Adolescents’ Perceptions of E-Cigarette Use and its Impact on Health

BY

EUN JUNG CHO

B.A., Washington University in St. Louis, 2012
D.D.S., State University of New York at Buffalo School of Dental Medicine, 2019

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THESIS

Submitted as partial fulfillment of the requirements

for the degree of Master of Science in Oral Sciences
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in the Graduate College of the

University of Illinois Chicago, 2021

Chicago, Illinois

Thesis Committee:

Dr. Brittaney Hill, Chair and Primary Advisor, Pediatric Dentistry

Dr. Charles Le Hew, Pediatric Dentistry
Dr. Maria Rahmandar, Lurie Children’s Hospital
Dr. Shahrbanoo Fadavi, Pediatric Dentistry
 ACKNOWLEDGEMENTS

I would like to thank my primary advisor, Dr. Brittaney Hill, for all of her continued

guidance and support throughout this project. Dr. Hill has been incredibly patient with me

throughout the research process over the last two years. She has been a wonderful mentor and

teacher.

I would like to also thank my thesis committee, Dr. Charles Le Hew, Dr. Maria

Rahmandar, and Dr. Shahrbanoo Fadavi, for their advice and suggestions on improvements to

the project. All of the members of this committee were truly integral to the completion of this

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project, and my research would not have been successful without their thoughtful feedbacks.

I would like to thank Dr. Flavia Lamberghini for helping me recruit patients at Apple
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Dental Care, as well as all of my co-residents for allowing me to interrupt their appointments in

order to recruit participants for my study.

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Lastly, I would like to thank my family for believing in me and encouraging me

throughout this entire process. I am forever indebted to my parents who have sacrificed so much
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for me to pursue my career.

EJC

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 TABLE OF CONTENTS

CHAPTER ............................................................................................................................ PAGE

1. INTRODUCTION .................................................................................................................. 1
1.1 Background .................................................................................................................... 1
1.2 Trends in E-Cigarette Use .............................................................................................. 2
1.3 Health Consequences of E-Cigarettes Use ..................................................................... 3
1.4 Nicotine in E-Cigarettes ................................................................................................. 4
1.5 Role of Advertisements .................................................................................................. 5
1.6 Artificial Flavorings in E-Cigarettes .............................................................................. 6
1.7 Social Acceptance of E-Cigarette Use ........................................................................... 7
1.8 E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) ......................... 8
1.9 Study Objectives........................................................................................................... 10

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1.10 Hypothesis .................................................................................................................... 10

2. MATERIALS AND METHODS.......................................................................................... 11

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2.1 Study Approval............................................................................................................. 11
2.2 Study Criteria ............................................................................................................... 11
2.3 Recruitment Process ..................................................................................................... 12
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2.4 Survey Tool .................................................................................................................. 13
2.5 Statistical Analysis ....................................................................................................... 13

3. RESULTS ............................................................................................................................. 15
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3.1 Data Collection ............................................................................................................. 15

3.2 Demographic Information ............................................................................................ 15
3.3 Survey Results .............................................................................................................. 17

4. DISCUSSION ....................................................................................................................... 31
4.1 Strength and Limitations of the Study .......................................................................... 31
4.2 Misconceptions Surrounding E-Cigarettes ................................................................... 32
4.3 Awareness of Nicotine Content in E-Cigarettes on Adolescent Perceptions of E-
Cigarettes ...................................................................................................................... 34
4.4 Awareness of EVALI on Adolescent Perceptions of E-Cigarettes .............................. 35
4.5 Impact of Advertisements and Peer Influence Surrounding E-Cigarette Use .............. 35
4.6 Role of Oral Health Providers ...................................................................................... 36
4.7 Future Studies ............................................................................................................... 37

5. CONCLUSIONS .................................................................................................................. 39

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 TABLE OF CONTENTS (continued)

REFERENCES ..................................................................................................................... 40

APPENDICES ...................................................................................................................... 44
APPENDIX A .............................................................................................................. 45
APPENDIX B............................................................................................................... 53
APPENDIX C............................................................................................................... 58
APPENDIX D .............................................................................................................. 59
APPENDIX E ............................................................................................................... 63

VITA ..................................................................................................................................... 67

