Duke et al., 2014).
There are evidences which show a relationship between e-cigarette smoking and being familiar to
it through advertisements (Heatherton & Sargent, 2009; Morgenstern et al., 2013).
Magazines: E-cigarettes are noncombustible products (NCPs), hence it has wider space for
advertising, as most of the restrictions are applicable on combustible products. For the three
months of survey done between 1st June 2012 to 1st September 2012, it was analyzed that almost
US $20 million were spent on print advertising (Richardson et al.).

Online Marketing:
It is the easiest route to market e-cigarettes as not many restrictions are implied on internet
marketing. It serves as a direct platform for e-cigarette marketing, at reduced cost. Two surveys
were conducted using three search engines: Google, Yahoo and Bing to know about the number
of advertisements available online. The first survey was conducted between May 2012 to August
2012 and second from December 2013 to January 2014. Thirteen different key words related to e-
cigarettes were used such as vape, vaper, e-cig etc. to detect various brands marketed online. It
was examined that 460 brands and 7,700 flavors, of e-cigarettes were marketed online. They were
marketed in different shapes and sizes and almost all of them had a common promoting line which
was being less harmful and cheaper than conventional cigarettes. From the survey it was analyzed
that, e-cigarette brands increased by 10.5% per month and 242 new flavors were added every
month (Zhu et al., 2014).
Another study on YouTube was conducted between July 1, 2012, and June 30, 2013, to
analyze the videos available for e-cigarettes. It was analyzed that total 28,000 videos related to e-
cigarettes were found. The rate of posting videos increased since 2007, which was detected to be
100 per month in 2009. In 2012 around 1000 videos per month related to e-cigarettes were found
and by June 2013 it increased nearly up to 2000 per month. The result says that 100 million
population viewed e-cigarette videos which includes 29 million youths. This platform reached
million youths and young adults easily (Huang et.al., 2016). Another study was conducted from
three sources namely YouTube, televised advertisements in the US, and the Stanford Research into
the Impact of Tobacco Advertising (SRITA) database. They were measured on Content Appealing
to Youth (CAY) index score and it was found that there is a marked increase in exposure to ads
for youths (Padon et.al., 2017). Both studies found that ads were majorly in the form of healthier
than conventional cigarettes and as smoking cessation or quit smoking option.
Figure 9: Estimated market growth rate by region from 2019-2024.
Reprinted from E-CIGARETTE MARKET - GROWTH, TRENDS AND FORECAST (2019 - 2024) by Mordor
Intelligence, 2019. Copyrights 2019 by Mordor Intelligence.
Awareness about Electronic Cigarettes and use
According to King et al., (2013), awareness about e-cigarettes among the population has
risen from 40.9% to 57.9% from 2010 to 2011 in a web survey. Young adults, non-Hispanic Whites
and current or former smokers comparatively possessed higher rate of awareness than others. To
support it, the survey conducted by Zhu et al. (2013), it was found that in the US 75.4% of the
population is aware about e-cigarettes through television, social contacts and the internet. Also
32.2% of current smokers had tried e-cigarettes, among those 32.2%, 6.3% were current users and
49.5% of current smokers were most likely to use e-cigarettes in future (Zhu et al., 2013). If we
look globally, a survey was conducted in 10 countries for comparing the level of awareness. The
highest awareness was found in Netherland 88%, than the Republic of Korea with 79% followed
by United States 73%, Australia 66% and least in China 31%. population are aware about e-
cigarettes (Gravely et al., 2014).

Increased e-cigarette use and awareness are related. As the awareness increased, use of it
also increased. Media plays a massive role in awareness of e-cigarettes. Most of the media channels
promote e-cigarettes as an alternative to conventional smoking, cheaper, less harmful, can be used
where smoking is not allowed, available in various flavors and as a smoking cessation tool and are
often compared to conventional tobacco smoking (Richardson et.al., 2014 & Zhu et.al., 2013).
Both traditional and social media platforms are used for promotion of e-cigarettes and the trendiest
media used are television advertisements, magazines and online marketing (Nagelhout et.al.,
2016). Online marketing is the best policy for approaching millions of adolescents and young
adults easily, as there are fewer policy restrictions and data shows increased internet use by
teenagers and young adults. According to Wallace (2014), 55% of youth aged between 12-13 and
82% between 14-17 use social networking sites. It is the most accessible path for targeting this
population group. According to a survey, the frequency of exposure to e-cigarettes advertising has
increased by 256% among youths and 321% among young adults from 2011 to 2013 (Duke et al.,
2014).
Advertising and use can be understood by cross sectional study, which explains that
increased exposure to advertisements was directly linked to increased use and the reasons were
being healthier than conventional smoking and as smoking cessation tool (Harrington et.al., 2014).
Not many studies are done to know the effect of awareness about e-cigarette through
advertisements and use of e-cigarette. In the article by Nagelhout et al. (2016), one of the studies
by Smith et al., (2015) in Dutch, tries to relate the relationship between advertisements and e-
cigarette use (Nagelhout et al., 2016). It was analyzed that, when there was a restriction on
advertisements of e-cigarette in Dutch between January 2008 to June 2012, the use of e-cigarette
decreased. But the use of e-cigarette increased up to four times in 2014 (16%) compared to 2013
(4%), after eliminating restrictions on advertising e-cigarettes on televisions (Nagelhout et al.,
2016).
Much further research is needed to know the actual and most affecting factors leading to
increased use of e- cigarettes. Not much is known but through various studies it can be said that
smoking awareness regarding e-cigarette as a smoking cessation tool, alternative to conventional
smoking, various flavors, less harmful are few aspects for hike in use and this awareness is
retrieved mainly through media advertisements. Although not much studies relates awareness and
media, but through the studies explained it can be said that media has played a vital role in bringing
awareness about e-cigarette, leading to increased use. The increased advertisements through
various media and considering the estimation to reach up to 53.4 billion USD by 2024, it should
be looked forward, the role of media in e-cigarette use.

Chapter 3: National Youth Tobacco Survey - 2018
Introduction
In the United States, the usage of e-cigarettes is highest among adolescents and young
adults. E-cigarettes are the most frequently used tobacco product among middle and high school
students in 2018, 4.9%, and 20.8%, respectively. Among the high school students, current e-
cigarette smokers increased from 1.5% in 2011 to 20.8% in 2018, accounting for 3.05 million
students. In one year (2017-2018), 78% of current e-cigarette users had increased in high schools’
students. The current e- cigarette smokers increased by 4.9% in 2018 among middle school
students, in contrast to 0.6% in 2011, which comprised 570,000 students (KA, et al., 2018).
The increased use of e-cigarette among adolescents and young adults may be due to
substantial promotion through media channels, their low cost, and the misbelief that e-cigarette is
safer than traditional cigarettes (Camenga & Klein, 2016; Tomashefski, 2016). Another study has
also reported that youth and young adults are attracted because of the perception that e-cigarette is
less harmful than cigarettes, and it is also available in thousands of flavors (e.g., fruit, chocolate,
peanut butter, bubble gum, gummy bear, among others) (Glantz & Bareham, 2018). E-cigarette
use among adults is used more commonly for the enjoyment of purpose (Delnevo, et al., 2016)
(Pepper & Brewer, 2015). One report showed that 51.5% of smokers who vaped previously and
quit, though continue smoking, considered that vaping is less dangerous than smoking. The former
smokers account for 90% who said vaping is less risky than smoking (McNeill, Brose, Calder,
Bauld, & Robson, 2018). A 2013 US survey found that 56% of participants had tried e-cigarettes
to quit or reduce their smoking habit, and 26% of participants use them in the area where smoking
was banned (Siu, 2015). Dual-use helps to stop smoking, and also decreases smoking dependency
among smokers (Simonavicius, McNeill, Arnott, & Brose, 2017). The availability of flavored e-
cigarettes attracts youth and young adults. Media advertisements may encourage nonsmoking
children and adults to try e-cigarette (Bauld, Angus, & Andrade, 2014) (Grana & Ling, 2014). In
addition to these, the e-cigarette has established a strong advertising presence on the internet, and
e-cigarette companies heavily advertise their products through electronic communications.
National Youth Tobacco Survey - 2016 reported various reasons for ever used e-cigarette among
the United States students. “Friends or family members used them” was the most common reason
(39%) followed by “Availability of flavors, such as mint, candy, fruits, or chocolate” (31%) and
“They are less harmful than other tobacco products such as cigarettes” (17%) (Tsai, et al., 2018).
To understand further the relationship between e-cigarette usage and factors influencing
them, secondary data from the National Youth Tobacco Survey - 2018 and primary data collected
through on-campus California State University San Marcos survey are used in this capstone. The
proposed capstone builds the base for future intervention to control these factors and reduce the
risk of health behaviors.
Goal 1: Review National Youth Tobacco Survey-2018
Specific Objectives: This analysis will address the following questions.
1. Is there a difference for e-cigarette use between the user and non-user by age groups?
2. Is there a difference for using an e-cigarette between the user and non-user by male and
female?
3. Is there a difference for e-cigarette use between the user and non-user by grade level?
4. Is there a difference in use of e-cigarette between the user and non-user by race?
5. What is the difference in various reasons for influencing the use of e-cigarette among the
users and non-users?

