25

Chapter 2 

Patterns of E-Cigarette Use Among U.S. Youth and 

Young Adults

Introduction 27

Sources of Data 27

Other Literature 27

Key Findings 28

Youth 28

Current Prevalence 28

Trends in Prevalence 28

Young Adults 37

Current Prevalence 37

Trends in Prevalence 37

E-Cigarette Use and Use of Other Tobacco Products 37

Cross-Sectional Studies 37

Longitudinal Studies 53

E-Cigarette Use and Other Substance Use 57

E-Cigarettes and Marijuana 58

Use of Flavored E-Cigarettes 58

Consumer Perceptions of E-Cigarettes 59

Perceived Harm of E-Cigarettes 59

Reasons for Use and Discontinuation 75

Evidence Summary 86

Conclusions 88

References 89

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 27

E-Cigarette Use Among Youth and Young Adults

Introduction

This chapter documents patterns and trends in 

awareness of electronic cigarettes (e-cigarettes), their 

use, and perceptions about these devices among youth 

and young adults in the United States. Both the awareness of e-cigarettes and levels of their use have increased 

rapidly throughout the U.S. population. Understanding 

young people’s patterns of e-cigarette use is essential 

to determining the scope of potential benefits or harms 

that these products may have from a public health perspective. This chapter summarizes the patterns of use of 

e-cigarettes, identifies subgroups at higher risk for using

them, highlights the ways in which e-cigarettes are used

with other tobacco products, and identifies correlates of

e-cigarette use, including knowledge, attitudes, beliefs,

and sociodemographic characteristics. In most cases, the

term “e-cigarette(s)” is used, but when needed to accord

with usage in the cited literature, the acronym “ENDS”

(electronic nicotine delivery systems) is employed.

Sources of Data

Data summarized in this chapter come from nationally representative datasets that were federally funded and 

peer-reviewed literature of subnational and international 

surveillance studies of e-cigarette use that were mostly 

cross-sectional in design. Appendix 2.1. and Table A2.1-1 

in that appendix1

1All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/

library/reports/

 describe all the years of data available 

for these data sources, but only selected years are used for 

this report. For youth, this report relies on data from the 

National Youth Tobacco Survey (NYTS) and the Monitoring 

the Future Study (MTF), as measures of e-cigarette 

use were available for at least two or more time points. 

For this reason, the report also relies on data from the 

National Adult Tobacco Survey (NATS) for young adults. 

More recently, the Youth Risk Behavior Surveillance 

System and other surveys from the National Center for 

Health Statistics have added measures of e-cigarette use 

to their surveys, but only one data point was available at 

the time this report was prepared. Only five longitudinal 

studies were available on this topic at the time this report 

was prepared (Leventhal et al. 2015; Primack et al. 2015; 

Barrington-Trimis et al. 2016; Unger et  al. 2016; Wills 

et al. 2016). Because e-cigarettes only became prevalent 

in the tobacco product marketplace in recent years, minimal data are available on their use before 2011. Given the 

paucity of surveillance information on e-cigarettes and the 

low prevalence of their use in the early years of their availability in the United States, peer-reviewed studies with 

smaller subnational samples are used in this chapter to 

complement national surveillance data. Surveillance of 

e-cigarette use presents a unique set of challenges, given

the emerging and dynamic market specific to these products (see Chapter 4 for more on the latter topic). Appendix

2.1 and Tables A2.2-1 and A2.2-2 in Appendix 2.2 summarize the key terms and measures used in this chapter.

Other Literature

This chapter also summarizes findings from peerreviewed literature on e-cigarettes that were identified 

through a systematic review of studies of these products 

from the United States and abroad. A literature search was 

conducted in April 2015 (Glasser et al. 2015) using the 

National Library of Medicine’s PubMed database and the 

following keywords: “e-cigarette*” OR “electronic cigarette” OR “electronic cigarettes” OR “electronic nicotine 

delivery” OR “vape” OR “vaping.” Articles were excluded 

from this review for any of five reasons: (1) the article was 

not available in English; (2) the article was not relevant 

to e-cigarettes; (3) the study included nonhuman subjects; (4) the study did not include original data; or (5) the 

study did not include findings specific to adolescents or 

young adults. More details about this review’s methodology are available in Glasser and colleagues’ (2015) report. 

The search was subsequently updated in November 2015, 

January 2016, and March 2016 during continued development of the report. For consistency, the same search 

strategy and databases were employed at all times. Studies 

on patterns of e-cigarette use behaviors for both youth and 

young adults are reviewed in the text and tables that follow. 

All other studies not explicitly described in the text are summarized in Appendix 2.3 and Tables A2.3-1 through A2.3-3.
A Report of the Surgeon General

28 Chapter 2

Key Findings

Youth

Current Prevalence

Ever Use

According to the 2015 National Youth Tobacco Survey 

(NYTS), an estimated 27.1% of U.S. adolescents, representing approximately 7,260,500 persons, had ever tried 

e-cigarettes (Centers for Disease Control and Prevention

[CDC], unpublished data [NYTS 2015]). This included

13.5% of middle school students and 37.7% of high school

students (Tables 2.1a and 2.1b). Among middle school students, use was comparable between boys and girls, but it

was higher among Hispanics compared with other racial/

ethnic groups (Table 2.1a). For high school students, use

was also comparable between boys and girls, but higher

among both White and Hispanic youth compared with

Black youth (Table 2.1b). According to data from the 2015

Youth Risk Behavior Survey (YRBS), a larger percentage

of high school students (44.9%) had ever used e-cigarettes

(Kann et al. 2016), while the Monitoring the Future (MTF)

survey does not collect data on ever use of e-cigarettes

(Johnston et al. 2016).