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 LIST OF TABLES

TABLE PAGE

I. Demographic Information of Adolescents Enrolled in the Study ............................... 16

II. Adolescents’ Personal Experiences with E-Cigarette and Tobacco Use .................... 18

III. Adolescents’ Knowledge, Perceptions, and Opinions of E-Cigarettes ....................... 20

IV. Chi Square Test: Association Between Awareness of Nicotine Content in E-

Cigarettes and Adolescents’ Perception that E-Cigarettes are Safer than Other
Tobacco Products ........................................................................................................ 21

V. Mann-Whitney U Analysis: Adolescents’ Personal Experiences with E-Cigarette and

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Tobacco Use and Their Harm Perceptions of E-Cigarettes ........................................ 23

VI. Mann-Whitney U Analysis: Adolescents’ Awareness of EVALI and Harm

Perceptions of E-Cigarettes......................................................................................... 25
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VII. Social Media Exposure and Peer Influence Surrounding Adolescents’ Use of E-
Cigarettes .................................................................................................................... 27
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VIII. Chi Square Test: Associations with Adolescents Reporting that Friends’ Choices
Affect Subject’s Choices............................................................................................. 28
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IX. Chi Square Test: Association Between Adolescents Who Have Seen Advertisements
for E-Cigarettes on Social Media and Harm Perceptions of E-Cigarettes .................. 30

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 SUMMARY

Electronic cigarettes, or e-cigarettes, emerged originally as smoking cessation aids and

promoted as a less-harmful tobacco substitutes. “Vaping” is a term used specifically for e-

cigarette use, as they produce aerosol rather than the traditional tobacco smoke seen from

combustible cigarettes. However, vaping is not without its consequences as they still produce

toxins since the composition of e-liquids often contain volatile organic compounds, carcinogenic

chemicals, and heavy metals.

In 2016, the U.S. Surgeon General’s office reported that vaping among high school

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students increased by 900% between 2011-2015. Among adolescents, the harm perception of
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vaping has decreased over time, especially when compared to combustible cigarettes. With this

decrease in harm perception, a recent outbreak of lung injuries related to e-cigarette use known
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as e-cigarette or vaping product use-associated lung injury (EVALI) has appeared.

The purpose of this study was to identify whether adolescents who were aware of e-

cigarette or vaping product use-associated lung injury (EVALI) were more likely to view e-
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cigarette use as harmful to their health, and to describe the misconceptions adolescents may have

regarding e-cigarette use.

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 LIST OF ABBREVIATIONS

AAPD American Academy of Pediatric Dentistry

CBD Cannabidiol

CDC Centers for Disease Control

COPD Chronic Obstructive Pulmonary Disease

EVALI E-Cigarette, or Vaping, Product Use-Associated Lung Injuries

IRB Institutional Review Board

PI Principal Investigator

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RNS Reactive Oxygen Species

ROS
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Reactive Nitrogen Species

THC Tetrahydrocannabinol
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UIC University of Illinois Chicago
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 1. INTRODUCTION

1.1 Background

Introduced in the United States in 2007, electronic cigarettes, or e-cigarettes, are

battery-operated devices that contain a solution of nicotine, flavorings, solvents (i.e.,

propylene glycol or glycerin), and other chemicals. “Vaping” is a term used specifically

for e-cigarette use, as they do not produce tobacco smoke but rather an aerosol containing

fine particles (CDC's Office on Smoking Health, 2020). Vaping is actually a misnomer,

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as e-cigarettes do not produce a harmless water vapor but a chemical-filled aerosol,

caused by the heating of a liquid that commonly consists of solvents like propylene glycol
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or glycerin.
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E-cigarettes have been marketed as a smoking cessation aid but are still

considered tobacco products as they commonly contain nicotine, a chemical derived from

the tobacco plant. They are often promoted as a less-harmful tobacco substitute since, in
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addition to not producing smoke, the main ingredients found in the liquid are compounds

also found in food, pharmaceuticals, and cosmetics. However, there is a lack of definitive

evidence that e-cigarettes are safer than conventional cigarettes or other combusted

tobacco products as inhalation exposure and daily use of chemicals found in the vaping

liquid is different from dietary intake or topical use of the compounds (Khan, 2019; Royal

College of Physicians and Tobacco Advisory Group, 2016). Furthermore, while e-

cigarettes may contain and generate lower levels of toxins when compared to

conventional cigarettes, they are not healthy or harmless, as they still contain volatile

organic compounds, carcinogenic chemicals, and heavy metals such as nickel, tin, and

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lead (CDC's Office on Smoking and Health, 2017), which can have serious implications

for the developing brain.