6. Is there a difference in use of e-cigarette among the users and non-users by various media
channels advertisements?
7. What is the difference in factors influencing e-cigarette use among the users and non-users?
Hypothesis
H0: There is no difference in factors influencing the use of e-cigarette among the users and non-
users.
H1: There is a difference in factors influencing the use of e-cigarette among the users and non-
users.
Study Procedure and Sampling
This study utilized secondary data analysis from the National Tobacco Youth Survey
(NYTS). The National Youth Tobacco Survey conjugated with the State Youth Tobacco Survey
(YTS) to analyze the trends and prevalence of tobacco use among adolescents and young adults
by implementing tobacco control policies. NYTS serves as a booster to achieve one of the goals
of healthy people 2020 to reduce tobacco use among youths. NYTS is about long-term,
intermediate, and short-term indicators vital to the design, implementation, and evaluation of
comprehensive tobacco prevention and control (TPC) programs (Office on Smoking and Health,
2018). First, NYTS conducted in fall 1999. Then again, in spring 2000, 2002, 2004, 2006, and
2009. After 2011, it started annually and collaborated with the department of Centers for Disease
Control and Prevention (CDC), and Food and Drug Administrative (FDA). They collected data on
tobacco-related indicators from all middle schools (grades 6-8) and high schools (grades 9-12) in
the 50 states and the District of Columbia. The indicators used to determine the tobacco use among
students includes type of tobacco use (e.g., bidis, cigarettes, cigars, tobacco pipes, smokeless
tobacco, snus, dissolvable tobacco products, hookahs, and electronic cigarettes); exposure to
secondhand smoke; smoking cessation; minors’ ability to purchase or get tobacco products; and
knowledge and attitudes about tobacco and familiarity with pro-tobacco and anti-tobacco media
messages (Office on Smoking and Health, 2018). It gives output regarding their tobacco-related
belief, attitude, behavior, exposure to pro, and anti-tobacco influences.
In the NYTS-2018 survey, participating students and schools were recruited voluntarily.
Schools signed a passive or active participation form. CDC’s Institutional Review Board (IRB)
required that parents must give consent for their students to participate in the survey (Office on
Smoking and Health, 2018). Participants were given a survey to complete with pencil and paper
using self- administered, scannable questionnaire booklets. Participation was anonymous, and
three cluster design was used to produce a nationally representative sample of students in grades
6-12 who attended private and public schools.
A total of 238 schools participated out of 310, with a participation rate of 76.8%. The total
number of participants who completed the survey are 20,189 out of 22,729, building participant
rates of 88.8% (Office on Smoking and Health, 2018).
Study method
The outcome of interest in our study was the use of e-cigarette (dependent variable). The
independent variables included: age group, gender, race, grade level, reasons to use an e-cigarette,
and media channels advertisement (Table 1).
Dependent variable:
Ever use of e-cigarette was a dependent variable in the analysis of this study. The study
population was categorized into two groups by the question, “Have you ever tried E-cigarette?”
Those who responded “yes” (coded as 1) were considered to have had experimented with e-
cigarettes, everyone else found as nonuser (coded as 0).

Independent variables:
The independent variables included demographic variables (age groups, gender, race, grade
levels), the reasons to use an e-cigarette, and the media channels advertisements. Table 1 shows
application of the TTI model in independent variables.

Table 1: Application of Theory of Triadic Influence (TTI) model
Dependent Variable E-cigarette use 1 -Users (Case)

0 - Non-users (Control)
Independent
variable
Intrapersonal Age group 0 - 9-14 years
1 - 15-19 years
Gender 0 - Female
1 - Male
Races American Indian
Black
Asian
Native Hawaiian
White
Reasons To try to quit using other tobacco products
They cost less than other tobacco products, such as
cigarettes
They are easier to get than other tobacco products,
such as cigarettes
They are less harmful than other forms of tobacco,
such as cigarettes
They are available in flavors, such as mint, candy, fruit,
or chocolate
They can be used in areas where other tobacco
products, such as cigarettes, are not allowed
I used them for some other reason
Social Reasons Friends and Family members
Famous people on TV or in movies use them
Environmental Media channels Internet 1 - Exposed
0 - Non-exposed
Newspapers or
Magazines 1 - Exposed
0 - Non-exposed
Convention stores/Gas
stations/super market 1 - Exposed
0 - Non-exposed
TV/Movies theaters 1 - Exposed
0 - Non-exposed
Application of Theory of Triadic Influence (TTI) model in independent variables (NYTS-2018).
1. Demographic factors included age, gender, race, and grade, which were our independent
variables. Research from previous articles found that 15 years is the critical age to adopt
social culture and change in their behavior (Qidwai et al., 2010 & Salam et al., 2016).
According to the United States education system, 9-14 years of age is considered for middle
school, and 15-19 years of age is included in high school (Sen, Partelow, & Miller, 2005).
Therefore, we categorized age in groups (code 0 for a group between 9 to 14 years and
code 1 for 15 to 19 years). We assessed race form question, “What race or races do you
consider yourself to be?” in the NYTS-2018 data set. Responses were recoded as code 0
for non-selected and code 1 for selected for individual races, which included; American
Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or other-
Pacific Islander; White. Gender dichotomized into male (coded as 1)/female (coded as 0).
Grade level recoded as a middle school for grades 6-8 (coded as 0) and high school for
grades 9-12 (coded as 1) (Office on Smoking and Health, 2018; Sen, Partelow, & Miller,
2005; USNEI, 2008).
2. The reasons influencing e-cigarette use is the independent variable in our analysis. We
assessed the reasons to use of the e-cigarette by asking, “What are the reasons you have
used e-cigarettes?”. Responses recoded as 0 for not selected and as 1 for selected each
reason.
3. Exposure to media channels advertising served as an independent variable in our analysis.
Types of various media channel advertisements were assessed by the questions from the
NYTS data: “When you are using the Internet, how often do you see ads or promotions for
e-cigarettes?”, “When you read newspapers or magazines, how often do you see ads or
promotions for e-cigarettes?”, “When you go to convenience stores, supermarkets, or gas
stations, how often do you see ads or promotions for e-cigarettes?”, and “When you watch
TV, how often do you see ads or promotions for e-cigarettes?” Participants responded to
each question from “never,” “rarely,” “sometimes,” “most of the time,” or “always.”
Consistent with previous research, respondents who answered “sometimes,” “most of the
time,” or “always” were categorized as being exposed to the respective media channels
(coded as 1). Respondents who answered “never,” “rarely,” as well as those who stated
they did not use the Internet, read newspapers/magazines, visit retail stores, or watch
TV/movies, were categorized as non-exposed (coded as 0) (Agaku & Ayo-Yusuf, 2014)
(Dube, Arrazola, Lee, Engstrom, & Malarcher, 2013) (Singh, et al., 2016).
Study participants
From the data set, we selected the population who answered the question, “Have you ever
tried e-cigarette?” The missing population (393 of 20189) removed from the data set. The new
population data set (n) was 19796.
Statistical Analysis
To evaluate the difference in the use of e-cigarette between the users and non-users by
demographic variables (age groups, gender, race, and grade), Pearson’s chi-square test was used,
p-value of less than 0.005 was considered significant. A multivariate logistic regression was
conducted to assess differences for the use of e-cigarette by various media channel advertisements
with covariates (age group, gender, grade, and race) to generate odds ratio. The statistical analysis
executed by the Statistical Package for the Social Science Version 24.0 (SPSS) (IBM Corp, 2016).
Results
Descriptive Statistics
Demographic Variables of the students
Table 2: Demographic Variables of the student population
Variables Ever e-cigarette use Chi square

Users Non-users value p Value
n (%) n (%) n (%) (χ2)
Totala 19796 100.0% 5071 100.0% 14725 100.0%
Age Group
0 - 9-14 year 9703 49.3% 1353 26.8% 8350 57.0%
1 - 15-19 year 9994 50.7% 3696 73.2% 6298 43.0% 1370.73 0.000
Gender
1 - Male 9829 50.1% 2662 53.0% 7167 49.1%
0 - Female 9796 49.9% 2365 47.0% 7431 50.9% 22.26 0.000
Races
American Indian 1560 7.9% 428 8.4% 1132 7.7% 2.94 0.086b
Asian 1201 6.1% 227 4.5% 974 6.6% 30.26 0.000
African American 3713 18.8% 656 12.9% 3057 20.8% 151.54 0.000
Native Hawaiian 563 2.8% 121 2.4% 442 3.0% 5.17 0.023*
White 12476 63.0% 3695 72.9% 8781 59.6% 283.39 0.000
Grade
0 - Middle (6-8) 8872 45.1% 1118 22.1% 7754 53.0%
1 - High (9-12) 10820 54.9% 3933 77.9% 6887 47.0% 1441.59 0.000
Demographic Variables of the student population, NYTS-2018 (n=19796).
p<0.001; *p<0.05
a= doesn’t include missing population,
b= statistically not significant.
Table 2 shows demographic variables of the student population. Total 19796 students were
included in the study; 5071 students reported using e-cigarette in their life compared to 14725
students who never tried e-cigarette. The ratio between the age groups of the study population was
1:1. The difference between the e-cigarette users and non-users by age groups was statistically
significant (𝛘𝛘2(1, N=19796) = 1370.73, p=0.000). Nearly 50% were male, and 50% were female;
there was statistical difference between the e-cigarette users and non-users by gender (𝛘𝛘2(1,
N=19796) =22.26, p=0.000). In the study, 55% students were in high school and 45% students
were in middle school. The proportion of e-cigarette users were less than non-users in middle
school. In contrast, high school had more e-cigarette users than non-users. There was statistically
significant among the e-cigarette users and non-users by grade level (p=0.000). Most of the
students were White (63%). The remaining races were the following: Black or African American
(19%), American Indian or Alaska Native (8%), Asian (6%), Native Hawaiian, or other pacific
islanders (3%). The proportion of e-cigarette non-users were higher than users in all races, except
white. There was a statistical difference between e-cigarette users and non-users by Asian, African
American, Native Hawaiian, and White. But there was no difference in American Indian race of
an e-cigarette use (𝛘𝛘2(1, N=19796) =2.94, p=0.086).
Table 3 shows various reasons and media channels advertisements influence for the e-
cigarette users and non-users from NYTS-2018. “Friends or family members used them” was the
main reason to use an e-cigarette, which accounts for 11% of total. “Availability of flavors in e-
cigarette, such as mint, candy, fruit, or chocolate,” was the second most common reason
influencing the use of e-cigarette in students (8%). The other reasons include; “They are less
harmful than other forms of tobacco, such as cigarettes”; “Try to quit using other tobacco products,
such as cigarettes”; “They can be used in areas where other tobacco products, such as cigarettes,
are not allowed”; “They are easier to get than other tobacco products, such as cigarettes”; “They
cost less than other tobacco products, such as cigarettes”; and “Famous people on TV or in movies
use them”. Despite using the e-cigarette, 404 students have responded as “I never tried an e-
cigarette”. Overall, e-cigarette users were more influenced by the various reasons than non-users;
the difference was significant p<0.001.

