What May Be Associated with Young Adult E-Cigarette Use?

Application of the Integrated Behavior Model and Affect Heuristic to Examine Key
Correlates

by Diane J. Martinez

B.A. in History of Science, History of Medicine, May 2005, Yale University

M.P.H in Chronic Disease Epidemiology, May 2008, Yale School of Public Health

A Dissertation submitted to

The Faculty of
The Milken Institute School of Public Health
of The George Washington University
in partial fulfillment of the requirements
for the degree of Doctor of Public Health

May 18, 2017

Dissertation directed by

Monique M. Turner
Associate Professor of Prevention & Community Health
The Milken Institute School of Public Health of The George Washington University

certifies that Diane J. Martinez has passed the Final Examination for the degree of Doctor

of Public Health as of March 23, 2017. This is the final and approved form of the

dissertation.

What May Be Associated with Young Adult E-Cigarette Use?

Application of the Integrated Behavior Model and Affect Heuristic to Examine Key
Correlates

Diane J. Martinez

Dissertation Research Committee:

Monique M. Turner, Associate Professor of Prevention & Community,

Dissertation Director

Kimberly A. Horn, Professor of Prevention & Community Health, Committee

Member

Kathleen M. Roche, Associate Professor of Prevention & Community Health,

Committee Member

ii
© Copyright 2017 by Diane J. Martinez
All rights reserved.

iii
 Acknowledgements

The author wishes to acknowledge the support network of family, friends, and

mentors who were there for me every step of the way while completing this dissertation. I

would first like to thank my parents, brother, and extended family members who have

been incredibly supportive of my educational pursuit and public health career path. My

parents taught me the value of perseverance and resilience to follow through in

implementing my goals and dreams. They also demonstrated through their own careers

the joy of finding your passion and sharing your skills and talents with others. This

dissertation is dedicated to my mom Denice W. Martinez, and my dad David R. Martinez,

who in my eyes have made contributions to their respective fields in education and

electrical engineering emblematic of doctoral training and accomplishments despite not

having the official degree.

Next, I would like to thank my dissertation chair Dr. Monique Turner, who has

become both a mentor and friend. Mo not only taught me theory in the classroom as her

TA and doctoral seminar student, but also through our real-world qualitative evaluation

of obesity interventions in three churches in KY, TN, and SC. Additionally, she opened

my eyes to the field of risk communication, which was my first exposure to how e-

cigarettes were marketed as less harmful alternatives to combustible cigarettes. Mo taught

me how to think, write, and speak at a doctoral level. She also is a mentor whom I truly

admire for her dedication to her students, research, and family. Thank you Mo for the

opportunity to work with you, and learn from you—it’s an experience I will cherish and

intend to pay forward!

iv
 I am also appreciative of my Committee Member and former boss Dr. Kimberly

Horn who mentored me while I directed a randomized controlled trial examining the

impact of reduced nicotine cigarette use among DC adult smokers. Her leadership

enabled me to grow as a tobacco control researcher by working with low-income DC

adult smokers, attending conferences and FDA grantee meetings, and publishing in the

field. By working and learning from Kim I have continued to strengthen my research,

communication, and management skills that will serve me well in my career.

I am also grateful for the mentorship, statistical guidance, and structural equation

model (SEM) skillset I acquired through working with Committee Member Dr. Kathleen

Roche. Katy’s invaluable advice of taking the SEM course at Stats Camp with Dr. Todd

Little gave me the knowledge, skills, and confidence to apply this technique for my

dissertation. While there were data analysis curveballs, Katy provided the type of

feedback necessary to overcome them, and see my dissertation to the finish line. I am

also indebted to her pet cats Kidden and Parker, her dog Sarah, and her frog Sheba for

their dissertation support while taking care of them in August 2016. Speaking of animal

shout-outs, I am appreciative of the following pets I have either house/pet sat for or spent

time with during my dissertation: Sasha, Nino, Misty, Rapunzel, Zebby, and Lulu.

Finally, I am forever appreciative to my support network of close friends and

colleagues who have been there for me throughout this journey. A dissertation really is a

marathon and I am so lucky to have had my dear friends to cheer me on as I achieved

each milestone and overcome curveballs along the way. This dissertation challenged me

to not only become a researcher, but also a writer. I am excited to apply these skills to the

next professional opportunity and door that opens in my career path.

v
 Abstract of Dissertation

What May Be Associated with Young Adult E-Cigarette Use?

Application of the Integrated Behavior Model and Affect Heuristic to Examine Key
Correlates

Increasing rates of e-cigarette use among young adults support the critical need

for research identifying how attitude, norm, intention, and risk perception may influence

e-cigarette use among this age group. Tobacco control approaches shown to prevent

cigarette smoking may not work as effectively for the prevention of e-cigarette use. To

address this research gap, the present study applied the Integrated Behavior Model (IBM)

encompassing the affect heuristic theory to examine individual-level correlates (i.e.,

attitude, perceived norm, personal agency, intention, and e-cigarette risk perception) of

young adults’ e-cigarette use. The 2013-2014 Population Assessment of Tobacco and

Health (PATH) Study Wave 1 baseline adult dataset consisted of 9,112 young adults

(ages 18-24). A total of 3,887 (42.7%) reported ever having used an e-cigarette even one

or two times, and reported now using e-cigarettes every day (n=160, 4.1%), some days

(n=947, 24.4%), or not at all/non-users (n=2,780, 71.5%). Findings from structural

equation models (SEM) indicated that the affect heuristic theory and constructs adapted

from the IBM were associated positively with e-cigarette use among young adults (CFI =

0.935; TLI = 0.925; RMSEA = 0.024, 90% CI: 0.022-0.026). As expected for the IBM,

young adults’ positive feelings, perceived benefits, and normative beliefs of e-cigarettes

were negatively associated with intention to quit e-cigarettes and, in turn, with a higher

likelihood of currently using e-cigarettes. Perceived benefit and positive feelings also

were associated inversely with young adults’ risk perceptions and, in turn, a higher

likelihood of currently using e-cigarettes. These findings suggest that communication,

vi
educational, and policy strategies to prevent e-cigarette use among young adults should

highlight the health risk of e-cigarettes in order to address the high perceived benefits and

low risk perceptions reported by young adults in this study.

vii
 Table of Contents

Acknowledgements ........................................................................................................................ iv

Abstract of Dissertation ................................................................................................................. vi

List of Figures ............................................................................................................................... xii

List of Tables ............................................................................................................................... xiii

Chapter 1: Introduction ................................................................................................................... 1

Purpose of the Dissertation ......................................................................................................... 3

Dissertation Objective ................................................................................................................. 6

Specific Aims .............................................................................................................................. 7

Summary ..................................................................................................................................... 9

Chapter 2: Literature Review ........................................................................................................ 10

Innovation of E-Cigarettes..................................................................................................... 12

Device Type & Characteristics .............................................................................................. 13

E-Cigarette Health Risks ....................................................................................................... 14

E-Cigarette Regulation .......................................................................................................... 17

E-Cigarette Marketing ........................................................................................................... 18

Industry Targeting Young Adults .......................................................................................... 20

Integrated Behavior Model (IBM) ............................................................................................ 21

Experiential Attitude.............................................................................................................. 23

Instrumental Attitude ............................................................................................................. 24

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 Perceived Benefit: Smoking Cessation and Cigarette Reduction .......................................... 25

Perceived Norm ..................................................................................................................... 29

Personal Agency .................................................................................................................... 31

E-Cigarette Risk Perception .................................................................................................. 33

Risk for Nicotine Dependence ............................................................................................... 34

Affect Heuristic Theory ............................................................................................................ 35

Dissertation Conceptual Framework ......................................................................................... 36

Research Aims and Hypotheses ................................................................................................ 38

Chapter 3: Methodology ............................................................................................................... 40

Study Design ............................................................................................................................. 40

Study Participation .................................................................................................................... 42

Eligibility Criteria .................................................................................................................. 42

Sample Size ........................................................................................................................... 42

Measures.................................................................................................................................... 43

Experiential Attitude (Positive Affect) .................................................................................. 45

Instrumental Attitude (Perceived Benefit) ............................................................................. 45

Perceived Norm ..................................................................................................................... 45

Personal Agency .................................................................................................................... 46

Quit Intention ......................................................................................................................... 47

E-Cigarette Risk Perception .................................................................................................. 47

ix
 Dependent Variable: E-Cigarette Use ................................................................................... 47

Covariates in Structural Model .............................................................................................. 48

Data Analysis Plan .................................................................................................................... 51

Univariate/Bivariate Analyses ............................................................................................... 51

Reliability Assessment and Exploratory Factor Analysis (EFA) .......................................... 53

Validity Assessment of Indicators: Confirmatory Factor Analysis (CFA) ........................... 54

Parceling Items ...................................................................................................................... 54

Fitting the Measurement Model ............................................................................................ 55

Structural Equation Modeling (SEM).................................................................................... 56

Chapter 4: Results ......................................................................................................................... 58

Univariate & Bivariate Results ................................................................................................. 59

Exploratory Factor Analysis Results ......................................................................................... 61

Confirmatory Factor Analysis Results ...................................................................................... 69

Structural Equation Modeling Results ...................................................................................... 71

Chapter 5: Discussion ................................................................................................................... 84

Interpretation of Findings .......................................................................................................... 84

Aim 1 ................................................................................................................................. 84

Aim 2 ................................................................................................................................. 85

Aim 3 ................................................................................................................................. 86

Final Structural Model Combining Aims 1-3 ........................................................................ 86

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 Implications of Findings............................................................................................................ 87

Influence of Attitude and Norm............................................................................................. 87

Risk Perception and E-Cigarette Use .................................................................................... 88

Limitations ................................................................................................................................ 90

E-Cigarette Use Measurement ............................................................................................... 90

Dual and Poly Tobacco Users ............................................................................................... 91

Frequency and Context of E-Cigarette Use ........................................................................... 92

Quit Intention Measure .......................................................................................................... 93

Same Survey Items for All Adults ......................................................................................... 94

Categorical Variables ............................................................................................................ 94

Cross-Sectional Design.......................................................................................................... 95

Application for Future Research ............................................................................................... 96

Longitudinal Examination ..................................................................................................... 96

Multi-Level Ecological Examination .................................................................................... 97

Conclusion................................................................................................................................. 98

References ................................................................................................................................... 100

Appendix A: List of Survey Items for Primary Outcome and Latent Constructs ....................... 116

Appendix B: Univariate and Bivariate Analyses Results for Each Construct ............................ 118

Appendix C: Post Hoc Analyses ................................................................................................. 128

xi
 List of Figures

Figure 1. Integrated Behavior Model (IBM) 5

Figure 2. Conceptual Framework 7

Figure 3. Comprehensive Measurement Model 44

Figure 4. Proposed Structural Equation Model 57

Figure 5. Quit Intention Histogram of Data Spread Among All Young Adults 61

Figure 6. Revised Measurement Model Based Upon EFA and CFA with Three Latent
Constructs (Experiential Attitude, Instrumental Attitude, E-Cigarette Risk Perception) 70

Figure 7. Aim 1 Structural Model 72

Figure 8. Aim 2 Structural Model 73

Figure 9. Aim 3 Structural Model 74

Figure 10. Overall Structural Model 77

Figure 11. PATH Study Conceptual Model 97

xii
 List of Tables

Table 1. Covariates in Structural Model 49

Table 2. Exclusive E-cigarette Use, Dual Use, and Poly Tobacco Use Frequency 50

Table 3. Demographics of Young Adults Aged 18-24 by E-Cigarette User Type 58

Table 4. Summary of Exploratory Factor Analysis Results for 23 Items Using Robust
Weighted Least Squares Estimation (WLSMV) with a Geomin Oblique Rotation 63

Table 5. Indicator Survey Questions Grouped by their Original Latent Construct and
Final Latent Construct Resulting from Exploratory Factor Analysis (EFA) 66

Table 6. Summary of Exploratory Factor Analysis Results for 14 Final Items Using
Robust Weighted Least Squares Estimation (WLSMV) with Geomin Oblique Rotation 68

Table 7. Fit Indices for EFA and CFA Measurement Model Fit Using Robust Weighted
Least Squares Estimation (WLSMV) 69

Table 8. Standardized Coefficients of Covariates in Structural Model (N = 3,866) 75

Table 9. Fit Indices for CFA Measurement Model Compared to Structural Models
for Aims1-3 and Combined 76

Table 10. Standardized and Unstandardized Coefficients from the Structural Pathways 79

Table 11. Total and Specific Indirect Effects of Pathways (N = 3,866) 80

xiii
 Chapter 1: Introduction

The U.S. Surgeon General Dr. Vivek Murthy sounded the alarm in Fall 2016 on the need

to address increasing electronic cigarette (e-cigarette) use among youth and young adults

(USDHHS, 2016a). In his 2016 Surgeon General Report exclusively focused on e-cigarette use

among this age group, Dr. Murthy declared: It is crucial that the progress made in reducing

cigarette smoking among youth and young adults not be compromised by the initiation and use

of e-cigarettes (pg 3) (USDHHS, 2016a). Since 2007, e-cigarettes have increased in popularity in

the United States due to the product’s appeal in mimicking the behavior of smoking a traditional

cigarette without burning carcinogenic combustible tobacco (Gray, 2013; Johnston, O’Malley,

Miech, Bachman, & Chulenberg, 2014; Pepper & Brewer, 2014; Pepper, Emery, Ribisl, &

Brewer, 2014). When a user draws air through a disposable e-cigarette, a sensor detects this air

flow and activates an atomizer that heats a cartridge often containing nicotine, propylene glycol,

glycerin, water, and flavor additives, which produces a vapor that is inhaled (White Cloud

Electronic Cigarettes, 2015). On May 5, 2016, the Food and Drug Administration (FDA)

finalized rules to extend the agency’s authority under the 2009 Family Smoking Prevention and

Tobacco Control Act to regulate all products that meet the definition of a tobacco product

including e-cigarettes, all cigars, hookah (water pipe) tobacco, pipe tobacco, and nicotine gels.

This rule went into effect on August 8, 2016 (FDA, 2016).

Prior to May 5, 2016, e-cigarettes were neither regulated by the FDA, nor subject to the

same state and federal laws enacted to prevent combustible cigarette use (Benowitz &

Goniewicz, 2013; Printz, 2014). Given this delay in FDA regulation, independent e-cigarette

manufacturers and the tobacco industry have influenced public perceptions of this product by

advertising e-cigarettes as healthier than cigarettes, effective for smoking cessation, and usable in

1
places where cigarettes are traditionally prohibited (Grana & Ling, 2014; Richardson, Ganz, &

Vallone, 2015; Zhu et al., 2014). A comprehensive internet search conducted by Zhu et al.

identified 466 different e-cigarette brands and 7,764 unique liquid flavors ranging from tobacco,

menthol, fruit, dessert, candy, alcohol, and coffee flavored vapors (Zhu et al., 2014). The

product’s appeal and increasing use over the last ten years has led to retail sales estimated at

approximately $2 billion in 2013, and $3.3 billion in 2015 (Herzog, 2015; Herzog, Gerberi, &

Scott, 2014). As a result, the development and marketing of e-cigarettes has created a new

landscape beyond combustible cigarettes that threatens existing tobacco control gains

(USDHHS, 2014).

Ten years of unrestricted marketing and the lack of federal regulation of e-cigarettes

challenge tobacco control researchers to learn how these products are currently perceived by

consumers and their motivations for use. With increasing prevalence of e-cigarette use among

youth and young adults (Agaku et al., 2014; Johnston et al., 2014), public health experts warn

that non-smokers who experiment with the device may transition to using more harmful

combustible tobacco products (USDHHS, 2014, 2016a). Young adults’ increasing prevalence of

e-cigarette use is particularly concerning for public health experts given that this audience

segment is the youngest sector of the population whom can be legally sold e-cigarettes and other

tobacco products. Young adulthood is a period associated with both tobacco use experimentation

and initiation of regular tobacco use (USDHHS, 2012). Young adults reported the highest rates

of e-cigarette experimentation in the 2014 National Health Interview Survey (NHIS) compared

to older adult groups (Delnevo et al., 2016). In another national study, 21.6% of young adults

between the ages of 18-24 years reported ever trying an e-cigarette and 5.1% reported current

use of e-cigarettes compared to, respectively, 12.6% and 3.7% of adults overall (Schoenborn &

2
Gindi, 2015). Rath et al.’s study showed that young adults have high rates of dual use and poly

use of tobacco products, with some young adults reporting use of e-cigarettes with other tobacco

products, including cigarettes (Rath, Villanti, Abrams, & Vallone, 2012). More specifically,

young adults who identify as current or former smokers report increased use of e-cigarettes. One

survey administered online in 2013 found that among young adults (18-29 years old) who were

current or former smokers, 18.9% currently used e-cigarettes (Giovenco, Lewis, & Delnevo,

2014). This finding was supported by another web-based survey in which 19.6% of young adult

smokers indicated currently using e-cigarettes (Rutten et al., 2015). This prevalence of e-

cigarette use among young adults requires an examination of the correlates of use—specifically,

the attitudes and beliefs of young adults possibly associated with use.

The 2012 Surgeon General Report, which focused on preventing tobacco use among

youth and young adults, presented evidence on the effectiveness of mass media campaigns,

comprehensive community programs, and school-based programs in decreasing cigarette

smoking initiation among this age group (USDHHS, 2012). However, Dr. Murthy acknowledged

in his 2016 Surgeon General Report that while these tobacco control approaches may also work

for preventing e-cigarette use, more research is needed on how this target population perceives e-

cigarettes to tailor communication and educational tobacco control strategies (USDHHS, 2016a).

This dissertation aimed to address this research gap by examining how young adults’ attitudes,

beliefs, and perceptions of e-cigarettes influenced their likelihood of currently using the device.

Purpose of the Dissertation

Scholars of health behavior have shown through numerous studies that an individual’s

attitudes and beliefs influence whether a certain health-related action is taken. Health behavior

3
change theories such as the Health Belief Model (Rosenstock, Strecher, & Becker, 1988), the

Extended Parallel Process Model (Witte, 1992), Social Cognitive Theory (Bandura, 1986), and

the Theory of Planned Behavior (Ajzen, 1991) can be applied to identify which individual-level

factors influence e-cigarette use among young adults. In this way, these theories can inform

future targeted behavior change interventions for young adults. In an assessment of the

commonalities among these theories, Fishbein and colleagues concluded that an individual’s

behavior and intentions are influenced by the following key factors: attitudes towards the

behavior, perceived norms of the behavior, and one’s perceived ability to perform the behavior

(Fishbein, 2000; Fishbein et al., 2002). These three factors comprise the Integrated Behavior

Model (IBM), which was used as the underlying theory guiding this dissertation.

The IBM (Figure 1) posits that if an individual has established a strong intention to

perform a behavior, necessary skills, and limited environmental constraints, then there is a high

likelihood that the individual will conduct the behavior. The IBM also demonstrates how the

constructs of attitude, perceived norm, and personal agency serve as the primary determinants of

intention to perform the behavior (Fishbein, 2000; Fishbein et al., 2002). In the IBM, the

construct attitude encompasses the sub-constructs experiential attitude (i.e., perceived feelings)

and instrumental attitude (i.e., perceived benefits). The construct perceived norm includes the

sub-constructs of injunctive norm (i.e., perception of what others think should be done) and

descriptive norm (i.e., perception of common behavior of others). The construct of personal

agency comprises the sub-constructs of perceived behavioral control (i.e., perceived

ease/difficulty performing the behavior) and self-efficacy (i.e., confidence in performing the

behavior) (Fishbein et al., 2002).

4
Figure 1. Integrated Behavior Model (IBM)

The purpose of this dissertation was to apply the Integrated Behavior Model to examine how

attitude towards e-cigarettes, perceived norms concerning e-cigarette use, and the perceived

ability to use e-cigarettes drive young adults’ intention and e-cigarette use behavior. By

examining how these constructs influence adult e-cigarette use one can learn whether certain

individual-level factors are more salient determinants of use. Determining whether e-cigarette

use among young adults is more attitudinally driven than normatively driven, for instance, will

help target future health campaign messaging to prevent uptake among this age group.

Additionally, when it comes to assessing risk-oriented behaviors, risk communication and

perception, scholars have long understood that risk perceptions predict health behaviors

(Finucane, Alhakami, Slovic, & Johnson, 2000; Lerner & Keltner, 2000; Rimal & Real, 2003;

Slovic, Finucane, Peters, & MacGregor, 2004; Turner, 2007). Studies have demonstrated that

young adults report using e-cigarettes because they are perceived to be less harmful than

cigarettes (Camenga et al., 2015; Choi, Fabian, Mottey, Corbett, & Forster, 2012; Glasser et al.,

2016). While Fishbein does not consider the construct of perceived risk to directly influence

5
behavior in the IBM (Fishbein, 2007; Fishbein et al., 2002), this dissertation applied aspects of

Slovic’s affect heuristic theory to test a direct relationship between e-cigarette risk perception

and use. Slovic’s affect heuristic theory posits that when an individual has a high perceived

benefit and positive feelings towards a behavior, the individual has a low risk perception

resulting in a higher likelihood of performing the behavior (Finucane et al., 2000; Slovic et al.,

2004). As shown in the Conceptual Framework on page 6 (Figure 2), this dissertation integrated

proxy measures of the affect heuristic theory into the IBM to test a direct relationship between e-

cigarette risk perception and e-cigarette use among young adults. Specifically, this dissertation

explored whether individuals’ perceived benefit of e-cigarettes (i.e., instrumental attitude) was

indirectly associated with e-cigarette risk perception through positive affect towards e-cigarettes

(i.e., experiential attitude). This, in turn, would result in young adults’ low risk perceptions

leading to a higher likelihood of e-cigarette use. As illustrated in the Conceptual Model on page

7 (Figure 2), this dissertation examined whether an expanded Integrated Behavior Model (IBM)

encompassing the affect heuristic theory revealed which individual-level factors (i.e., attitude,

perceived norm, personal agency, intention, and e-cigarette risk perception) were key

determinants of young adults’ e-cigarette use. This dissertation research focus was divided into

three aims later outlined on page 8 under the Specific Aims section.

Dissertation Objective

Secondary data analysis was conducted with the 2013-2014 Population Assessment of

Tobacco and Health (PATH) Study Wave 1 baseline adult dataset, which is comprised of young

adults (ages 18-24) who reported ever using an e-cigarette. These data, collected prior to FDA

regulation of e-cigarettes, examined whether the IBM constructs of attitude, perceived norm,

6
Figure 2. Conceptual Framework

personal agency, and intention were salient correlates of young adults’ e-cigarette use. In

addition, the affect heuristic theory was tested to explore if there was a direct relationship

between e-cigarette risk perception and e-cigarette use among young adults. Structural equation

modeling (SEM) was utilized to analyze which constructs were key determinants of e-cigarette

use among young adults. Determining whether e-cigarette use among young adults is more

attitudinally driven than normatively driven, for instance, will help target future prevention

approaches for this age group.

Specific Aims

This cross-sectional study examined three aims. Chapter 2 outlines the theoretical

rationale for these aims and identifies research-supported hypotheses where applicable. Chapter

3 presents the methodology for testing this dissertation’s aims and hypotheses.

7
Aim 1: Determine the extent to which e-cigarette attitude, perceived norm, and personal agency

are statistically significant correlates of intention to quit e-cigarettes.

H1a: More positive attitudes towards e-cigarettes will be associated with lower levels of e-

cigarette quit intention.

H1b: More positive perceived norms regarding e-cigarette use will be associated with lower

levels of e-cigarette quit intention.

H1c: More positive personal agency (i.e., higher levels of perceived ease and confidence in

using e-cigarettes) will be associated with lower levels of e-cigarette quit intention.

Aim 2: Determine whether intention to quit using e-cigarettes is a significant correlate of e-

cigarette use among young adults.

H2a: More negative e-cigarette quit intention will be associated with higher levels of e-cigarette

use.

Aim 3: Determine the extent to which e-cigarette risk perception is a significant correlate of e-

cigarette use among young adults.

H3a: Higher levels of perceived benefit of e-cigarette use (i.e., positive instrumental attitude)

will be positively associated with more positive affect toward e-cigarettes (i.e., experiential

attitude).

H3b: Higher levels of positive affect toward e-cigarettes (i.e., experiential attitude) will be

negatively associated with e-cigarette risk perception.

H3c: Lower levels of e-cigarette risk perception will be associated with higher levels of e-

cigarette use.

8
Summary

Time magazine journalist, Eliza Gray, expressed the novelty and impact of e-cigarettes as

being a product that “could save lives—or hook a new generation on nicotine” (Gray, 2013).

Both the tobacco control and public health communities are divided on the impact e-cigarettes

will have on the public’s health. Whether e-cigarettes serve as a harm reduction tool helping

smokers quit combustible cigarettes or cause more Americans to be addicted to nicotine is yet to

be determined (Abrams, 2014; Nocera, 2015). Given increasing rates of e-cigarette use among

young adults (Agaku et al., 2014; Schoenborn & Gindi, 2015), research is needed on the attitudes

and beliefs that may be associated with use among this age group. Tobacco control approaches

used to prevent cigarette smoking may not work as effectively for preventing e-cigarette use. To

address this research gap, this dissertation applied the Integrated Behavior Model (IBM)

encompassing the affect heuristic theory to examine the individual-level determinants (i.e.,

attitude, perceived norm, personal agency, intention, and e-cigarette risk perception) of young

adults’ e-cigarette use. By understanding young adults’ attitudes, beliefs, and perceptions of e-

cigarettes, tobacco control efforts can be effectively targeted to address the changing landscape

of non-cigarette tobacco use to reduce tobacco-related health risks at a population level.

9
 Chapter 2: Literature Review

One of public health’s greatest achievements is the lowering of cigarette smoking rates

among youth and adults over the past 50 years following the first U.S. Surgeon General report on

the risks of smoking in 1964 (USDHHS, 2014). Cigarette smoking rates among U.S. adults ages

eighteen and older decreased between 2005 and 2015 from 20.9% (approximately 45.1 million

people) to 15.1% (36.5 million) (CDC, 2016). Tobacco control efforts responsible for this public

health achievement comprised a multi-level ecological approach implementing interventions and

policies affecting individuals, interpersonal dynamics, and the communities in which they live.