There exists a diverse array of e-cigarette designs and solutions, with most of the

devices containing a mouthpiece, a heating coil activating system, a battery, a heating coil

or atomizer, and a reservoir or tank of the solution. Initially, e-cigarettes were designed to

mimic the look, feel, and taste of conventional cigarettes with glowing tips during

inhalation. As designs have evolved over the years, e-cigarettes can now resemble

everyday items such as pens or USB flash drives with LED lights that change colors with

each inhalation, characteristics that appeal to youth due to their sleek designs and

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concealability.
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1.2 Trends in E-Cigarette Use
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E-cigarettes have skyrocketed in popularity in the United States, especially among

adolescents and young adults. According to a 2016 report by the US Surgeon General’s
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office, vaping among high school students increased by 900% between 2011-2015. In

2018, 42.2% of American adolescents in grades 9-12 had tried an e-cigarette, estimated at

approximately 1.3 million students (Singh et al., 2020). Among high school students, e-

cigarette use, defined by use on at least one day in the past 30 days, almost doubled from

11.7% to 20.8% between 2017 and 2018, reflecting the largest annual increase ever

recorded for any adolescent substance use (Monitoring the Future National Survey

Results on Drug Use, 1975-2016; CDC's Office on Smoking and Health, 2020).

Additionally, the proportion of high school students reporting e-cigarette use for 20 days

or more in the past 30-day period increased from 20% to 27.7% between 2017 and 2018.

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Since then, according to the 2019 National Youth Tobacco Survey, more than 5 million

middle and high school students reported that they had used e-cigarettes in the prior 30-

day period and almost one million students reported daily use (CDC’S Office on Smoking

and Health, 2020). E-cigarette use is soaring at an alarming rate among adolescents, and

vaping now places second only to alcohol in use by adolescents (National Institute on

Drug Abuse, 2020).

1.3 Health Consequences of E-Cigarettes Use

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Because e-cigarette products are fairly new to the market, long-term consequences

from chronic e-cigarette use are not well known. However, it is known that when the user
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inhales aerosolized liquid, the vapor diffuses into pulmonary blood vessels, transporting

the chemicals in the vaping liquid both centrally to the brain and systemically to the
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peripheral organs (Kitzen et al., 2019). While studies definitively concluding long-term

outcomes from e-cigarette use are not yet sufficient and limited in scope, there is
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sufficient evidence that e-cigarette use is associated with oxidative stress, a condition that

results from an altered reduction-oxidation state involving mitochondria dysfunction, the

excessive generation of reactive oxygen species (ROS) or reactive nitrogen species

(RNS), and the dysfunction of the ROS/RNS scavenging antioxidant system. Oxidative

stress is responsible for the alteration and dysfunction of the DNA repair system, which

subsequently contributes to the development of various respiratory, metabolic,

psychiatric, and neurodegenerative diseases (Song and Zou, 2015). The human brain

develops well beyond the teenage years and does not reach full maturity until the age of

25, leaving the adolescent brain especially susceptible to oxidative damage due to its high

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oxygen consumption, large percentage of sensitive immature cells, poor antioxidants

capacity, and elevated levels of metals catalyzing free radical formation and unsaturated

fatty acids (Leslie, 2010; Ikonomidou and Kaindl, 2011). Moreover, e-cigarette use and

the associated increased oxidate stress have been implicated in increased odds of

depression, suicide, sleep impairment, cognitive impairment, attention deficits, and

aggressive and impulsive behavior, all of which may detrimentally contribute to poor

health outcomes and social well-being in adolescents and young adults (Tobore, 2019).