Among the total population, the conventional stores (44%) were the most common source
of commercials for an e-cigarette. The second-largest source of e-cigarette advertisement was
Internet (26%), followed by TV/Movie theaters (23%), and Newspapers or Magazines (14%).
Table 3: Various reasons and media channels advertisements among total population from NYTS-2018 (n=19796)
a= doesn’t include missing population
Overall Ever e-cigarette use Chi

square
Variables
Users Non-users p value
n (%)
n (%) n (%)
Totala 19796 100.0% 5071 100.0% 14725 100%
Various Reasons
Friends or Families member used them 2092 10.6% 2009 36.6% 83 0.6% 0.000
To try to quit using other tobacco such as
cigarette 358 1.8% 329 6.5% 29 0.2% 0.000
They cost less than other tobacco
products, such as cigarettes 194 1.0% 176 3.5% 18 0.1% 0.000
They are easier to get than other tobacco
products, such as cigarettes 244 1.2% 233 4.6% 11 0.1% 0.000
Famous people on TV or in movies use
them 89 0.4% 68 1.3% 21 0.1% 0.000
They are less harmful than other forms of
tobacco, such as cigarettes 1000 5.1% 982 19.4% 18 0.1% 0.000
They are available in flavors, such as
mint, candy, fruit, or chocolate 1526 7.7% 1492 29.5% 31 0.2% 0.000
They can be used in areas where other
tobacco products, such as cigarettes, are
not allowed 260 1.3% 248 4.9% 12 0.1% 0.000
I used them for some other reason 1374 6.9% 1338 26.4% 36 0.2% 0.000
I have never tried an e-cigarette 14887 75.2% 404 8.0% 14483 98.4% 0.000
Media channels advertisements
Internet Exposed 5798 30.7% 1961 40.8% 3837 27.2%
Non-exposed 13100 69.3% 2846 59.2% 10254 72.8% 0.000

Newspapers/Magazines Exposed 3080 16.3% 1061 22.1% 2019 14.3%
Non-exposed 15796 83.7% 3738 77.9% 12058 87.5% 0.000

Conventional stores Exposed 8224 43.6% 2530 52.7% 5694 40.5%
Non-exposed 10644 56.4% 2274 47.3% 8370 59.5% 0.000

Overall Ever e-cigarette use Chi

square
Variables
Users Non-users p value
n (%)
n (%) n (%)
TV/Movies Exposed 5029 26.4% 1461 30.2% 3568 25.1%
Non-Exposed 14005 73.6% 3378 69.8% 10627 74.9% 0.000
The proportion of e-cigarette users was higher than non-user in all types of media channels
advertisement exposure; the differences were significant (p=0.000).

Logistic Regression
Table 4: Logistic regression
Independent Odd
(95%CI) p value
Variables ratio
Media channels ads
Internet Non-exposed 1
Exposed 1.57 (1.438-1.723) 0.000
Newspapers/Magazines Non-exposed 1
Exposed 1.13 (1.017-1.255) 0.023**
Conventional Stores Non-exposed 1
Exposed 1.28 (1.183-1.386) 0.000
TV/Movies Non-exposed 1
Exposed 0.87 (0.790-0.955) 0.004*
Age Groups
9-14 years 0.59 (0.514-0.681) 0.000
15-19 years 1.69 (1.468-1.946) 0.000
Gender
Male 1.19 (1.108-1.275) 0.000
Female 0.84 (0.785-0.903) 0.000
Grade level
Middle school 0.42 (0.358-0.481) 0.000
High school 2.40 (2.078-2.791) 0.000
Race
American Indian 1.46 (1.274-1.672) 0.000
Asian 0.74 (0.621-0.872) 0.000
Black 0.73 (0.651-0.872) 0.000
Native Hawaiian 1.08 (0.864-1.352) 0.498a
White 1.59 (1.440-1.748) 0.000
Logistic regression for various media channels advertisements and covariates (age groups, gender, grade level, and
race) predicting e-cigarette use from NYTS-2018 (n=19796)
CI=confidence interval
p<0.001, *p<0.005, **p<0.05
a= statistically not significant
Table 4 displayed the logistic regression predicting use of an e-cigarette (dependent factor)
by various media channels advertisements and covariates (age groups, gender, grade level, and
race). The odds ratio was statistically significant for all variables except for Native Hawaiian race
(p=0.498).
Figure 10: Odds ratio of various media channels ads and covariates for e-cigarette use.
Primary independent variables: Media channels advertisements (Internet, Conventional Stores,