Tobacco control policies have given adults greater access to cessation opportunities through quit

lines, provider counseling, and treatment through the use of nicotine replacement therapy and

pharmacological quitting aids. Individuals’ cessation efforts are reinforced by clean indoor air

laws prohibiting smoking in bars, restaurants, hospitals, workplaces, schools, and other public

spaces. Mass communication on the health consequences of smoking, and youth-driven anti-

smoking campaigns exposing manipulative tobacco industry marketing tactics created a social

stigma against smoking cigarettes. State-level cigarette taxation, and the prohibition of tobacco

retailers selling cigarettes to minors further deters youth uptake and use (USDHHS, 2014).

Additionally, federal policy prohibits tobacco companies from television, radio, and outdoor

advertising of combustible cigarettes to prevent targeted marketing towards youth (USDHHS,

2010a, 2014; Warner & Goldenhar, 1989).

Despite the effectiveness of these tobacco control approaches in preventing cigarette

smoking, U.S. Surgeon General Dr. Vivek Murthy acknowledged in his 2016 Surgeon General

Report that they may not work as effectively for preventing youth and young adults’ use of e-

cigarettes (USDHHS, 2012, 2016a). E-cigarettes are advertised by both independent

10
manufacturers and the tobacco industry as a healthier alternative to combustible cigarettes given

their ability to simulate smoking behavior and deliver nicotine through vapor instead of burning

tobacco (Johnson Creek, 2014; GreenSmoke, 2014).

Given increasing rates of e-cigarette use among young adults, research is needed on the attitudes

and beliefs that drive use among this age group. More specifically, Dr. Murthy presented the

following call to action in his 2016 Surgeon General Report:

The adoption of public health strategies that are precautionary to protect youth and young
adults from adverse effects related to e-cigarettes is justified. A broad program of
behavioral, communications, and educational research is crucial to assess how youth [and
young adults] perceive e-cigarettes and associated marketing messages, and to determine
what kinds of tobacco control communication strategies and channels are most effective
(pg 7) (USDHHS, 2016a).

This dissertation aimed to address this research gap by examining how young adults’ attitudes,

beliefs, and perceptions of e-cigarettes influenced their likelihood of currently using the device.

This chapter illustrates how the Integrated Behavior Model (IBM) with the addition of

the affect heuristic theory can be applied to elucidate key determinants of young adult e-cigarette

use. This chapter begins with an overview of how e-cigarettes have reshaped the landscape of

available tobacco products. Next, the application of the IBM and model constructs to examine e-

cigarette use among young adults is illustrated. Then, this chapter outlines the argument for

expanding the IBM to include the affect heuristic theory, with particular attention given to

treating the construct of risk perception as a latent construct in the model with a hypothesized

direct association with e-cigarette use among young adults. Finally, a theoretical rationale for the

inclusion of constructs in the Dissertation Conceptual Framework (Figure 2) and research-

supported hypotheses on the relationships between the constructs and young adult e-cigarette use

are presented.

11
Innovation of E-Cigarettes

The first version of the e-cigarette was invented in 1963 by American Herbert A. Gilbert

who patented “a smokeless non-tobacco cigarette” that “replaced burning tobacco and paper with

heated, moist, flavored air” (Gilbert, 1965); however, this device was never successfully

commercialized in the United States (P.H., 2014). Forty years later Chinese chemist Lik Hon

invented the first modern e-cigarette in 2003. Given Hon’s own smoking habit, failed quit

attempts, and his father’s death from lung cancer, he sought to “solve a social problem” by

creating a device that would deliver nicotine into the bloodstream through the lungs without

burning tobacco (Ridley, 2015). Hon’s device consisted of a piezoelectric ultrasound-emitting

element to vaporize liquid stored in a cartridge containing nicotine and propylene glycol (Ridley,

2015; Vapestores.com, 2015). The Beijing company Golden Dragon Holdings, later renamed

Ruyan meaning “resembling smoking” in Chinese, manufactured Hon’s invention and began

exporting this product to Europe in 2006 and to the United States in 2007 (CASAA, 2012;

Vapestores.com, 2015).

Between 2007 and 2009, U.S.-based companies such as NJOY, White Cloud, and blu

eCigs® also began developing and selling e-cigarettes. These companies marketed first

generation battery-powered devices, known as ‘cigalikes,’ that are shaped like cigarettes and

mimic smoking behaviors without burning tobacco (Blu, 2015; NJOY, 2015; White Cloud

Electronic Cigarettes, 2015). When a user draws air through ‘cigalikes,’ a sensor detects this air

flow and activates an atomizer that heats a cartridge often containing nicotine, propylene glycol,

glycerin, water, and flavor additives, which produces a vapor that is then inhaled. Users who

make the distinction between smoking a cigarette and using an e-cigarette refer to this experience

as ‘vaping.’ Some ‘cigalikes’ also feature an LED light at the tip of the device that lights up

12
when the vaper inhales the e-cigarette (Blu, 2015; NJOY, 2015; White Cloud Electronic

Cigarettes, 2015). These first-generation e-cigarettes are designed as either one-time, disposable

products or devices with replaceable cartridges that vary in flavor and nicotine strength and can

be recharged through a USB port (Blu, 2015).

Device Type & Characteristics

E-cigarette technology has evolved to include e-hookahs and vape pens (Richtel, 2014);

second generation devices with more powerful batteries, a push-button switch, and refillable

tanks for flavored e-cigarette liquid, or ‘e-juice’; third generation devices known as ‘mods’

giving users the ability to personalize use by modifying the voltage and plume of vapor (Brown

& Cheng, 2014); and fourth generation devices utilizing digital technology (Brandon et al., 2015;

Vuse, 2015). Illest Vapes e-cigarettes utilize Bluetooth technology that tracks the number of

puffs taken each day and integration of the device with an iPhone or Android app (Indiegogo,

2015). Vaporcade has further advanced e-cigarette technological innovation through

development of its Jupiter cellular phone that integrates talking, texting, and vaping into one

device (Vaporcade, 2015). This myriad of device types was reflected in a comprehensive internet

search conducted by Zhu et al. of online marketing revealing that by January 2014, there were

466 different e-cigarette brands and 7,764 unique e-juice flavors ranging from tobacco, menthol,

fruit, dessert, candy, alcohol, and coffee flavored vapors to e-juice flavors with unique names

such as Thug Juice and Unicorn Milk (Rimer, 2015; Zhu et al., 2014).

Research is currently inconclusive on the health risks of using the device and risks from

being exposed to the aerosol vapor emitted by the device. This gap in scientific knowledge has

resulted in a misperception that the aerosol emitted from e-cigarettes is purely water vapor. For

instance, one college-aged e-cigarette user exclaimed in a focus group: An e-cigarette . . . takes

13
water vapor from the air and filters it through nicotine and flavoring and releases it back into

the air (Case, Crook, Lazard, & Mackert, 2016). The next section summarizes the current state of

the science on e-cigarette health risks that may inform individuals’ attitude towards and risk

perception of the product.

E-Cigarette Health Risks

Unlike combustible cigarettes with over 7,000 chemicals and more than 70 cancer-

causing compounds (USDHHS, 2010b), e-cigarettes do not burn tobacco and instead deliver

nicotine through an inhaled aerosol (Hajek, Etter, Benowitz, Eissenberg, & Mcrobbie, 2014).

Recent scientific findings on potential health risks from e-cigarette use has begun to emerge in

the literature (Cheng, 2014; Goniewicz et al., 2014; Williams, Villarreal, Bozhilov, Lin, &

Talbot, 2013). The most common reported health problems experienced by e-cigarette users

include respiratory symptoms, headache, nausea, mouth and throat irritation, dizziness, and dry

cough (Farsalinos, Romagna, Tsiapras, Kyrzopoulos, & Voudris, 2014; Hua, Alfi, & Talbot,

2013). Reports have also emerged of e-cigarettes overheating, catching on fire, or exploding

resulting in some instances of life-threatening injury, permanent disability, and property damage

(Rudy & Durmowicz, 2016).

An established risk of e-cigarette use is nicotine consumption. Nicotine is a highly

addictive neurotoxin that has been proven to be as addictive as heroin and cocaine (NIDA, 2012;

USDHHS, 2014). Nicotine affects the cardiovascular and central nervous systems resulting in

constricted blood vessels and raised pulse and blood pressure. Fetal exposure to nicotine during

pregnancy is associated with preterm delivery, low birth weight, and stillbirth (USDHHS, 2014).

Furthermore, research suggests that nicotine exposure during adolescence when the prefrontal

14
cortex is still developing increases risk for psychiatric disorders and cognitive impairment

(Goriounova & Mansvelder, 2012).

The level of health risk associated with nicotine exposure is dependent on the amount and

frequency of ingestion (Niaura, 2016; USDHHS, 2014). Currently there is no standardization in

the amount of nicotine e-cigarettes deliver. Studies show that the nicotine content in the flavored

liquid and aerosol produced vary by brand, device type, and individual use patterns (Farsalinos,

Romagna, Tsiapras, Kyrzopoulos, & Voudris, 2013b; Glasser et al., 2016; Goniewicz, Kuma,

Gawron, Knysak, & Kosmider, 2013; Hajek et al., 2015). Laboratory studies of first generation

‘cigalikes’ demonstrated slow nicotine delivery and rates of absorption compared to combustible

cigarettes among smokers who were using the device for the first time (Bullen, McRobie,

Thornley, Glover, & Laugesen, 2010; Vansickel, Cobb, Weaver, & Eissenberg, 2010). As

subsequent generations of e-cigarettes have been developed, laboratory studies and user feedback

demonstrated improved nicotine delivery from second and third generation devices equivalent to

cigarette smoking (Vansickel & Eissenberg, 2013; Yingst et al., 2015).

Laboratory studies also discovered discrepancies between manufacturer labeled nicotine

contents and actual measured contents (Goniewicz, Kuma, et al., 2013; Schober et al., 2014).

The variability in nicotine content is alarming to many public health researchers given that

higher doses can be potentially lethal in adults and children if the e-cigarette liquid is used

inappropriately. For example, one teaspoon (5 mL) of a 1.8% nicotine solution is considered an

amount that could be lethal if orally consumed by a 200 pound person (Bassett, Osterhoudt, &

Brabazon, 2014). Between 2010 and 2014, the Centers for Disease Control and Prevention

(CDC) reported that the number of calls to poison control centers involving liquid nicotine

increased from one per month to 215 per month. Children under the age of five experienced the

15
most adverse exposures ranging from inhalations, eye exposure, skin exposures, and ingestion

(Chatham-Stephens et al., 2014). As a result, legislation has been implemented in some states

requiring child-proof packaging for containers of liquid nicotine used to refill e-cigarettes to

prevent such adverse exposures and risk for poisoning (Kovac, 2015; Pucci, 2014).

Research has demonstrated evidence of higher nicotine dependence among e-cigarette

users (Foulds et al., 2015; Goniewicz, Lingas, & Hajek, 2013; Yingst et al., 2015). One study

found that e-cigarette users reported using e-cigarettes within 30 minutes of waking (Goniewicz

& Lee, 2015); which is a traditional indicator of nicotine dependence (Heatherton, Kozlowski,

Frecker, & Fagerstrom, 1991). Two studies using the Penn State E-cigarette Dependence Index

revealed that users of advanced e-cigarette devices including ‘mods’ and vaporizers had higher

nicotine dependence scores than those using first-generation devices (Foulds et al., 2015; Yingst

et al., 2015). However, two other research studies found that nicotine dependence from e-

cigarettes was lower compared to combustible cigarettes (Farsalinos, Romagna, Tsiapras,

Kyrzopoulos, & Voudris, 2013a; Foulds et al., 2015).

In addition to nicotine, e-cigarettes have been reported to contain propylene glycol,

glycerin, water, and flavoring additives. The FDA has classified propylene glycol as an

acceptably safe substance used in flavorings, drugs, food, and cosmetics (FDA, 2014). However,

when propylene glycol is inhaled by e-cigarette users, research shows that this chemical may

contribute to users’ upper airway irritation (Vardavas et al., 2012). Jensen et al. found that when

propylene glycol and glycerin were heated at high temperatures, the e-cigarette aerosol produced

the toxic carbonyl compound of formaldehyde (Jensen, Luo, Pankow, Strongin, & Peyton, 2015).

Creamy buttery flavorings of diacetyl and acetyl propionyl while also approved by the FDA for

use in food, were found in 74.2% of 159 tested e-cigarette liquid samples, exposing users to

16
higher than safety levels that can cause respiratory disease (i.e., ‘popcorn lung’) when inhaled

(Allen et al., 2015; Farsalinos, Kistler, Gillman, & Voudris, 2015). Another study revealed that

some cinnamon-flavored e-juices contain cinnamaldehyde and 2-methoxycinnamaldehyde which

are both cytotoxic and pose potential harm for consumers (Behar et al., 2014). Additionally,

carcinogenic and toxic compounds have been detected in some e-cigarette liquids and aerosols

including tobacco-specific nitrosamines, acetaldehyde, acrolein, polycyclic hydrocarbons, and

heavy metals (Cheng, 2014; Goniewicz et al., 2014; Williams et al., 2013). Although levels of

these toxic compounds were reported to be lower than in combustible cigarette smoke, their

existence in e-cigarette liquids and aerosols demonstrates that e-cigarettes are not harmless. It is

unclear whether certain e-juice flavors and chemical compositions of e-juices present greater

health risk than others. There is also preliminary evidence that the emitted aerosol from the

device may expose non-users to nicotine (Czogala et al., 2014) and toxic and carcinogenic

carbonyls (Goniewicz, Kuma, et al., 2013), but the authors concluded that levels of exposure

were considerably less than exposure from combustible cigarettes. Other studies identified

potential harm from third-hand exposure to nicotine with it remaining on surfaces after e-

cigarettes were used in a laboratory (Goniewicz & Lee, 2015), and within homes of e-cigarettes

users (Bush & Goniewicz, 2015).

E-Cigarette Regulation

Prior to May 2016, e-cigarettes were not regulated by the federal government. When

these devices first entered the U.S. market in 2007, some manufacturers claimed e-cigarettes

could help with smoking cessation. Notably, these claims were not scientifically supported

resulting in the Food and Drug Administration (FDA) determining that e-cigarettes were not

FDA-approved drugs or medical devices (Walton et al., 2015). Under the 2009 Family Smoking

17
Prevention and Tobacco Control Act, the FDA was granted the authority to regulate the

manufacture, distribution, advertising, and promotion of cigarettes, cigarette tobacco, roll-your-

own tobacco, and smokeless tobacco (111th Congress, 2009). Although e-cigarettes did not

immediately fall under the FDA’s regulatory purview under the Tobacco Control Act, the U.S.

Court of Appeals for the District of Columbia Circuit ruled in 2010 that e-cigarettes and other

products “made or derived from tobacco” could be regulated as tobacco products. Further, the

court stipulated that unless e-cigarettes were marketed for therapeutic purposes, they were not

drugs or medical devices (Sotera, Inc. v. Food and Drug Administration, 2010). This ruling led

to the FDA proposing to extend its authority by recommending a rule that would deem e-

cigarettes as tobacco products in April 2014 (FDA, 2015). The FDA finalized this deeming rule

on May 5, 2016. Provisions aimed at restricting youth access to e-cigarettes include the

following: prohibiting the sale (both in-person and online) of e-cigarettes to minors under the age

of 18; requiring age verification by photo ID; and not allowing the distribution of free samples

(FDA, 2016). Such laws may prevent youth from using e-cigarettes. However, young adults

between the ages of 18 to 24 are particularly vulnerable to using tobacco products such as e-

cigarettes since they are the youngest age group the tobacco industry can legally sell its products

(Ling & Glantz, 2002).

E-Cigarette Marketing

Both the lack of regulation prior to May 5, 2016, and inconclusive science on the risks of

vaping enabled e-cigarette companies and the tobacco industry to shape how the product was

advertised through channels that strictly prohibit combustible cigarette advertising. Since the

1970 Public Health Cigarette Smoking Act, television and radio marketing of combustible

cigarettes has been banned in the United States (Warner & Goldenhar, 1989). Under the 1999

18
Tobacco Master Settlement Agreement, tobacco companies are currently prohibited from

outdoor advertising and must comply with event sponsorship restrictions (USDHHS, 2014). In

contrast, Kantar Media found during their Industry Watch assessment that e-cigarette companies

predominantly use print and television advertising channels. Their marketing expenditures

reached $28 million in 2013, eight times the total in 2012 (Kornfield, Huang, Vera, & Emery,

2015). Online advertising has been an effective marketing channel given its broad reach, social

media promotion, and affiliate marketing tactics directing viewers to e-cigarette vendors from

search engines and banner advertising (Cobb, Brookover, & Cobb, 2015; Grana & Ling, 2014;

Richardson et al., 2015).

E-cigarette advertising methods have been criticized for their attempts to focus on

changing anti-smoking social norms (Fairchild, Bayer, & Colgrove, 2014). Tobacco control

advocates have compared e-cigarette advertising to methods previously used by major tobacco

companies to market combustible cigarettes. For instance, e-cigarette ads feature celebrity

endorsements and TV personalities, e-cigarette companies sponsor sports and music festivals,

and the product has been marketed in print ads as masculine, sexy, and rebellious in magazines

including Rolling Stone, Sports Illustrated, InStyle, and UsWeekly (CTFK, 2013). E-cigarette

manufacturers have shaped the story on how e-cigarettes may be beneficial and less harmful than

combustible cigarettes. For instance, some companies stated claims that these devices improve

smoking cessation, decrease smoking consumption, are healthier than cigarettes, and are socially

and legally accepted in public and private locations (Richardson, Ganz, Stalgaitis, Abrams, &

Vallone, 2014; Richardson et al., 2015).

The marketing of e-cigarettes has evolved with the emergence of second and third

generation devices. In an assessment of e-cigarette marketing changes between 2012 and 2014,

19
Zhu and colleagues found that differences in message framing between the top five older brands

selling e-cigarettes online in 2012 (i.e., blu eCigs®, NJOY, Green Smoke, Vapor4life, and White

Cloud) and newer brands that emerged online by 2014 (Zhu et al., 2014). Findings indicated that

the top five older brands were more likely than newer brands to focus on the advantages of e-

cigarettes over combustible cigarettes. In contrast, newer brands selling vaporizers, tanks, and

accompanying e-cigarette juices were more likely than older brands to market consumer choice

and the ability to customize the vaping experience by manipulating nicotine content and flavors

(Zhu et al., 2014).

E-cigarette marketing has also been significantly influenced by the tobacco industry with

Lorillard Inc. purchasing blu eCigs® in 2012 and Altria/Philip Morris marketing its MarkTen e-

cigarette brand in 2013. R.J. Reynolds launched its Vuse e-cigarette in 2013, bought blu eCigs®

from Lorillard Inc. in 2014, and then sold the company to Imperial Tobacco to circumvent

regulatory opposition in merging with blu eCigs® (TobaccoTactics, 2015). With both

independent e-cigarette companies and the tobacco industry marketing this product, retail sales

have increased from $500 million in 2012 to approximately $3.3 billion in 2015 (Herzog, 2015;

Herzog et al., 2014).

Industry Targeting Young Adults

The fact that the tobacco industry is selling e-cigarettes poses increased risk for uptake

and use among young adults. In an assessment of tobacco industry documents that became

publicly available following the Tobacco Master Settlement Agreement, researchers Ling and

Glantz found that young adults have been strategically targeted by the tobacco industry (Ling &

Glantz, 2002). Young adulthood is recognized as a period of transition in which individuals may

begin working, leave home to attend college or enlist in the military, and they may explore and

20
adopt new behaviors (Arnett, 2000). Ling and Glantz discovered that tobacco industry

documents classified the transition to young adulthood as causing increased levels of uncertainty,

stress, and anxiety that may provoke younger adults to begin smoking as a means to cope (Ling

& Glantz, 2002). Tobacco industry documents have shown that Philip Morris effectively targeted

its marketing towards young adults by administering surveys to learn about their beliefs, norms,

values, leisure activities, and socialization patterns (Hafez & Ling, 2005; Ling & Glantz, 2002).

Whether the tobacco industry is using these same approaches for e-cigarette marketing

towards young adults is uncertain. However, research has shown that this age group is influenced

by tailored tobacco industry marketing (Biener & Albers, 2004; Rath et al., 2012). One recent

study specifically found that college students’ positive reactions to e-cigarette ads and a belief

that the devices are not as addictive as cigarettes were both associated with high intentions for e-

cigarette use (Trumbo & Kim, 2015). These individual-level factors of beliefs and intention have

been shown to be associated with e-cigarette use—but the question remains on the specific set of

individual-level factors correlated with use among young adults. This dissertation sought to

address this research gap. The next section outlines how the Integrated Behavior Model (IBM)

incorporating individual-level constructs can be applied to understand key correlates of e-

cigarette use among young adults.

Integrated Behavior Model (IBM)

The Integrated Behavior Model (IBM) was developed by Fishbein and colleagues after

investigating the commonalities among health behavior change theories such as the Health Belief

Model (Rosenstock et al., 1988), the Extended Parallel Process Model (Witte, 1992), Social

Cognitive Theory (Bandura, 1986), and the Theory of Planned Behavior (Ajzen, 1991). Each of

these theories has demonstrated that an individual’s attitudes and beliefs influence whether a

21
certain health-related action is taken. In an assessment of the commonalities among these

theories, Fishbein and colleagues concluded that an individual’s behavior and intentions are

influenced by the following key factors: attitudes towards the behavior, perceived norms of the

behavior, and one’s perceived ability to perform the behavior (Fishbein, 2000; Fishbein et al.,

2002). These three factors comprise the Integrated Behavior Model (IBM), which was used as

the underlying theory guiding this dissertation.

The IBM shown on page 20 (Figure 1) posits that if an individual has established a strong

intention to conduct a behavior, the individual has necessary skills, and has limited

environmental constraints then there is a high likelihood that the individual will conduct the

behavior. The IBM also demonstrates how the constructs of attitude, perceived norm, and

personal agency serve as the primary determinants of intention to execute the behavior (Fishbein,

2000; Fishbein et al., 2002).

Figure 1. Integrated Behavior Model (IBM)

The next section explains these IBM constructs in greater detail and presents empirical research

on attitudes towards using e-cigarettes, perceived norms concerning e-cigarettes, and personal

22
agency (i.e., control/confidence) in using e-cigarettes. Although research on young adults’ use of

e-cigarettes is scant and newly emergent, the most up-to-date research and existing findings for

this population are highlighted. This Chapter concludes with a presentation of this dissertation’s

Conceptual Framework and accompanying aims and hypotheses.

Experiential Attitude

In the IBM, an individual’s behavioral intention is partially influenced by the construct

attitude, which encompasses the sub-constructs experiential attitude and instrumental attitude.

Experiential attitude is defined as the feelings one has about performing the behavior (Fishbein et

al., 2002). Fishbein differentiates this sub-construct from overall mood or temperaments such as

feeling happy or anxious; which are considered affective states (Fishbein, 2007). Instead,

experiential attitude is considered a part of the overall evaluation of a behavior. For example,

those with a strong negative emotional response toward using a tobacco product would have a

lower likelihood of performing the behavior given the negative attitude towards the tobacco

product.

A 2016 systematic review of e-cigarettes examining published articles through May 2016

conducted by Glasser et al. found that twenty-four studies captured emotional responses related

to e-cigarette use that fit within the experiential attitude sub-construct definition (Glasser et al.,

2016). In one study, Vansickel and colleagues assessed whether e-cigarette use helped study

participants feel more awake, calm, and assisted with concentration. They also investigated

whether using the e-cigarette was pleasant, satisfying, reduced hunger for food, and tasted good.

Among e-cigarette users who used their preferred device in a lab, all of the emotional response

measures increased during a standard 10-puff period and peaked when participants could freely

use the device (Vansickel & Eissenberg, 2013). Another study investigated the experience of e-

23
cigarette use among current smokers with no prior use of the device and who were uninterested

in quitting smoking. Overall, the majority of participants rated their own brand of cigarettes as

more enjoyable and satisfying than the e-cigarettes they used in the study (Wagener et al., 2014).

These two studies demonstrate how feelings (i.e., positive or negative) towards e-cigarette use

shape one’s attitude towards the behavior and the likelihood of using the product.

Instrumental Attitude

The second sub-construct contributing to one’s attitude in the IBM is instrumental

attitude, which is defined as one’s beliefs about the outcome of the behavior (Fishbein et al.,

2002). The IBM posits that a person will have a more positive attitude towards performing a

behavior if he or she has a strong belief that the positive outcomes of performing the behavior

will outweigh the negative outcomes. For instance, McQueen and colleagues found that

immediate health benefits of e-cigarettes carried more importance for users than potential long-

term harms. One vaper stated that e-cigarettes have “improved my quality of life so much that

whatever negative there is, I will deal with it when we discover it” (McQueen, Tower, &

Sumner, 2011). The majority of adult vape shop customers surveyed in this Midwest study

reported improved overall health (84.6%), decreased smokers’ cough (78.9%), increased ability

to exercise (58.1%), increased sense of smell (79.5%) and increased sense of taste (77.9%)

(McQueen et al., 2011).

Young adults’ positive attitudes toward flavored tobacco products, may also be

contributing to e-cigarette use among this age group. The 2009 Family Smoking Prevention and

Tobacco Control Act banned the sale of candy and fruit-flavored cigarettes (111th Congress,

2009). The justification for this ban centered on studies demonstrating that flavored tobacco

products were targeted towards youth and young adults (Klein et al., 2008; Lewis & Wackowski,

24
2006). Although e-cigarettes are regulated under the Tobacco Control Act, they are not held

subject to the flavor ban instituted for cigarettes (111th Congress, 2009). A recent systematic

review assessing use and attitudes toward these previously unregulated products found that

flavored tobacco use was strongly associated with the young adult age group, and flavored

products were perceived more favorably than non-flavored products (Feirman, Lock, Cohen,

Holtgrave, & Li, 2015). Another study found that young adults ages 18-24 years were 1.9 times

more likely than adults ages 25-34 years to use flavored tobacco products (Villanti, Richardson,

Vallone, & Rath, 2013). E-cigarettes users’ perceived health benefit has also influenced

smokers’ use of the device for cessation and cigarette reduction. The next section outlines

evidence of the effectiveness for this rationale for e-cigarette use.