Past-30-Day Use

According to the 2015 NYTS, an estimated 620,000 

middle school students and 2,390,000 high school students 

had used e-cigarettes at least once in the past 30 days (CDC 

2016). This was an increase from the 2014 NYTS, which 

reported 450,000 middle school students and 2,010,000 high 

school students had used e-cigarettes in the past 30 days 

(CDC 2015c). Levels of past-30-day use were 5.3% for 

middle school students and 16% for high school students in 

2015 (Tables 2.2a and 2.2b), compared with 3.9% for middle 

school students and 13.4% for high school students in 2014. 

Sociodemographic differences in past-30-day use for middle 

and high school students had the same patterns as those for 

ever use (Tables 2.2a and 2.2b). In 2015, according to the 

YRBS, 24.1% of high school students had used e-cigarettes 

at least once in the past 30 days (Kann et al. 2016). The 2015 

MTF shows past-30-day prevalence of e-cigarette use among 

adolescents was 9.5% among 8th graders, 14% among 

10th graders, and 16% among 12th graders (Johnston et al. 

2016). Notably, data from NYTS, YRBS, and MTF show that 

in 2014 exclusive past-30-day use of e-cigarettes exceeded 

exclusive past-30-day use of conventional cigarettes for the 

first time since these types of data were collected (University 

of Michigan 2014; CDC 2015c).

Frequency of Use

Among middle school students, according to the 

2015 NYTS, 5.3% were current users of e-cigarettes, 

and 0.6% used e-cigarettes frequently (defined as using 

an e-cigarette 20 or more days in the past 30 days preceding the survey) (Table 2.1a). Among high school students, these estimates were 15.5% and 2.5%, respectively 

(Table  2.1b). Due to smaller sample sizes, confidence 

intervals were too wide to determine sociodemographic 

differences in these measures. These estimates are consistent with a report by CDC (2015b).

A recent analysis of 2014 MTF data, specific to high 

school seniors, showed the frequency of e-cigarette use 

(defined as the number of days in the past 30 days a student 

used an e-cigarette) increases with ever cigarette smoking 

(Warner et al. 2016). Among high school seniors who used 

at least 1 e-cigarette in the past 30 days, the frequency 

of e-cigarette use was almost twice as high (10.2  days) 

among those who regularly smoke conventional cigarettes, compared to those who had never smoked a conventional cigarette (5.8 days). However, the frequency of 

e-cigarette use did not vary substantially among current

cigarette smokers. Among high school seniors who used

at least 1 e-cigarette in the past 30 days, the frequency

of e-cigarette use averaged 8–10 days for “heavy cigarette

smokers” (those who smoked more than a half pack of

cigarettes per day), “light cigarette smokers” (those who

smoked 1–5 cigarettes per day), and “very light cigarette

smokers” (those who smoked fewer than 1 cigarette per

day) (Warner et al. 2016).

Susceptibility to Use

Among those who had never used an e-cigarette, 

32.1% of middle school students and 38.4% of high school 

students were susceptible to using e-cigarettes in the 

future. That is, these students did not have a firm resolve 

not to use e-cigarettes in the future. This is according to the 

2015 NYTS (Tables 2.1a and 2.1b). No differences in susceptibility to use e-cigarettes were observed by gender or race/

ethnicity for either middle school or high school students.

Trends in Prevalence

Ever Use

Overall, according to the NYTS, ever use of 

e-cigarettes among students in grades 6–12 increased

from 3.3% in 2011, to 6.8% in 2012, to 8.1% in 2013, to

19.8% in 2014, and then to 27% in 2015 (Figure 2.1). As
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 29

Table 2.1a Percentage of middle school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 

2015

Ever usea Current useb

Frequent usec: 

Among current 

users

Frequent usec: 

Among all students

Susceptibility to 

used: Among never 

users

Susceptibility to 

used: Among all 

students

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 13.5 (11.8–15.5) 0.9 5.3 (4.6–6.2) 0.4 11.7 (8.6–15.8) 1.8 0.6 (0.4–0.9) 0.1 32.1 (29.7–34.7) 1.3 41.4 (38.3–44.5) 1.5

Gender

Female 12.2 (10.5–14.1) 0.9 4.8 (4.0–5.6) 0.4 11.0 (6.9–17.0) 2.5 0.5 (0.3–0.8) 0.1 33.1 (30.2–36.2) 1.5 41.4 (38.0–44.8) 1.7

Male 14.9 (12.9–17.2) 1.1 5.9 (4.7–7.2) 0.6 11.8 (8.3–16.5) 2.0 0.7 (0.5–1.0) 0.1 31.3 (28.2–34.6) 1.6 41.6 (37.9–45.4) 1.9