Newspapers/Magazines, TV/Movies theaters).
Covariates: Age group (8-14 years and 15-19 years), Gender (Male and Female), Grade level (Middle and High
school), Race (African American/Black, American Indian, Asian, White, Native Hawaiian).
Figure 10 shows a scatter plot of the odds ratio of various media channel ads and covariates
for e-cigarette use among the study population. The odds ratio that cross one (1) on the x-axis are
not statistically significant. The odds ratio that are on the left of one (1) on the x-axis statistically
significant lower the risk of an e-cigarette use (protect), while the values that are on the right of 1
on the x-axis statistically significant increase the use of an e-cigarette (risk). The media channels
advertisements, which are statistically significant increasing the use of an e-cigarette, were internet
[OR=1.57, CI (1.438-1.723), p=0.000], conventional stores/supermarkets/gas stations [OR=1.28,
CI (1.183-1.386), p=0.000], and newspapers/magazines [OR=1.13, CI (1.017-1.255), p=0.023].
The covariates, which are statistically significant increasing the use of an e-cigarette, were 15-19
years of age group [OR=1.69, CI (1.468-1.946), p=0.000], male [OR=1.19, CI (1.108-1.275),
p=0.000], high school students [OR=2.40, CI (2.078-2.791), p=0.000], American Indian
[OR=1.46, CI (1.274-1.672), p=0.000], and White [OR=1.59, CI (1.440-1.748), p=0.000].
Among the exposure, TV/Movie theaters advertisements were statistically significantly
lower the use of e-cigarette [OR=0.87, CI (0.790 - 0.955), p=0.004]. The covariates statistically
lower the risk of e-cigarette use were female [OR=0.84, CI (0.785-0.903), p=0.000], 9-14 years of
age group [OR=0.59, CI (0.514-0.681), p=0.000], students in middle school [OR=0.42, CI (0.358-
0.481), p=0.000], Asian [OR=0.74, CI (0.621-0.872), p=0.000], Black [OR=0.73, CI (0.651-
0.872), p=0.000].
Native Hawaiian race is the only covariates which was not statistically significantly
influenced to use an e-cigarette [OR=1.08, CI (0.864-1.352), p=0.498].
Discussion
The secondary data analysis was performed from the NYTS-2018 to determine the factors
influencing the use of e-cigarette among adolescents and young adults. Ever use of an e-cigarette
was the dependent variable of the study. The independent variables include age groups, gender,
race, grade level, various reasons to use an e-cigarette, different media channels advertisements.
Chi-square test was done to analyze various demographic variables among the e-cigarette
users and non- users. The study findings demonstrated that males showed higher prevalence of e-
cigarette use than females. Also comparing for age demographics, one third of e-cigarette users
were 15 years or older and if we compare between high and middle school students, high school
students showed higher prevalence than middle school students. More knowledge and easy
accessibility of an e-cigarette are the major reason to influence the use among high school students.
Among all races, white students were more prevalent among the e-cigarette users.
The demographic variables, as covariates, were analyzed in logistic regression to predict
the use of an e-cigarette. It was analyzed that 15-19 years of age group was at higher risk for use
of an e-cigarette compared to less than 15 years of age groups. The risk of e-cigarette use was 19
% more among males than females. High school students were 2.4 times more predicted to use an
e-cigarette compared to middle school students. White students were 59 times higher in risk to
use an e-cigarette compared to other races. Overall, the e-cigarette usage is higher among the
middle and high school male students. Differences in an e-cigarette use by the gender and by the
grade level have been documented in the studies that have looked at the trends across several
countries (Perialathan et al., 2018) (Perikelous et.al., 2018) (Piñeiro, et al., 2016).
Among various reasons to use an e-cigarette in NYTS-2018, “Friends or family members
used them”, “They are available in flavors, such as mint, candy, fruit, or chocolate”, “They are less
harmful than other forms of tobacco, such as cigarettes” were the most common significant
reasons. Social determinants (Friends or family members used e-cigarette) were most common
among the all reasons to use an e-cigarette (11%). The findings suggest that choosing friends has
a significant impact on using e-cigarettes among adolescents. Parents’ monitoring and helping
children to select friends enable them to make a healthy choice of not using e-cigarettes in their
lives. Self-belief of e-cigarette use such as, availability of various flavors and e-cigarettes are less
harmful, leads to misperception and increases the chances of using e-cigarette. “Try to quit
tobacco”, “low cost of e-cigarette”, “Famous people on TV advertisement” were minimal reasons
to use an e-cigarette among adolescents.
Various media channels were analyzed to determine their advertisements’ exposure
influencing an e-cigarette use among users and non-users by Chi-square test. E-cigarette users
have a higher exposure to media channels advertisements compared to non-users. Various media
channels advertisements increase the odds of e-cigarette use among the exposures in logistic
regression, except TV/Movies theaters advertisements. Online media marketing with the e-
cigarette promotional messages was the reason to increase the use of e-cigarettes among
adolescents and young adults (Zhu, et al., 2014). A majority of websites also promote flavors such
as vanilla, chocolate, coffee, and other candy or dessert essences. Price advertising and price-
reducing promotions in conventional stores can raise purchase and use of e-cigarettes (Wagoner,
et al., 2016). Empirical evidence also suggests that TV advertisements increase the use of e-
cigarettes (Duke, et al., 2014). In contrast, findings of logistic regression in the study showed that
e-cigarette promotions in TV/Movies lower the risk of e-cigarette use in exposure by 17%. The
previous study also found that the exposure to a new advertisement of e-cigarettes on TV increases
the quit rate of traditional cigarettes by one-tenth (Dave, DanielDench, Grossman, S.Kenkel, &
Saffer, 2019). Also, the FDA launched the first e-cigarette prevention campaign to educate about
the dangers of e-cigarette use, as part of “The Real Cost” Youth E-cigarette Prevention Campaign.
Further research is needed to find out the relation between TV advertisements and e-cigarette
usage.
Since increased use of an e-cigarette among middle and high school students is a growing
concern, the Food and Drug Administration’s new rules and regulations for e-cigarettes’
manufacturing and marketing may discourage adolescents from initiating or trying e-cigarette
(FDA, 2019). The current trend of e-cigarette use among middle and high school students increases
the health risk of cardiovascular diseases, lung diseases. The required labeling and packaging of
e-cigarettes, which contain a health statement and graphics displaying the harmful effects of
smoking, can aid in warning adolescents and help them to make healthy and better choices.
According to an article by Wang et.al. 2019, it shows an increase of 10% in the price of cigarette
aid in reduced consumption. Similar policy can be adapted for e-cigarettes to reduce the use till
studies prove it to be safe from a health perspective.
Media increases the chances of e-cigarette use and most advertisements promote e-cigarette
to be less harmful than conventional tobacco products, smoking cessation tools and various flavors
to choose from. The data does not directly correlate all these factors with the media but it would
be more interesting to know how these factors are related with the media by doing studies and
surveys in future.
Global Relevance
Looking at global prevalence of e-cigarette among adolescents, a marked increase has been
seen in various parts of the world. Also, a significant rise of e-cigarette use has been seen among
non-conventional smokers and there is an increased percentage of dual use (e-cigarette and
conventional smoking). For a survey in Poland by Goniewicz et.al. (2014), it was found that use
of e-cigarette among adolescents 15-19 years has increased to 62.1% in 2013-14 compared to
16.8% in 2010-11. The dual use also increased from 3.6% in 2010–2011 to 21.8% in 2013–2014.
If focus is done on non-smokers (conventional smoking) it highlights that in 2010-11, 0.6% were
current e-cigarette users who had never used conventional tobacco. This rate increased to 2.0% in
2013-14 (Goniewicz et.al., 2014). Korean adolescents aged between 13-18 years showed rapid
increase in e-cigarette use between 2008 to 2011 (Lee et al., 2014). Another school-based survey
in Hong Kong highlights an increase in e-cigarette use among adolescents (Jiang et. al., 2016).
Among the e-cigarette smokers 11.7% were never smokers, 39.3% were former cigarette smokers,
and 33.2 % were current cigarette smokers. NYTS data also highlights notable increases in e-
cigarette use among adolescents from 2011 to 2019 and the highest hike was seen between 2011-
2013 (Carroll et.al., 2014; Centers for Disease Control and Prevention, 2013). Article by Bunnel
et.al. (2014) draws attention that according to data pooled from 2011, 2012 and 2013 NYTS reveals
that 43.9% of e-cigarette users intend to smoke conventional tobacco in future. These results from
various studies globally for increased use of e-cigarette among adolescents are almost comparable
to NYTS-2018 outcome.
The results reveal that currently substantial portions of adolescents are first exposed to
nicotine through e-cigarette. Also as said, the initial idea behind e-cigarette was to be nicotine free
which has vanished with time. Almost all brands contain nicotine in varying amounts and are
available in more than 7000 flavors. It was introduced as an alternative to conventional tobacco
and as a smoking cessation tool. But the number draws attention towards dual use and also a good
portion of adolescent’s intention to use conventional tobacco in future. So instead of being a
smoking cessation tool, it is giving rise to a new public health issue, of dealing with dual smokers.
These increased uses of e-cigarette in various articles also highlights the factors responsible
for it. Major reasons for increased popularity are said to be heavy marketing (Media), availability
in flavors, less harmful than conventional smoking and smoking cessation tools. From NYTS
analysis similar factors are found to be significant for increased use. The awareness of availability
in various flavors, cessations tools, and less harmful than conventional smoking are the taglines
for most of the e-cigarette advertisements. Also, there is marked increase in the advertisement of
e-cigarette both on traditional and social media platforms (Nagelhout et.al., 2016). The
adolescent’s use of social media has increased with time and also e-cigarette markets are targeting
social media to reach millions of youths and young adults (Duke et.al., 2014; Richardson et.al.,
2014 & Zhu et.al., 2013; Nagelhout et.al., 2016). Future studies should investigate how various
factors, such as flavors, cessation tools, less harmful, low cost, are related with media
advertisement for increased e-cigarette use.

Limitation
This study has several limitations. First, the NYTS sample only included students in public
and private sectors from middle and high school. Therefore, the findings were not generalized to
young adults who homeschooled, school dropouts, or in the detention centers. Secondly, we
included only those students who answered the question, “Have you ever tried e-cigarette?”, so
393 students were excluded, which might affect results. Third, the current user might better recall
the reasons influencing the use of e-cigarette than ever e-cigarette users. The reasons selected by
the users for e-cigarette use might not be consistent with actual reasons for the use of e-cigarettes
before the survey. We only assessed predominantly the potential reasons rather than participants
reported reasons for the use of the e-cigarette, such as 26.4% of participants answered: “I used
them for some other reasons.” Thus, the importance of this reason cannot be assessed potentially.
Even though 404 participants were using an e-cigarette, they answered: “I never tried e-cigarette”.
The result might be affected due to this. Fourthly, self-reporting of the reasons for influencing the
use of e-cigarette and various media channels advertising exposure might be subject to bias. The
study assumed that the participants understood the questions and responded honestly and
accurately. Since the data was self-reported, there might be a possibility of under-reporting or
never reporting the use of the e-cigarettes among adolescents in the derived study results.
Finally, there might be an under-selection of other relevant reasons which could influence
the use of the e-cigarette, such as media. The media channels, such as radio, sports events, were
not assessed, which might underestimate the results. The survey didn’t include the demographic
variables, such as socio-economic status, which can deviate the results.

Chapter 4: California State University San Marcos Campus Survey
E-cigarette use is rising concern among college students. From the NYTS-2018 data, we
determined various factors to use an e-cigarette. These information and analysis could determine
the pattern and influence for e-cigarette use among the college students. To obtain further
information, the survey was made available among the California State University San Marcos
campus students.
Goal 2: To assess the factors influencing the use of e-cigarette among the college e-cigarette users
(18+years) in California State University San Marcos from the campus survey.
Specific Objectives:
Objective 1: To analyze if media has higher influence for e-cigarette use compared to other
factors.
Objective 2: To determine whether internet media has higher influence for e-cigarette use
compared to other media channels.
Hypothesis:
Hypothesis 1: Media has higher influence for e-cigarette use compared to other factors.
Hypothesis 2: Internet advertisements have higher influence for e-cigarette use compared
to other media channels.
Study Procedure and Study Population
We conducted the survey “E-cigarette use and the factors influencing its use” on California
State University San Marcos (CSUSM) campus. We distributed the flyers on campus for
participants’ enrolment. Participants went through the Qualtrics link attached to the flyer to
complete the survey. The survey contains questions about demographic characteristics, the e-
cigarette uses, and the reasons influencing them (Appendix 1). The survey questions were referred
from the National Youth Tobacco Survey to correlate the factors influencing the use of e-cigarette
(Office on Smoking and Health, 2018). As from the previous researches, we modified some
questions, such as including media as reasons for influencing the use of e-cigarette (Camenga &
Klein, 2016; Tomashefski, 2016)
All study procedures were approved by the CSUSM Institutional Review Board (IRB).
Participants of 18 years or older provided informed consent before participation.
The final sample consists of 130 volunteer students. The sample included the participants
who completed the survey without leaving the study in between.
Study method
The outcome of interest in the study was the use of e-cigarette among the CSUSM campus
students. The independent variables included: age group, gender, race, grade level, reasons to use
an e-cigarette, and various media channels advertisement (Table 5).
Dependent Variable:
Ever use of e-cigarette was assessed by the question, “Have you ever tried an e-cigarette?”
Those who responded “yes” (coded as 1) considered as e-cigarette users, else who answered “no”
was considered as non-user (coded as 0).
Independent Variables:
The independent variables included demographic variables (age groups, gender, race, grade
levels), the reasons to use an e-cigarette, and the media channels advertisements. Table 5 shows
application of the TTI model in independent variables.
1. Demographic variants included gender, age, race, and grade level, in which gender was
dichotomized into male and female, coded as 1 and 0 accordingly, and age recorded
between 18 to 99 years. We categorized age into two groups, according to undergraduate
and graduate education levels: 18-22 years and more than 22 years (USNEI, 2008). Race
categorized according to the United States Census Bureau into American Indian and Alaska
Native, African American or Black, Asian, Native Hawaiian and other Pacific islander,
white, and others (United States Census Bureau, 2020). According to the structure of the
U.S. Education, the grade level coded as 0 for undergraduate and 1 for graduate (USNEI,
2008).
Table 5: Dependent and Independent variables with application of Theory of Triadic Influence (TTI), CSUSM survey.
Dependent Variable E-cigarette use 1 -Users