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1.4 Nicotine in E-Cigarettes

One primary ingredient found across the majority of e-cigarettes is nicotine, a

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highly addictive chemical that binds to nicotinic cholinergic receptors in the brain and

raises levels of dopamine that produces feelings of pleasure and reward (Benowitz, 2009).
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The plastic nature of the adolescent brain predisposes them to be more vulnerable to the

effects of nicotine, as the neurochemical response to nicotine in adolescents differs from

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those in adults, with the adolescent response resulting in a permanent alteration of the

serotonin response system. Furthermore, chronic exposure to nicotine is found to have

detrimental effects on the brain development in the pre-frontal cortex, affecting cognition

and behavior with reduced attention span and greater impulsivity, as well as enhanced

anxiety and fear (Leslie, 2020; Theron et al., 2019; McKelvey et al., 2018; Yuan et al.,

2015). Beyond neurochemical changes, prolonged exposure to nicotine places adolescents

at risk for nicotine sickness, also referred to as “nic-sick”, with symptoms including

abdominal pain, nausea or vomiting, breathing difficulties, cardiac arrest, and respiratory

failure (American Lung Association, 2021). Unlike a traditional cigarette where there is a

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tangible stopping point at the end of each smoking session, vaping is particularly

dangerous for adolescents because there is no concrete stop point that indicates that their

vaping session is complete, leaving youth to inhale high concentrations of nicotine for

prolonged periods of time (Singh et al., 2020). However, in the face of these adverse

health consequences of nicotine in e-cigarettes, adolescents often have limited knowledge

about whether their e-cigarettes even contain nicotine. In the case of a JUUL pod, each e-

cigarette liquid pod contains approximately 1 pack of cigarettes’ worth of nicotine, yet

most youth are unaware of the nicotine content in JUULs. Even with regulatory efforts

mandating nicotine labels on e-cigarettes, many adolescents are falsely misled to believe

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that “5% strength” of nicotine correlates to a low nicotine concentration in each pod
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(Morean et al., 2019). Further contributing to the misinformation is that many adolescents

inaccurately view nicotine as artificial rather than being made from tobacco, and this
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imprecise knowledge can cause adolescents to think that nicotine is “safe” (East et al.,

2018; Pepper et al., 2018). Additionally, studies have shown that an earlier use of nicotine

is highly predictive of future nicotine use. With the rising prevalence of e-cigarette use
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among adolescents and young adults, concerns arise surrounding early nicotine exposure

and its potential to act as a gateway drug for conventional cigarettes, cannabis, and

cocaine use (Fadus et al., 2019).

1.5 Role of Advertisements

Adolescents and young adults often have limited knowledge and report

misconceptions about e-cigarettes, with both use and overall positive beliefs rising. A

major force contributing to positive beliefs of e-cigarettes can be attributed to

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advertisements that have been targeted specifically towards youth and young adults.

Commercials promoting e-cigarettes on televisions increased by 256% from 2011 and

2013, with advertisements targeting minors as young as 12-year-olds (Wagoner et al.,

2019). In 2014, 68.9% of middle and high school students reported exposure to e-

cigarette marketing from retail stores, Internet, television, movies, newspapers, and

magazines, many of which highlighted that e-cigarettes do not generate ash or

combustible smoke, do not contain tobacco and tar, and are healthier and safer

alternatives to conventional cigarettes. E-cigarette companies have also sponsored or have

directly provided samples at sporting events including NASCAR rallies and football

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games, as well as utilized endorsements from celebrities whom adolescents may see as
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role models (Phua et al., 2018). More recently, e-cigarettes have been heavily promoted

on social media outlets such as Facebook, Twitter, Instagram, and YouTube, implying
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that e-cigarettes are often enjoyed in social settings by young adults. Studies have shown

that advertisements have a significant impact on the decrease of harm perception of e-

cigarettes by promoting them as fashionable, socially enhancing, and safer alternatives to

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cigarettes (Kim et al., 2019; Pokhrel et al., 2019).

1.6 Artificial Flavorings in E-Cigarettes

Another factor contributing to the rise of e-cigarette use in adolescents is the

addition of artificial flavorings in e-cigarette liquid pods. Research has shown that

availability of appealing flavors such as fruit, candy, or dessert is one of the top reasons

for e-cigarette curiosity and experimentation among youth (Cooper et al., 2016).