Race/ethnicity

White 12.2 (10.1–14.5) 1.1 4.4 (3.6–5.5) 0.5 10.8 (6.5–17.5) 2.7 0.5 (0.3–0.8) 0.1 29.7 (26.1–33.6) 1.9 38.0 (33.7–42.5) 2.2

Black or 

African 

American

11.7 (9.5–14.3) 1.2 4.1 (3.1–5.3) 0.6 14.0 (5.9–29.6) 5.7 — — 34.7 (30.7–39.0) 2.1 42.5 (39.0–46.2) 1.8

Hispanic or 

Latino

18.6 (15.9–21.5) 1.4 8.3 (6.8–10.0) 0.8 12.1 (7.5–18.9) 2.8 1.0 (0.6–1.6) 0.2 38.0 (35.2–40.8) 1.4 49.8 (46.9–52.7) 1.5

Othere 11.9 (8.2–17.1) 2.2 4.6 (2.7–7.7) 1.2 — — — — 30.4 (24.7–36.8) 3.1 39.5 (33.2–46.2) 3.3

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.

aIncludes those who reported using an e-cigarette, even once or twice.

bIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.

cIncludes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?” 

See CDC (2015b).

dIncludes those who failed to respond “definitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”; 

(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic

cigarette or e-cigarette, even once or twice?”

eIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General

30 Chapter 2

Table 2.1b Percentage of high school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 2015

Ever usea Current useb

Frequent usec: 

Among current 

users

Frequent usec: 

Among all students

Susceptibility to 

used: Among never 

users

Susceptibility to 

used: Among all 

students

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 37.7 (35.3–40.2) 1.2 16 .0 (14.1–18.0) 1.0 15.5 (12.9–18.4) 1.4 2.5 (1.9–3.2) 0.3 38.4 (36.5–40.4) 1.0 61.1 (59.0–63.2) 1.0

Gender

Female 34.6 (31.9–37.3) 1.4 12.8 (11.0–15.0) 1.0 10.1 (7.2–14.0) 1.7 1.3 (0.9–1.8) 0.2 39.8 (37.4–42.2) 1.2 60.3 (58.1–62.5) 1.1

Male 40.7 (37.7–43.7) 1.5 19.0 (16.5–21.7) 1.3 19.1 (15.6–23.1) 1.9 3.6 (2.7–4.8) 0.5 36.9 (34.3–39.5) 1.3 61.8 (59.2–64.4) 1.3

Race/ethnicity

White 38.0 (35.1–41.0) 1.5 17.2 (14.7–19.9) 1.3 16.8 (13.4–20.8) 1.9 2.9 (2.1–3.9) 0.4 36.3 (33.4–39.4) 1.5 60.1 (57.4–62.7) 1.3

Black or 

African 

American

28.5 (25.5–31.8) 1.6 8.9 (7.4–10.8) 0.8 8.5 (3.9–17.4) 3.2 0.8 (0.3–1.7) 0.3 37.2 (32.2–42.5) 2.6 54.5 (51.0–57.9) 1.7

Hispanic or 

Latino

43.0 (38.9–47.2) 2.1 16.4 (14.1–19.0) 1.2 12.8 (9.3–17.3) 2.0 2.1 (1.4–3.1) 0.4 44.6 (41.2–48.0) 1.7 67.8 (64.3–71.1) 1.7

Othere 37.4 (24.8–52.1) 7.0 18.9 (10.3–32.2) 5.5 18.2 (11.2–28.2) 4.3 3.4 (2.1–5.7) 0.9 41.2 (35.4–47.3) 3.0 62.6 (54.0–70.5) 4.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported using an e-cigarette, even once or twice.

bIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.

cIncludes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?” 

See CDC (2015b).

dIncludes those who failed to respond “definitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”; 

(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic

cigarette or e-cigarette, even once or twice?”

eIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 31

Table 2.2a Percentage of middle school students who used e-cigarettes in the past 30 daysa, by gender and race/ethnicity; National Youth Tobacco 

Survey (NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4

Gender

Female 0.4 (0.2–0.7) 0.1 0.8 (0.5–1.1) 0.1 0.9 (0.6–1.4) 0.2 3.3 (2.5–4.3) 0.5 4.8 (4.0–5.6) 0.4

Male 0.7 (0.4–1.3) 0.2 1.5 (1.1–2.1) 0.3 1.4 (0.9–1.9) 0.2 4.5 (3.4–5.9) 0.6 5.9 (4.7–7.2) 0.6

Race/ethnicity

White 0.6 (0.3–1.0) 0.2 0.9 (0.6–1.3) 0.2 0.9 (0.6–1.4) 0.2 3.1 (2.2–4.2) 0.5 4.4 (3.6–5.5) 0.5

Black or African 

American

— — 1.1 (0.6–2.2) 0.4 1.4 (0.7–2.5) 0.4 3.8 (2.5–5.6) 0.7 4.1 (3.1–5.3) 0.6

Hispanic or 

Latino

0.6 (0.4–1.1) 0.2 2.0 (1.4–2.9) 0.4 1.8 (1.1–2.7) 0.4 6.2 (4.8–7.9) 0.8 8.3 (6.8–10.0) 0.8

Otherb — — — — — — 3.2 (1.6–6.3) 1.1 4.6 (2.7–7.7) 1.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of 

questions used to measure e-cigarette use varied from 2011 to 2015.