0 - Non-users
Independent
variable
Intrapersonal Age group 0 - 18-22 years
1 - >22years
Gender 0 - Female
1 - Male
Races American Indian
Black
Asian
Native Hawaiian
White
Reasons For trying to quit other tobacco product
Cost is less compared to other tobacco product
Easily available
Availability in flavors
Dual use
Social Reasons Friends
Family members
Role model (Famous people on TV or in movies)
Environmental Reasons Media channels advertisement
1 - Internet
2 - Newspapers or Magazines
3 - Conventional stores/supermarkets/gas stations
4 - TV/Movies
2. The reasons for influencing the use of e-cigarette use was the independent variable. It was
determined by the question, “Which of the following factors have influenced you for using
E-cigarette?” Responses coded as 0 for not selected and as 1 for selected each reason.
3. Various media advertisements were the independent variable and assessed by the question,
“Which of the following Media advertisements have ever influenced you for using E-
cigarette?” Response for each media channel advertisement coded 0 and 1 for non-selected
and selected cases, respectively.
Statistical Analysis
The goal for CSUSM on-campus survey was to assess the factors influencing the use of e-
cigarette among the college students. Person’s Chi Square test was used to evaluate demographic
variables, p-value of less than 0.005 was considered significant. Descriptive frequency analysis
was performed to evaluate frequencies of independent variables. The statistical analysis performed
by the Statistical Package for the Social Science Version 24.0 (SPSS).
Results
Descriptive Statistics
Demographic variables of college students
Table 6: Demographic characteristic of the study population, CSUSM survey-2019 (n=130)
Variables Overall Ever e-cigarette use

Yes No p value
n (%)
n (%) n (%)
Total 130 100.0% 47 100.0% 83 100.0%
Age Groups
18-22 years 48 35.4% 8 17.0% 38 45.8%
>22 years 84 64.6% 39 83.0% 45 54.2% 0.001
Gender
Male 73 56.2% 31 66.0% 42 50.6%
Female 57 43.8% 16 34.0% 41 49.4% 0.90a
Grade level
Undergrads 76 58.5% 21 44.7% 55 66.3%
Graduates 54 41.5% 26 55.3% 28 33.7% 0.26a
Race
American Indian 17 13.1% 5 10.6% 12 14.5%
Black 20 15.4% 11 23.4% 9 10.8%
Asian 28 21.5% 8 17.0% 20 24.1%
Hawaiian 7 5.4% 1 2.1% 6 7.2%
White 44 33.8% 19 40.4% 25 30.1%
Other 14 10.8% 3 6.4% 11 13.3% 1.67a
a= statistically not significant
Table 6 shows demographic variables of the student population. Total 130 students were
included in the study; 47 students reported using e-cigarette once in their life compared to 83
students who never tried e-cigarette. 35% of the study subjects were 18-22 years of age group and
65% were more than 22 years of age. The association between the e-cigarette users and non-users
by age groups was statistically significant (p=0.000). Nearly 56% were male, and 44% were
female. The proportion of e-cigarette users were higher than non-users in males compared to
females. There was no statistical difference between the e-cigarette users and non-users by gender
(p=0.90). In the study, 59% students were in undergraduate and 41% students were in graduate
school. The proportion of e-cigarette users was higher than non-users in graduate school compared
to undergraduates. There was no statistical difference among the e-cigarette users and non-users
by grade level (p=0.26). Most of the students were White (39%). The remaining races were the
following: Black or African American (15%), American Indian or Alaska Native (13%), Asian
(22%), Native Hawaiian, or other pacific islanders (5%). There were more e-cigarette users in
white and black race than non-users. In contrast, American Indian, Asian, and Native Hawaiian
have less e-cigarette users than non-users. There was no statistical difference between e-cigarette
users and non-users by race (p=1.67).
Table 7: Descriptive frequencies of variables among the e-cigarette users from CSUSM survey-2019 (n=47).
Variables Responses Percent of Cases

Frequencies Percent
reasons I Never Tried 1 0.9% 2.1%
Friends 19 17.1% 40.4%
Family 12 10.8% 25.5%
quit 7 6.3% 14.9%
Cost is less 2 1.8% 4.3%
Easily Available 10 9.0% 21.3%
Role model 8 7.2% 17.0%
Flavors 12 10.8% 25.5%
Dual 12 10.8% 25.5%
Media 27 24.3% 57.4%
Other 1 0.9% 2.1%
Total 111 100.0% 236.2%
Media channels Internet 36 46.8% 76.6%
Newspaper 7 9.1% 14.9%
Store 11 14.3% 23.4%
TV 13 16.9% 27.7%
Total 77 100.0% 163.8%
Table 7 displayed frequencies of variables to use an e-cigarette among the users. The
students had given media channels advertisements as one of the most common reasons to use e-
cigarette (58%). The second most common reason was “Friends” (40%). “Family members”,
“Available in flavors”, and “Dual-use” equally influenced the use of the e-cigarette (26%). The
other reasons included: “Easy availability” (21%), “Role model” (17%), “For trying to quit other
tobacco” (15%), “The cost is less compared to other tobacco products” (4%), and “Other reasons”
(2%).
Among the various media channels, Internet advertisements (77%) had the highest
influence of e-cigarette use. Other commercial sources included conventional stores (23%),
TV/Movie theaters (28%), and Newspapers or Magazines (15%).
Discussion
The CSUSM survey was conducted for e-cigarette use among on campus students and the
factors influencing its use. The variables were adopted from the NYTS survey and some were
modified from other research such as including media advertisements. It was an online survey and
to recruit student participants, flyers were distributed across the campus. Chi-square test was done
to analyze the demographic variables. From the result obtained it was analyzed that male showed
higher prevalence of e-cigarette use than females. Comparing the data for graduates and under-
graduates, graduate students showed higher use.
The descriptive frequency test was done to analyze various factors influencing the use of
e-cigarette. Among all the factors, media advertisements were the most significant factor
influencing the use of e-cigarette followed by “Friends”, “Family members”, “Availability in
flavors” and “Dual use” to potentially influence the use of e-cigarette. From all the media channels
internet advertisements was the most influencing factor. Other minor factors influencing the use
were “Easy availability”, “Role model”, “For trying to quit other tobacco”, “The cost is less
compared to other tobacco products”, and “Other reasons”. The findings raise the concern, for
24% reporting media to be influencing factors. Also, among all media channels, internet
advertising influence comprises 46.8%, followed by television (16.9%), stores (14.3%) and then
newspaper (9.1%). The exposure to increased advertisement has led to increased use. Consistent
with previous studies, exposure to media advertisement is likely to increase the intention of e-
cigarette use. The findings are of precise concern when there is an increase in e-cigarette
advertisement expenditure at various media platforms and have seen a hike of three folds during
2011-2013 (Kim, Arnold, & Makarenko, 2014). The estimated global market for e-cigarette
advertisement is predicted to increase by 21.4% from 2019 to 2024 reaching nearly USD 53.4
billion (Kumar K., 2019). Studies also reveal non-users likely to use e-cigarette and the increased
exposure to advertisements can heighten the risk of using e-cigarettes. Internet sales are estimated
to be the large portion of e-cigarette marketing as not many restrictions are applicable to it. The
outcome of CSUSM survey and relation to e-cigarette advertisement exposure has a positive
correlation for increased use among young adults.
In September 2012, the U.S. Department of Health and Human Services, the University of
Michigan, and the American College Health Association collaboratively launched the Tobacco-
Free College Campus Initiative (TFCCI) to promote and support the voluntary adoption and
implementation of tobacco-free policies at universities, colleges, and other institutions of higher
learning across the United States. Healthy People 2020 objective TU-13.17 monitors the number
of states and the District of Columbia that have enacted laws that prohibit smoking on college and
university campuses (The American Cancer Society, 2020). CSUSM is a smoking free campus
which includes e-cigarettes also, even though there is still an ongoing debate of e-cigarette being
tobacco or non-tobacco products. These policies have been endorsed by the Executive Cabinet and
even after implication of such policy notable percentage of students are using e-cigarettes. The
limitation of study here is that the sample size was relatively low compared to students on campus.
But it definitely brings attention that even after an existing smoke free policy; students do use e-
cigarette, maybe not on campus, but beyond the campus. Because the majority of adult smokers
begin smoking at young adulthood, colleges and universities can serve an important role in
preventing tobacco product use initiation among nonusers (Wang et. al.,2018). Maybe some
change in the policy can definitely bring more positive outcomes. Smoking prevention not only
protects students but also faculty, staff members and guests from secondhand smoke exposure.
The assessment concluded that the topic should be addressed and policies should be revised to
combat increased use of e-cigarette. Awareness programs about the ill effect of e-cigarette use on
health and regulation for e-cigarette marketing can discourage an individual from initiating or
continuing the further use of e-cigarette.
Global Relevance
Studies around the world give a clear idea for increased use of e-cigarette among young
adults. According to NYTS data, the young adults of age group 18-24 years show higher
prevalence than other age groups. In the US, by NYTS 2018 data, 7.6% of young adults use e-
cigarette. For Poland survey among universities, 19% of young adults had used e-cigarette
(Goniewicz and Zielinska 2012). The article by Adkison et.al. (2013), analyzes the prevalence of
e-cigarette among adults in four countries which included the US, Canada, Australia and UK. It
was evaluated that males showed higher use of e-cigarette than females and young adults aged 18-
24 years had a higher proportion of e-cigarette use compared to other adult age groups. The reasons
for use were mainly smoking cessation tool, availability of flavors and less harmful than
conventional smoking. The increased awareness was related to increased use (Adkison et.al. 2013).
In another article by Filippidis et.al. (2017), the trend of e-cigarette use in 27 European
Union member states was analyzed between 2012-2014. The prevalence of e-cigarette use
increased from 7.2% in 2012 to 11.6% in 2014. From sociodemographic results it was found that
males have higher use of e-cigarettes than females. Young adults showed higher prevalence than
other adult age groups. The most common factors reported for e-cigarette use were cessation tool,
less harmful than conventional smoking and availability in flavors. Increased awareness was
related to increased use (Filippidis et.al., 2017)
Relating the CSUSM on campus survey and two studies described, it can be concluded that
young adults aged 18-24 years old show higher use of e-cigarettes than other age groups.
Awareness about availability in flavors, quit smoking/cessation tool and less harmful than
conventional smoking are the most influencing factors in all studies. It can be related that these
awareness about e-cigarette can be mostly through media advertisement as most of the
advertisements are shown as cessation tools, various flavors and less harmful than conventional
smoking. The increased use and studies revealing the harmful effect on health due to e-cigarette
use, draws attention to implement laws that can aid in decreased use. Further studies and research
should be encouraged to identify factors affecting the use of e-cigarette and see if it has positive
correlation with increased use and media advertisement.
Limitation
The campus survey at CSUSM has a specific limitation. The study population was too
small compared to NYTS data. In this survey, the data was self-reported, which can lead to
reporting bias. The participating students were mostly at the graduate level, which can affect the
results. The survey questionnaire did not include variables, such as ethnicity, socio-economic
status, smoking-associated with other addictive substances (marijuana, alcohol), usage of other
tobacco products (snus, pipe, hookah), the current status of smoking and e-cigarette use.
Chapter 5: Discussion
The purpose of this study was to determine the association between the use of e-cigarettes
and the factors influencing the use of e-cigarettes among adolescents and young adults. This study
assessed the factors influencing the use of the e-cigarette, and the likelihood of using an e-cigarette
due to various media channel advertisements using the NYTS 2018 survey. The factors influencing
the use of e-cigarette, such as “Friends or family members used them”, “Try to quit using other
tobacco products”, “Less cost”, “Easier to get than other tobacco products”, “Famous people on
TV or in movies used them (role model)”, “Less harmful than other tobacco products”, “Available
in various flavors”, “Use in area where other tobacco products are not allowed”, were explored to
determine their relation with e-cigarette use. Various media channel advertisements, such as in the
internet, newspapers, or magazines, the conventional stores/gas stations/supermarkets, and
TV/movie theaters, were assessed to determine the influence for using e-cigarette among
adolescents and young adults. To accomplish our findings from previous literature and National
Youth Tobacco Survey 2018 analysis, we conducted a survey in CSUSM campus to determine
whether the media has stronger influence on the use of e-cigarette than other reasons (referred
from NYTS and modified). These associations and relations of our analysis is discussed in this
chapter with the application of the TTI model.
Application of the Theory of Triadic Influence in Findings
Interpersonal, social, and cultural streams of the Theory of Triadic Influence (TTI) model
could be applied to predict specific responses to use of an e-cigarette among adolescents and young
adults. TTI theory has provided a useful framework for understanding the association between
reasons influencing the use of e-cigarette and e-cigarette use, and various media channel
advertisements and the e-cigarette use.