Adolescents and young adults have strong preferences for sweet tastes, as the

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consumption of sugar releases opioids and dopamine. By incorporating such flavorings,

e-cigarettes can be vaped in a more enjoyable manner for the users due to sensory

similarities between sugary foods and sweet artificial flavorings (Chen-Sankey et al.,

2019). Laboratory experiments have shown that flavors that produce sensory perceptions

of sweetness, in comparison to menthol and tobacco flavors, generate greater appeal that

contribute to youths’ willingness to use e-cigarettes again. Research has shown that

artificial flavorings may “mask” and diminish harm perceptions of e-cigarette use, and

adolescents who vape flavored e-cigarettes are more likely to continue vaping and take

more inhalations per vaping when compared to those who exclusively vape non-flavored

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e-cigarettes (Leventhal et al., 2019). Furthermore, the addition of artificial flavorings
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significantly diminishes the perceived addictiveness of e-cigarettes and facilitates the

social acceptance norm of vaping, further lowering barriers to e-cigarette use (Chen-
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Sankey et al., 2019).
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1.7 Social Acceptance of E-Cigarette Use

Social influence from peers and friends is a significant factor that affects the

initiation of e-cigarette use in adolescents and young adults, as individual behavior and

actions are often swayed by their peers and groups to which they are connected through

social networks. Advertisements featuring e-cigarette use in social settings convey the

message that vaping is a fun and social activity that “cool” people engage in (Pokhrel et

al., 2018). Previous research has identified that e-cigarette use is highly influenced by

social enhancement expectancies, suggesting that participating in vaping would result in

being more popular, being liked by others, and appearing fashionable (Pokhrel et al.,

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2018; Pokhrel et al., 2015). Furthermore, e-cigarette usage is viewed as a lifestyle,

considered a trend that tastes good, and seen as fun to use, rather than as a risk

(Romijnders et al., 2019). Adolescents also often document and share their vaping

experiences on their social media accounts, perpetuating the gradually cavalier attitudes

towards e-cigarette use (Kong et al., 2019; Barrington-Trimis et al., 2016). The result is a

social normalization of vaping, which subsequently lowers psychological barriers that

might otherwise identify e-cigarette use as a deviant and harmful behavior (Hwang and

Park, 2016).

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1.8 E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI)
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As the product landscape of e-cigarettes has evolved from disposable ciga-likes to

rechargeable pens, mods, and USB flash drives, newer generations of e-cigarettes have
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expanded to deliver not just nicotine, but also marijuana, specifically

tetrahydrocannabinol (THC), the main psychoactive component found in cannabis, and

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cannabidiol (CBD), a non-psychoactive chemical in cannabis with anxiolytic effects

(Muthumalage et al., 2020). With an increasing number of U.S. states legalizing

marijuana use, in conjunction with a shift in decreased perception of harm in e-cigarette

use and the accessibility of a wide range of e-cigarette products in the marketplace, there

has been a recent outbreak of lung injuries related to e-cigarette use among young people.

Termed e-cigarette or vaping product use-associated lung injury (EVALI), the condition

refers to a serious respiratory illness that results from an inflammatory response in the

lungs triggered by the inhaled substances. While the exact pathogenesis of EVALI is not

known, it is an acute condition characterized by respiratory symptoms including dyspnea,

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 coughing, and chest pain, as well as gastrointestinal and constitutional symptoms. It is

thought that the alveolar damage caused by vaping strongly contributes to lung diseases,

such as asthma and chronic obstructive pulmonary disease (COPD). In severe cases,

patients with EVALI may present with symptoms that closely resemble pneumonia with

sepsis and, in the most extreme cases, death from respiratory failure (Aldy et al., 2020).

As of February 18, 2020 (prior to the Centers for Disease Control & Prevention (CDC)

switching focus to the COVID-19 pandemic), there were a total of 2,807 hospitalizations

or deaths reported to the CDC from all 50 states of United States, the District of

Columbia, Puerto Rico, and U.S. Virgin Islands (CDC’S Office on Smoking and Health,

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2020). Findings released by the CDC indicate that vitamin E acetate, a thickening agent
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in THC-containing e-cigarettes, were strongly associated with the sharp rises in EVALI

cases in August and September 2019, but this has not been determined as a singular cause
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of the illness as EVALI cases have been observed from non-THC containing e-cigarette

use as well (Krishnasamy et al., 2020). Furthermore, other chemicals found in e-

cigarettes, such as acetaldehyde, acrolein, and formaldehyde, are known to cause lung
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disease as well as cardiovascular disease (Ogunwale et al., 2017). The declines in the

number of EVALI cases since its peak in fall 2019 has been encouraging news to public

health, but given the uncertainty elucidating exactly which chemicals in e-cigarettes

definitively contribute to pathophysiology of EVALI and the lack of long-term follow-up

on the health consequences from EVALI, among other health risks, vaping remains a

significant public health threat among adolescents and young adults.

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