Perceived Benefit: Smoking Cessation and Cigarette Reduction

FDA-approved smoking cessation medications such as nicotine replacement therapy (i.e.,

lozenges, gum, patch), and prescriptions (i.e., buproprion and varenicline) have demonstrated an

increased likelihood of quitting combustible cigarettes when combined with behavioral

counseling programs (Fiore et al., 2008). However, their lower efficacy levels in sustaining

cessation positions e-cigarettes as another potential method of quitting given the device’s design

to mimic smoking a traditional cigarette but without combustible tobacco (Barbeau, Burda, &

Siegel, 2013b; Hughes, Shiffman, Callas, & Zhang, 2003; Pepper & Brewer, 2014). Research

indicates that the majority of e-cigarette users believe this device can enable people to either quit

smoking combustible cigarettes or to reduce the number of cigarettes smoked (Barbeau et al.,

2013b; Etter & Bullen, 2011; Foulds, Veldheer, & Berg, 2011; Goniewicz, Lingas, et al., 2013;

Vickerman, Carpenter, Altman, Nash, & Zbikowski, 2013). The ability to maintain smoking

actions of holding an e-cigarette and taking a puff from it and the view that these devices were

25
comparatively healthier than cigarettes were some reasons listed by interviewed college smokers

and non-smokers on how this device may facilitate smoking cessation (Camenga et al., 2015). E-

cigarette users’ perceptions that these devices help reduce tobacco cravings and withdrawal

symptoms further suggest their ability to aid in smoking cessation (Etter & Bullen, 2011; Harrell

et al., 2015). However, randomized controlled trials, longitudinal studies, and cohort studies

show mixed results on the effectiveness of e-cigarettes for smoking cessation (Glasser et al.,

2016; Hartmann-Boyce et al., 2016; McRobbie, Bullen, Hartmann-Boyce, & Hajek, 2014).

A 2014 Cochrane Review investigated the current literature to determine whether e-

cigarettes can help people stop smoking or reduce the amount of cigarettes they smoke, and

whether the devices are safe for these purposes. The authors concluded that the quality of

evidence supporting the effectiveness of e-cigarette use for smoking cessation is low given that

only two randomized controlled trials (RCT) have been conducted with modest effects

(McRobbie et al., 2014). This systematic review was conducted again two years later with the

2016 Cochrane Review authors adding eleven observational and un-randomized studies to the

review. The authors’ original conclusions remained the same with additional evidence suggesting

that e-cigarettes may help smokers quit without any reported serious side effects after using the

device for two years (Hartmann-Boyce et al., 2016).

One clinical trial conducted by Bullen and colleagues in New Zealand, randomized 657

adult smokers who wanted to quit to one of three groups: use of an Elusion-brand e-cigarette

with 16 mg nicotine cartridges, 21 mg/24-hour nicotine patches, or an Elusion-brand e-cigarette

without nicotine. Study participants were either mailed the two types of e-cigarettes or mailed

vouchers to procure the nicotine patches at a pharmacy. All participants were instructed to use

these products one week before their target quit date and 12 weeks after this date. They also were

26
invited to use a telephone-based behavioral support Quitline or text-messaging support through

Txt2Quit. To objectively verify self-reported smoking abstinence, participants provided exhaled

breath carbon monoxide measures, a biomarker of exposure to cigarette smoke, six months after

their quit date. The prevalence of smoking abstinence at 6 months was low (7.3% for the nicotine

e-cigarette group, 5.8% for the nicotine patch group, and 4.1% for the non-nicotine e-cigarette

group) with no statistically significant differences between treatment arms. However, among the

nicotine e-cigarette group, 57% reduced daily cigarettes by at least 50% at six months; which

was statistically significant compared to the nicotine patch group with 41% of participants

experiencing this reduction (Bullen et al., 2013).

Another clinical trial conducted by Caponnetto and colleagues in Italy, randomized 300

smokers not intending to quit to one of three groups: use of a Categoria-brand e-cigarette with

7.2 mg nicotine cartridges for 12 weeks, use of a Categoria-brand e-cigarette with 7.2 mg

nicotine cartridges for 6 weeks followed by 5.4 mg nicotine cartridges for the remaining 6

weeks, or use of Categoria-brand e-cigarettes containing no nicotine for 12 weeks. Participants

attended nine in-person visits over 52 weeks to measure exhaled carbon monoxide levels and

track daily cigarettes and any adverse events. Across all three groups, 10.7% of e-cigarette users

reported complete abstinence from smoking after 12 weeks of use. One year smoking abstinence,

defined as not smoking for 6 months verified by carbon monoxide readings, was experienced by

8.7% of participants across groups. Although not statistically significant, the highest one-year

quit rate occurred among 13% of participants in the high nicotine e-cigarette group compared to

9% in the reduced nicotine group, and 4% in the non-nicotine group. A reduction of 50% or

more of daily cigarettes consumed since baseline was experienced by 22.3% of participants

across all groups after 12 weeks and 10.3% after a year; with between-group differences not

27
demonstrating statistical significance. E-cigarette use among smokers across all groups resulted

in a significant reduction in reported frequency of cough, dry mouth, shortness of breath, and

headache during study visits (Caponnetto et al., 2013).

A limitation of both clinical trials was use of first-generation ‘cigalike’ e-cigarettes,

which were found to not deliver nicotine effectively (Bullen et al., 2013; Caponnetto et al.,

2013). In fact, Caponnetto and colleagues stated that the Categoria-brand e-cigarette was

discontinued by its manufacturers during the writing of their manuscript due to its poor

performance compared to other e-cigarette models. Study participants using the Categoria-brand

e-cigarettes reported that these devices were difficult to use, lacked durability, and tasted poorly

(Caponnetto et al., 2013). As a result, the authors of both studies concluded that future smoking

cessation RCT studies should use e-cigarettes that have demonstrated more effective nicotine

delivery.

The intensity and frequency of e-cigarette use are additional factors shown to impact the

likelihood of quitting smoking, quit attempts, and reduction in cigarette smoking. In their

longitudinal study of adult smokers living in Dallas and Indianapolis, Biener and Hargreaves

categorized e-cigarette use into three groups: intensive (used daily for at least a month),

intermittent (more than once but not daily use for a month or more), or non-use/tried once or

twice (Biener & Hargraves, 2014). These researchers found during a two-year interview follow-

up period that intensive users of e-cigarettes were six times more likely than non-users/triers to

report that they quit smoking. Intermittent users did not exhibit an increased likelihood of

quitting compared to non-users/triers (Biener & Hargraves, 2014). Brose and colleagues

demonstrated the importance of differentiating between daily and non-daily use when examining

the impact of e-cigarette use on cessation behaviors. Among adult British smokers surveyed at a

28
one-year follow-up, daily e-cigarette use at baseline was associated with increased cessation

attempts compared to non-use. Daily e-cigarette use was associated with increased odds of

reducing daily cigarette consumption by at least 50% compared to non-use. In contrast, non-daily

e-cigarette use at baseline was not significantly associated with cessation attempts or reduced

smoking. Study participants did not demonstrate an increased likelihood of smoking cessation

through daily or non-daily e-cigarette use (Brose, Hitchman, Brown, West, & McNeill, 2015).

As a result, both the randomized controlled trials and these observational studies provide

stronger evidence for e-cigarettes in effectively reducing daily cigarette consumption and

minimal support for the device’s effectiveness in successful smoking cessation. However,

tobacco control researchers point out that a reduction in the number of cigarettes does not confer

the same health benefits as quitting smoking completely (USDHHS, 2014). The fact that there is

stronger evidence for e-cigarettes in effectively reducing daily cigarette consumption rather than

successful smoking cessation means that smokers who use e-cigarettes for quitting may be at

increased risk for becoming dual users of both products. The 2014 National Health Interview

Survey found that one in six adult cigarette smokers (15.9%) currently use e-cigarettes

(Schoenborn & Gindi, 2015). These findings suggest that reasons for current use of e-cigarettes

may differ by motivations for use and past experiences at quitting combustible cigarettes. One’s

social pressure to use the device may also influence e-cigarette use, which is presented in the

next section.

Perceived Norm

As previously stated, the IBM posits that the likelihood of performing a behavior is

influenced by an individual’s behavioral intention, which is influenced in part by the individual’s

perceived social pressure to engage in the behavior. The IBM construct perceived norm is

29
defined as a combination of the sub-construct injunctive norm (i.e., perception of what others

think should be done) and descriptive norm (i.e., perception of common behavior of others)

(Fishbein et al., 2002). It is well-established in the literature that young adults who believe their

friends approve of smoking have an increased risk of becoming smokers (Freedman, Nelson, &

Feldman, 2012). Research is just beginning to emerge on the impact that friends and family

members have on e-cigarette use among young adults.

College students in one study reported a higher acceptance rate of e-cigarette smoking in

public compared to combustible cigarette smoking (Trumbo & Harper, 2013). Kong and

colleagues found, through interviews, that college students were more likely to experiment with

e-cigarettes because of friends’ influence compared to middle and high school students (Kong,

Morean, Cavallo, Camenga, & Krishnan-Sarin, 2014). Another study reported that a positive

social norm for e-cigarette use independently predicted use of e-cigarettes among young adults

(Trumbo & Harper, 2015a). Interviewed young adults stated that either family members or their

peers often provided participants with their first e-cigarette. Some participants stated that friends

or roommates shared an e-cigarette with the participants until they could afford to buy their own

device (Cheney, Gowin, & Wann, 2016). This act of sharing the device can result in both

positive injunctive norms and descriptive norms for the individual who believes that others

condone e-cigarette use and are themselves e-cigarette users.

In a study of the social influences of cigarette, e-cigarette, and hookah use among college

students, Noland and colleagues found that survey respondents indicated a high level of

acceptance for e-cigarettes compared to cigarettes and an overestimation of peer use of these

three products (Noland et al., 2016). Among interviewed e-cigarettes users, the majority

perceived that their peers would approve of their use of the device. In addition, some of these e-

30
cigarette users stated that their family would prefer that they use e-cigarettes instead of smoking

combustible cigarettes given the known health risks associated with smoking (Case et al., 2016).

This approval of e-cigarette use by peers and family members is an example of a third type of

norm called subjective norm (i.e., an individual’s perception of whether people important to the

individual think the behavior should be performed) (Ajzen, 1991). This dissertation will assess

whether the construct perceived norm, defined by the sub-constructs injunctive, subjective, and

descriptive norm, contributes to e-cigarette use. One’s perceived ability to use the device may

also influence e-cigarette use, which is presented in the next section.

Personal Agency

In the IBM, an individual’s behavioral intention is also influenced by the construct of

personal agency, which consists of the sub-constructs perceived behavioral control and self-

efficacy. Perceived behavioral control is defined as a person’s perception of their ability to

perform a particular behavior (i.e., perceived ease/difficulty). For instance, multiple studies have

demonstrated that e-cigarettes are used where smoking cigarettes isn’t allowed (Adkison et al.,

2013; Patel et al., 2016; Rutten et al., 2015; Zhu et al., 2013).

Access to e-cigarettes through multiple sources (i.e., high perceived behavioral control)

may be another significant predictor of e-cigarette use among young adults. When first

generation ‘cigalikes’ were introduced to the U.S. market, they were predominantly sold online,

and then expanded to convenience stores, gas stations, and in mall kiosks. In one study, high

school and college e-cigarette users mentioned using the device since the product was readily

available in malls and convenience stores (Kong et al., 2014). As the technology advanced to

second and third generation devices, independent retail specialty stores opened, known as ‘vape

31
shops,’ with more than 3,500 independent stores currently operating nationwide (Lee & Kim,

2015).

These vape shops created a unique shopping experience by demonstrating how to use and

modify different types of e-cigarettes, and giving consumers the opportunity to sample different

e-juices, some of which are developed and mixed at the stores (Tackett et al., 2015). One New

York City store known as ‘Vaporium,’ is designed as a bar with vaping experts, or ‘vapologists,’

who serve e-juices tailored to consumers’ flavor preferences (Henley, 2015). Vape shops also

foster a sense of community featuring entertainment and lounging areas enabling customers to

socialize and share vaping experiences and product preferences (Lee & Kim, 2015; Tackett et al.,

2015). This opportunity to learn how to use e-cigarettes in vape shops may help potential users

become more comfortable in using the device. This is an example of the second personal agency

sub-construct of self-efficacy; which is defined as one’s confidence in performing the behavior)

(Fishbein et al., 2002).

In summary, the Integrated Behavior Model (IBM) can serve as an effective framework

to examine how attitude towards e-cigarettes, perceived norms concerning e-cigarette use, and

the perceived ability to use e-cigarettes drive young adults’ intention and e-cigarette use

behavior. However, a limitation of the IBM is that the model does not recognize an individual’s

risk perception as having a direct influence on one’s health behavior (Fishbein, 2000). Fishbein

stated the following argument for classifying risk perception as a distal factor (shown in Figure

1):

Those who do and do not perceive risk for a given illness may hold different attitudinal,
normative, or self-efficacy beliefs with respect to one behavior, but may hold similar
beliefs with respect to another. Thus, there is no necessary relation between these
external or background variables and any given behavior (pg 95) (Fishbein et al., 2002).

32
Despite not being included as a distinct construct within the IBM, investigation of how an

individual’s risk perception influences e-cigarette use is warranted. Perceptions of risk have

been shown to predict health behavior in models such as the Health Belief Model (Rosenstock et

al., 1988), and Paul Slovic’s affect heuristic theory (Slovic, 2002). The next section presents

empirical research on the role individuals’ risk perception plays in e-cigarette use, and how

application of the affect heuristic theory in this dissertation can further contribute towards

understanding key determinants of e-cigarette use among young adults.

E-Cigarette Risk Perception

Multiple studies have shown that young adults view e-cigarettes as being healthier than

cigarettes (Camenga et al., 2015; Choi et al., 2012; Choi & Forster, 2013; Kong et al., 2014),

implying that this audience segment has low risk perceptions for e-cigarettes. Smokers and

former smokers frequently perceive that the device is less harmful than combustible cigarettes

since nicotine and flavored vapor are emitted without burning tobacco (Barbeau, Burda, &

Siegel, 2013a; Dawkins, Turner, Roberts, & Soar, 2013; Etter, 2010; Etter & Bullen, 2011;

Foulds et al., 2011; Goniewicz, Lingas, et al., 2013; McQueen et al., 2011; Pearson, Richardson,

Niaura, Vallone, & Abrams, 2012). One vaper, who was interviewed, exclaimed that by using e-

cigarettes “I can get the main things I want from smoking, plus without the negative health

aspects of smoking” (McQueen et al., 2011). Among a national sample of 6,607 adult smokers,

the majority of participants believed e-cigarettes were less likely to cause lung cancer, heart

disease and oral cancer compared to combustible cigarettes (Pepper, Emery, Ribisl, Rini, &

Brewer, 2015). In addition to viewing e-cigarettes as safer than cigarettes, 215 adult vape shop

customers in the Midwest also perceived the device to be significantly less harmful than all other

tobacco products, all nicotine replacement products, and all smoking cessation medications

33
(Tackett et al., 2015). Another study found that e-cigarettes were viewed as less risky than both

cigarettes and nicotine replacement therapy among vapers who were former smokers (Harrell et

al., 2015).

However, e-cigarette users recognize that the device may pose some risk. Among a

convenience sample of Polish adult non-smokers and smokers who currently use e-cigarettes,

82% did not think they were absolutely safe for their health, but viewed the device as less

dangerous than cigarettes (Goniewicz, Lingas, et al., 2013). Focus groups attended by smokers

and former smokers in Central Scotland revealed concerns over not knowing whether nicotine

and the chemicals in e-juices were harmful or not. Participants also expressed mistrust over e-

cigarettes being unregulated and manufactured in other countries (Rooke, Cunningham-Burley,

& Amos, 2015).

Risk for Nicotine Dependence

Some e-cigarette users view the device as less addictive than combustible cigarettes

(Goniewicz, Lingas, et al., 2013; Harrell et al., 2015). This perception of a lower comparative

risk for addiction may result from the fact that e-cigarettes and e-juices are available in a variety

of nicotine strengths including zero nicotine, which provides the opportunity to change one’s

nicotine strength overtime (Zhu et al., 2014). First-generation ‘cigalikes’ were reported to deliver

nicotine more slowly compared to second and third generation devices; which may also

contribute to these perceptions (Farsalinos, Spyrou, et al., 2014; Vansickel & Eissenberg, 2013).

Collectively, these empirical studies justify investigation of how the construct e-cigarette risk

perception influences young adult e-cigarette use. As a result, this dissertation aims to examine

the direct association between e-cigarette risk perception and use of the device through

application of affect heuristic theory, described in the next section.

34
Affect Heuristic Theory

Dr. Paul Slovic’s affect heuristic theory can be applied to explore whether young adults’

benefit of e-cigarettes impacts individuals’ positive feelings towards the product (i.e., positive

affect) and e-cigarette risk perception (Finucane et al., 2000; Slovic et al., 2004). A direct

relationship between e-cigarette risk perception and e-cigarette use among young adults can then

be examined. The construct of affect is defined by Finucane et al. as “a feeling state that people

experience, such as happiness or sadness. It may be viewed as a quality (i.e., goodness or

badness) associated with a stimulus” (pg.2) (Finucane et al., 2000). The influential role affect

plays on decision-making was first presented by Zajonc (1980), who argued that all perceptions

of stimuli contain affect. Zajonc argued that a person “does not just see ‘a house,’ [but rather

sees] a ‘handsome house, an ugly house, or a pretentious house.’” (pg. 154) (Zajonc, 1980).

Slovic expanded on this work through his research which found that an individual’s affect

influenced both decision-making and risk perception (Slovic, Finucane, Peters, & MacGregor,

2004; Slovic, 2002). The affect heuristic is grounded in the thinking that there are two thinking

systems responsible for emotional reactions: the analytic system and the experiential system

(Epstein, 1994). The experiential system, namely the sub-conscious emotional reaction towards a

stimulus, has been demonstrated by multiple researchers to influence an individual’s perception

of risk (Finucane, Alhakami, Slovic, & Johnson, 2000; Slovic, 2002).

In one study, Slovic et al. found that when individuals begin smoking they do not

perceive the long-term effects of smoking. Rather, “smokers give little conscious thought to risk

when they begin to smoke; they appear to be lured into the behavior by the prospects of fun and

excitement” (pg. 319). Slovic also found that risks with a high perceived benefit are viewed as

less risky than those that are perceived with low perceived benefit (Slovic, 2002). Furthermore, if

35
the benefits of a behavior are high, a person is more likely to exhibit favorable feelings (i.e.,

affect) towards a stimulus, and he or she is more likely to judge the risk as low. The preceding

influence perceived benefit has on an individual’s positive affect, which influences his or her

perceived risk is known as the affect heuristic theory. Whether the relationships between

perceived benefit, positive affect, and low risk perception predict e-cigarette use among young

adults is undetermined. The next section presents the Dissertation Conceptual Framework and

illustrates how this dissertation integrates the affect heuristic theory into the Integrated

Behavioral Model (IBM); facilitating the determination of the most salient individual-level

drivers of e-cigarette use among young adults.

Dissertation Conceptual Framework

In this dissertation, constructs from the Integrated Behavior Model (IBM) and affect

heuristic theory served as the guiding framework for this study shown on page 33 in Figure 2

(Fishbein, 2000; Fishbein et al., 2002). This dissertation hypothesized that higher levels of

perceived benefit and positive affect will be negatively associated with e-cigarette risk

perception. The likelihood of e-cigarette use would then become higher with lower levels of e-

cigarette risk perception. This dissertation further hypothesized that young adults may have

lower intentions to quit using e-cigarettes if they reported more positive attitudes toward using e-

cigarettes, more social pressure to engage in the behavior, and if more personal agency (i.e.,

higher levels of perceived ease and confidence) to control use of e-cigarettes. Young adults

reporting lower intentions to quit using e-cigarettes would be associated with higher levels of

using e-cigarettes. Within the Conceptual Framework, the affect heuristic constructs of perceived

benefit and positive affect are represented by proxy measures of the IBM constructs instrumental

attitude and experiential attitude, respectively.

36
Figure 2. Conceptual Framework

The maroon arrows in Figure 2 illustrate how instrumental attitude (i.e., perceived benefit) may

indirectly be associated with e-cigarette risk perception through the construct experiential

attitude (i.e., positive affect). In addition, the Dissertation Conceptual Framework shows how the

constructs of attitude (measured by sub-constructs experiential and instrumental attitude),

perceived norm (measured by sub-constructs injunctive, subjective, and descriptive norm), and

personal agency (measured by sub-constructs perceived behavioral control and self-efficacy)

may indirectly be associated with e-cigarette use through the construct quit intention.

By examining how the constructs in the Dissertation Conceptual Framework influence

adult e-cigarette use one can learn whether certain individual-level factors are more salient

correlates of use. Specifically, both IBM and affect heuristic theory can be applied to identify

whether e-cigarette use is more normatively driven or influenced heavily by risk perception. This

determination can inform future targeted behavior change interventions for this population. The

37
final section in this chapter lists this dissertation’s research aims and corresponding hypotheses;

with the directional relationships between constructs illustrated above in the Dissertation

Conceptual Framework.

Research Aims and Hypotheses

This study addressed three research aims informed by the Dissertation Conceptual

Framework (Figure 2) and illustrated in the Comprehensive Measurement Model (Figure 3) in

the Methods Section (Chapter 3). The study hypotheses are listed after each aim.

Aim 1: Determine the extent to which e-cigarette attitude, perceived norm, and personal agency

are statistically significant correlates of intention to quit e-cigarettes.

H1a: More positive attitudes towards e-cigarettes will be associated with lower levels of e-

cigarette quit intention.

H1b: More positive perceived norms regarding e-cigarette use will be associated with lower

levels of e-cigarette quit intention.

H1c: More positive personal agency (i.e., higher levels of perceived ease and confidence in

using e-cigarettes) will be associated with lower levels of e-cigarette quit intention.

Aim 2: Determine whether intention to quit using e-cigarettes is a significant correlate of e-

cigarette use among young adults.

H2a: More negative e-cigarette quit intention will be associated with higher levels of e-cigarette

use.

38
Aim 3: Determine the extent to which e-cigarette risk perception is a significant correlate of e-

cigarette use among young adults.

H3a: Higher levels of perceived benefit of e-cigarette use (i.e., positive instrumental attitude)

will be positively associated with more positive affect toward e-cigarettes (i.e., experiential

attitude).

H3b: Higher levels of positive affect toward e-cigarettes (i.e., experiential attitude) will be

negatively associated with e-cigarette risk perception.

H3c: Lower levels of e-cigarette risk perception will be associated with higher levels of e-

cigarette use.

39
 Chapter 3: Methodology

This study investigated whether an expanded Integrated Behavior Model (IBM)

encompassing the affect heuristic theory showed which individual-level factors (i.e., attitude,

perceived norm, personal agency, intention, and e-cigarette risk perception) were key

determinants of young adults’ e-cigarette use. Secondary data analysis was conducted with the

2013-2014 Population Assessment of Tobacco and Health (PATH) Study Wave 1 baseline adult

dataset comprised of young adults ages 18 to 24 (n=3,887) who reported ever using an e-

cigarette. Structural equation modeling (SEM) was utilized to analyze which constructs grouped

under the IBM and affect heuristic were associated with e-cigarette use. This chapter provides

analytical and logistical details of the study’s methodology and approach.

Study Design

This dissertation employed secondary data analysis of the 2013-2014 Population

Assessment of Tobacco and Health (PATH) Study Wave 1 adult baseline public-use dataset.

PATH is a national, longitudinal cohort study of tobacco use and health in the United States

sponsored and conducted by the National Institute on Drug Abuse (NIDA), and the Food and

Drug Administration’s (FDA) Center for Tobacco Products (Hyland et al., 2016; NIH, 2015).

PATH consists of a nationally representative sample (n=45,971) of U.S. civilian, non-

institutionalized population ages 12 and older (n=13,651 youth; n=32,320 adults) who are never,

current, and former tobacco users. After cognitive interviewing and field testing in Fall 2012,

Wave 1 baseline data collection was administered between September 2013 and December 2014

through the following four instruments: household screener, adult extended questionnaire, youth

extended questionnaire, and parent questionnaire. An automated computer-assisted self-interview

40
(ACASI) system featuring pictures of tobacco products was implemented to administer the youth

and adult extended questionnaires. Coordinators used a computer-assisted personal interviewing

(CAPI) data collection approach to conduct the screeners, and parent questionnaires. All

surveyed adults provided blood and urine samples and a portion of baseline adult respondents

provided buccal cell samples. The PATH study is a four-stage, stratified probability sample

design starting with a stratified sample of 156 geographical primary sampling units (PSU) at the

county level, then grouping the PSU’s into smaller geographical segments, then sampling among

household addresses, and finally selecting household members to interview. Up to two adults and

two youth were surveyed per household; with oversampling of young adults between the ages 18

and 24 and African-American adults (Hyland et al., 2016; Hyland & Taylor, 2015; USDHHS,

2016b).

The primary objectives of the PATH study are to monitor and examine between-person

differences and within-person changes in behaviors, attitudes, risk perceptions, biomarkers, and

health outcomes associated with tobacco use. This longitudinal design with three waves of data

collection from September 2013 through 2016 will enable researchers to examine tobacco

product use initiation, cessation, and relapse; poly tobacco use and switching between products;

the emergence of addiction and dependence; tobacco product related disease progression;

changes in awareness, knowledge, attitudes, and beliefs about tobacco products; and the

influence of tobacco product marketing and Tobacco Control Act regulation on tobacco product

use (Hyland & Taylor, 2015). The PATH study advances the tobacco control field through its

design to examine tobacco use behaviors among and within subgroups defined by race, ethnicity,

gender, age, and higher risk populations including individuals with mental health disorders,

41
lesbian, bisexual, gay, transgender, queer (LBGTQ) community members, and co-occurring

substance use (i.e., marijuana, alcohol, illegal drug use) (NIH, 2015).