Intrapersonal stream
Intrapersonal stream of the TTI begins at the ultimate level with personal characteristics,
self-determination, and general skills. Personal characteristics include, age, gender, grade level,
and race. Self-determination includes trying to quit smoking, less harmful. General skills include
cheaper cost, ease of availability, available in various flavors, and use of e-cigarette in restricted
areas.
Age:
Adolescents and young adults are considered to be a critical for developing and adopting
various skills as they undergo rapid physical and psychological changes and are easy to influence.
Finding from the literature review and both studies concluded that the prevalence of e-cigarette
use was higher among adolescents and young adults. This trend has also been documented in
different studies form several countries (Cho et.al., 2011) (Electronic Cigarettes, 2019) (Singh, et
al., 2016) (Zavala-Arciniega et.al., 2018). Increased usage of vaping could be the gateway to use
traditional cigarettes, illicit drugs (opioid, marijuana, cannabis) among adolescents (Cooke, DO,
Bulkhi, & B.Casale, 2015; Franck, Budlovsky, Windle, Filion, & Eisenberg, 2014).
Gender:
The analysis from two different data NYTS 2018 and CSUSM survey supports that e-
cigarette users are more prevalent in males than females. Research studies also support that males
are more addicted to use of an e-cigarette compared to females (Perikelous et.al., 2018) (Piñeiro,
et al., 2016). In contrast, a study aimed to identify the reasons to use an e-cigarette among male
and female showed that females were more frequently reported using e-cigarettes due to addiction
and stress (Santistevan, 2016). Future studies should include a better understanding of gender
differences in e-cigarette use that can provide valuable information about underlying mechanisms
of initiation, experimentation, and continuing use of e-cigarettes. Finding reported gender
differences might help in the design of interventions or campaigns specific to females or males
aimed at prevention and cessation of e-cigarettes use.
Grade level:
The study found that high school students had more than one-third of the students using an
e-cigarette compared to middle school, as they have more knowledge and easy accessibility to e-
cigarettes (Perikelous et.al., 2018). The U.S. surgeon general report of 2016 also highlighted that
e-cigarette use is higher among middle and high school students, and college students (U.S.
Department of Health and Human Services., 2016). The respondents were also higher from the
graduate school in the campus survey, even though the CSUSM has a smoking free campus and
clean air policy. Implication of rules and health awareness campaign in the school and college
campus could halt the trend of e-cigarette use among students.
Race:
Consistent with the previous research, the prevalence of e-cigarette was highest among
White. In contrast, Asian and Black students use less e-cigarette. The former literature also
supported that White races are more likely to experiment with tobacco products than others,
especially among adolescents (Electronic Cigarettes, 2019; U.S. Department of Health and Human
Services., 2016). Some of the studies aggregated data for racial minorities but didn’t report the
prevalence of e-cigarette users (Webb Hopper & Kolar, 2016).
Try to quit smoke:
Self-determinants of e-cigarettes, such as “Trying to quit smoke” and “Less harmful than
other tobacco products”, increased the use of e-cigarettes among adolescents and young adults,
also found in the study. But “Trying to quit smoke” was found as an uncertain reason to use e-
cigarettes in adolescents (Ebbert, Agunwamba, & Rutten, 2015). In contrast, adults were using an
e-cigarette to get rid of smoking, as a safer alternative to traditional cigarettes, and also as a way
to conveniently get around smoke-free laws (Glantz & Bareham, 2018). Therefore, the dual-use of
e-cigarette and traditional tobacco is a rising concern (Ebbert, Agunwamba, & Rutten, 2015).
Dual-use of e-cigarettes and conventional cigarettes or hookah is common among young adults. In
a quantitative study of dual-users, it was founded that e-cigarettes were substituted by cigarettes
and hookah where smoking is not allowed, or when cigarettes and hookah are not available
(Pokhrel, Herzog, Muranaka, Regmi, & Fagan, 2015). Traditional smokers double the odds of e-
cigarette use and also predicted to use e-cigarette more in follow-up than previous. Young adults
who started e-cigarette use could continue using traditional cigarettes. Some of them maintain e-
cigarette use due to pleasant initial experiences, or to reduce health risks, circumvent ETS policies,
or in preparation for quitting smoking. In contrast, the study demonstrated that the dual-use of
tobacco and e-cigarette decreased traditional cigarette smoking among adults (Etter & Bullen,
2014). “Try to quit smoking” also raises concern, as dual use of traditional cigarettes and e-
cigarette use potentially increases the risk of nicotine addiction among the young population (Bold,
Kong, Cavallo, Camenga, & Krishnan-Sarin, 2016). Future research is needed to examine the
impact of dual tobacco smoking and e-cigarette use in smoking cessation.
Less Harmful:
Glantz & Bareham also stated that young adults are attracted by the perception that e-
cigarettes are less harmful or harmless than other tobacco products (Glantz & Bareham, 2018).
Findings from our study also support that “less harmful than other tobacco” was one of the most
common reasons to use e-cigarette among middle and high school students, regardless of e-
cigarette smoking history. Youth also perceive that smoking-related harm decrease as the
frequency and intensity of cigarette smoking decrease. This perception of the absolute and relative
harmfulness of tobacco products may provide early warning of increasing acceptability and
eventual initiation of new tobacco products like e-cigarettes.
Available in various flavors:
“They are available in flavors, such as mint, candy, fruit, or chocolate” was found most
common reason to use e-cigarette among school and college students, regardless of smoking
history. The findings upheld that the availability of e-cigarettes in various colors, flavors, and
scents attracted young adults (Camenga & Klein, 2016) (Delnevo, et al., 2016) (Smith, Brar,
Srinivasan, Enja, & Lippmann, 2016). Another study also documented that adults preferred a
greater number of flavors compared to adolescents (Morean, et al., 2018). Adults are more likely
to use an e-cigarette than adolescents as a substitute for cigarettes, and therefore prefer flavors that
mimic traditional tobacco products like tobacco and menthol. Future research should investigate
whether adults’ use of multiple flavors is linked to factors like e-cigarette experience (e.g., duration
of e-cigarette use), device features (e.g., using customizable models that permit mixing multiple
flavors together in the tank), economic ability to sample different e-liquid flavors, or the ability to
purchase e-liquids legally from vape shops that often offer samples and sell a wide variety of
flavors. E-cigarette flavorings could potentially be harmful to humans if inhaled into the lungs.
Prior research found that the concentrations of some flavor chemicals in e-cigarette fluids are
sufficiently high for inhalation exposure by vaping to be of toxicological concern.
Low cost and Used in restricted areas:
Our findings suggest that lower cost of an e-cigarette was considered to be a positive factor
to use e-cigarettes in school and college students. It was similar to the research studies, which
reported that lower cost of e-cigarette increased its use and e-cigarettes are perceived to be less
expensive than tobacco smoking (Bold, Kong, Cavallo, Camenga, & Krishnan-Sarin, 2016;
Wagoner, et al., 2016). Exposure to e-cigarette advertisements in various media channels claiming
lower costs compared to tobacco cigarettes may influence interest in trying e-cigarettes. Choi et
al.,2012 also reported that e-cigarettes made tobacco use more accessible and convenient as it can
be used at anytime and anywhere (Choi, Fabian, Mottey, Corbett, & Forster, 2012).
Social stream
The social influence stream of the TTI framework exists within the interpersonal stream.
Friends, family members, and role models are the social influences of e-cigarettes.
Friends and Family members:
Socialization and acceptance by peer groups is crucial for adolescents (Cattelino, et al.,
2014). Peers are often pressured or influenced by their friends who are using e-cigarette. Peers
increase the risk of engaging in smoking behavior. Our findings demonstrated “Friend or Family
member” was the most common reason to use e-cigarette among middle and high school students,
regardless of cigarette smoking history. It is also a consistent reason among the CSUSM campus
e-cigarette smokers. Adolescents have close relations with friends and family members. The use
of e-cigarette among friends and family members may influence teens’ perceptions and attitudes
toward e-cigarette smoking. Studies have also reported an association between the parents’
tobacco use and teens’ e-cigarette use (Anand, et al., 2015; Dautzenberg, Berlin, Tanguy, Rieu, &
Birkui, 2015; Goniewicz & Zielinska-Danch, 2012). Older siblings were a significant predictors
of adolescents’ current and lifetime smoking (Avenevoli & Merikangas, 2009). Some of the studies
also elucidated that young adults, who vape but don’t smoke, were more than twice than their
peers, who do not vape (Zhong, Cao, Gong, Fei, & Wang, 2016). The current smoking status of
siblings was not only associated with the use of e-cigarette among adolescents but also the
conventional cigarettes, hookah, cannabis (Dautzenberg, Berlin, Tanguy, Rieu, & Birkui, 2015).
Conversely, findings from other studies showed that teenagers, whose parents are current smokers,
are less aware of and willing to try e-cigarettes compared with teenagers whose parents had never
or rarely smoked (Pepper, et al., 2013).
However, parents can also play an essential role in preventing tobacco use, including e-
cigarettes, by monitoring teens’ behavior, protecting them against smoking, and influencing health
beliefs and choice of peers (Avenevoli & Merikangas, 2009). Parents’ efforts can prevent
adolescents’ tobacco use (including e-cigarette use), which include parents’ modeling of non-
tobacco use, monitoring teen behavior, and communicating with them. Teenagers’ hormonal
changes, rebellious behavior during puberty, cultural differences, and controlling parental behavior
might be some of the external factors associated with e-cigarette use. Further studies should
explore parenting styles, characteristics, and social norms about teens’ e-cigarette use. Prevention
programs should make parents and family members aware about health effects and risks of using
e-cigarettes.
Role Models:
“Famous person on TV or movie theaters” was the least common reason to use e-cigarette
among middle and high school students, and CSUSM college students in the current study. A
survey from NYTS 2016 also documented that 2% of responses were recorded for “Famous people
on TV or movies use them” among the middle and high school students (Tsai, et al., 2018). In
contrast to our findings, Duke’s study from Nielson data illustrates that there was increased use of
e-cigarettes among the young due to television advertisements by celebrities (Duke, et al., 2014).
Further research is needed to determine whether “Famous persons on TV or movies” influence the
use of e-cigarette among young adults.