aIncludes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.

bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General

32 Chapter 2

Table 2.2b Percentage of high school students who used e-cigarettes in the past 30 daysa, by gender and race/ethnicity; National Youth Tobacco Survey 

(NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 1.5 (1.2–2.0) 0.2 2.8 (2.3–3.5) 0.3 4.5 (3.8–5.3) 0.4 13.4 (11.2–16.1) 1.2 16.0 (14.1–18.0) 1.0

Gender

Female 0.7 (0.5–1.0) 0.1 1.9 (1.5–2.4) 0.2 3.5 (2.8–4.3) 0.4 11.9 (9.7–14.5) 1.2 12.8 (11.0–15.0) 1.0

Male 2.3 (1.7–3.2) 0.4 3.7 (2.9–4.8) 0.5 5.5 (4.5–6.8) 0.6 15.0 (12.4–18.2) 1.4 19.0 (16.5–21.7) 1.3

Race/ethnicity

White 1.8 (1.3–2.4) 0.3 3.4 (2.7–4.2) 0.4 4.8 (3.8–6.1) 0.6 15.3 (12.4–18.8) 1.6 17.2 (14.7–19.9) 1.3

Black or African 

American

— — 1.1 (0.7–1.9) 0.3 2.7 (1.9–3.9) 0.5 5.6 (3.7–8.5) 1.2 8.9 (7.4–10.8) 0.8

Hispanic or 

Latino

1.3 (0.8–2.1) 0.3 2.7 (1.9–3.8) 0.5 5.3 (4.2–6.6) 0.6 15.3 (11.8–19.5) 1.9 16.4 (14.1–19.0) 1.2

Otherb — — — — 4.0 (2.3–6.9) 1.1 9.4 (6.8–12.9) 1.5 18.9 (10.3–32.2) 5.5

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of 

questions used to measure e-cigarette use varied from 2011 to 2015.

a Includes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.

b Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 33

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 28.)

discussed in Appendix 2.2 (see NYTS Measures—Special 

Issues), measures of e-cigarette use were changed for 

the 2014 NYTS, as signaled by the dotted line in the 

figure. Research conducted using the New Jersey Youth 

Tobacco Survey suggests that the NYTS measures used 

in 2011–2013 may potentially underestimate use, compared with the 2014 measure (Delnevo et al. 2016). For 

the 2011−2015 period, use of e-cigarettes was higher in 

each year among high school students than among middle 

school students (Tables 2.3a and 2.3b).

Figure 2.1 Trends in ever e-cigarette usea among U.S. middle and high school students; National Youth Tobacco 

Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).

Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this 

estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.

aIncludes those who responded “1 or more” to the following question: During the last 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?

Middle school students. Trends in ever use of 

e-cigarettes among U.S. middle school students are presented in Table 2.3a and Figure 2.1, using data from the

2011–2015 NYTS. The prevalence of ever use increased

from 1.4% in 2011 to 2.7% in 2012, to 3.0% in 2013, to

10.1% in 2014, and then to 13.5% in 2015. The jump in

prevalence between 2013 and 2014 may be an artifact of a

change in how the use item was asked (see Appendix 2.2.

Key Measures of Use). Nonetheless, prevalence of use would

be expected to be minimal prior to 2011, suggesting that a

considerable increase in use was still observed during this

relatively short 4-year period. In 2015, among middle school 

students, an estimated 1,595,481 had ever tried e-cigarettes

(CDC, unpublished data [NYTS 2015]). From 2011 to 2013,

the prevalence of ever use did not differ significantly by 

gender or race/ethnicity. There remained no significant difference in ever use by gender in the 2014 or 2015 NYTS, but 

by 2014 and still in 2015, a greater percentage of Hispanic 

middle school students (18.6%) had tried e-cigarettes than 

White (12.2%) or Black (11.7%) students or students of 

other races/ethnicities (11.9%) (Table 2.3a).

High school students. Trends in ever use of 

e-cigarettes among U.S. high school students are presented in Tables 2.3b and Figure 2.1, using data from the

2011–2015 NYTS. The prevalence of ever use increased

from 4.7% in 2011 to 10% in 2012, to 11.9% in 2013,

to 27.3% in 2014, and then to 37.7% in 2015. In that year,

an estimated 5,624,876 high school students had ever

used e-cigarettes (CDC, unpublished data [NYTS 2015]).

In 2011–2013, male high school students had a higher

rate of ever use each year compared with female students,

but in 2014 the genders did not differ significantly in their

rates. From 2011 to 2015, White and Hispanic high school

students were more likely each year to be ever users than

were Black students: In 2015, these figures were 38% and

43%, respectively, for White and Hispanic students compared with 28.5% for Black students.
A Report of the Surgeon General

34 Chapter 2

Table 2.3a Percentage of middle school students who have ever used e-cigarettesa, by gender and race/ethnicity; National Youth Tobacco Survey 

(NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9

Gender

Female 1.2 (0.8–1.6) 0.2 2.4 (1.9–3.0) 0.3 2.8 (2.3–3.5) 0.3 9.9 (7.8–12.6) 1.2 12.2 (10.5–14.1) 0.9