Study Participation

Eligibility Criteria

The analytical sample for this dissertation included men and women between the ages 18

and 24 years, who responded to the 2013-2014 Population Assessment of Tobacco and Health

(PATH) Study Wave 1 baseline adult questionnaire, hereafter, referred to as the PATH

questionnaire. Two precursor questions for inclusion encompassed young adults who answered

yes to ever seeing or hearing of an e-cigarette before the study and who answered yes to ever

using e-cigarettes, even one or two times. These two questions in the PATH questionnaire

determined whether or not survey respondents were asked whether they now use e-cigarettes

every day, some days, not at all, which was the primary outcome measure for this study. Young

adults ages 18 to 24 who answered all three questions were included in this cross-sectional study.

No restrictions were made on smoking or tobacco use status. Exclusion criteria included

individuals less than 18 or greater than 24 years of age, and anyone who reported never using an

e-cigarette even one or two times. The decision to exclude young adults who have never used an

e-cigarette stemmed from skip patterns in the PATH questionnaire, which prevented non-users

from answering all of the items included in the Measurement Model (Figure 3) and listed in

Appendix A.

Sample Size

The PATH questionnaire consisted of 9,112 young adults (ages 18-24). A total of 8,587

(94.2%) young adults reported ever seeing or hearing about e-cigarettes before completing the

PATH questionnaire. Among this subset of young adults, a total of 3,887 (42.7%) reported yes to

42
ever having used an e-cigarette even one or two times. These same 3,887 young adults who have

ever used an e-cigarette completed the question on whether they now use e-cigarettes every day

(n=160, 4.1%), some days (n=947, 24.4%), or not at all/non-users (n=2,780, 71.5%).

Researchers employing structural equation modeling (SEM) recommend that a large

sample size (n > 200) be used. Additional considerations for sample size include measurement

model complexity, distributional characteristics of observed variables, and whether there is

anticipated missing data (Kline, 2005; Lei & Wu, 2007; Little, 2013). Little stated that the key

issue for sample size is determining whether your sample provides a strong representation of the

population to calculate a variance/covariance matrix and indicator means that reflect the

population (Little, 2013). The overall sample size of 3,887 young adults who now use e-

cigarettes every day, some days, or not at all was sufficient for the SEM analyses performed in

this study.

Measures

The Comprehensive Measurement Model (Figure 3) shown on the next page illustrates

the Integrated Behavior Model (IBM) and the affect heuristic theory constructs, and the indicator

variables used to measure each construct. As previously presented in the Conceptual Framework

section in Chapter 2, the affect heuristic theory constructs of perceived benefit and positive affect

are represented by proxy measures of the IBM constructs instrumental attitude and experiential

attitude, respectively. It should be noted that the PATH dataset was not developed with the

purpose of testing the IBM or affect heuristic theory. Thus, the indicators that were chosen as

operational representations of the underlying constructs were post-fitted by the author through

face validity guided by the theoretical literature presented in Chapter 2.

43
Figure 3. Comprehensive Measurement Model

44
 A detailed list of the survey items and corresponding response options comprising the

constructs are included in Appendix A. Summaries of each latent construct and the indicator

variables used to measure the constructs are presented below.

Experiential Attitude (Positive Affect)

The construct of experiential attitude (proxy for positive affect in affect heuristic) was

measured by four items. One item was from the E-Cigarette Section asking whether using an e-

cigarette felt like smoking a regular cigarette; which was recoded as 1=yes and 0=no. Three

items were derived from the Nicotine Dependence Section, which asked respondents to indicate

how true it is of them on a scale from 1 (not at all true of me) to 5 (extremely true of me) that e-

cigarettes helped the respondent feel better, think better, and if the respondent would feel alone

without an e-cigarette, with higher scores indicating greater experiential attitude/positive affect.

Instrumental Attitude (Perceived Benefit)

Six items from the “reasons people use e-cigarettes” sub-section of the E-Cigarette

Section were applied as measures of the instrumental attitude construct (proxy for perceived

benefit construct in affect heuristic). Survey items asked about whether e-cigarettes came in

pleasing flavors, didn’t smell as bad as cigarettes, helped people quit smoking, was an alternative

to quitting smoking, and whether they liked to socialize with the device. These items were coded

as 1=yes and 0=no; with a higher score indicating greater instrumental attitude/perceived benefit

of e-cigarettes.

Perceived Norm

Perceived norm for e-cigarette use was measured by six items defined through face

validity as the three sub-constructs of injunctive norm, subjective norm, and descriptive norm.

Appendix A displays the item categorization by the three sub-constructs. Three items were from

45
the “reasons people use e-cigarettes” sub-section of the E-Cigarette Section. One question asked

whether e-cigarettes were more acceptable to non-tobacco users with options coded as 1=yes and

0=no. Two items from the Peer and Family Influences section asked respondents to rate the

opinion on using tobacco among “most people” and among “people who are important to you”

(very positive, positive, neither positive nor negative, negative, very negative). These two items

were reverse coded as 5=very positive, 4=positive, 3=neither positive nor negative, 2=negative,

1=very negative; with higher scores indicating greater social approval of tobacco use. One item

from the Nicotine Dependence Section inquired how true it is of them on a scale from 1 (not at

all true of me) to 5 (extremely true of me) that most people whom the respondent spent time with

were tobacco users.

Personal Agency

The PATH questionnaire did not explicitly include typical questions used to

operationalize the two sub-constructs of personal agency, which are perceived behavioral control

(PBC) and self-efficacy. Here, proxy questions were employed to assess whether participants

believed they could control their own e-cigarette use (i.e., PBC) and if they did not find it hard to

use the device (i.e., self-efficacy). As such, PBC included two items from the “reasons people

use e-cigarettes” sub-section of the E-Cigarette Section asking whether respondents used e-

cigarettes because they were affordable and if they used them at times when smoking cigarettes

isn’t allowed. These two items were coded as 1=yes and 0=no. Two proxy measures from the

Nicotine Dependence Section were applied to measure the sub-construct of self-efficacy. Both

questions from this section asked respondents how true it is of them on a scale from 1 (not at all

true of me) to 5 (extremely true of me) on it being hard to not use e-cigarettes. These two items

were reverse-coded on a scale from 5 (not at all true of me) to 1 (extremely true of me).

46
Quit Intention

Quit intention was measured using the item: Overall, on a scale from 1 to 10 where 1 is

not at all interested and 10 is extremely interested, how interested are you in quitting [e-

cigarettes]? Respondents were asked this question for one or more tobacco products they

reported using in the PATH questionnaire. All respondents in this study were asked this question

for interest in quitting e-cigarettes; however, it was not possible to isolate answers for only those

who answered the question for e-cigarettes due to the limitation with the public use dataset. The

quit intention score remained as a continuous variable. As this was the only intention-related

question in the PATH questionnaire, it was assumed in this dissertation that people who were

interested in quitting had a future intention to quit.

E-Cigarette Risk Perception

The latent construct e-cigarette risk perception was measured by four indicator variables.

One item from the Product Regulation—Modified Risk Tobacco Products section asked: Is using

e-cigarettes less harmful, about the same, or more harmful than smoking cigarettes? This item

was coded as 1=less harmful, 2=about the same, 3=more harmful. An item from the Nicotine

Dependence Section asked whether respondents believe using e-cigarettes was causing or

making a health problem worse coded as 1=yes and 0=no. Two items from the “reasons people

use e-cigarettes” sub-section of the E-Cigarette Section asked whether respondents used the

device because it is less harmful to them or less harmful to other people; which was reverse

coded as 1=no and 0=yes.

Dependent Variable: E-Cigarette Use

There currently is no established definition of e-cigarette use implemented consistently

by tobacco researchers (Amato, Boyle, & Levy, 2015). Some studies have defined current e-

47
cigarette use as respondents who reported use at least once in the past 30 days (Choi & Forster,

2013; King, Patel, Nguyen, & Dube, 2015) or respondents who reported using the device every

day and some days (Agaku et al., 2014). Other researchers have demonstrated the value in

further classifying e-cigarette users by their intensity and frequency of use (i.e., intensive,

intermittent use) (Biener & Hargraves, 2014), or differentiating between daily and non-daily use

(Brose et al., 2015).

Current e-cigarette users were defined in the PATH questionnaire as respondents who

ever used e-cigarettes and now use the product every day and some days (Hyland et al., 2016).

First the PATH questionnaire identified e-cigarette users by asking whether respondents have

ever seen or heard of e-cigarettes, and whether they have ever used an e-cigarette, even one or

two times. Among respondents who said yes to both questions, these respondents were asked

whether they now use e-cigarettes every day, some days, or not at all. The primary outcome

measure for this dissertation included young adult ever e-cigarette users who now use e-

cigarettes every day, some days, or not at all (n=3,887). This item was reverse-coded with

3=every day, 2=some days, and 1=not at all, with the highest score reflecting the greatest

frequency of e-cigarette use.

Covariates in Structural Model

Sociodemographic covariates controlled for confounding effects in the structural model.

Efforts were made to limit the number of covariates in the model to avoid over-controlling for

confounding effects, which can interfere with accurately modeling primary pathways (Little,

2013). Table 1 on page 43 summarizes the covariates from the PATH questionnaire included in

this dissertation based on prior research demonstrating the association between these covariates

with latent constructs in the model (Foulds et al., 2015; USDHHS, 2012, 2014). Recoded

48
variables created by the PATH study team with imputed data were used for the covariates

gender, education, race, and ethnicity. Imputation by the PATH study team entailed one of the

following approaches: cross-verification of the PATH questionnaire variable with household

screener data; “hot deck imputation” whereby missing values were replaced by an observed

response when demographic characteristics representative of that variable were available (i.e.,

using Census Region, age category and gender for hot deck imputation of the variable

education); and random assignment (i.e., half of the missing gender values assigned male and the

other half assigned female) (USDHHS, 2016b). The percentage of imputed missing covariates

for the entire PATH adult baseline sample (n=32,320) was the following: gender (0.1%), race

(2.6%), and ethnicity (1.5%). A six-level variable for education developed by the PATH study

team was used with an unknown imputed percentage (USDHHS, 2016b). The education variable

was recoded with five-levels for this study. Race and ethnicity were combined into one variable

and recoded with four-levels.

Table 1
Covariates in Structural Model
Variable PATH Question/Item(s) Answer Options/Scale
Description
Gender What is your sex? Male, Female

Education What is the highest grade or level Less Than High School; GED; High School
of school you completed? Graduate; Some College/Associate Degree;
Bachelor’s Degree or higher.

Race/Ethnicity What is your race? White Non-Hispanic, Black Non-Hispanic,

Are you Hispanic, [Latino/Latina], Hispanic, Other race.
or of Spanish origin?

Other tobacco Do you now smoke [tobacco
product use product] Every day, some days, not
(in addition to at all, Don’t Know.
e-cigarettes) *tobacco products (other than e-
cigarettes) include: cigarettes,
cigars, cigarillos, filtered cigars,
pipe tobacco, hookah, snus,
smokeless, or dissolvable tobacco
Ever e-cigarette users who:
1=now use one or more tobacco products every day
or some days
0=never used or currently do not use another
tobacco product

49
 The fifth covariate of other tobacco product was created to identify ever e-cigarette users

who reported ever using another tobacco product and currently use the product every day or

some days. Other tobacco products asked in the PATH questionnaire included cigarettes, cigars,

cigarillos, filtered cigars, pipe tobacco, hookah, snus, smokeless, or dissolvable tobacco. The

count command in Stata 14.2 (StataCorp, 2015), produced the frequencies for exclusive ever e-

cigarette use, dual use of e-cigarettes with one other tobacco product, and poly use of e-cigarettes

with two or more other tobacco products, shown below in Table 2. These counts were then

recoded as a binary covariate for other tobacco product use (in addition to e-cigarettes) with

1=use one or more tobacco products every day or some days, and 0=never used another tobacco

product or don’t use other tobacco product(s) currently.

Table 2:
Exclusive E-cigarette Use, Dual Use, and Poly Tobacco Use Frequency, PATH 2013 (n=3,887)
# Tobacco Total # of Young Adults
Tobacco User Type
Products Used Reporting Use (n=3,887)
0 n=1,001 Exclusive E-cigarette User

1 n=1,351 E-cig Dual User (1 other tobacco product)

2 n=763 E-cig Poly User (2 other tobacco products)

3 n=371 E-cig Poly User (3 other tobacco products)

4 n=214 E-cig Poly User (4 other tobacco products)

5 n=109 E-cig Poly User (5 other tobacco products)

6 n=43 E-cig Poly User (6 other tobacco products)

7 n=18 E-cig Poly User (7 other tobacco products)

8 n=10 E-cig Poly User (8 other tobacco products)

9 n=2 E-cig Poly User (all 9 other tobacco products)

Note: Exclusive e-cigarette user definition: never using or not currently using another tobacco product. Dual user definition: use
e-cigarettes with one other tobacco product every day or some days. Poly user definition: use e-cigarettes with two or more other
tobacco products every day or some days.

50
Data Analysis Plan

Univariate/Bivariate Analyses

This study examined multiple survey items to measure the IBM and affect heuristic

theory individual-level factors (i.e., attitude, perceived norm, personal agency, intention, and e-

cigarette risk perception). All analyses were conducted using the replicate survey weights

provided in the PATH dataset; which were formed from the balanced repeated replication (BRR)

method (Hyland et al., 2016; USDHHS, 2016b). The validity of each latent construct depicted in

the Comprehensive Measurement Model (Figure 3) was dependent on the indicators used to

measure the constructs. Before examining the validity and reliability of latent constructs, each

indicator variable was assessed for univariate normality using Stata 14.2 (StataCorp, 2015).

Among the 24 indicator variables chosen to measure the latent constructs, only one item

was continuous. There were 14 binary indicator variables with yes/no responses, one three-level

ordinal variable, and nine five-level ordinal variables (listed in Appendix A). Means, standard

deviations, histograms and tests of skewness and kurtosis were conducted to examine whether

the responses were normally distributed for the continuous item and five-level ordinal items

(normality identified as -1.25 < skewness < 2.0; -1.0 < kurtosis <0.08) (Kline, 2005). All nine

ordinal variables demonstrated high levels of skewness and kurtosis. The decision was made to

treat these variables as categorical variables due to their floor effects with most responses on the

lower end of the spectrum (i.e., not at all true answer option). This decision was made since

maximum likelihood estimation (ML) used for continuous variables in exploratory factor

analysis cannot appropriately account for floor and ceiling effects in ordinal variables.

Statisticians argue that treating categorical variables as continuous would result in attenuated

relationships between indicators and inaccurate test statistics and standard errors. Treating the

51
five-level ordinal items as categorical ensured that the items could be appropriately run in

exploratory factor analysis using robust weighted least squares estimation (WLSMV) (Brown,

2015; Muthén & Muthén, 2009b).

Univariate statistics for the categorical dichotomous and ordinal items required

examining the proportion of young adult ever e-cigarette users who answered each response

option. For example, a mean for each binary item was calculated to determine the percentage of

young adults who chose the answer option yes coded as 1. Since the reported standard deviation

assumed that the test statistic was a mean for the binary item, the proportion standard deviation

was calculated as the square root of the mean multiplied by one minus the mean (Elliott, 2014).

The binomial exact 95% confidence intervals were calculated to ensure accurate standard errors.

This approach facilitated 95% confidence that the true population proportion of yes coded as 1

was between the confidence interval (Elliott, 2014). Unweighted data were reported for the

overall binary item mean, proportional standard deviation and binomial exact 95% confidence

interval; which resulted from the inability to apply complex survey weights while calculating the

binomial exact 95% confidence interval. BRR survey weights were applied to binary response

option data and all ordinal variable data to ensure accurate proportions, standard errors, and 95%

confidence intervals.

Cross tabulations with Chi-square (χ2) significance tests were run for bivariate analyses

that examined associations between e-cigarette user type (i.e., now use every day, some days, or

not at all) and covariates, including gender, race, ethnicity, education, and other tobacco product

use. Bivariate analyses were also conducted for each set of indicator items for the IBM and affect

heuristic theory constructs.

52
Reliability Assessment and Exploratory Factor Analysis (EFA)

Due to the majority of indicator variables being binary and ordinal, tetrachoric and

polychoric correlation matrices, respectively, were examined (UCLA, 2016). These matrices

were created using Stata 14.2 (StataCorp, 2015). The bivariate correlations did not indicate a

threat of multicollinearity, that is, the correlations were less than 0.85 (Hirsch & Poneleit, 2006;

Lei & Wu, 2007). Given that the majority of indicators were categorical, it was not possible to

calculate Cronbach’s alpha to measure the internal consistency of each latent construct (Cortina,

1993).

Exploratory factor analysis (EFA) was conducted applying robust weighted least squares

estimation (WLSMV) and BRR complex survey weights using Mplus® 7.4 (Muthén & Muthén,

2016). The missing data option was written in the Mplus analysis code to prevent list-wise

deletion of observations with missing data (Muthén & Muthén, 2009a). First, a factor structure

without a fixed number of factors was produced to examine whether the indicators loaded

according to the expected number of factors for each construct based off of the theory presented

in Chapter 2 as well as face validity. A scree plot for the indicators illustrated where the slope

substantially dropped in magnitude, and suggested the number of factors that should be retained

in each construct. Kaiser’s criterion estimated the number of factors based on factors having

eigenvalues greater than 1.0, encompassing the majority of total variance explained. Items were

assessed by how strongly they loaded onto each factor and whether items cross-loaded across

multiple factors (Brown, 2015). Robust factor loadings above 0.40 illustrated that a construct

highly predicted responses on that indicator (Little, 2013). When necessary, an iterative process

of removing problematic items was conducted to see how the removal of certain items impacted

factors loadings. To make the factor loadings more definitive, a geomin oblique rotation was

53
used allowing the factors to be correlated. In addition to examining the geomin factor loadings,

the geomin factor correlations and factor structure (i.e., correlations between items and factors)

informed whether to maintain all of the proposed indicators measuring each latent construct in

the Comprehensive Measurement Model (Figure 3).

Validity Assessment of Indicators: Confirmatory Factor Analysis (CFA)

Next, the validity of the indicators measuring each of the IBM and affect heuristic

constructs were examined through confirmatory factor analysis (CFA) using Mplus® 7.4

(Muthén & Muthén, 2016). For each latent construct, CFA was conducted to determine how well

the indicators loaded onto a fixed number of factors for the construct. The advantage of CFA was

its ability to correct for item measurement error that may have existed between indicators and

latent constructs. The magnitude of the factor loadings informed the decision to parcel certain

indicators in the same construct.

Parceling Items

This dissertation employed the technique of parceling items recommended by Little and

colleagues (Little, Rhemtulla, Gibson, & Schoemann, 2013). Researchers conducting structural

equation modeling (SEM) suggest a minimum of three items measuring each construct (Little,

2013; Wills & Cleary, 2000). However, Little et al. recommend the parceling technique of taking

two or more items and averaging them together to create a more reliable indicator of the

construct (Little et al., 2013). This technique was applied to constructs with only two items by

adding and averaging them. Parceling items into more reliable indictors minimized the problem

of dual factor loading. Furthermore, by averaging indicators, the covariance between two

indicators still existed but was represented as an uncorrelated residual. As a result, parceling

54
provided the advantage of high reliability, lower likelihood of distributional violations, fewer

parameter estimates, and reduced sources of sampling error (Little et al., 2013).

Fitting the Measurement Model

Fitting the measurement model using CFA was a precursor step to SEM. The

measurement model specified the number of factors (i.e., constructs), how strongly the indicators

loaded onto the factors, and the relationships among indicator residual variances (i.e., error

variance) (Brown, 2015). As described by Brown “a key aspect of CFA evaluation is the ability

of the parameters from the measurement model to reproduce the observed relationships among

the indicators” (pg 45) (Brown, 2015). Given this goal, robust weighted least squares estimation

(WLSMV) and BRR complex survey weights were applied using Mplus® 7.4 (Muthén &

Muthén, 2016). As previously described, this parameter estimation was chosen due to the

analysis of categorical variables.

The effects coding method was employed to set the scale for each latent construct. For

each construct, the loadings were constrained to average to 1.0. This resulted in indicator

intercepts totaling to zero. The latent construct variance represented the average of the

indicators’ variances explained by the construct (Brown, 2015). The residual variances and

correlations among latent factors were freely estimated.

It is common for researchers to use both model- and equation-level goodness-of-fit

statistics with Chi-square (χ2) and R2 to identify the most representative model of the data

(Trumbo & Harper, 2015a, 2015b). However, Little argued that the Chi-square fit statistic is not

sufficient for assessing model fit given its dependence of sample size (Little, 2013). Instead, the

following three fit indices were used to evaluate model fit of the measurement model: Root

Mean Square Error Of Approximation (RMSEA) and its corresponding 90% confidence interval,

55
Comparative Fit Index (CFI), and the Tucker-Lewis Index/Non-Normed Fit Index (TLI/NNFI)

(Little, 2013). The RMSEA is a measure of practical fit comparing the predicted model to the

saturated (perfect) model; with values below 0.08 indicating acceptable model fit, and below

0.05 showing good fit (Brown, 2015). CFI and TFI/NNFI are measures of relative fit by

comparing the predicted model to the null model; with values above 0.90 indicating acceptable

model fit, and above 0.95 showing good fit for both indices (Brown, 2015).

If confirmatory factor analysis of the measurement model showed poor fit, post-hoc

adjustments were made to the model dependent on how the indicators loaded onto the constructs.

While potential modifications were data-driven they also had to have strong theoretical

justification (Little, 2013). Once certain adjustments were made, a final measurement model was

run using robust weighted least squares estimation (WLSMV) and BRR complex survey weights

to inform the structural equation model.

The covariates of gender, education, race/ethnicity, and other tobacco product use were

statistically controlled in the model. These covariates were treated as semi-partial effects

removing the covariate effects from the dependent variable now use e-cigarettes. Confirmatory

factor analysis of the final measurement model was performed with the covariates to assess how

they impacted model fit.

Structural Equation Modeling (SEM)

For this study, structural equation modeling (SEM) was implemented using Mplus® 7.4

to specify the structural relationships among the latent variables to test an integrated theoretical

model. A major strength of SEM for this study (also referred to as latent regression) was that it

facilitated the examination of multiple intervening variables and dependent variables

simultaneously, as well as the testing of indirect effects (Little, 2013). SEM also corrected for

56
measurement error by removing error from the structural paths. Furthermore, SEM increased the

validity of constructs by using multiple indicators to measure them (Schreiber, Stage, King,

Nora, & Barlow, 2006).

The structural equation model is shown below in Figure 4. As done during CFA, SEM

was run with robust weighted least squares estimation (WLSMV) and BRR complex survey

weights with the following three fit indices to evaluate model fit: Root Mean Square Error Of

Approximation (RMSEA), Comparative Fit Index (CFI), and the Tucker-Lewis Index/Non-

Normed Fit Index (TLI/NNFI) (Little, 2013). Post-hoc adjustments such a model pruning of

removing non-significant paths was made to the model if there was theoretical justification, and

if the changes resulted in increases in model fit (Little, 2013). Indirect effects shown in Figure 4

were also examined. For example, the study assessed whether the construct attitude had an

indirect effect on e-cigarette use through the construct quit intention.

Figure 4: Proposed Structural Equation Model

57
 Chapter 4: Results

The 2013-2014 Population Assessment of Tobacco and Health (PATH) Study Wave 1

baseline adult dataset consisted of 9,112 young adults (ages 18-24). A total of 3,887 (42.7%)

reported yes to ever having used an e-cigarette even one or two times, and reported now using e-

cigarettes every day (n=160, 4.1%), some days (n=947, 24.4%), or not at all/non-users (n=2,780,

71.5%).. Table 3 below illustrates the demographics of young adults in this study by e-cigarette

user type. Young adults who reported the highest prevalence for now using e-cigarettes every

day or somedays were male, white non-Hispanic, and those with a high school degree or some

college or associate’s degree. The majority of every day e-cigarette users (83.7%) and some day

Table 3
Demographics of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
Now Use E-Cigarettes Every day Some days Not at all, but
(n=160) (n=947) yes, have ever
used e-cigarettes
(n=2,780)
Gender*** n=160 n=947 n=2,780
Male 72.5% (112) 62.8% (582) 57.6% (1,564)
Female 27.5% (48) 37.2% (365) 42.4% (1,216)

Racea n=160 n=947 n=2,780

White non-Hispanic (NH) 72.1% (111) 61.1% (552) 61.1% (1,585)
Black non-Hispanic (NH) 3.8% (7) 8.2% (87) 9.3% (294)
Hispanic 10.4% (18) 17.0% (178) 16.3% (503)
Other race (mixed race) 13.8% (24) 13.7% (130) 13.3% (398)

Highest Level of Educationa,* n=159 n=939 n=2,770

Less than high school 12.2% (21) 14.3% (144) 11% (347)
GED 6.7% (12) 9.2% (90) 6.8% (222)
High school graduation 29.6% (53) 29.5% (316) 27.1% (837)
Some college or associate’s degree 44.8% (62) 39.6% (332) 44.9% (1,140)
Bachelor’s degree or higher 6.7% (11) 7.5% (57) 10.2% (224)

Now Use 1 or More Tobacco Products with E- n=160 n=947 n=2,780

Cigarettes Every Day/Some Daysb,***
Yes 83.7% (134) 87.1% (831) 67.% (1,916)
No 16.3% (26) 12.9% (116) 32.5% (864)
a
percentages may not add up to 100 due to rounding. bTobacco products include cigarettes, cigars, cigarillos, filtered cigars, pipe
tobacco, hookah, snus, smokeless, or dissolvable.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

58
users (87.1%) reported using one or more other tobacco products every day or some days.

Univariate & Bivariate Results

Appendix B includes the detailed tables for univariate and bivariate analyses for each of

the following constructs in the Comprehensive Measurement Model (Figure 3): attitude (sub-

constructs instrumental and experiential attitude), perceived norm (sub-constructs injunctive,

subjective, and descriptive norm), personal agency (sub-constructs perceived behavioral control

and self-efficacy), and e-cigarette risk perception. Those who now use not at all will be referred

to herein as current non-users.