Cultural - Environmental stream
Cultural - environmental stream of the TTI model explains how people perceive the
information about the e-cigarette from mass media marketing (internet, newspaper or magazine,
conventional store, and TV/Movie theaters).
The findings from logistic regression stated that various media channel advertisements
significantly influence the use of e-cigarettes in exposures. The study results also extended the
previous research findings that e-cigarette use was higher among those who were exposed to media
marketing (Pepper, et al., 2013). This study highlights various media channels advertising and
promoting e-cigarette use through various platforms, which increase the odds of using e-cigarettes
among exposed adolescents. E-cigarette users are more exposure to media channels advertisements
compared to non-users. In online media, the messages, included; “healthier than cigarettes, can
use where smoking banned, cheaper than cigarettes, effective quitting aid (indirect claim),
effective quitting aid (direct claim), and disclaimer”, were the reasons to increase the use of e-
cigarettes among adolescents and young adults (Zhu, et al., 2014). E-cigarette advertisements are
not only limited to online websites but widespread on YouTube, Twitter, Facebook, or Instagram.
Also, conventional stores, supermarkets, and gas stations have a higher promotion of disposable
and rechargeable e-cigarette devices near the college campus. Price advertising and price-reducing
promotions in conventional stores can raise purchase and use of e-cigarettes among young adults
(Wagoner, et al., 2016). The approaches to reduce youth access to e-cigarettes and exposure to e-
cigarette advertising could include regulation of youth-oriented marketing, restrictions on youth
access to tobacco products in retail settings, and high-impact youth-focused tobacco education
campaigns. In response to high media advertisement, the FDA launched the first smoking
prevention “The Real Cost” campaign to address the at-risk teens in the United States. The FDA
is also planning to develop and distribute new lesson plans and resources for middle school
teachers, students and parents that are expected to be made available throughout the 2019-2020
school year.
Chapter 6: Global Health Relevance
Hopes that e-cigarettes would be both less harmful to conventional smoking and also help
in quitting smoking, does not seem to have brought a positive effect into the real world. On other
hand e-cigarettes have become an additional product into the tobacco category. In 2006 e-
cigarettes were introduced in Europe, 2007 in the US and within decade its use spread globally.
The prevalence of e-cigarette has increased on a wide scale globally among adolescents and young
adults (CDC, Youth and Tobacco Use. 2019; Goniewicz and Zielinska 2012; Zavala-Arciniega
et.al., 2018; Cho et.al., 2011). Also, no studies have been able to prove that e-cigarettes are safer
than conventional tobacco products. On contrary studies reveals that e-cigarettes are not safe from
health perspective and have negative effect (Park S. H., 2011; Drummond and Upson., 2014;
Eissenberg. 2010 & Vansickel and Eissenberg., 2013; Bekki et.al., 2014; Sussan et.al., 2015;
Lerner et.al., 2015; Hua, Alfi and Talbot, 2013; Allen et.al., 2016 ). The increased use of e-cigarette
and also the ongoing studies about the effect on health by its use has become a matter of concern
from public health point of view universally.
This paper provides data to be evidence-based for making decisions to administer and
monitor the use of e-cigarette, and a need for policy implementation. The study conducted at
CSUSM on campus, NYTS and Literature Review exemplify five SDGs (United Nations, 2019).
SDG 3 is to ensure healthy lives and promote well-being for all ages. The study through various
articles found that e-cigarettes are launched as less harmful than conventional tobacco, but on
contrary studies have revealed harmful effects on health due to e-cigarette use.
SDG 1 is to end poverty; SDG 2 is to end hunger; and SDG 4 is education for all. Though
no evaluation is done in the study on the basis of country in relation to socioeconomic status and
e-cigarette use, the majority of the tobacco users are from low socioeconomic countries. Initial
idea of e-cigarette being nicotine free has vanished and currently it contains nicotine in varying
amounts. Also marketing of e-cigarette is expected to grow at a Compound Annual Growth Rate
(CAGR) of 21.4% rise from 2019 to 2024 reaching nearly USD 53.4 billion (Kumar K., 2019).
Expenses done on e-cigarette can be used to decrease poverty, hunger and invest in education.
The finding of the study reveals inequality in the law to govern e-cigarette use worldwide.
To regulate the use of e-cigarette globally no such laws has been put forward on paper by the
World Health Organization Framework Convention on Tobacco Control (FCTC). It is a treaty
adopted by the World Health Assembly, which regulates the universal laws and standards to reduce
the devastating effects of tobacco on a global level. 181 countries are parties of FCTC. They
regulate laws to govern tobacco products and not the non-tobacco products. Electronic cigarettes
and other electronic nicotine delivery systems (ENDS) are classified as non-tobacco products, and
no such treaty has been signed for the same (WHO FCTC, 2018). According to the latest report, it
is still under debate, whether ENDS should be considered as a tobacco product or not. No such
uniformity in laws exists for e-cigarettes, as prevailing for tobacco products. SDG 17 addresses
Global Partnership and WHO FCTC can play a vital role for controlling e-cigarette use as done
for conventional tobacco products. Universal laws should be implemented till studies prove it to
be less harmful than conventional tobacco.
Due to the absence of universal law globally for e-cigarette, every country has its own
classification and policy domain for ENDS. According to the recent Conference of the Parties
(COP), looking at the skyrocket marketing and increased use of ENDS, they have proposed a few
policy domains for regulating e-cigarettes. It was suggested to come up with a clear definition and
classification of e-cigarette within existing laws and regulations. Also, some policy domains were
identified for governance of ENDS, such as minimum age, distribution, importation, sales, use
restriction etc. It was found that 102 out of 181 countries have ENDS available and 39 countries
from those 102 countries do not have any regulations for e-cigarette use. As per the report, 30
countries have banned ENDS products and for the remaining countries, only 65 countries have
regulations over it (WHO FCTC, 2018).
ENDS products have displayed increased use globally and the consequences of its use are
still skeptical. It sounds mandatory and appropriate that parties develop a uniform regulation for
the use of e-cigarettes. The uniform laws will help in regulation of e-cigarette use globally as done
for other tobacco products, which will aid in decreasing the negative effect of e-cigarette use
worldwide.
Chapter 7: Conclusion
E-cigarettes are battery operated devices, introduced as an alternative to conventional
smoking and as a cessation tool. Initial concept of e-cigarette was to be nicotine free, but currently
is available with varying amount of nicotine levels. From its availability in the market from 2006,
the use has escalated staggeringly just within 10 years. From various studies it can be concluded
that adolescents and young adults display higher use compared to other age groups. Males have
higher prevalence of e-cigarette use than females (Centers for Disease Control and Prevention
(CDC) 2013; Perikelous et.al. 2018 & Perialathan et al., 2018). The increased usages among
adolescents draws attention because this age is considered to be a critical for developing and
adopting various skills as they undergo rapid physical and psychological changes and are easy to
influence (Qidwai et al., 2010 & Salam et al., 2016).
Various factors influencing e-cigarette use are gender, age, flavors, smoking cessation,
friends, family, media advertisements etc. As e-cigarettes are new to market, not much of the
research and studies are carried out to know the factors trailing for heightened use. But if we go
through literature as described in paper, it can be said that the media has played a massive role.
Awareness about factors influencing the use such as flavor, cessation tool, cheaper, less harmful,
alternative to smoking etc. are accessed mainly through media advertisements. Most of the
advertisements on traditional and social media are promoted as an alternative to conventional
smoking, cheaper, less harmful, can be used where smoking is not allowed, available in various
flavors and as a smoking cessation tool and are often compared to conventional form of smoking
(Richardson et.al., 2014 & Zhu et.al., 2013). Also, not many restrictions are imposed on non-
combustible products advertisements, especially for online marketing and increased usage of
internet and social media sites have provided a substantial platform for e-cigarettes companies to
target million adolescents and young adults’ population. For one of the surveys between 2011 and
2013, exposure frequency for e-cigarettes advertising increased by 256% among youths and 321%
among young adults (Duke et al., 2014). The expenditure for e-cigarettes marketing is at skyrocket.
It is estimated to reach 53.4 billion USD by 2024, depicting 21.4% rise than 2019 (Kumar K.,
2019).
Also, with increased use of e-cigarette comes the concern for health. There are mixed
considerations for the health outcome by e-cigarettes use. E-cigarette is new to market, so not
many studies are carried out to know the health effect of its use. The nicotine content in e-cigarette
impacts on health after a long-term use and e-cigarettes are being used since last decade (Winickoff
et.al., 2009). From the few studies it brings attention that short term use of e-cigarette affects
various biological systems of the body. The most affected are the pulmonary and neurological
systems. The carbonyl compound released from vaping can lead towards lung toxicity (Huaa, Alfi
and Talbot, 2013; Lerner et.al., 2015 & Sussan et.al., 2015). Also, studies reveal that diacetyl
content present in various flavors can cause “popcorn lungs” (Joseph et.al., 2016).
On a global scale World Health Organization Framework Convention on Tobacco Control
(WHO FCTC), has taken an initiative with its parties, to bring forward the uniformity in regulation
of e-cigarette on global scale as done for tobacco products. Currently countries have their own
laws and regulations as they fit into their framework of regulation. Still the future consequences
of e-cigarettes are not known, but viewing at the increased use within a decade of its sale, gives an
alarming sign to deliberately look into the various factors influencing its use and effect on health.
Media advertisement can or cannot be the main factor, but glancing at various other factors and
interconnecting them, some way media seems to be portrayed as a dominant factor.