Male 1.7 (1.1–2.7) 0.4 3.0 (2.4–3.6) 0.3 3.1 (2.5–3.9) 0.3 10.3 (8.6–12.3) 0.9 14.9 (12.9–17.2) 1.1

Race/ethnicity

White 1.5 (0.9–2.3) 0.3 2.6 (2.1–3.3) 0.3 3.0 (2.4–3.7) 0.3 8.9 (7.2–11.1) 1.0 12.2 (10.1–14.5) 1.1

Black or African 

American

1.2 (0.7–2.0) 0.3 2.3 (1.3–4.2) 0.7 2.7 (1.9–3.7) 0.5 9.7 (7.9–11.9) 1.0 11.7 (9.5–14.3) 1.2

Hispanic or Latino 1.6 (1.1–2.3) 0.3 3.3 (2.3–4.6) 0.6 3.9 (2.9–5.2) 0.6 14.6 (12.2–17.4) 1.3 18.6 (15.9–21.5) 1.4

Otherb — — 1.0 (0.5–2.2) 0.4 — — 6.5 (3.9–10.9) 1.7 11.9 (8.2–17.1) 2.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of 

questions used to measure e-cigarette use varied from 2011 to 2015.

aIncludes those who reported ever trying e-cigarettes.

bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 35

Table 2.3b Percentage of high school students who have ever used e-cigarettesa, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 

2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2

Gender

Female 3.5 (2.7–4.4) 0.4 8.0 (6.7–9.5) 0.7 9.9 (8.3–11.7) 0.8 24.5 (21.4–27.9) 1.6 34.6 (31.9–37.3) 1.4

Male 5.9 (4.7–7.3) 0.7 12.0 (10.2–14.1) 1.0 13.8 (12.1–15.8) 0.9 30.1 (27.2–33.3) 1.5 40.7 (37.7–43.7) 1.5

Race/ethnicity

White 5.8 (4.6–7.4) 0.7 12.3 (10.5–14.4) 1.0 14.7 (12.8–16.9) 1.0 29.7 (26.2–33.4) 1.8 38.0 (35.1–41.0) 1.5

Black or African 

American

1.5 (0.9–2.4) 0.4 4.0 (3.1–5.1) 0.5 4.9 (3.6–6.6) 0.7 17.6 (14.1–21.8) 1.9 28.5 (25.5–31.8) 1.6

Hispanic or 

Latino

3.7 (2.5–5.5) 0.7 8.5 (6.6–10.8) 1.0 10.4 (8.6–12.5) 1.0 29.9 (25.4–34.9) 2.4 43.0 (38.9–47.2) 2.1

Otherb 2.8 (1.7–4.6) 0.7 6.0 (3.3–10.8) 1.8 8.3 (5.3–12.8) 1.8 18.7 (14–24.5) 2.6 37.4 (24.8–52.1) 7.0

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. Wording of questions used to measure e-cigarette use varied from 2011 to 2015.

aIncludes those who reported ever trying e-cigarettes.

bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General

36 Chapter 2

Past-30-Day Use

According to the NYTS, past-30-day use of 

e-cigarettes among students in grades 6−12 in the

United States increased from 1.1% in 2011 to 2.1% in

2012, to 3.1% in 2013, to 9.3% in 2014, and then 11.3%

in 2015 (CDC 2013b; Ambrose et al. 2014; Lippert 2015;

CDC, unpublished data) (Figure 2.2). In 2015, approximately 3,038,000 middle and high school students were

past-30-day users of e-cigarettes (CDC, unpublished

data [NYTS 2015]). Across all years, past-30-day use of

e-cigarettes was higher among high school students than

middle school students (Figure 2.2; Tables 2.2a and 2.2b).

In the MTF, estimates were stable from 2014 to 2015;

among 8th, 10th, and 12th graders, past-30-day use went

from 8.7% to 9.5%, 16.2% to 14%, and 17.1% to 16.2%,

respectively (University of Michigan, Institute for Social

Research, unpublished data). Differences in trends in past30-day use between the NYTS and MTF may be due to differences in age groups (e.g., the NYTS includes all grades

in middle school and all grades in high schools) and the

way in which these measures were asked on the instruments (see Table A2.2-1 in Appendix 2.2).

Figure 2.2 Trends in past-30-day e-cigarette usea among U.S. middle and high school students; National Youth 

Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).

Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this 

estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.

aIncludes those who responded “1 or more” for the following question: “During the last 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?”

Middle school students. Trends in past-30-day use of 

e-cigarettes among middle school students in the United

States are presented in Table 2.2a and Figure 2.2, again

using data from the 2011–2015 NYTS. The prevalence of

such use in this population increased from 0.6% in 2011

to 1.1% in 2012 and 2013, to 3.9% in 2014, and then to

5.3% in 2015 (Table 2.2a) (CDC 2016). Between 2011 and

2015, there were no significant differences in prevalence

by gender; unstable estimates (see notes to the table)

precluded an examination of differences in past-30-day

e-cigarette use by race/ethnicity for 2011–2013. In 2014,

the prevalence of past-30-day use was higher among

Hispanics (6.2%) than Whites (3.1%), a trend that was also

seen in 2015 with 8.3% of Hispanics and 4.4% of Whites

reporting past-30-day use. From 2011 to 2015, increases

were seen among females (0.4% to 4.8%), males (0.7% to

5.9%), Whites (0.6% to 4.4%), Hispanics (0.6% to 8.3%),

and Blacks (1.1% in 2012 to 4.1%) (Table 2.2a) (CDC 2013b; 

CDC 2015c; CDC 2016).