Among the instrumental attitude items, the majority of young adults reported that e-

cigarettes came in flavors that they like (77.8%), didn’t smell (74.6%), and they believed that e-

cigarettes could help people to quit smoking (64.2%). Compared to some days users and non-

users, every day e-cigarette users reported the highest frequency among those who said yes that

e-cigarettes can help people to quit smoking cigarettes (83.%), and can be used as an alternative

to quitting (80.4%). All three types of e-cigarettes users reported that the device came in flavors

that they like and didn’t smell. For the experiential items, the majority of young adults who ever

used an e-cigarette did not believe that the device helped them feel better when feeling down

(69.8%), think better (75.5%), or made them feel less alone (88.0%). While 51.4% of every day

users agreed that e-cigarettes felt like a cigarette, 68.7% of some day users and 70.8% of non-

users disagreed with this statement.

All three types of e-cigarette users viewed the device as more acceptable to non-tobacco

users (69.8% overall). Young adult e-cigarette users, regardless of type, also reported that people

important to them did not use e-cigarettes (77.8%). All three types of users described most

people’s opinion on tobacco as negative (48.6%). Some day users compared to the other two

59
types reported a very negative opinion on using tobacco among people who are important to

them (28.9%). Current non-users reported a negative view on using tobacco (31.6%) among

important people to them. Non-users reported it being extremely true that most people they spent

time with were tobacco users (64.9%) compared to every day users (33.6%) and some day users

(26.8%).

Every day users compared to the other two types reported the highest percentage of

agreement in using e-cigarettes because they were affordable (80.8%). Every day users and non-

users indicated they use e-cigarettes at times when or in places where smoking cigarettes was not

allowed (89.4% and 85.6%, respectively). Some day users and non-users said it wouldn’t be hard

to not use e-cigarettes in general or for a week compared to every day users who exhibited more

variance in their responses.

Every day users reported the highest percentage of agreement for the statement e-

cigarettes might be less harmful to me than cigarettes (93.3%) compared to some day users

(78.7%) and non-users (85.7%). Overall, all three types of users believed that e-cigarettes might

be less harmful to people around them than cigarettes (81.5%). Every day users believed that e-

cigarettes were less harmful than smoking cigarettes (90.5%) compared to some day users

(70.3%) and non-users (55.7%).

Figure 5 on page 61 illustrates the range in responses on interest in quitting one or more

tobacco products they reported using in the PATH questionnaire. The majority of every day e-

cigarette users reported extreme interest in quitting (33.5%) compared to some days (18.6%) and

non-users (21.2%).

60
 Figure 5. Quit Intention Histogram of Data Spread Among All Young Adult E-Cigarette Users
.8
.6
Density

.4
.2
0

0 2 4 6 8 10
Interest in Quitting

Exploratory Factor Analysis Results

Exploratory Factor Analysis (EFA) was first performed on the indicator items for each

construct using robust weighted least squares estimation (WLSMV) with a geomin oblique

rotation. For EFA of the experiential attitude (i.e., feelings) sub-construct, three of the four

original items (i.e., “feel better”, “think better”, “alone”) loaded strongly on the same construct.

Among the five items for instrumental attitude (i.e., benefits), the items “help quit” and

“alternative to quitting” loaded strongly together in a factor separate from the other three benefits

items. The multidimensionality of the benefits construct suggested that a facet related to e-

cigarettes as a smoking alternative may be warranted to include in the revised measurement

model. EFA of the six perceived norm items did not support the proposed division of the

construct into the sub-constructs injunctive norm, subjective norm, and descriptive norm. Rather,

items from separate sub-constructs (i.e., “most people’s opinion on tobacco” and “important

people’s opinion on tobacco)” loaded strongly together to create the construct representing norm.

EFA of the four items in the personal agency construct did not support the proposed division of

61
the construct into sub-constructs of perceived behavior control and self-efficacy. Rather, two

items - “hard to not use e-cigarettes” and “hard to not use e-cigarettes for a week” loaded on a

single factor. Finally, EFA for the four items in the e-cigarette risk perception construct showed

robust positive factor loadings loading on a single factor for three items; due to the low factor

loading for “vulnerable,” this item was removed.

When EFA was performed on the 23 items measuring the constructs in the

Comprehensive Measurement Model, the following four factors emerged: experiential attitude,

instrumental attitude, e-cigarette risk perception, and norm. Table 4 on page 63 shows the factor

loadings for all 23 items across these four factors. Table 4 reveals that items “help quit,”

“alternative to quitting,” “e-cigarettes might be less harmful to me,” and “e-cigarettes might be

less harmful to people” had robust loadings on a third factor. This third factor was first

considered to be called “e-cigarette benefit compared to cigarettes.” Upon further examination

this third construct was renamed e-cigarette risk perception to create a construct representative of

perceived risk that could be tested in the measurement model and structural model. As a result,

four items that loaded strongly on the third factor in Table 4 that did not reflect risk perception

were deleted from the model (i.e., “smell”, “help quit”, “alternative to quitting”, “allowed”).

The item “feels like a cigarette” had weak cross-loadings across multiple factors and was

deleted from the model. The item “most people use tobacco” cross-loaded weekly across

multiple factors and was deleted from the model. When the items “feels like a cigarette” and

“people use tobacco” were deleted due to low cross-loadings, these items did not alter the way

the items loaded across the four factors. The item “affordable” also cross-loaded weakly across

multiple factors and was deleted. The item “celebrity use” loaded onto the Instrumental Attitude

construct, but did not appear through face validity to represent the construct of an actual benefit

62
Table 4
Summary of Exploratory Factor Analysis Results for All 23 Items Using Robust Weighted Least Squares Estimation (WLSMV) with a Geomin
Oblique Rotation (n= 3,887)
Factor Loadings
CodeName Item Experiential Instrumental E-Cig Risk Norm
Attitude Attitude Perception
Flavors E-cigarettes come in flavors that I like. 0.01 0.57 0.27 0.09
Smell E-cigarettes don’t smell. 0.04 0.07 0.48 -0.069
HelpQuit Using e-cigarettes helps people to quit smoking cigarettes. -0.06 -0.16 0.77 0.09
Socialize I like socializing while using an e-cigarette. 0.24 0.62 -0.00 -0.05
AltToQuit Did you use e-cigarettes as an alternative to quitting 0.08 -0.19 0.63 -0.00
tobacco altogether?
Feelbetter E-cigarettes help me feel better if I’ve been feeling down. 0.81 0.05 -0.05 -0.07
Thinkbetter E-cigarettes help me think better. 0.80 0.02 -0.02 -0.06
Alone I feel alone without my e-cigarette. 0.86 0.02 -0.00 0.02
FeelsLikeCig Using an e-cigarette feels like smoking a regular cigarette. 0.25 0.06 0.27 0.10
Acceptance E-cigarettes are more acceptable to non-tobacco users. -0.13 0.58 0.27 0.09
MostPlpOpinion How would you describe most people’s opinion on using 0.00 0.10 -0.12 0.59
tobacco?
ImpPlpOpinion Thinking about the people who are important to you, how -0.05 -0.00 -0.01 0.78
would you describe their opinion on using tobacco?
ImpPlpUseEcig People who are important to me use e-cigarettes. 0.11 0.64 0.03 0.06
CelebrityUse People in the media or other public figures use e- -0.01 0.58 0.00 0.21
cigarettes.
PeopleUseTob Most of the people I spend time with are tobacco users. 0.16 -0.12 0.04 0.23
Affordable I use e-cigarettes because they are affordable. 0.17 0.26 0.39 0.08
Allowed I can use e-cigarettes at times when or in places where 0.01 0.15 0.45 0.05
smoking cigarettes isn't allowed.
Hard1 I would find it really hard to not use e-cigarettes. 0.94 -0.04 0.07 0.12
Hard2 I would find it hard to not use e-cigarettes for another 0.91 -0.06 0.10 0.04
week.
MeHarm They might be less harmful to me than cigarettes. 0.00 -0.03 -0.87 0.10
PlpHarm They might be less harmful to people around me than -0.03 -0.17 -0.73 0.11
cigarettes.
Vulnerable Do you believe that using an e-cigarette is causing a health 0.01 -0.24 0.14 -0.01
problem or making it worse?

63
Harm-ecig Is using e-cigarettes less harmful, about the same, or more -0.09 0.05 -0.45 -0.00
harmful than smoking cigarettes?
Eigenvalues 6.65 2.62 2.06 1.55
% of variance 28.91 11.39 8.96 6.74
Note: Factor loadings over .40 appear in bold.

64
of e-cigarette use and was deleted. Table 5 on page 66 displays the indicator survey questions

grouped by their original latent construct and final latent construct resulting from Exploratory

Factor Analysis (EFA).

The deletion of these multiple items from the model did not alter the item grouping or

magnitude of loadings for the remaining items in the model. These factor loadings are shown in

in Table 6 on page 68 with a summary of exploratory factor analysis results for the final 14

items. Examination of the geomin factor correlations among the four resulting factors showed

weak to moderate correlations between the factors (results not illustrated in a table). Negative

correlations resulted between e-cigarette risk perception and experiential attitude (i.e., feelings)

(-0.26), and between e-cigarette risk perception and instrumental attitude (i.e., benefits) (-0.31).

Positive correlations were between experiential attitude and instrumental attitude (0.16), and

norm and e-cigarette risk perception (0.14). Negative correlations resulted between norm and

experiential attitude (-0.07), and between norm and instrumental attitude (-0.07). Since the fourth

factor norm only had two items it became a manifest variable with the items averaged during

Confirmatory Factor Analysis (CFA).

65
Table 5
Indicator Survey Questions Grouped by their Original Latent Construct and Final Latent Construct Resulting from Exploratory Factor Analysis
(EFA)
Code Name Indicator Survey Question Answer Options Original Construct Final Construct
Feelbetter E-cigarettes help me feel better if I’ve been 1 (not at all true of me), 2, 3, 4, 5 Experiential Attitude Experiential Attitude
feeling down. (extremely true of me), DK, (Positive Affect) (Positive Affect)
refused
Thinkbetter E-cigarettes help me think better. 1 (not at all true of me), 2, 3, 4, 5 Experiential Attitude Experiential Attitude
(extremely true of me), DK, (Positive Affect) (Positive Affect)
refused
Alone I feel alone without my e-cigarette. 1 (not at all true of me), 2, 3, 4, 5 Experiential Attitude Experiential Attitude
(extremely true of me), DK, (Positive Affect) (Positive Affect)
refused
Hard1 I find it really hard to not use e-cigarettes. 1 (not at all true of me), 2, 3, 4, 5 Self-Efficacy Experiential Attitude
(extremely true of me), DK, (Positive Affect)
refused
Hard2 I would find it hard to not use e-cigarettes for 1 (not at all true of me), 2, 3, 4, 5 Self-Efficacy Experiential Attitude
another week. (extremely true of me), DK, (Positive Affect)
refused

Flavors E-cigarettes come in flavors that I like. Yes, No, DK, refused Instrumental Attitude Instrumental Attitude
(Perceived Benefit) (Perceived Benefit)
Socialize I like socializing while using an e-cigarette. Yes, No, DK, refused Instrumental Attitude Instrumental Attitude
(Perceived Benefit) (Perceived Benefit)
Acceptance E-cigarettes are more acceptable to non- Yes, No, DK, refused Injunctive Norm Instrumental Attitude
tobacco users. (Perceived Benefit)
ImpPlpUseEcig People who are important to me use e- Yes, No, DK, refused Subjective Norm Instrumental Attitude
cigarettes. (Perceived Benefit)

MeHarm They might be less harmful to me than Yes, No, DK, refused E-Cigarette Risk E-Cigarette Risk
cigarettes. Perception Perception
PlpHarm They might be less harmful to people around Yes, No, DK, refused E-Cigarette Risk E-Cigarette Risk
me than cigarettes. Perception Perception
Harm-ecig Is using e-cigarettes less harmful, about the Less harmful, About the same, E-Cigarette Risk E-Cigarette Risk
same, or more harmful than smoking More harmful, DK, refused Perception Perception
cigarettes?

66
MostPlpOpin How would you describe most people’s Very positive, Positive, Neither Injunctive Norm Norm
opinion on using tobacco? positive nor negative, Very
negative, DK, refused
ImpPlpOpinion Thinking about the people who are important Very positive, Positive, Neither Subjective Norm Norm
to you, how would you describe their opinion positive nor negative, Very
on using tobacco? negative, DK, refused

Vulnerable Do you believe that using an e-cigarette is Yes, No, DK, refused E-Cigarette Risk Deleted during EFA
causing a health problem or making it worse? Perception
CelebrityUse People in the media or other public figures Yes, No, DK, refused Descriptive Norm Deleted during EFA
use e-cigarettes.
Smell E-cigarettes don’t smell. Yes, No, DK, refused Instrumental Attitude Deleted during EFA
(Perceived Benefit)
HelpQuit Using e-cigarettes helps people to quit Yes, No, DK, refused Instrumental Attitude Deleted during EFA
smoking cigarettes. (Perceived Benefit)
AltToQuit Did you use e-cigarettes as an alternative to Yes, No, DK, refused Instrumental Attitude Deleted during EFA
quitting tobacco altogether? (Perceived Benefit)
FeelsLikeCig Using an e-cigarette feels like smoking a Yes, No, DK, refused Experiential Attitude Deleted during EFA
regular cigarette. (Positive Affect)
PeopleUseTob Most of the people I spend time with are 1 (not at all true of me), 2, 3, 4, 5 Descriptive Norm Deleted during EFA
tobacco users. (extremely true of me), DK,
refused
Affordable I use e-cigarettes because they are affordable. Yes, No, DK refused Perceived Behavioral Deleted during EFA
Control
Allowed I can use e-cigarettes at times when or in Yes, No, DK refused Perceived Behavioral Deleted during EFA
places where smoking cigarettes isn't Control
allowed.

67
Table 6
Summary of Exploratory Factor Analysis Results for 14 Final Items Using Robust Weighted Least Squares Estimation (WLSMV) with a Geomin
Oblique Rotation (N = 3,886)
Factor Loadings
CodeName Item Experiential Instrumental E-Cig Risk Norm
Attitude Attitude Perception
Feelbetter E-cigarettes help me feel better if I’ve been feeling down. 0.80 0.24 0.05 -0.08
Thinkbetter E-cigarettes help me think better. 0.80 0.18 0.02 -0.08
Alone I feel alone without my e-cigarette. 0.85 0.10 -0.02 0.00
Hard1 I would find it really hard to not use e-cigarettes. 0.87 -0.07 -0.25 0.03
Hard2 I would find it hard to not use e-cigarettes for another 0.85 -0.05 -0.28 0.05
week.
Flavors E-cigarettes come in flavors that I like. 0.00 0.64 -0.13 0.14
Socialize I like socializing while using an e-cigarette. 0.17 0.64 0.03 0.02
Acceptance E-cigarettes are more acceptable to non-tobacco users. -0.14 0.60 -0.34 -0.04
ImpPlpUseEcig People who are important to me use e-cigarettes. 0.02 0.65 -0.00 0.12
Harm-ecig Is using e-cigarettes less harmful, about the same, or more -0.05 0.02 0.50 -0.05
harmful than smoking cigarettes?
MeHarm They might be less harmful to me than cigarettes. 0.02 -0.05 0.93 0.01
PlpHarm They might be less harmful to people around me than -0.08 -0.27 0.64 0.05
cigarettes.
MostPlpOpinion How would you describe most people’s opinion on using 0.03 0.05 0.11 0.56
tobacco?
ImpPlpOpinion Thinking about the people who are important to you, how -0.03 -0.01 -0.00 0.83
would you describe their opinion on using tobacco?
Eigenvalues 5.15 2.23 1.59 1.20
% of variance 36.79 15.93 11.36 8.57
Note: Factor loadings over .40 appear in bold.

68
Confirmatory Factor Analysis Results

EFA resulted in the following three factors: experiential attitude (i.e., reporting that e-

cigarettes help respondents feel and think better), instrumental attitude (i.e., benefit of e-

cigarettes coming in pleasant flavors and being more acceptable to non-tobacco users), and e-

cigarette risk perception. The two items for the norm factor were averaged to create a single

parcel manifest item for norm. Figure 6 on page 70 illustrates the Revised Measurement Model

based upon EFA and CFA. Table 7 below illustrates the overall EFA model fit and CFA model

fit from one to three factors. During CFA, no additional items were removed due to good model

fit during model building. CFA model fit statistics for the Revised Measurement Model with

three latent constructs indicated good fit (CFI = 0.988; TLI = 0.985; RMSEA = 0.02, 90% CI:

0.015 0.024; χ2 (51) = 124.50, p < 0.001).

Table 7
Fit Indices for EFA and CFA Measurement Model Fit Using Robust Weighted Least Squares Estimation
(WLSMV)
RMSEA
Model Tested χ2 df RMSEAa CFIb TLIb
90%CI

EFA with 4 88.26 41 0.02 0.012 0.022 0.99 0.99

Factors:
ExpAtt, InstrAtt,
RiskPer, Norm

CFA with 1 Factor: 50.62 5 0.12 0.092 0.151 0.99 0.98

ExpAtt

CFA with 2 66.25 26 0.04 0.025 0.046 0.99 0.99

Factors:
ExpAtt, InstrAtt

CFA with 3 124.50 51 0.02 0.015 0.024 0.988 0.985

Factors:
ExpAtt, InstrAtt,
RiskPer
a
RMSEA acceptable fit < 0.08; good fit < 0.05. bCFI and TLI acceptable fit > 0.90.

69
Figure 6. Revised Measurement Model Based Upon EFA and CFA with Three Latent Constructs (Experiential Attitude, Instrumental
Attitude, E-Cigarette Risk Perception)

70
Structural Equation Modeling Results

Aim 1

EFA and CFA resulted in Aim 1 being revised to: determine the extent to which positive

attitudes about e-cigarettes (i.e., experiential attitude), perceived benefits of e-cigarettes (i.e.,

instrumental attitude), and e-cigarette use norms are associated with a higher intention to quit e-

cigarettes. During EFA and CFA, the constructs of perceived norm and personal agency were

removed from the measurement model. It was hypothesized that as perceived benefits, feelings,

and norm became more positive, these constructs would be associated with lower levels of e-

cigarette quit intention. The structural model for Aim 1 shown in Figure 7 on page 72 indicated

support for the hypothesis that higher levels of perceived benefits from e-cigarette use (i.e.,

instrumental attitude) were associated with a lower likelihood of e-cigarette quit intention (β = -

0.17, SE = 0.06, p < 0.01). Also consistent with the hypothesis, findings indicated that higher

levels of perceived norms around e-cigarette use were associated with lower scores on quit

intention (β = -0.18, SE = 0.03, p < 0.001). Contrary to the hypothesis, however, more positive

feelings towards e-cigarettes (i.e., experiential attitude) were not associated negatively with e-

cigarette quit intention (β = 0.07, SE = 0.06, p= 0.293).

71
Figure 7. Aim 1 Structural Model

72
Aim 2

Addressing Aim 2, there was support for the hypothesis that intention to quit using e-

cigarettes would be associated with a lower likelihood of using e-cigarettes (β = -0.33, SE = 0.04,

p < 0.001) . As shown in Figure 8 below, the Aim 2 structural model featured the quit intention

variable as being correlated with the constructs of experiential attitude (β = -0.60, SE = 0.08, p <

0.001), and norm (β = -0.25, SE = 0.05, p < 0.001). Contrary to the hypothesis, however, more

positive benefits towards e-cigarettes (i.e., instrumental attitude) were not associated negatively

with e-cigarette quit intention (β = 0.12, SE = 0.06, p < 0.05). Semi-partial effects controlled for

covariate effects on the dependent variable.

Figure 8. Aim 2 Structural Model

73
Aim 3

The objective of Aim 3 was to determine the extent to which e-cigarette risk perception

was a significant correlate of e-cigarette use among young adults. As hypothesized and shown in

Figure 9 below, individuals reporting a greater perceived benefit of e-cigarette use reported a

greater positive feelings (i.e., affect) regarding e-cigarette use (β = 0.51, SE = 0.05, p < 0.001),

which, in turn, was associated with less e-cigarette risk perception (β = -0.78, SE = 0.05, p <

0.001). As hypothesized, e-cigarette risk perception also was associated with a lower likelihood

of e-cigarette use (β = -0.19, SE = 0.02, p < 0.001). These findings held even after accounting for

the influence of covariates including gender, race/ethnicity, education, and other tobacco use on

e-cigarette use.

Figure 9. Aim 3 Structural Model

74
 Before conducting SEM of the overall model, the covariates of gender, education,

race/ethnicity, and other tobacco product use were statistically controlled in the Revised

Measurement Model. These covariates were treated as semi-partial effects removing the

covariate effects from only the dependent variable (DV) now use e-cigarettes. Dummy variables

were created for the nominal variables education and race/ethnicity with the reference category

as the one with highest frequency for race/ethnicity (i.e., White non-Hispanic) and education

(i.e., Some College or Associate’s Degree). Table 8 below shows standardized coefficients of

covariates in the final structural model. The final structural model controlling for covariate

effects on the dependent variable indicated acceptable model fit (χ2(202) = 663.48, p < 0.001;

CFI = 0.935; TLI = 0.925; RMSEA = 0.024, 90% CI: 0.022-0.026).

Table 8
Standardized Coefficients of Covariates in Structural Model (N = 3,866)
Standardized
Parameter Estimate
β p
Now Use E-Cigarettes (DV)
Male–> DV 0.10 <0.01
Black non-Hispanic–> DV -0.14 0.03
Hispanic–> DV -0.03 ns
Other Race–> DV 0.01 ns
Less than HS–> DV 0.09 ns
GED–> DV 0.07 ns
High School Graduation–> DV 0.05 ns
Bachelor’s Degree/Higher–> DV -0.07 ns
Use Other Tobaccoo–> DV 0.37 <0.01
Note: Reference category for race was White non-Hispanic. Reference category for education was Some College or Associate’s
Degree. ns = non-significant, where p > 0.05. STDY Standardization used for binary covariates. Pathways are from full structural
model: χ2(202) = 663.48, p < 0.001; CFI = 0.935; TLI = 0.925; RMSEA = 0.024, 90% CI: 0.022-0.026.

SEM was then conducted step-wise by combining the structural models for Aims 1-3.

Table 9 on page 76 illustrates strong model fit (CFI > 0.95) for Aim 1 and acceptable model fit

(CFI > 0.90) for Aims 2 and 3. When these three models were combined, the overall structural

model with the best fit resulted from the addition of a path added from e-cigarette risk

75
Table 9
Fit Indices for CFA Measurement Model Compared to Structural Models for Aims 1-3 and Combined
RMSEA
Model Tested χ2 df RMSEAa CFIb TLIb
90%CI

Measurement Model
CFA with 3 124.50 51 0.02 0.015 0.024 0.988 0.985
Factors:
ExpAtt, InstrAtt,
RiskPer
SEM Aim 1: Quit Intention on ExpAtt, InstrAtt, and Norm
QuitInt on ExpAtt, 1078.04 78 0.058 0.055 0.061 0.838 0.812
InstrAtt, Norm
SEM Aim 2 controlling for semi-partial effects on dependent variable (DV)
DV on QuitInt w/ 1630.638 208 0.042 0.040 0.044 0.799 0.777
ExpAtt, InstrAtt,
Norm
SEM Aim 3 Affect Heuristic
ExpAtt on InstrAtt 586.516 171 0.025 0.023 0.027 0.942 0.933
RiskPer on ExpAtt
DV on RiskPerc
Final Model: Combining Aims 1, 2, and 3 with path added from RiskPer to QuitInt
QuitInt on ExpAtt, 663.477 202 0.024 0.022 0.026 0.935 0.925
InstrAtt, Norm, and
RiskPer
ExpAtt on InstrAtt
RiskPer on ExpAtt
DV on QuitInt
DV on RiskPer
a
RMSEA acceptable fit < 0.08; good fit < 0.05. bCFI and TLI acceptable fit > 0.90.

76
Figure 10. Overall Structural Model

77
perception to the manifest variable quit intention. The final overall structural model is shown in

Figure 10 on page 79.

The final structural model demonstrated acceptable fit (CFI = 0.935; TLI = 0.925;

RMSEA = 0.024, 90% CI: 0.022-0.026). Young adults’ positive feelings (i.e., experiential

attitude) (β = -0.29, SE = 0.17, p = 0.08), perceived benefit (i.e., instrumental attitude) (β = -

0.14, SE = 0.07, p = 0.06), and perceived norm (β = -0.19, SE = 0.03, p < 0.001) were

negatively associated with intention to quit e-cigarettes. Intention to quit e-cigarettes was

negatively associated with e-cigarette use (β = -0.04, SE = 0.02, p < 0.05). These findings also

demonstrated that young adults’ positive feelings towards e-cigarettes were associated positively

with perceived benefits (β = 0.50, SE = 0.05, p < 0.001), and associated negatively with e-

cigarette risk perception (β = -0.77, SE = 0.05, p < 0.001). Lower levels of e-cigarette risk

perception were associated with higher levels of use of the device (β = -0.19, SE = 0.02, p <

0.001). The path from risk perception to quit intention was added to the model to facilitate

acceptable model fit, and produce standardized coefficients that were significant with

hypothesized positive/negative magnitudes of association. This additional path illustrated that

lower levels of risk perception were associated with higher levels of quit intention (β = -0.41, SE

= 0.15, p < 0.01).

Table 11 on page 80 illustrates the indirect paths examined for the overall structural

model. The majority of indirect paths from instrumental attitude (i.e., benefits) and from

experiential attitude (i.e., feelings) to now use e-cigarettes (dependent variable DV) were non-

significant. The path from benefits to feelings to e-cigarette risk perception to the DV (β = 0.07,

p <0.01), support the affect heuristic theory. The indirect path from feelings to risk perception to

the DV (β = 0.08, p <0.01), further supports the affect heuristic theory.