Recommendation for future
The limitation of this study is that, e-cigarette is new to the market and not much research
has been done. This monograph focused on various factors influencing e-cigarette use and links it
with media advertisements to see if it has higher influence for e-cigarette use. Future studies should
be focused on media advertisements and e-cigarette use among adolescents and young adults. Also,
a longitudinal study should focus on initiation of e-cigarette and continuous use in future.
This study linked various factors influencing e-cigarette use with media advertisements
and found that awareness about being less harmful, available in various flavors, cessation tool etc.
are somewhere connected to media advertisements. The aftermath effect of e-cigarette use is still
a controversy. The studies about short-term use of e-cigarettes give a warning about the impending
health in the near future. Laws and restrictions should be applied as normal tobacco product, till
there is enough evidence to prove e-cigarette being safe.
Parents can play a vital role by talking to their children and explaining both sides of its use.
To further recommend on a global level, WHO FCTC, should be able to implement laws as soon
as possible, to avoid the negative outcome by e-cigarette use and avoiding future consequences,
before it's too late.

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nt/23/suppl_3/iii3.long
Appendix A
1. What is your gender?

Male
Female
2. What is your age?
Specify_____
3. What grade are you in?
Freshmen
Sophomore
Junior
Senior
Graduate
4. What ethnicity do you consider to be?
American Indian and Alaska
African American or Black
Asian
Native Hawaiian and other Pacific islander
White
Other
5. Have you ever smoked tobacco?
Yes
No
6. Have you ever smoked E-cigarette?
Yes
No
7. Which of the following factors have influenced you for using E-cigarette? (select all that
apply):
I have never tried an e-cigarette
Friends
Family
For trying to quite other tobacco
Cost is less compared to other tobacco products
Easy availability
Role model
Availability in various flavors
Dual Use
Media
Others
8. Which of the following factors have influenced you for using E-cigarette? (select all that
apply):
I have never tried an e-cigarette
Internet
Newspaper or Magazine
Advertisements at Conventional Stores, Supermarket or Gas stations
Television
None

Factors Influencing The Use of E-Cigarettes

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PROJECT

CALIFORNIA STATE UNIVERSITY SAN MARCOS

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF PUBLIC HEAL TH

AUTHOR(S): Krupali Desai, Dipen Patel

DATE OF SUCCESSFUL DEFENSE: 11/19/2019

THE PROJECT HAS BEEN ACCEPTED BY THE PROJECT COMMITTEE IN

PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF PUBLIC HEAL TH

Asherlev Santos May 4, 2020

Kimberley Pulvers May 4, 2020

COMMITTEE MEMBER SIGNATURE DATE

COMMITTEE MEMBER SIGNATURE DATE

Title: FACTORS INFLUENCING THE USE OF E-CIGARETTES AMONG

Thesis Chair Committee: Dr. AsherLev Santos

List of figures .......................................................................................................................................... 5

Chapter 1: Introduction of study .......................................................................................................... 6

Chapter 2: Literature Review................................................................................................................ 9

What are e-cigarette and its history? .................................................................................................................. 10

Prevalence of E-cigarette ................................................................................................................................... 12

Health effect due to e-cigarette smoking............................................................................................................ 14

Theory of Triadic Influence (TTI) ..................................................................................................................... 18

Awareness about Electronic Cigarettes and use ................................................................................................. 26

Chapter 3: National Youth Tobacco Survey - 2018 ........................................................................... 29

Specific Objectives ............................................................................................................................................ 30

Study Procedure and Sampling .......................................................................................................................... 31

Study method ..................................................................................................................................................... 32

Global Relevance ............................................................................................................................................... 46

Chapter 4: California State University San Marcos Campus Survey ............................................. 49

Study Procedure and Study Population .............................................................................................................. 49

Study method ..................................................................................................................................................... 50

Global Relevance ............................................................................................................................................... 57

Chapter 5: Discussion ........................................................................................................................... 59

Application of the Theory of Triadic Influence in Findings .............................................................................. 59

Chapter 6: Global Health Relevance .................................................................................................. 68

Recommendation for future ............................................................................................................................... 73

Chapter 8: References .......................................................................................................................... 74

Table 1: Application of Theory of Triadic Influence (TTI) model ............................................... 34

Table 2: Demographic Variables of the student population ......................................................... 37

Table 4: Logistic regression .......................................................................................................... 41

(TTI), CSUSM survey. ................................................................................................................. 51

Figure 1: Parts and design of e-cigarettes. .................................................................................... 11

Figure 2: Types of e-cigarettes ..................................................................................................... 11

Figure 3: Prevalence of e-cigarette use among adolescents in the US ......................................... 13

Figure 4: Prevalence of e-cigarette use among adults in the US. ................................................. 13

Figure 6: Theory of Triadic Influence .......................................................................................... 19

Figure 9: Estimated market growth rate by region from 2019-2024. ........................................... 26

Chapter 1: Introduction of study

Arciniega, et al., 2018).

pros and cons of its use.

objectives are as follows:

Aim: To assess factors contributing to the use of e-cigarette

Goal 1: Review the National Youth Tobacco Survey-2018.

Objective 1: To determine if there is variation for e-cigarette use by age groups

Objective 2: To analyze if there is a difference among gender for e-cigarette use.

Objective 3: To determine if there is difference among different grade levels for e-

Objective 4: To analyze e-cigarette use among different races.

Objective 5: To analyze various reasons influencing the use of e-cigarette among

Objective 6: To determine the influence of media channels advertisements among

Goal 2: Survey California State University San Marcos students

Objective 1: To analyze if media has higher influence for e-cigarette use

compared to other factors.