High school students. Trends in past-30-day use 

of e-cigarettes among high school students are also presented in Table 2.2b and Figure 2.2, again using data from 

the 2011−2015 NYTS. The prevalence of such use in this 

population increased from 1.5% in 2011 to 2.8% in 2012, 
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 37

E-Cigarette Use Among Youth and Young Adults

to 4.5% in 2013, to 13.4% in 2014, and then to 16% in 

2015. From 2011 to 2013 and in 2015, males were significantly more likely each year to be past-30-day users than 

were females, but this difference was not significant in 

2014 (Table 2.2b). From 2012 to 2015, Black high school 

students were less likely each year to be past-30-day 

users than were White or Hispanic high school students (Table  2.2b). During 2011–2015, large increases 

in past-30-day use were seen among females (0.7% to 

12.8%), males (2.3% to 19%), Whites (1.8% to 17.2%), 

and Hispanics (1.3% to 16.4%) (Table 2.2b) (CDC 2013b, 

2015c, 2016).

Young Adults

Current Prevalence

According to the 2013–2014 National Adult Tobacco 

Survey (NATS), among young U.S. adults aged 18–24 years, 

the prevalence of ever use and current use of e-cigarettes 

was 35.8% and 13.6%, respectively (Table 2.4a). These 

percentages were significantly higher than for the same 

measures among adults aged 25 years or over (16.4% and 

5.7%, respectively) (Table 2.4b). Among young adults, 

ever and current use were both higher among males than 

females and for Whites than in other racial/ethnic groups 

(Table  2.4a). By educational attainment, among young 

adults, both ever and current use were lowest among 

those with a college degree (Table 2.4a). Among all young 

adults, 2% reported using e-cigarettes “every day”; while 

among current users in this age group, 15% reported this 

frequency (Table 2.4a). Use of e-cigarettes “every day” 

among older adults (≥25 years of age) was 1.3% overall 

and 22% among current users (Table 2.4b). Among young 

adults, sociodemographic differences in frequent use followed the same pattern as those for ever and current use 

(Table 2.4a).

Trends in Prevalence

According to the Styles (also known as HealthStyles 

or Summer Styles) survey, the prevalence of ever use of 

e-cigarettes among young adults aged 18–24 years was

6.9% in 2011, 4.1% in 2012, 7.8% in 2013, and 14.3% in

2014, a year that saw the addition of other products to

this measure, including e-hookahs and e-pipes or e-cigars

(Figure 2.3). Although the prevalence of ever use of

e-cigarettes among young adults remained consistent

from 2010 to 2013, it doubled from 2013 to 2014, presumably reflecting in part the addition of new products

to the definition of e-cigarettes. In 2010, young adults

(18–24 years) were more likely than older adults (25–44

and 45–64 years of age) to be ever users of e-cigarettes

(King et al. 2015). In 2014, ever use of e-cigarettes or similar products was statistically equivalent between young 

adults (18–24 years old) at 14.3%, adults 25–44 years old 

at 15%, and adults 45–64 years old at 11.9% (p  >0.05) 

(CDC, unpublished data [Styles 2014]).

E-Cigarette Use and Use of Other

Tobacco Products

Evidence from both national and regional studies 

suggests that e-cigarette use is strongly associated with 

other tobacco use, especially the use of combustible products (including conventional cigarettes, cigar products, 

and hookahs). However, many youth and young adults 

use e-cigarettes exclusively, too. Estimates from crosssectional surveys such as the NYTS, MTF, and NATS are 

presented below for youth and young adults, followed by 

longitudinal studies that examine whether e-cigarette use 

precedes the use of other tobacco products (Leventhal 

et al. 2015; Primack et al. 2015; Barrington-Trimis et al. 

2016; Unger et al. 2016; Wills et al. 2016).

Cross-Sectional Studies

Youth

Current prevalence. Using data from the 2015 MTF 

survey, Figure 2.4 and Table 2.5 show past-30-day use of 

e-cigarettes and conventional cigarettes, including both

exclusive and combined use of these products, among

8th-, 10th-, and 12th-grade students. In the 2015 MTF

survey, 10.4% of 12th graders used e-cigarettes only,

5.3%  used conventional cigarettes only, and 5.8% used

both e-cigarettes and conventional cigarettes at least once

in the past 30 days (Table 2.5) (MTF 2015a,b). For all grade

levels, exclusive use of e-cigarettes was more prevalent

(6.8%, 10.4%, and 10.4% of 8th, 10th, and 12th graders,

respectively) than exclusive use of conventional cigarettes

alone (1.4%, 2.2%, 5.3%, respectively). In the 8th and

10th grades, the combined or dual use of e-cigarettes and

conventional cigarettes was also more prevalent than the

use of conventional cigarettes alone (2.4% vs. 1.4%, and

3.5% vs. 2.2% for 8th and 10th graders, respectively); while 

in the 12th grade, the prevalence in the two categories was

nearly identical (5.8% vs. 5.3%). As grade level increases,

the ratio of any e-cigarette use to any conventional cigarette use decreases. Among 12th graders, dual use of these

products was higher among boys than girls and among

Whites than Blacks. In all grade levels, dual use was much

higher among students who planned to attend fewer

than 4 years of college compared to those who planned

to attend 4 years of college. No other sociodemographic
A Report of the Surgeon General