78
Table 10
Standardized and Unstandardized Coefficients from the Structural Pathways (N = 3,866)
Unstandardized Standardized
Parameter Estimate b (S.E.) β
p
Primary Model Paths
Experiential Attitude –> Quit Intention -0.966 (0.547) -0.294 0.078
Instrumental Attitude–> Quit Intention -0.571 (0.303) -0.135 0.058
Norm–> Quit Intention -0.538 (0.088) -0.188 <0.001
Experiential Attitude–> E-Cigarette Risk Perception -0.595 (0.046) -0.769 <0.001
Instrumental Attitude–> Experiential Attitude 0.648 (0.065) 0.504 <0.001
E-Cigarette Risk Perception –> Quit Intention -1.726 (0.638) -0.406 0.006
E-Cigarette Risk Perception –> Now Use E-
Cigarettes -0.154 (0.013) -0.189 <0.001
Quit Intention –> Now Use E-Cigarettes -0.008 (0.046) -0.041 0.046
Note: ns = non-significant, where p > 0.10. STDY Standardization used for binary covariates. χ2(202) = 663.48,
p < 0.001; CFI = 0.935; TLI = 0.925; RMSEA = 0.024, 90% CI: 0.022-0.026; Model also included covariates
not listed in this table (See Table 9).

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Table 11
Total and Specific Indirect Effects of Pathways (N = 3,866)
Estimated
Indirect paths Mediated p
Effecta (β)
Instrumental Attitude–>Now Use E-cigarettes (DV)
Instrumental Attitude –> Experiential Attitude –> E-Cigarette Risk
Perception –> Quit Intention–> DV -0.01 ns
Instrumental Attitude –> Experiential Attitude –> E-Cigarette Risk
Perception –> DV 0.07 p <0.01
Instrumental Attitude –> Experiential Attitude –> Quit Intention –>
DV 0.01 ns
Instrumental Attitude –>Quit Intention –> DV 0.01 ns
Sum of Indirect Paths 0.08 p <0.01
Experiential Attitude–> Now Use E-cigarettes (DV)
Experiential Attitude –> E-Cigarette Risk Perception –> Quit
Intention–> DV -0.01 ns
Experiential Attitude –> E-Cigarette Risk Perception –> DV 0.15 p <0.01
Experiential Attitude –> Quit Intention –> DV 0.01 ns
p
Sum of Indirect Paths 0.15 <0.01
Norm–> Now Use E-cigarettes (DV)
Norm –>Quit Intention –> DV 0.01 ns
E-Cigarette Risk Perception –> Now Use E-cigarettes (DV)
E-Cigarette Risk Perception –> Quit Intention–> DV 0.02 ns
a
Note: ns = non-significant, where p > 0.05. STDY Standardization coefficients shown.

80
Post Hoc Analyses

Post hoc analyses were conducted to explore whether the final structural equation model

combining Aims 1-3 and relationships between the latent construct relationships could differ by

gender, race/ethnicity, education, or use of other tobacco products with e-cigarettes. Tests of

moderation were not implemented, but will be considered for future analyses. Instead, cross

tabulations with Chi-square (χ2) significance tests were run for bivariate analyses for the final set

of 14 indicator items measuring experiential attitude, instrumental attitude, norm, and risk

perception, and whether there were differences by gender, race/ethnicity, education, and other

tobacco product use. Appendix C includes the post hoc bivariate analyses tables.

As shown in Tables 1C and 2C on pages 128-129, there were no significant differences

between male and female young adults for the five experiential items (i.e., feelings), or the four

instrumental items (i.e., perceived benefit). Among the two norm items, females reported the

highest percentage of people important to them having a negative opinion on using tobacco

(33.5%) compared to males (28.0%). The majority of males believed e-cigarettes were less

harmful than smoking cigarettes (63.3%), which was higher than females reporting the same

belief (56.6%).

Tables 4C and 5C on pages 131-132, illustrated no significant differences among the four

race/ethnicity groups for the five experiential items (i.e., feelings), or the four instrumental items

(i.e., perceived benefit). Black Non-Hispanic (NH) young adults reported low frequencies for

negative normative beliefs compared to the other three race/ethnicity categories. White NH

young adults also reported the highest frequency of perceiving e-cigarettes as less harmful than

smoking cigarettes (62.9%) compared to Hispanic (51.8%), Black NH (61.4%), and Other race

(59.9%).

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 Regarding educational differences, those with either less than a high school education or

GED had the highest frequency for e-cigarettes coming in pleasing flavors (80.5%) compared to

high school graduates (77.0%), some college (79.3%), and a Bachelor’s degree or higher

(62.8%). Young adults with either less than a high school education or GED had the lowest harm

perception frequency of e-cigarettes compared to smoking cigarettes (55.9%) compared to the

other education-level groups.

To assess differences among different types of e-cigarettes users, the prevalence of using

e-cigarettes with the following nine other tobacco products was examined: cigarettes, cigars,

cigarillos, filtered cigars, pipe tobacco, and hookah. Only the frequencies of combustible tobacco

products were assessed since the non-combustible (i.e., snus, smokeless, and dissolvable)

products had low frequencies of use for the sample of young adults in the study. Next, a four-

level variable was created representative of mutually exclusive current e-cigarette use (n=1,001),

current dual use of e-cigarettes with cigarettes (n=773), current dual use of e-cigarettes with

hookah (n=394), and current dual use of e-cigarettes with cigarillos (n=91). Then, cross

tabulations with Chi-square (χ2) significance tests were run for bivariate analyses between the

items measuring the constructs of interest in the final measurement model and the four-level

variable e-cigarette user type.

Mutually exclusive current dual users of hookah with e-cigarettes reported the highest

prevalence for reporting that e-cigarettes came in pleasing flavors (87.6%), compared to

exclusive e-cigarette users (76.0%), cigarette dual users (71.9%), and cigarillo dual users

(58.1%). Hookah dual users also indicated a higher prevalence for their enjoyment using e-

cigarettes while socializing (58.1%), compared to exclusive e-cigarette users (45.1%), dual

cigarillo users (41.4%), and dual cigarette users (33.4%). Exclusive e-cigarette users reported the

82
highest prevalence for important people having very negative opinions on tobacco (38.7%)

compared to the other three e-cigarette user types. Dual users of cigarillos reported the highest

frequency on perceiving e-cigarettes to be less harmful to the respondent (86.9%) compared to

dual cigarette users (83.4%), exclusive e-cigarette users (80.5%), and hookah dual users (70.3%).

These bivariate results support future testing of moderation within SEM by e-cigarette user type.

83
 Chapter 5: Discussion

Given increasing rates of e-cigarette use among young adults, research is warranted on

the attitudes and beliefs that are associated with use among this age group. U.S. Surgeon General

Dr. Vivek Murthy sounded the alarm in his 2016 Surgeon General Report that while some

evidence-based cigarette smoking strategies may work for preventing e-cigarette use, more

research is needed on how young adults perceive e-cigarettes to tailor communication and

educational tobacco control strategies (USDHHS, 2016a). Scholars of health behavior have

shown through numerous studies that an individual’s attitudes and beliefs influence whether a

certain health-related action is taken. Therefore, this dissertation aimed to address this research

gap by examining how young adults’ attitudes, beliefs, and perceptions of e-cigarettes influenced

their likelihood of currently using the device.

Interpretation of Findings

The present study applied the Integrated Behavior Model (IBM) encompassing the affect

heuristic theory to examine the individual-level correlates (i.e., attitude, perceived norm,

personal agency, intention, and e-cigarette risk perception) of young adults’ e-cigarette use. A

summary of the findings for Aims 1-3 are provided below.

Aim 1

Aim 1 sought to determine the extent to which experiential attitude (i.e., feelings),

instrumental attitude (i.e., benefits), and perceived norm were statistically significant predictors

of intention to quit e-cigarettes. Typically when the IBM is operationalized, the intention

measure is defined as the intention to perform the behavior (Fishbein et al., 2002). Since quit

intention was the only intention-related measure available in the PATH questionnaire, the

84
relationships between the attitude constructs and norm construct with quit intention are unique to

this study.

The final structural model for Aim 1 showed that young adults’ more positive feelings

associated with e-cigarettes (i.e., experiential attitude) were not associated significantly with

intention to quit e-cigarettes. Lack of support for the hypothesis regarding experiential attitude

might have resulted from the small number of young adults in this study reporting that the device

helped them feel better when feeling down, think better, or made them feel less alone. The

hypothesis that more positive instrumental attitude (i.e., benefit of e-cigarettes coming in

pleasant flavors and being more acceptable to non-tobacco users) was associated with lower

levels of quit intention was consistent with the data. The negative association between perceived

norm (i.e., most people’s opinion on using tobacco) and quit intention was also supported in the

analysis. But, it was expected that the magnitudes of these two negative associations would be

larger than the resulting weak associations shown in Figure 7. Although perceived norm and

personal agency were constructs removed from the Revised Measurement Model (Figure 6), the

results from Aim 1 suggest that future interventions based on the IBM should consider

addressing young adults’ perceived benefit towards and norms related to e-cigarette use to lower

future levels of intention to use e-cigarettes.

Aim 2

Aim 2 sought to determine whether intention to quit using e-cigarettes was a significant

correlate of e-cigarette use among young adults. Support for the hypotheses informing this aim

was mixed. The primary hypothesis held with more negative e-cigarette quit intention associated

with higher levels of e-cigarette use. Consistent with expectations, young adults with more

positive feelings related to e-cigarette use (i.e., experiential attitude) and perceiving more

85
positive social norms around e-cigarette use reported less intention to quit using e-cigarettes.

However, contrary to theory and prior research, perceptions of e-cigarettes as more appealing

(more positive instrumental attitude) were associated with greater intention to quit e-cigarette

use. This positive association may have resulted from the quit intention measure which

accounted for intention to quit e-cigarettes and other tobacco products used concurrently. Young

adults with higher perceived benefits may have a lower intention to quit e-cigarettes, but a higher

intention to quit other tobacco products.

Aim 3

Aim 3 sought to determine the extent to which e-cigarette risk perception was a

significant correlate of e-cigarette use among young adults. The structural model of Aim 3

shown in Figure 9 demonstrated that the affect heuristic theory held. Specifically, higher

perceived benefits associated with e-cigarette use, such as pleasing flavors and the device being

acceptable to others, was positively associated with positive feelings (i.e., affect). As expected,

higher levels of positive feelings towards e-cigarettes were negatively associated with e-cigarette

risk perception. Lower levels of risk perception were associated with higher levels of e-cigarettes

use. But, it was expected that the magnitude of the negative association between risk perception

and the dependent variable e-cigarette use would be larger than the resulting weak negative

association shown in Figure 9. These Aim 3 results support future application of the affect

heuristic theory when designing communication and educational strategies to prevent e-cigarette

initiation among young adults.

Final Structural Model Combining Aims 1-3

The final overall structural model demonstrated stronger support for the affect heuristic

compared to the Integrated Behavior Model (IBM) in illustrating salient correlates of e-cigarette

86
use among young adults. These findings demonstrated that young adults’ positive affect

(experiential attitude) was negatively associated with e-cigarette risk perception. As

hypothesized, low e-cigarette risk perception was associated with a higher likelihood of using the

device among this age group. However, the path from risk perception to the dependent variable

was low in magnitude, possibly resulting from the addition of a new path in the final structural

model from risk perception to quit intention; with a moderately negative association.

These data did not fully support the expected hypotheses for the IBM. Young adults’

experiential attitude (i.e., feelings), instrumental attitude (i.e., benefits), and perceived norm were

each negatively associated with intention to quit e-cigarettes, but the attitude constructs had non-

significant paths to quit intention. The negative association between quit intention and the

dependent variable e-cigarette use was quite low in magnitude. This weak association suggests

that the single measure of quit intention from the PATH questionnaire was not robustly

correlated with using e-cigarettes among young adults.

Implications of Findings

Influence of Attitude and Norm

There are similarities between this study’s results and the work of Trumbo and Harper

who examined how college students perceived e-cigarettes (Trumbo & Harper, 2013). These

authors applied the Diffusion of Innovations Theory, and the Theory of Reasoned Action (TRA),

which is reflected in the IBM for the constructs attitude and perceived norm. They measured

behavioral intention to use e-cigarettes as “How likely do you think it is that you would use an e-

cigarette in the not-too distant future, say in the next six months?”; with a seven-point scale

ranging from absolutely not to absolutely yes. Their norms construct consisted of three paired

items for the statements “It would be acceptable to [referent groups] if I used e-cigarettes,” and

87
“When it comes to things like e-cigarettes it is important for me to follow the wishes of [referent

groups]. The referent groups included “my closest friends,” “most people I know,” and “closest

family members.” Their attitude construct comprised three items assessing whether respondents

agreed or disagreed on a five-point scale with the following statements: use of e-cigarettes

should be legal for adults, e-cigarettes are a big step forward, and belief that e-cigarettes are a

more modern way of using tobacco (Trumbo & Harper, 2013). Trumbo and Harper found

positive though non-significant associations between intention to use e-cigarettes regressed on

attitude, and between intention regressed on norms. They did not examine whether intention was

predictive of e-cigarette use among surveyed college students. Their findings provide evidence

for the association between attitude and norm with intention to use e-cigarettes among college

students; which was shown in this study but with a negative association between quit intention

and attitude and norm among young adults.

Risk Perception and E-Cigarette Use

While the IBM does not recognize an individual’s risk perception as having a direct

influence on one’s health behavior (Fishbein, 2000), this study demonstrated that e-cigarette risk

perception was directly associated with current e-cigarette use. The Aim 3 structural model

showed that the affect heuristic theory held with lower risk perception increasing the likelihood

of currently using e-cigarettes. Fishbein stated the following argument for classifying risk

perception as a distal factor rather than having a direct association with the behavior within the

IBM:

Those who do and do not perceive risk for a given illness may hold different attitudinal,
normative, or self-efficacy beliefs with respect to one behavior, but may hold similar
beliefs with respect to another. Thus, there is no necessary relation between these
external or background variables and any given behavior (pg 95) (Fishbein et al., 2002).

88
For this study, the three types of users reported similar beliefs of low e-cigarette risk perception.

Specifically, every day users believed that e-cigarettes might be less harmful to them than

cigarettes (93.3%) compared to some day users (78.7%) and non-users (85.7%). Every day users

believed that e-cigarettes were less harmful than smoking cigarettes (90.5%) compared to some

day users (70.3%) and non-users (55.7%). These bivariate results and the SEM analyses support

this study’s expanded Integrated Behavior Model (IBM) encompassing the affect heuristic

theory.

Multiple studies have found low e-cigarette risk perceptions as being a reason for

reported use among adult e-cigarette users (Adkison et al., 2013; Etter, 2010; Etter & Bullen,

2011; Foulds et al., 2011; Gallus et al., 2014; Goniewicz, Lingas, et al., 2013; Patel et al., 2016;

Pepper et al., 2015; Rutten et al., 2015; Zhu et al., 2013), and specifically young adult e-cigarette

users (Biener, Song, Sutfin, Spangler, & Wolfson, 2015; Camenga et al., 2015; Kong et al.,

2014; Sutfin, McCoy, Morrell, Hoeppner, & Wolfson, 2013). A recent study conducted by

Majeed et al. found that e-cigarette risk perception and risk for addiction increased among

surveyed adults between 2012 and 2015. Among 18-24 year olds surveyed in 2015, 45.5%

believed e-cigarette were less harmful than cigarettes, 31.3% believed they had the same level of

harm, and 2.6% reported e-cigarettes as more harmful than cigarettes (Majeed et al., 2016).

Overall, Majeed et al. found that young adults had the lowest e-cigarette risk perceptions

compared to adults ages 25 and older. Continued investigation of how young adults’ beliefs

change over time is warranted as more information becomes available on established risks

through empirical studies; which in turn, may affect young adults’ attitudes, norms, risk

perceptions, and use.

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Limitations

E-Cigarette Use Measurement

Limitations of this study include the challenge of measuring e-cigarette use. The

landscape of e-cigarettes has evolved from ‘cigalikes’ that were modeled to look like cigarettes

to vaporizers and devices where consumers can insert their own liquid cartridges and manipulate

the plume of vapor emitted. Unlike standardized cigarette smoking measures, there is no

established standard for e-cigarette use given the variance in modes of use (Agaku et al., 2014;

Biener & Hargraves, 2014; Brose et al., 2015). Additionally, e-cigarettes are referred to by users

and researchers under different names. For instance, some tobacco researchers classify e-

cigarettes as electronic nicotine delivery systems (ENDS), making the distinction that these

devices deliver nicotine while not burning tobacco (Cobb et al., 2015). Depending on the device

type, e-cigarette users may refer to the product as vape pens, hookah pens, e-cigs, e-juice, vapes,

juice, smoke juice, mods, or PVs (personal vaporizers) (DrugFreeAZKids.org, 2015; Richtel,

2014).

Through preliminary cognitive and field testing in Fall 2012, the Population Assessment

of Tobacco and Health (PATH) Study team discovered the value of including pictures of tobacco

products and descriptive introductory statements before each section of tobacco product use

questions to establish survey terminology with respondents (Hyland & Taylor, 2015). The

baseline 2013-2014 Wave 1 PATH adult survey instrument used in this dissertation described e-

cigarettes with the following descriptive statements:

E-cigarettes can be bought as one-time, disposable products, or can be bought as re-

usable kits with a cartridge. Some people refill their own cartridges with nicotine fluid,
sometimes called “e-juice” or “e-liquid.” Disposable e-cigarettes, e-cigarette cartridges,
and e-liquid come in many different flavors and nicotine concentrations (NIH, 2015).

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Subsequent waves of the PATH adult questionnaire revised this e-cigarette description and the

pictures to be more inclusive of mods, tanks, and personal vaporizers that are “refillable with

multiple components and parts” (Hyland & Taylor, 2015). Therefore, this dissertation may

underestimate use of e-cigarettes among young adults compared to use patterns in Wave 2

(administered Fall 2014) and Wave 3 (administered Fall 2015), since the Wave 1 baseline adult

questionnaire used in this dissertation did not encompass updated descriptions of the expanding

category of e-cigarettes.

Dual and Poly Tobacco Users

This study’s sample comprised 3,887 young adults who have ever used an e-cigarette and

now use e-cigarettes every day (n=160), some days (n=947), or not at all/non-users (2,780). The

three types of e-cigarette users examined in this study were not exclusive e-cigarette users. As

shown in Table 2, e-cigarette users reported also using other tobacco products asked in the

PATH questionnaire (i.e., cigarettes, cigars, cigarillos, filtered cigars, pipe tobacco, hookah,

snus, smokeless, or dissolvable tobacco). The use of other tobacco products with current e-

cigarette use reflects other studies with young adults reporting high prevalence rates for currently

using any tobacco product (SAMHSA, 2014), and for using multiple types of tobacco products

concurrently (Backinger et al., 2008; Rath et al., 2012; Richardson, Williams, Rath, Villanti, &

Vallone, 2014). While this study controlled for the covariate effects of other tobacco product use

on the dependent variable, further investigation of dual and poly tobacco e-cigarette use is

warranted.

Research has demonstrated the value in examining differences in tobacco risk profiles by

classifying current tobacco users by the total number of products used. For example, Ali et al.

found higher nicotine dependence was associated with youth poly tobacco use (Ali, Gray,

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Martinez, Curry, & Horn, 2016). Future research should consider how the IBM and affect

heuristic theory change depending on whether a current e-cigarette user is an exclusive user, dual

user with one other tobacco product, or a poly user with two or more tobacco products.

Frequency and Context of E-Cigarette Use

When considering e-cigarette user type by the number of other tobacco products

concurrently used, one must also consider the timeframe of use for each type of tobacco product

within the same specified end point (i.e., 30 day use, 1 week). For instance, some current young

adult e-cigarette users may use the product only on weekends socially but smoke every day.

Other e-cigarette users may use the device at times when they cannot smoke but smoke cigarettes

every day. Other young adult e-cigarette users may socially use e-cigarettes and hookah on

weekends. Whether attitude and perceived norm influence intention and e-cigarette use may

differ between these three types of e-cigarette user types. Fishbein made a similar distinction for

marijuana use stating:

The barriers to trying and/or the outcomes (or consequences) of trying marijuana may be
very different from those associated with using marijuana occasionally or regularly. Yet
it is these specific beliefs that must be addressed in an intervention if one wishes to
change intentions and behavior (pg 95) (Fishbein et al., 2002).

Additionally, differentiation among different types of young adult e-cigarette users could

elucidate whether certain types of users are more attitudinally driven or normatively.

Another critique of this study encompasses the wording of the PATH questionnaire

items. In their presentation of an integrative model of behavioral prediction, Fishbein and

Cappella stated the importance of defining a behavior with a specific action, target, context, and

time (Fishbein & Cappella, 2006). A comparison was made between getting (action) a

mammogram (target) at a Women’s Clinic (context) a month ago (time) versus getting a

mammogram at a University Hospital three years ago. The same comparison could be made for

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how e-cigarette use was defined in the PATH questionnaire. For instance, when a respondent

reported using e-cigarettes some days, the questionnaire did not define the number of days in the

past 30 days as the timeframe for some day use. Furthermore, none of the PATH questionnaire

items specified the context of e-cigarette use; which may vary between social use at a party or

regular use at home. While the context of use may be more effectively captured through

qualitative interviews, future research should consider innovative ways to account for context

and time when measuring e-cigarette use in questionnaires.

Quit Intention Measure

The measure of quit intention was another limitation for this study. The IBM defines the

construct of intention as the intention to perform the behavior; which has been shown to be

predictive of the likelihood of performing a behavior (Fishbein et al., 2002). For this study, the

only intention-related question in the PATH questionnaire was the single item of quit intention:

Overall, on a scale from 1 to 10 where 1 is not at all interested and 10 is extremely interested,

how interested are you in quitting [e-cigarettes]? It was assumed in this dissertation that people

who were interested in quitting had a future intention to quit e-cigarettes and a lower likelihood

of using e-cigarettes. A negative weak association between quit intention and e-cigarette use was

found in this study. This may have resulted from the fact that respondents were asked this

question for one or more tobacco products they reported using in the PATH questionnaire. All

respondents in this study were asked this question for interest in quitting e-cigarettes. The

inability to isolate answers for only those who answered the question for e-cigarettes was

reflected in the results.

Additionally, this study found a negative association between e-cigarette risk perception

and quit intention. This may have resulted from respondents having a low e-cigarette risk

93
perception and low intention to quit e-cigarettes, but who reported a higher intention to quit

another tobacco product(s) used concurrently with e-cigarettes. Future research should examine

the relationship between intention to use e-cigarettes and the behavior to see how their

association differs from this study’s examination of quit intention and e-cigarette use.

Same Survey Items for All Adults

Future research applying the IBM should consider conducting preliminary work to

understand the unique perceptions and attitudes of the population under investigation. Fishbein

and Yzer contend that “although investigators can sit in their offices and develop measures of

attitudes, perceived norms, and self-efficacy, they cannot tell what a particular population (or a

given person) believes about performing a given behavior” pg 168 (Fishbein & Yzer, 2003) . As

previously mentioned, through preliminary cognitive and field testing in Fall 2012, the PATH

Study team discovered the value of including pictures of tobacco products and descriptive

introductory statements before each section of tobacco product use questions to establish survey

terminology with respondents (Hyland & Taylor, 2015). This preliminary testing was effective

for a national assessment of tobacco use among all adults ages 18 years and older. But future

research applying the IBM should consider preliminary cognitive and field testing among young

adults ages 18 to 24 to understand the behavior of e-cigarette use from the perspective of this

specific target population.

Categorical Variables

The use of categorical variables as construct indicators was another limitation for this

study as SEM is typically conducted with continuous data. Among the 24 indicator variables

chosen to measure the latent constructs, only one item was continuous (i.e., quit intention). There

were 14 binary indicator variables with yes/no responses, one three-level ordinal variable, and

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nine five-level ordinal variables (listed in Appendix A). This study utilized robust weighted least

squares estimation (WLSMV) for EFA, CFA, and SEM and produced a final structural model

with acceptable fit. However, future research should use continuous indicator items to examine

whether constructs from the IBM and affect heuristic theory produce even more robust predictors

of e-cigarette use. Use of continuous items would facilitate the ability to calculate Cronbach’s

alpha coefficient to measure the internal consistency reliability for each latent construct (Cortina,

1993). Given that the majority of indicators were categorical, this calculation was not possible.

Continuous variables would also enable the creation of a more accurate variance/covariance

matrix for all indicators to examine if certain items were highly correlated with items in a

different constructs; which may indicate cross-loading. Since the majority of indicator variables

were binary and ordinal, tetrachoric and polychoric correlation matrices were produced instead

for binary and ordinal variables, respectively (UCLA, 2016). Efforts were also made to examine

cross-loading among the categorical indicators during EFA.

Cross-Sectional Design

The cross-sectional design was another limitation impacting the interpretation of the

results. The resulting structural equation pathways could only be interpreted as associations or

correlates between the latent constructs. Had this dissertation utilized longitudinal data it would

be possible to examine the bi-directionality of associations. For instance, young adult e-cigarette

users may have higher perceived benefits of e-cigarettes (i.e., instrumental attitude) as a result of

first using e-cigarettes. While this dissertation examined unidirectional pathways supported by

the Integrated Behavior Model and affect heuristic, longitudinal data could suggest how the

latent constructs influence either other linearly (i.e., as risk perceptions decrease linearly, the

likelihood of e-cigarette use increases linearly).

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 Additional potential limitations include missing data and recall bias among survey

respondents. Appropriate statistical techniques were used to account for potential missing data.

Given that latent constructs in the comprehensive measurement model (Figure 3) were comprised

of multiple items with different response categories, efforts were made to appropriately create

latent constructs with low measurement error. CFA was conducted when specifying the

measurement model to make sure the variables adequately measured the latent constructs before

assessing relationships between constructs in SEM.

Application for Future Research

Longitudinal Examination

As previously stated, the PATH study has a longitudinal design with three waves of data

collection from September 2013 through 2016. At the time of this study, only PATH Wave 1

baseline data was available for analysis. However, once Waves 2 and 3 of the Population

Assessment of Tobacco and Health (PATH) Study are available, researchers will be able to

conduct longitudinal analyses of transitions between using tobacco products and how factors

predicting use change overtime (NIH, 2015). Specifically, this dissertation’s conceptual model

can be applied to the subsequent waves of data to examine the degree to which individual-level

constructs from the IBM and affect heuristic remain as determinants of e-cigarette use. For

instance, this study found that low e-cigarette risk perception was associated with a higher

likelihood of e-cigarette use among young adults. Since Majeed et al. have found increasing e-

cigarette risk perceptions overtime (Majeed et al., 2016), the subsequent PATH waves may find

changes overtime in how e-cigarette risk perception influences e-cigarette use.

96
Multi-Level Ecological Examination

This dissertation examined individual-level factors from the IBM and affect heuristic to

explore key determinants of e-cigarette use among young adults in the PATH Study Wave 1

baseline adult dataset. The relationships between these individual-level factors and e-cigarette

use are reflected in the overall PATH study conceptual model depicted in Figure 11 below. The

PATH study conceptual model is based on the Host, Agent, Vector, Environment (HAVE) model

which illustrates how these factors interact to influence tobacco use behavior, harmful exposures,

and health outcomes (Hyland et al., 2016). This dissertation examined the Host factors (i.e.,

attitude, perceived risk, norm) within the PATH study conceptual model and their relationship

with current e-cigarette use behavior every day, some days, and not at all. As shown in Figure

11, future research can expand upon this dissertation by examining how agent factors of

advertising and product design influence young adults’ attitudes

Figure 11. PATH Study Conceptual Model (simplified by author for dissertation)

97
towards e-cigarettes, that in turn influence their current use of the device. Future research could

also examine how environmental factors such as health warning labels on tobacco products that

are regulated by the FDA influence young adults’ e-cigarette risk perceptions and their use of the

device (Hyland et al., 2016).

The impact of advertising and health warning labels on young adults’ attitudes and risk

perceptions illustrates how external influences can shape individual-level beliefs that in turn

affect the likelihood of using e-cigarettes. Behavioral scientists understand that even when

individuals hold perceptions indicative of healthy (or risk averse) behaviors and have

interpersonal connections that are supportive of healthy behaviors—they may still live and exist

in an environment that supports risk. Therefore, this dissertation could be expanded beyond

individual-level determinants and include examination of multi-level ecological factors at the

interpersonal level (i.e., interactions with family, friends and social networks that impact health

behaviors), community-level, organizational level, and policy level. Collectively, these

concentric levels of influence impact health behavior and are effectively represented in the

Ecological Model of Health Behavior (McLeroy, Bibeau, Steckler, & Glanz, 1988).

Conclusion

In his 2016 U.S. Surgeon General Report, Dr. Vivek Murthy declared the need for a

research agenda in which behavioral, communications, and educational studies determine “what

kinds of tobacco control communication strategies and channels are most effective” in

preventing e-cigarette use among youth and young adults (pg 7) (USDHHS, 2016a). Of concern

to public health experts is the threat of e-cigarettes renormalizing smoking and compromising

progress in reducing cigarette smoking among youth and young adults. This dissertation aimed to

address this research gap among young adults through examination of the Integrated Behavior

98
Model (IBM) and affect heuristic theory by assessing how individuals’ attitudes, beliefs, and

perceptions of e-cigarettes were associated with current use of the device among this age group.

Higher positive feelings, perceived benefits, and normative beliefs of e-cigarettes were

associated with lower levels of intention to quit e-cigarettes. Low quit intention was then

associated with high levels of currently using e-cigarettes. More positive feelings were

associated with lower risk perceptions resulting in a higher likelihood of using the device. These

findings suggest that future communication, educational, and policy strategies to prevent e-

cigarette use among young adults should highlight the health risk of e-cigarettes to address the

high perceived benefits/positive attitudes and low risk perception reported by young adults in

this study. Since young adulthood is a period in which health behaviors are established (Arnett,

2000), continued research is warranted to understand how young adults’ e-cigarette attitudes,

norms, and risk perception change overtime to inform tailored intervention design to prevent use.

99
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 Appendix A: List of Survey Items for Primary Outcome and Latent Constructs

Answer Options
PATH
Construct Question (bold indicates responses of
Q#
interest)
OUTCOME: E-CIGARETTE USE
[Asked of respondents who say ‘yes’ to
having ever used an e-cigarette even one or
two times] 1 Every day
2 Some days
NowUseEcig AE1003 Do you now use e-cigarettes . . . 3 Not at all (but yes, ever used)
ATTITUDE
Experiential Attitude (Positive Affect)
Using an e-cigarette feels like smoking a
FeelsLikeCig AE1066 regular cigarette. Yes, No, DK, refused
1 (not at all true of me), 2, 3, 4,
AN0070 E-cigarettes help me feel better if I’ve been 5 (extremely true of me), DK,
Feel better E feeling down. refused
1 (not at all true of me), 2, 3, 4,
AN0075 5 (extremely true of me), DK,
Think better E E-cigarettes help me think better. refused
1 (not at all true of me), 2, 3, 4,
AN0080 5 (extremely true of me), DK,
Alone E I feel alone without my e-cigarette. refused
Instrumental Attitude (Perceived Benefit)
Flavors AE1063 E-cigarettes come in flavors that I like. Yes, No, DK, refused
Smell AE1065 E-cigarettes don’t smell. Yes, No, DK, refused
Using e-cigarettes helps people to quit
HelpQuit AE1064 smoking cigarettes. Yes, No, DK, refused
Socialize AE1069 I like socializing while using an e-cigarette. Yes, No, DK, refused
Did you use e-cigarettes as an alternative to
AltToQuit AE1081 quitting tobacco altogether? Yes, No, DK, refused
PERCEIVED NORM
Injunctive Norm
E-cigarettes are more acceptable to non- Yes, No, DK, refused
Acceptance AE1067 tobacco users. [injunctive norm]
Very positive, Positive, Neither
How would you describe most people’s positive nor negative, Very
MostPlpOpinion AX0007 opinion on using tobacco? negative, DK, refused

116
Subjective Norm
Thinking about the people who are important to Very positive, Positive, Neither
you, how would you describe their opinion on positive nor negative, Very
ImpPlpOpinion AX0071 using tobacco? negative, DK, refused
People who are important to me use e- Yes, No, DK, refused
ImpPlpUseEcig AE1068 cigarettes. [descriptive norm]
Descriptive Norm
People in the media or other public figures use
CelebrityUse AE1061 e-cigarettes. Yes, No, DK, refused
1 (not at all true of me), 2, 3, 4,
Most of the people I spend time with are 5 (extremely true of me), DK,
PeopleUseTob AN0255 tobacco users. refused
PERSONAL AGENCY
Perceived Behavioral Control
Affordable AE1060 I use e-cigarettes because they are affordable. Yes, No, DK refused
I can use e-cigarettes at times when or in places
Allowed AE1085 where smoking cigarettes isn't allowed. Yes, No, DK refused
Self-Efficacy
1 (not at all true of me), 2, 3, 4,
5 (extremely true of me), DK,
Hard1 AN085E I find it really hard to not use e-cigarettes. refused
1 (not at all true of me), 2, 3, 4,
AN0090 I would find it hard to not use e-cigarettes for 5 (extremely true of me), DK,
Hard2 E another week. refused
E-CIGARETTE QUIT INTENTION

Overall, on a scale from 1 to 10 where 1 is not

at all interested and 10 is extremely interested, 1 (not at all interested), 2, 3, 4,
how interested are you in quitting [e- 5, 6, 7, 8, 9, 10 (extremely
Intention AN0810 cigarettes]? Please enter a number from 1 to 10. interested), DK, refused
E-CIGARETTE RISK PERCEPTION
They might be less harmful to me than
MeHarm AE1062 cigarettes. Yes, No, DK, refused
They might be less harmful to people around
PlpHarm AE1075 me than cigarettes. Yes, No, DK, refused
Is using e-cigarettes less harmful, about the
same, or more harmful than smoking Less harmful, About the same,
Harm-ecig AE1099 cigarettes? More harmful, DK, refused
Do you believe that using an e-cigarette is
Vulnerable AN0110 causing a health problem or making it worse? Yes, No, DK, refused

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 Appendix B: Univariate and Bivariate Analyses Results for Each Construct

Table 1B. Univariate Analysis of Indicator Variables for Experiential and Instrumental Attitude Sub-
Constructs of the Latent Construct Attitude, PATH 2013
ATTITUDE Obs Mean Proportion Prop. Standard 95% Confidence
CONSTRUCT Std. Dev. Error Interval
EXPERIENTIAL ATTITUDE
FeelsLikeCiga 1,261 0.343 n/a 0.499 0.013 0.317 0.370
Yesb 433 n/a 0.336 n/a 0.013 0.310 0.363
No 828 n/a 0.664 n/a 0.013 0.637 0.690
FeelBetterb 628 1.637 n/a n/a 0.044 1.550 1.725
not at all true 442 n/a 0.698 n/a 0.018 0.663 0.733
not true 76 n/a 0.122 n/a 0.013 0.096 0.148
neutral 46 n/a 0.071 n/a 0.012 0.046 0.095
true 36 n/a 0.065 n/a 0.010 0.044 0.086
extremely true 28 n/a 0.045 n/a 0.009 0.027 0.062
ThinkBetterb 628 1.470 n/a n/a 0.040 1.391 1.548
not at all true 480 n/a 0.755 n/a 0.019 0.716 0.793
not true 58 n/a 0.105 n/a 0.015 0.076 0.134
neutral 54 n/a 0.081 n/a 0.011 0.059 0.102
true 21 n/a 0.035 n/a 0.008 0.020 0.050
extremely true 15 n/a 0.025 n/a 0.007 0.011 0.038
Aloneb 630 1.217 n/a n/a 0.023 1.170 1.263
not at all true 553 n/a 0.880 n/a 0.012 0.856 0.903
not true 45 n/a 0.071 n/a 0.011 0.048 0.094
neutral 10 n/a 0.014 n/a 0.004 0.006 0.022
true 14 n/a 0.023 n/a 0.006 0.010 0.035
extremely true 8 n/a 0.013 n/a 0.004 0.005 0.020
INSTRUMENTAL ATTITUDE
Flavor a 1260 0.785 n/a 0.492 0.012 0.761 0.807
Yesb 989 n/a 0.778 n/a 0.012 0.754 0.801
No 271 n/a 0.222 n/a 0.012 0.199 0.246
Smella 1,261 0.743 n/a 0.496 0.012 0.718 0.767
Yesb 937 n/a 0.746 n/a 0.013 0.720 0.772
No 324 n/a 0.254 n/a 0.013 0.228 0.280
a
HelpQuit 1,257 0.643 n/a 0.500 0.014 0.616 0.669
Yesb 808 n/a 0.642 n/a 0.014 0.614 0.670
No 449 n/a 0.358 n/a 0.014 0.330 0.386
Socializea 1,258 0.450 n/a 0.500 0.014 0.422 0.478
Yesb 566 n/a 0.450 n/a 0.015 0.420 0.480
No 692 n/a 0.550 n/a 0.015 0.520 0.580
a
AltToQuit 882 0.498 n/a 0.500 0.017 0.464 0.531
Yesb 439 n/a 0.509 n/a 0.019 0.472 0.547
No 443 n/a 0.491 n/a 0.019 0.453 0.528
a
Unweighted data reported for overall binary item mean, proportional standard deviation and binomial exact 95% confidence
interval. bBRR survey weights applied to binary response option data and all ordinal variable data to ensure accurate proportions,
standard errors, and 95% confidence intervals.

118
Table 2B. Attitudes of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
Now Use E-Cigarettes Every day Some days Not at all, but yes, have ever
(n=160) (n=947) used e-cigarettes (n=2,780)
EXPERIENTIAL ATTITUDE
(AFFECT)
E-cigarettes help me feel better if I’ve n=126 n=365 n=137
been feeling down a,***
not at all true 38.5% (54) 72.6% (261) 92.0% (127)
not true 25.9% (28) 10.7% (44) 3.1% (4)
neutral 11.0% (16) 7.7% (28) 1.6% (2)
true 12.1% (14) 6.3% (20) 1.6% (2)
extremely true 12.4% (14) 2.7% (12) 1.8% (2)
E-cigarettes help me think better a,*** n=127 n=364 n=137
not at all true 47.7% (65) 77.5% (283) 96.6% (132)
not true 24.8% (26) 9.0% (31) 0.7% (1)
neutral 11.3% (16) 9.3% (35) 1.9% (3)
true 9.5% (12) 2.6% (9) 0.0% (0)
extremely true 6.7% (8) 1.5% (6) 0.8% (1)
I would feel alone without my e- n=128 n=365 n=137
cigarettes a, ***
not at all true 71.1% (91) 90.4% (328) 97.9% (134)
not true 14.1% (18) 6.7% (25) 1.4% (2)
neutral 2.4% (4) 1.3% (5) 0.7% (1)
true 6.7% (8) 1.5% (6) 0.0% (0)
extremely true 5.7% (7) 0.1% (1) 0.0% (0)
E-cigarettes feels like cigarette*** n=160 n=943 n=158
yes 51.4% (84) 31.3% (302) 29.2% (47)
no 48.6% (76) 68.7% (641) 70.8% (111)
INSTRUMENTAL ATTITUDE
(BENEFIT)
E-cigarettes come in flavors I like n=160 n=942 n=158
yes 80.3% (128) 77.2% (733) 78.7% (128)
no 19.7% (32) 22.8% (209) 21.3% (30)
E-cigarettes don’t smell n=160 n=943 n=158
yes 80.0% (124) 73.3% (692) 76.2% (121)
no 20.0% (36) 26.7% (251) 23.8% (37)
E-cigarettes help people to quit smoking n=160 n=939 n=158
cigarettes***
yes 83.0% (132) 60.7% (571) 64.9% (105)
no 17.0% (28) 39.3% (368) 35.1% (53)
Like socializing while using n=160 n=940 n=158
e-cigarettes **
yes 58.8%(91) 42.3% (400) 46.3% (75)
no 41.2% (69) 57.7% (540) 53.7% (83)
Used e-cigarettes as alternative to n=128 n=636 n=118
quitting tobacco***
yes 80.4% (101) 40.5% (250) 74.0% (88)
no 19.6% (27) 59.5% (386) 26.0% (30)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

119
Table 3B
Univariate Analysis of Indicator Variables for Injunctive, Subjective, and Descriptive Norm Sub-
Constructs of Latent Construct Perceived Norm, PATH 2013
PERCEIVED Obs Mean Proportion Prop. Standard 95% Confidence Interval
NORM Std. Dev. Error
CONSTRUCT
INJUNCTIVE NORM
Acceptable a 1,261 0.695 n/a 0.498 0.013 0.668 0.720
Yes b 876 n/a 0.698 n/a 0.014 0.669 0.726
No 385 n/a 0.302 n/a 0.014 0.274 0.331
MostPlpOpin b 3,879 2.214 n/a n/a 0.015 2.184 2.244
very negative 700 n/a 0.183 n/a 0.007 0.169 0.196
negative 1,816 n/a 0.486 n/a 0.010 0.466 0.507
neither 1,139
positive nor n/a 0.278 n/a 0.008 0.262 0.294
negative
positive 167 n/a 0.040 n/a 0.003 0.033 0.047
very positive 57 n/a 0.013 n/a 0.002 0.008 0.017
SUBJECTIVE NORM
ImpPlpUseEcig a 1,261 0.223 n/a 0.493 0.012 0.200 0.247
Yes b 281 n/a 0.222 n/a 0.012 0.198 0.246
No 980 n/a 0.778 n/a 0.012 0.754 0.802
ImpPlpOpin b 3,873 2.261 n/a n/a 0.017 2.228 2.295
very negative 995 n/a 0.269 n/a 0.007 0.256 0.283
negative 1,180 n/a 0.313 n/a 0.009 0.294 0.331
neither 1,359
positive nor n/a 0.337 n/a 0.008 0.322 0.352
negative
positive 206 n/a 0.050 n/a 0.004 0.042 0.058
very positive 133 n/a 0.031 n/a 0.003 0.025 0.038
DESCRIPTIVE
NORM
CelebrityUse a 1,257 0.185 n/a 0.487 0.011 0.164 0.208
Yes b 233 n/a 0.179 n/a 0.011 0.157 0.200
No 1024 n/a 0.821 n/a 0.011 0.800 0.843
b
PeopleUseTob 3,329 3.213 n/a n/a 0.029 3.155 3.270
not at all true 611 n/a 0.189 n/a 0.007 0.175 0.203
not true 418 n/a 0.127 n/a 0.007 0.113 0.140
neutral 739 n/a 0.227 n/a 0.008 0.211 0.244
true 652 n/a 0.198 n/a 0.007 0.184 0.212
extremely true 909 n/a 0.259 n/a 0.010 0.240 0.278
a
Unweighted data reported for overall binary item mean, proportional standard deviation and binomial exact 95% confidence
interval. b BRR survey weights applied to binary response option data and all ordinal variable data to ensure accurate proportions,
standard errors, and 95% confidence intervals.

120
Table 4B
Perceived Norm of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
Now Use E-Cigarettes Every day Some days Not at all, but
(n=160) (n=947) yes, have ever
used e-cigarettes
(n=2,780)
INJUNCTIVE NORM
E--cigarettes are more acceptable to non-tobacco n=160 n=943 n=158
users
yes 75.3% (120) 69.2% (648) 67.3% (108)
no 24.7% (40) 30.8% (295) 32.7% (50)
How would you describe most people’s opinion n=160 n=946 n=2,773
on using tobacco? a
very negative 19.2% (29) 18.6% (178) 18.1% (493)
negative 45.6% (74) 46.0% (422) 49.7% (1,320)
neither positive nor negative 28.2% (45) 29.5% (287) 27.2% (807)
positive 5.4% (9) 4.5% (43) 3.8% (115)
very positive 1.7% (3) 1.3% (16) 1.2% (38)
SUBJECTIVE NORM
People who are important to me use e-cigarettes n=160 n=943 n=158
yes 21.3% (35) 22.4% (210) 22.0% (36)
no 78.7% (125) 77.6% (733) 78.0% (122)
Thinking about people who are important to you, n=160 n=945 n=2,768
how would you describe their opinion on using
tobacco?*** , a
very negative 28.9% (46) 21.9% (199) 28.4% (750)
negative 30.0% (49) 30.4% (284) 31.6% (847)
neither positive nor negative 29.9% (46) 37.6% (360) 32.6% (953)
positive 5.3% (9) 7.4% (75) 4.2% (122)
very positive 5.9% (10) 2.7% (27) 3.1% (96)
DESCRIPTIVE NORM
People in the media/public figures use e-cigarettes n=160 n=940 n=157
yes 15.6% (25) 18.7% (183) 15.6% (25)
no 84.4% (135) 81.3% (757) 84.4% (132)
Most of the people I spend time with are tobacco n=160 n=945 n=2,224
users*, a
not at all true 11.2% (22) 16.0% (149) 20.6% (440)
not true 11.1% (18) 12.2% (113) 13.0% (287)
neutral 21.9% (36) 24.9% (223) 21.9% (480)
true 22.2% (34) 20.2% (192) 19.5% (426)
extremely true 33.6% (50) 26.8% (268) 64.9% (591)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

121
Table 5B
Univariate Analysis of Indicator Variables for Perceived Behavioral Control and Self-Efficacy for Sub-
Constructs of Latent Construct Personal Agency, PATH 2013
PERSONAL Obs Mean Proportion Prop. Standard 95% Confidence Interval
AGENCY Std. Dev. Error
CONSTRUCT
PERCEIVED BEHAVIORAL
CONTROL
Affordable a 1,260 0.544 n/a 0.500 0.014 0.516 0.571
Yes b 685 n/a 0.539 n/a 0.016 0.506 0.571
No 575 n/a 0.461 n/a 0.016 0.429 0.494
Allowed a 1,259 0.807 n/a 0.489 0.011 0.784 0.828
b
Yes 1,016 n/a 0.807 n/a 0.012 0.783 0.832
No 243 n/a 0.193 n/a 0.012 0.168 0.217
SELF-
EFFICACY
Hard1 b 628 1.426 n/a n/a 0.044 1.338 1.514
not at all true 504 n/a 0.789 n/a 0.018 0.752 0.825
not true 53 n/a 0.089 n/a 0.013 0.063 0.116
neutral 35 n/a 0.058 n/a 0.010 0.038 0.079
true 19 n/a 0.035 n/a 0.009 0.017 0.053
extremely true 17 n/a 0.029 n/a 0.008 0.013 0.044
Hard2 b 629 1.428 n/a n/a 0.044 1.341 1.515
not at all true 510 n/a 0.803 n/a 0.016 0.771 0.836
not true 47 n/a 0.082 n/a 0.012 0.058 0.106
neutral 25 n/a 0.039 n/a 0.007 0.025 0.053
true 21 n/a 0.036 n/a 0.010 0.017 0.056
extremely true 26 n/a 0.040 n/a 0.007 0.026 0.054
a
Unweighted data reported for overall binary item mean, proportional standard deviation and binomial exact 95% confidence
interval. b BRR survey weights applied to binary response option data and all ordinal variable data to ensure accurate proportions,
standard errors, and 95% confidence intervals.

122
Table 6B
Personal Agency of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
Now Use E-Cigarettes Every day Some days Not at all, but
(n=160) (n=947) yes, have ever
used e-cigarettes
(n=2,780)
PERCEIVED BEHAVIORAL CONTROL
Use e-cigarettes because they are affordable*** n=160 n=942 n=158
yes 80.8% (128) 48.4% (465) 58.2% (92)
no 19.2% (32) 51.6% (477) 41.8% (66)
Can use e-cigarettes at times when or in places n=160 n=941 n=158
where smoking cigarettes isn’t allowed**
yes 89.4% (141) 78.4% (739) 85.6% (136)
no 10.6% (19) 21.6% (202) 14.4% (22)
SELF-EFFICACY
I find it really hard to not use e-cigarettes *** , a n=127 n=364 n=137
not at all true 45.8% (62) 84.3% (310) 96.2% (132)
not true 13.1% (18) 10.2% (33) 1.4% (2)
neutral 18.8% (23) 2.5% (9) 2.4% (3)
true 11.0% (11) 2.1% (8) 0.0% (0)
extremely true 11.3% (13) 0.9% (4) 0.0% (0)
I would find it hard to not use e-cigarettes for a n=127 n=365 n=137
week*** , a
not at all true 43.9% (57) 87.1% (320) 97.0% (133)
not true 15.7% (19) 7.8% (25) 1.9% (3)
neutral 11.9% (16) 2.4% (9) 0.0% (0)
true 12.2% (14) 1.5% (6) 1.0% (1)
extremely true 16.2% (21) 1.1% (5) 0.0% (0)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

123
Table 7B
Univariate Analysis of Indicator Variables for Latent Construct E-Cigarette Risk Perception, PATH 2013
E- Obs Mean Proportion Prop. Standard 95% Confidence Interval
CIGARETTE Std. Dev. Error
RISK
PERCEPTION
CONSTRUCT
MeHarm a 1,261 0.185 n/a 0.488 0.012 0.161 0.210
Yes b 1,026 n/a 0.815 n/a 0.012 0.790 0.839
No 235 n/a 0.185 n/a 0.012 0.161 0.210
PlpHarm a 1,260 0.185 n/a 0.486 0.013 0.160 0.210
Yes b 1,033 n/a 0.815 n/a 0.013 0.790 0.840
No 227 n/a 0.185 n/a 0.013 0.160 0.210
HarmEcig b 3,854 1.435 n/a n/a 0.012 1.412 1.458
less harmful 2,303 n/a 0.606 n/a 0.011 0.585 0.627
about the same 1,384 n/a 0.353 n/a 0.010 0.333 0.374
more harmful 167 n/a 0.041 n/a 0.003 0.034 0.048
Vulnerable a 3,250 0.583 n/a 0.500 0.009 0.566 0.600
Yes b 1,894 n/a 0.580 n/a 0.010 0.559 0.600
No 1,356 n/a 0.420 n/a 0.010 0.400 0.441
a
Unweighted data reported for overall binary item mean, proportional standard deviation and binomial exact 95% confidence
interval. b BRR survey weights applied to binary response option data and all ordinal variable data to ensure accurate proportions,
standard errors, and 95% confidence intervals.

124
Table 8B
Risk Perception of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
Now Use E-Cigarettes Every day Some days Not at all, but
(n=160) (n=947) yes, have ever
used e-cigarettes
(n=2,780)
E-CIG RISK PERCEPTION
E-cigarettes might be less harmful to me than n=160 n=943 n=158
cigarettes***
yes 93.3% (148) 78.7% (741) 85.7% (137)
no 6.7% (12) 21.3% (202) 14.3% (21)
E-cigarettes might be less harmful to people n=160 n=942 n=158
around me than cigarettes
yes 89.0% (144) 80.2% (759) 81.4% (130)
no 11.0% (16) 19.8% (183) 18.6% (28)
Is using e-cigarettes less harmful, about the same, n=160 n=939 n=2,755
or more harmful than smoking cigarettes? *** , a
less harmful 90.5% (142) 70.3% (658) 55.7% (1,502)
about the same 8.6% (16) 26.8% (256) 39.6% (1,112)
more harmful 0.89% (2) 2.9% (25) 4.7% (140)
Do you believe that using an e-cigarette is causing n=157 n=885 n=2,208
a health problem/making it worse?
yes 59.7% (97) 59.2% (522) 57.4% (1,275)
no 40.3% (60) 40.8% (363) 42.6% (933)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

125
Table 9B
Univariate Analysis of Manifest Variable Quit Intention, PATH 2013
E- Obs Mean Proportion Prop. Standard 95% Confidence Interval
CIGARETTE Std. Dev. Error
QUIT
INTENTION
Quit Intention a 1,850 6.318 n/a n/a 0.074 6.172 6.464
1 (Not at All 154
n/a 0.085 n/a 0.007 0.070 0.099
Interested)
2 88 n/a 0.047 n/a 0.005 0.038 0.057
3 124 n/a 0.067 n/a 0.006 0.056 0.079
4 123 n/a 0.064 n/a 0.006 0.052 0.077
5 276 n/a 0.145 n/a 0.009 0.128 0.162
6 153 n/a 0.084 n/a 0.006 0.072 0.096
7 173 n/a 0.097 n/a 0.007 0.082 0.111
8 238 n/a 0.132 n/a 0.009 0.114 0.151
9 116 n/a 0.065 n/a 0.006 0.052 0.078
10 (Extremely 405
n/a 0.213 n/a 0.011 0.192 0.234
Interested)
a
BRR survey weights applied to variable to ensure accurate proportions, standard errors, and 95% confidence intervals.

Table 10B
E-Cigarette Quit Intention of Young Adults Aged 18-24 Univariate Results, PATH 2013
E- Obs Mean Std. Dev. Variance Skewness Kurtosis
CIGARETTE
QUIT
INTENTION
Intention a 1,850 6.325 2.904 8.435 -0.301 1.947
a
Unweighted data reported for multivariate normality tests of skewness and kurtosis

126
Table 11B
E-Cigarette Quit Intention of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
Now Use E-Cigarettes Every day Some days Not at all, but
(n=160) (n=947) yes, have ever
used e-cigarettes
(n=2,780)
E-CIG QUIT INTENTION
How interested are you in quitting [e-cigarettes]? a n=125 n=552 n=1,173
1 (not at all interested) 10.5% (12) 8.6% (46) 8.2% (96)
2 5.5% (8) 4.1% (24) 5.0% (56)
3 3.8% (6) 6.6% (35) 7.1% (83)
4 4.4% (6) 7.4% (41) 6.2% (76)
5 10.9% (14) 15.8% (90) 14.3% (172)
6 8.6% (11) 8.7% (48) 8.3% (94)
7 4.2% (4) 11.5% (61) 9.4% (108)
8 10.9% (12) 13.1% (69) 13.5% (157)
9 7.8% (10) 5.6% (32) 6.7% (74)
10 (extremely interested) 33.5% (42) 18.6% (106) 21.2% (257)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

127
 Appendix C: Post Hoc Analyses

Table 1C
Experiential Attitude of Young Adults Aged 18-24 by Gender, PATH 2013 (n=3,887)
Gender Male Female
(n= 2,258) (n= 1,629)
EXPERIENTIAL ATTITUDE
(AFFECT)
E-cigarettes help me feel better if I’ve n=402 n=226
been feeling down a
not at all true 68.5% (278) 72.1% (164)
not true 13.3% (53) 10.0% (23)
neutral 7.2% (29) 6.8% (17)
true 6.3% (24) 6.9% (12)
extremely true 4.6% (18) 4.2% (10)
E-cigarettes help me think better a n=402 n=226
not at all true 73.4% (299) 79.2% (181)
not true 13.2% (45) 5.5% (13)
neutral 8.1% (36) 8.0% (18)
true 3.0% (13) 4.4% (8)
extremely true 2.2% (9) 2.9% (6)
I would feel alone without my e- n=403 n=227
cigarettes a
not at all true 88.3% (353) 87.4% (200)
not true 6.0% (27) 9.1% (18)
neutral 1.5% (6) 1.3% (4)
true 3.0% (12) 0.8% (2)
extremely true 1.2% (5) 1.4% (3)
I find it really hard to not use e-cigarettes n=402 n=226
a

not at all true 78.9% (323) 78.7% (181)

not true 8.3% (32) 10.2% (21)
neutral 5.7% (22) 6.1% (13)
true 3.4% (12) 3.6% (7)
extremely true 3.7% (13) 1.4% (4)
I would find it hard to not use e- n=403 n=226
cigarettes for a week a
not at all true 51.4% (323) 29.7% (187)
not true 4.9% (31) 2.5% (16)
neutral 2.5% (16) 1.4% (9)
true 2.5% (16) 0.8% (5)
extremely true 2.7% (17) 1.4% (9)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

128
Table 2C
Instrumental Attitude and Norm of Young Adults Aged 18-24 by Gender, PATH 2013 (n=3,887)
Gender Male Female
(n= 2,258) (n= 1,629)
INSTRUMENTAL ATTITUDE
(BENEFIT)
E-cigarettes come in flavors I like n=790 n=470
yes 76.3% (607) 80.4% (382)
no 23.7% (183) 19.6% (88)
Like socializing while using e- cigarettes n=788 n=470
yes 45.8%(361) 43.4% (205)
no 54.2% (427) 56.6% (265)
E-cigarettes are more acceptable to non- n=791 n=470
tobacco users
yes 70.7% (558) 68.0% (318)
no 29.3% (233) 32.0% (152)
People who are important to me use e- n=791 n=470
cigarettes
yes 21.2% (167) 24.1% (114)
no 78.8% (624) 75.9% (356)
NORM
How would you describe most people’s n=2,253 n=1,626
opinion on using tobacco? a
very negative 17.4% (391) 19.6% (309)
negative 49.3% (1,081) 47.6% (735)
neither positive nor negative 28.0% (651) 27.5% (488)
positive 3.8% (92) 4.3% (75)
very positive 1.4% (38) 1.0% (19)
Thinking about people who are important n=2,247 n=1,626
to you, how would you describe their
opinion on using tobacco?** , a
very negative 29.8% (540) 25.0% (455)
negative 28.0% (741) 33.5% (439)
neither positive nor negative 34.3% (765) 33.3 % (594)
positive 4.5% (126) 5.3% (80)
very positive 3.4% (75) 2.9% (58)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

129
Table 3C
Risk Perception of Young Adults Aged 18-24 by Gender, PATH 2013 (n=3,887)
Gender Male Female
(n= 2,258) (n= 1,629)
E-CIG RISK PERCEPTION
E-cigarettes might be less harmful to me n=791 n=470
than cigarettes
yes 81.9% (644) 80.8% (382)
no 18.1% (147) 19.2% (88)
E-cigarettes might be less harmful to n=790 n=470
people around me than cigarettes
yes 82.0% (650) 80.6% (383)
no 18.0% (140) 19.4% (87)
Is using e-cigarettes less harmful, about n=2,233 n=1,621
the same, or more harmful than smoking
cigarettes? *** , a
less harmful 63.3% (1,388) 56.6% (915)
about the same 32.7% (751) 39.2% (633)
more harmful 4.1% (94) 4.2% (73)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

130
Table 4C
Experiential Attitude of Young Adults Aged 18-24 by Race/Ethnicity, PATH 2013 (n=3,887)
Race/Ethnicity White NH Black NH Hispanic Other race
(n=2,248) (n=388) (n=699) (n=552)
EXPERIENTIAL ATTITUDE
(AFFECT)
E-cigarettes help me feel better if I’ve n=391 n=52 n=113 n=72
been feeling down a
not at all true 67.0% (266) 75.0% (37) 74.9% (83) 75.7% (56)
not true 12.0% (48) 7.8% (4) 16.3% (18) 10.4% (6)
neutral 8.3% (33) 7.2% (5) 3.0% (4) 5.2% (4)
true 7.2% (24) 4.4% (2) 4.5% (6) 6.4% (4)
extremely true 5.5% (20) 5.6% (4) 1.3% (2) 2.3% (2)
E-cigarettes help me think better a n=390 n=52 n=113 n=73
not at all true 73.3% (291) 79.7% (40) 80.9% (91) 77.8% (58)
not true 10.8% (37) 10.3% (5) 10.3% (12) 9.3% (4)
neutral 8.6% (34) 9.0% (6) 7.0% (8) 5.9% (6)
true 4.5% (17) 0.0% (0) 1.8% (2) 1.8% (2)
extremely true 2.7% (11) 1.0% (1) 0.0% (0) 5.2% (3)
I would feel alone without my e-cigarettes n=392 n=52 n=113 n=73
a

not at all true 86.8% (341) 86.7% (43) 91.3% (102) 91.6% (67)
not true 8.1% (31) 5.6% (4) 6.1% (8) 3.9% (2)
neutral 1.4% (6) 3.2% (2) 0.0% (0) 2.0% (2)
true 2.6% (10) 1.7% (1) 1.7% (2) 1.2% (1)
extremely true 1.1% (4) 2.8% (2) 1.0% (1) 1.3% (1)
I find it really hard to not use e-cigarettesa n=390 n=52 n=113 n=73
not at all true 76.1% (301) 81.6% (41) 86.9% (98) 82.5% (64)
not true 9.4% (35) 8.4% (5) 7.6% (9) 8.6% (4)
neutral 7.1% (27) 7.3% (4) 3.1% (3) 1.0% (1)
true 4.6% (15) 0.0% (0) 1.5% (2) 2.2% (2)
extremely true 2.9% (12) 2.7% (2) 1.0% (1) 5.8% (2)
I would find it hard to not use e-cigarettes n=391 n=52 n=113 n=73
for a week a
not at all true 78.5% (309) 82.6% (41) 84.2% (96) 84.1% (64)
not true 7.7% (29) 5.5% (4) 9.5% (9) 11.4% (5)
neutral 4.7% (18) 4.4% (3) 2.0% (3) 1.1% (1)
true 4.0% (14) 4.8% (2) 3.4% (4) 1.2% (1)
extremely true 5.1% (21) 2.7% (2) 1.0% (1) 2.3% (2)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

131
Table 5C
Instrumental Attitude and Norm of Young Adults Aged 18-24 by Race/Ethnicity, PATH 2013 (n=3,887)
Race/Ethnicity White NH Black NH Hispanic Other race
(n=2,248) (n=388) (n=699) (n=552)
INSTRUMENTAL ATTITUDE
(BENEFIT)
E-cigarettes come in flavors I like n=765 n=110 n=220 n=165
yes 78.0% (597) 73.3% (82) 80.5% (181) 76.2% (129)
no 77.0% (168) 26.7% (28) 19.5% (39) 23.8% (36)
Like socializing while using e- cigarettes n=765 n=110 n=219 n=164
yes 43.8% (333) 53.5% (60) 43.6% (97) 47.2% (88)
no 56.2% (432) 46.5% (50) 56.4% (122) 52.8% (76)
E-cigarettes are more acceptable to non- n=764 n=112 n=220 n=165
tobacco users
yes 68.9% (519) 70.8% (83) 72.4% (160) 70.1% (114)
no 31.1% (245) 29.2% (29) 27.6% (60) 29.9% (51)
People who are important to me use e- n=765 n=111 n=220 n=165
cigarettes
yes 20.2% (155) 27.9% (32) 23.3% (52) 27.4% (42)
no 79.8% (610) 72.1% (79) 76.7% (168) 72.6% (123)
NORM
How would you describe most people’s n=2,244 n=388 n=697 n=550
opinion on using tobacco?*** , a
very negative 18.2% (405) 22.0% (82) 16.5% (112) 18.1% (101)
negative 52.5% (1,142) 35.5% (133) 41.5% (288) 48.3% (253)
neither positive nor negative 25.5% (605) 30.8% (127) 34.3% (241) 28.3% (166)
positive 3.2% (77) 7.9% (31) 5.4% (39) 3.9% (20)
very positive 0.6% (15) 3.8% (15) 2.4% (17) 1.5% (10)
Thinking about people who are important n=2,241 n=385 n=696 n=551
to you, how would you describe their
opinion on using tobacco?*** , a
very negative 26.0% (557) 25.2% (92) 31.1% (208) 27.4% (138)
negative 32.0% (698) 28.7% (108) 29.4% (205) 32.0% (169)
neither positive nor negative 35.7% (834) 31.8% (129) 28.8% (206) 31.6% (190)
positive 4.2% (96) 8.3% (33) 5.7% (42) 5.5% (35)
very positive 2.2% (56) 5.9% (23) 5.0% (35) 3.5% (19)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

132
Table 6C
Risk Perception of Young Adults Aged 18-24 by Race/Ethnicity, PATH 2013 (n=3,887)
Race/Ethnicity White NH Black NH Hispanic Other race
(n=2,248) (n=388) (n=699) (n=552)
E-CIG RISK PERCEPTION
E-cigarettes might be less harmful to me n=765 n=111 n=220 n=165
than cigarettes*
yes 83.0% (631) 89.0% (98) 76.1% (170) 75.5% (127)
no 17.0% (134) 11.0% (13) 23.9% (50) 24.5% (38)
E-cigarettes might be less harmful to n=765 n=110 n=220 n=165
people around me than cigarettes
yes 81.6% (629) 81.5% (90) 82.0% (182) 80.2% (132)
no 18.4% (136) 18.5% (20) 18.0% (38) 19.8% (33)
Is using e-cigarettes less harmful, about n=2,233 n=381 n=694 n=546
the same, or more harmful than smoking
cigarettes? *** , a
less harmful 62.9% (1,393) 61.4% (229) 51.8% (360) 59.9% (321)
about the same 33.7% (762) 32.3% (128) 42.2% (292) 36.5% (202)
more harmful 3.4% (78) 6.3% (24) 6.0% (42) 3.6% (23)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

133
Table 7C
Experiential Attitude of Young Adults Aged 18-24 by Education, PATH 2013 (n=3,887)
Education LessHS/GED High School Some Bachelor’s
(n=836) (n=1,206) College or Higher
(n=1,534) (n=292)
EXPERIENTIAL ATTITUDE
(AFFECT)
E-cigarettes help me feel better if I’ve n=141 n=199 n=248 n=35
been feeling down a
not at all true 62.8% (91) 72.6% (143) 71.9% (181) 65.7% (24)
not true 13.5% (19) 9.9% (21) 13.0% (31) 13.2% (5)
neutral 6.1% (9) 8.0% (16) 6.1% (16) 9.2% (3)
true 8.4% (9) 5.5% (12) 5.5% (12) 12.0% (3)
extremely true 9.2% (13) 3.9% (7) 3.4% (8) 0.0% (0)
E-cigarettes help me think better * , a n=141 n=200 n=247 n=35
not at all true 69.8% (101) 77.9% (159) 77.9% (193) 67.1% (24)
not true 8.1% (11) 9.4% (16) 12.0% (26) 13.7% (5)
neutral 13.6% (17) 8.8% (18) 4.8% (15) 7.5% (2)
true 3.4% (5) 3.3% (6) 2.5% (6) 11.8% (4)
extremely true 5.2% (7) 0.6% (1) 2.8% (7) 0.0% (0)
I would feel alone without my e-cigarettes n=142 n=200 n=248 n=35
a

not at all true 85.5% (121) 88.1% (176) 89.7% (221) 82.5% (30)
not true 7.1% (10) 6.7% (14) 6.8% (18) 11.4% (3)
neutral 2.2% (4) 1.8% (3) 0.6% (2) 2.2% (1)
true 4.1% (5) 2.8% (6) 1.4% (3) 0.0% (0)
extremely true 1.0% (2) 0.5% (1) 1.4% (4) 3.9% (1)
I find it really hard to not use e- n=140 n=200 n=248 n=35
cigarettes** ,a
not at all true 74.9% (107) 81.9% (166) 81.3% (204) 61.6% (23)
not true 7.6% (10) 9.5% (18) 8.0% (20) 18.0% (5)
neutral 11.8% (15) 3.5% (6) 4.6% (11) 4.2% (2)
true 2.4% (4) 1.7% (3) 3.3% (7) 16.2% (5)
extremely true 3.3% (4) 3.5% (7) 2.8% (6) 0.0% (0)
I would find it hard to not use e-cigarettes n=141 n=200 n=248 n=35
for a week a
not at all true 73.7% (106) 85.3% (171) 82.2% (205) 66.8% (24)
not true 11.6% (15) 4.8% (9) 7.3% (17) 18.6% (6)
neutral 3.4% (5) 3.6% (7) 4.3% (11) 1.7% (1)
true 6.7% (9) 1.5% (3) 3.5% (7) 4.9% (2)
extremely true 4.5% (6) 4.8% (10) 2.7% (8) 7.9% (2)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

134
Table 8C
Instrumental Attitude and Norm of Young Adults Aged 18-24 by Education, PATH 2013 (n=3,887)
Education LessHS/GED High School Some Bachelor’s
(n=836) (n=1,206) College or Higher
(n=1,534) (n=292)
INSTRUMENTAL ATTITUDE
(BENEFIT)
E-cigarettes come in flavors I like** n=299 n=413 n=466 n=73
yes 80.5% (239) 77.0% (325) 79.3% (373) 62.8% (45)
no 19.5% (60) 23.0% (88) 20.7% (93) 37.2% (28)
Like socializing while using e- cigarettes n=298 n=412 n=466 n=73
yes 38.6% (112) 44.1% (187) 47.4% (221) 51.6% (39)
no 61.4% (186) 55.9% (225) 52.6% (245) 48.4% (34)
E-cigarettes are more acceptable to non- n=299 n=413 n=467 n=73
tobacco users
yes 68.0% (200) 68.7% (284) 72.9% (341) 62.3% (46)
no 32.0% (99) 31.3% (129) 27.1% (126) 37.7% (27)
People who are important to me use e- n=300 n=413 n=466 n=73
cigarettes
yes 20.8% (62) 22.3% (93) 22.1% (103) 25.4% (19)
no 79.2% (238) 77.7% (320) 77.9% (363) 74.6% (54)
NORM
How would you describe most people’s n=834 n=1,200 n=1,534 n=292
opinion on using tobacco?*** , a
very negative 16.5% (137) 18.7% (212) 18.4% (285) 20.7% (64)
negative 38.2% (313) 41.6% (503) 54.3% (812) 64.6% (179)
neither positive nor negative 36.1% (308) 33.5% (405) 23.9% (382) 11.6% (37)
positive 6.7% (55) 4.5% (56) 3.0% (48) 1.9% (7)
very positive 2.5% (21) 1.8% (24) 0.4% (7) 1.3% (5)
Thinking about people who are important n=835 n=1,202 n=1,527 n=290
to you, how would you describe their
opinion on using tobacco?*** , a
very negative 20.8% (168) 23.9% (279) 29.3% (438) 38.2% (107)
negative 27.6% (226) 29.3% (345) 32.8% (496) 37.2% (105)
neither positive nor negative 40.1% (342) 36.6% (449) 32.0% (502) 19.7% (60)
positive 6.6% (58) 5.9% (73) 3.8% (59) 4.0% (14)
very positive 5.0% (41) 4.3% (56) 2.0% (32) 1.0% (4)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

135
Table 9C
Risk Perception of Young Adults Aged 18-24 by Education, PATH 2013 (n=3,887)
Education LessHS/GED High School Some Bachelor’s
(n=836) (n=1,206) College or Higher
(n=1,534) (n=292)
E-CIG RISK PERCEPTION
E-cigarettes might be less harmful to me n=300 n=413 n=466 n=73
than cigarettes
yes 79.0% (235) 81.8% (337) 81.2% (382) 90.2% (66)
no 21.0% (65) 18.2% (76) 18.8% (84) 9.8% (7)
E-cigarettes might be less harmful to n=299 n=413 n=466 n=73
people around me than cigarettes
yes 82.6% (247) 83.4% (344) 80.2% (376) 78.3% (59)
no 17.4% (52) 16.6% (69) 19.9% (90) 21.7% (14)
Is using e-cigarettes less harmful, about n=829 n=1,200 n=1,517 n=290
the same, or more harmful than smoking
cigarettes? *** , a
less harmful 55.9% (458) 60.7% (720) 61.0% (921) 69.0% (198)
about the same 38.0% (318) 36.3% (440) 35.4% (539) 25.7% (77)
more harmful 6.1% (53) 3.0% (40) 3.6% (57) 5.3% (15)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

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Table 10C
Experiential Attitude of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
E-Cigarette User Type Exclusive E- Dual E-Cig+ Dual E-Cig+ Dual E-Cig+
cig Use Cigarette Hookah Cigarillo
(n=1,001) (n=773) (n=394) (n=91)
EXPERIENTIAL ATTITUDE
(AFFECT)
E-cigarettes help me feel better if I’ve n=68 n=113 n=82 n=14
been feeling down a
not at all true 63.7% (46) 75.1% (87) 75.4% (60) 65.3% (10)
not true 12.3% (8) 9.9% (10) 10.7% (9) 15.0% (2)
neutral 6.3% (5) 9.6% (10) 7.8% (7) 0.0% (0)
true 10.6% (5) 4.5% (5) 5.3% (5) 13.0% (1)
extremely true 7.2% (4) 0.9% (1) 0.8% (1) 6.7% (1)
E-cigarettes help me think better * , a n=68 n=112 n=82 n=14
not at all true 71.0% (51) 80.6% (92) 87.1% (71) 65.3% (10)
not true 7.4% (5) 6.8% (7) 3.2% (3) 21.7% (3)
neutral 6.6% (4) 8.9% (9) 5.4% (5) 0.0% (0)
true 7.4% (4) 3.7% (4) 4.3% (3) 0.0% (0)
extremely true 7.6% (4) 0.0% (0) 0.0% (0) 13.0% (1)
I would feel alone without my e-cigarettes n=68 n=113 n=82 n=14
** ,a
not at all true 83.8% (58) 88.8% (101) 92.5% (76) 72.9% (11)
not true 5.9% (3) 10.4% (11) 5.5% (4) 7.4% (1)
neutral 2.2% (2) 0.8% (1) 2.0% (2) 0.0% (0)
true 2.3% (2) 0.0% (0) 0.0% (0) 13.0% (1)
extremely true 5.8% (3) 0.0% (0) 0.0% (0) 6.7% (1)
I find it really hard to not use e-cigarettesa n=67 n=113 n=82 n=14
not at all true 68.2% (48) 81.3% (94) 86.4% (70) 72.7% (11)
not true 16.1% (8) 7.1% (7) 11.2% (10) 14.3% (2)
neutral 7.1% (5) 7.8% (8) 2.4% (2) 0.0% (0)
true 5.3% (3) 2.5% (3) 0.0% (0) 0.0% (0)
extremely true 3.3% (3) 1.4% (1) 0.0% (0) 13.0% (1)
I would find it hard to not use e-cigarettes n=68 n=113 n=82 n=14
for a week a
not at all true 73.1% (49) 82.3% (95) 88.4% (73) 59.7% (24)
not true 9.3% (6) 10.0% (10) 6.0% (4) 13.0% (6)
neutral 5.0% (4) 0.9% (1) 4.6% (4) 7.6% (1)
true 4.1% (3) 4.0% (4) 0.0% (0) 6.7% (2)
extremely true 8.4% (6) 2.7% (3) 1.0% (1) 13.0% (2)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

137
Table 11C
Instrumental Attitude and Norm of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013
(n=3,887)
E-Cigarette User Type Exclusive E- Dual E-Cig+ Dual E-Cig+ Dual E-Cig+
cig Use Cigarette Hookah Cigarillo
(n=1,001) (n=773) (n=394) (n=91)
INSTRUMENTAL ATTITUDE
(BENEFIT)
E-cigarettes come in flavors I like** n=171 n=220 n=135 n=17
yes 76.0% (133) 71.9% (160) 87.6% (118) 58.1% (10)
no 24.0% (38) 28.1% (60) 12.4% (17) 41.9% (7)
Like socializing while using e- n=169 n=220 n=135 n=17
cigarettes***
yes 45.1% (76) 33.4% (73) 58.1% (81) 41.4% (6)
no 54.9% (93) 66.6% (147) 41.9% (54) 58.6% (11)
E-cigarettes are more acceptable to non- n=172 n=220 n=134 n=17
tobacco users*
yes 73.9% (128) 61.7% (133) 70.5% (98) 86.7% (15)
no 26.1% (44) 38.3% (87) 29.5% (36) 13.4% (2)
People who are important to me use e- n=172 n=220 n=135 n=17
cigarettes
yes 23.1% (40) 19.5% (41) 33.6% (48) 28.6% (4)
no 76.9% (132) 80.5% (179) 66.4% (87) 71.4% (13)
NORM
How would you describe most people’s n=997 n=770 n=394 n=91
a
opinion on using tobacco?
very negative 16.5% (165) 20.1% (147) 19.1% (75) 20.7% (10)
negative 51.6% (482) 47.8% (352) 49.0% (190) 64.6% (39)
neither positive nor negative 26.1% (285) 27.4% (231) 28.5% (113) 11.6% (34)
positive 4.3% (49) 3.8% (32) 2.7% (12) 1.9% (5)
very positive 1.5% (16) 0.8% (8) 0.8% (4) 1.3% (3)
Thinking about people who are important n=997 n=771 n=394 n=91
to you, how would you describe their
opinion on using tobacco?*** , a
very negative 38.7% (368) 23.5% (175) 28.4% (112) 12.7% (13)
negative 30.3% (300) 29.3% (211) 32.3% (120) 25.3% (23)
neither positive nor negative 23.9% (248) 39.2% (320) 31.0% (128) 49.3% (42)
positive 4.0% (48) 5.3% (39) 4.7% (20) 5.9% (7)
very positive 3.1% (33) 2.8% (26) 3.5% (14) 6.8% (6)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

138
Table 12C
Risk Perception of Young Adults Aged 18-24 by E-Cigarette User Type, PATH 2013 (n=3,887)
E-Cigarette User Type Exclusive E- Dual E-Cig+ Dual E-Cig+ Dual E-Cig+
cig Use Cigarette Hookah Cigarillo
(n=1,001) (n=773) (n=394) (n=91)
E-CIG RISK PERCEPTION
E-cigarettes might be less harmful to me n=172 n=220 n=135 n=17
than cigarettes
yes 86.8% (148) 83.6% (183) 79.4% (108) 77.8% (13)
no 13.2% (24) 16.4% (37) 20.6% (27) 22.2% (4)
E-cigarettes might be less harmful to n=171 n=220 n=135 n=17
people around me than cigarettes*
yes 80.5% (139) 83.4% (184) 70.3% (100) 86.9% (15)
no 19.6% (32) 16.6% (36) 29.7% (35) 13.1% (2)
Is using e-cigarettes less harmful, about n=995 n=762 n=392 n=91
the same, or more harmful than smoking
cigarettes? a
less harmful 59.2% (576) 55.2% (418) 65.0% (253) 51.2% (50)
about the same 36.9% (377) 41.0% (312) 31.9% (129) 42.6% (35)
more harmful 3.9% (42) 3.8% (32) 3.1% (10) 6.2% (6)
a
percentages may not add up to 100 due to rounding.
*χ2 significant at p<0.05. ** χ2 significant at p<0.01. *** χ2 significant at p<0.001.

139