38 Chapter 2

Table 2.4a Percentage of young adults (18–24 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult 

Tobacco Survey (NATS) 2013–2014

Ever usea Current useb

Frequent usec: Among 

current users

Frequent usec: 

Among all young adults

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 35.8 (34.1–37.6) 0.9 13.6 (12.5–14.8) 0.6 15.0 (12.1–18.5) 1.6 2.0 (1.6–2.6) 0.2

Gender

Female 28.4 (26.1–30.8) 1.2 9.8 (8.3–11.5) 0.8 10.0 (6.5–15.1) 2.2 1.0 (0.6–1.5) 0.2

Male 42.9 (40.4–45.3) 1.2 17.1 (15.4–19.0) 0.9 17.8 (13.9–22.5) 2.2 3.0 (2.3–4.0) 0.4

Race/ethnicity

White 39.7 (37.4–41.9) 1.2 16.1 (14.5–17.8) 0.9 15.3 (11.7–19.7) 2.0 2.5 (1.9–3.2) 0.4

Black or African 

American

23.1 (19.0–27.8) 2.3 5.4 (3.7–7.9) 1.1 — — — —

Hispanic or Latino 36.6 (32.6–40.7) 2.1 13.4 (10.9–16.4) 1.4 12.0 (6.8–20.2) 3.3 1.6 (0.9–2.8) 0.5

Otherd 30.8 (25.8–36.3) 2.7 10.8 (8.1–14.2) 1.6 21.5 (11.6–36.4) 6.3 2.3 (1.2–4.4) 0.8

Education

< High school 44.8 (38.9–50.9) 3.1 15.2 (11.5–19.7) 2.1 9.8 (4.8–18.8) 3.4 1.5 (0.7–3.0) 0.5

High school 39.4 (36.7–42.2) 1.4 14.9 (13.1–17.0) 1.0 17.6 (13.0–23.4) 2.6 2.6 (1.9–3.6) 0.4

Some collegee 34.3 (31.6–37.0) 1.4 14.7 (12.8–16.8) 1.0 14.8 (10.2–21.0) 2.7 2.2 (1.5–3.2) 0.4

College degreef 16.9 (14.2–20.0) 1.5 4.5 (3.1–6.4) 0.8 — — — —

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.

aIncludes those who reported they had heard of e-cigarettes and tried e-cigarettes.

bIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

cIncludes those who reported they had heard of e-cigarettes, tried e-cigarettes, and reported using e-cigarettes every day at the time of the interview.

dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

eIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

f

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 39

Table 2.4b Percentage of adults (≥25 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult Tobacco Survey 

(NATS) 2013–2014

Ever usea Current useb

Frequent usec: Among 

current users

Frequent usec: 

Among all adults

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 16.4 (15.9–16.8) 0.2 5.7 (5.5–6.0) 0.1 22.0 (20.1–24.0) 1.0 1.3 (1.1–1.4) 0.1

Gender

Female 14.7 (14.2–15.3) 0.3 5.0 (4.7–5.4) 0.2 20.6 (18.1–23.3) 1.3 1.0 (0.9–1.2) 0.1

Male 18.3 (17.6–18.9) 0.3 6.6 (6.1–7.0) 0.2 23.0 (20.2–25.9) 1.5 1.5 (1.3–1.7) 0.1

Race/ethnicity

White 16.2 (15.8–16.7) 0.2 6.0 (5.7–6.4) 0.2 23.9 (21.7–26.3) 1.2 1.4 (1.3–1.6) 0.1

Black or African 

American

15.1 (13.9–16.5) 0.7 3.8 (3.2–4.5) 0.3 15.2 (10.2–22.2) 3.0 0.6 (0.4–0.9) 0.1

Hispanic or Latino 15.6 (14.3–17.0) 0.7 4.9 (4.1–5.8) 0.4 15.8 (10.4–23.4) 3.3 0.8 (0.5–1.2) 0.2

Otherd 21.0 (19.2–22.9) 0.9 8.0 (6.7–9.4) 0.7 19.4 (14.0–26.2) 3.1 1.5 (1.1–2.1) 0.3

Education

<High school 18.2 (16.8–19.7) 0.8 5.2 (4.4–6.1) 0.4 20.8 (15.2–27.7) 3.2 1.1 (0.8–1.5) 0.2

High school 20.6 (19.7–21.6) 0.5 7.6 (7.0–8.3) 0.3 19.2 (16.1–22.7) 1.7 1.5 (1.2–1.8) 0.1

Some collegee 19.7 (18.9–20.5) 0.4 7.4 (6.8–7.9) 0.3 24.5 (21.4–27.8) 1.6 1.8 (1.6–2.1) 0.1

College degreef 8.7 (8.2–9.1) 0.2 2.8 (2.5–3.1) 0.1 22.0 (18.1–26.4) 2.1 0.6 (0.5–0.8) 0.1

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported they had heard of and tried e-cigarettes.

bIncludes those who reported they had heard, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

cIncludes those who reported they had heard of, tried, and reported using e-cigarettes every day at the time of the interview.

dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

eIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

f

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
A Report of the Surgeon General

40 Chapter 2

Figure 2.3 Trends in ever e-cigarette usea among U.S. adults by age group; Styles 2010–2014

Source: King et al. (2015) (data: HealthStyles 2010–2013); Centers for Disease Control and Prevention, unpublished data (data: 

HealthStyles 2014).

Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of 

this estimate to those collected in previous years. The dotted lines from 2013 to 2014 represent these differences.

aIncludes those who responded “electronic cigarettes or e-cigarettes” to the following question, “Have you ever tried any of the 

following products, even just one time? Electronic cigarettes or e-cigarettes, such as Ruyan or NJOY?”

Figure 2.4 Percentage of students in grades 8, 10, and 12 who used e-cigarettes and cigarettes in the past 30 days; 

Monitoring the Future (MTF) 2015

Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).

Note: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four 

forms only.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 41

Table 2.5 Percentage of students in grades 8, 10, and 12 who used e-cigarettes, cigarettes, or both products in the past 30 days, by sociodemographic characteristics; 

Monitoring the Future (MTF) 2015

8th grade 10th grade 12th grade

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Overall 89.4 

(88.4–90.5)

6.8 

(5.8–7.8)

1.4 

(0.9–1.8)

2.4 

(1.9–2.9)

83.9 

(81.9–85.9)

10.4 

(9.0–11.8)

2.2 

(1.7–2.7)

3.5 

(2.8–4.3)

78.5 

(76.7–80.3)

10.4 

(9.1–11.8)

5.3 

(4.6–6.0)

5.8 

(5.0–6.6)

Gender

Female 90.2 

(88.7–91.7)

6.2 

(4.9–7.5)

1.4 

(0.7–2.0)

2.2 

(1.6–2.9)

85.6 

(83.6–87.6)

8.6 

(7.2–10.1)

2.4 

(1.6–3.1)

3.4 

(2.5–4.3)

84.4 

(82.8–86.0)

7.1 

(6.2–8.0)

4.7 

(3.6–5.7)

3.8 

(3.1–4.6)

Male 88.9 

(87.3–90.4)

7.2 

(6.0–8.5)

1.4 

(0.7–2.0)

2.5 

(1.7–3.3)

82.2 

(79.6–84.7)

12.2 

(10.2–14.2)

2.0 

(1.3–2.7)

3.6 

(2.6–4.7)

72.9 

(70.2–75.6)

14.1 

(11.8–16.3)

5.6 

(4.6–6.6)

7.5 

(6.1–8.9)

Race/ 

ethnicity

White 90.1 

(88.6–91.6)

6.2 

(4.9–7.4)

1.2 

(0.6–1.8)

2.6 

(1.7–3.4)

82.1 

(79.5–84.7)

11.2 

(9.2–13.2)

2.3 

(1.6–2.9)

4.4 

(3.4–5.4)

75.2 

(72.7–77.7)

12.0 

(10.4–13.6)

5.8 

(4.7–6.9)

7.1 

(5.9–8.3)

African 

American

91.2 

(88.2–94.1)

5.3 

(2.7–7.8)

2.1 

(0.6–3.7)

1.5 

(0.0–2.9)

89.9 

(85.7–94.1)

6.6 

(3.6–9.5)

1.8 

(0.4–3.1)

1.7 

(0.4–3.1)

87.7 

(85.1–90.3)

5.2 

(3.8–6.6)

5.1 

(3.3–6.8)

2.0 

(1.1–3.0)

Hispanic 88.7 

(85.8–91.5)

8.2 

(6.1–10.4)

0.9 

(0.2–1.6)

2.2 

(1.2–3.2)

84.6 

(81.5–87.6)

10.5 

(7.6–13.4)

2.4 

(0.9–4.0)

2.5 

(0.8–4.2)

80.9 

(78.0–83.7)

10.3 

(8.0–12.5)

4.4 

(3.2–5.5)

4.5 

(3.1–6.0)

College 

plans

None or 

<4 years

76.8 

(71.0–82.5)

10.1 

(6.1–14.0)

4.9 

(1.7–8.1)

8.3 

(4.8–11.8)

66.3 

(61.1–71.5)

15.4 

(11.3–19.4)

7.0 

(3.8–10.2)

11.3 

(7.6–15.1)

65.1 

(61.2–68.9)

13.0 

(9.7–16.3)

10.2 

(8.2–12.3)

11.7 

(9.5–13.9)

Complete 

4 years

90.5 

(89.4–91.5)

6.5 

(5.5–7.4)

1.1 

(0.7–1.5)

2.0 

(1.5–2.5)

85.7 

(83.6–87.7)

9.8 

(8.3–11.4)

1.7 

(1.3–2.2)

2.8 

(2.1–3.5)

81.6 

(79.9–83.2)

9.9 

(8.6–11.1)

4.1 

(3.4–4.8)

4.5 

(3.8–5.2)
A Report of the Surgeon General

42 Chapter 2

8th grade 10th grade 12th grade

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Parental 

educationa

1–2 (Low) 88.1 

(83.9–92.2)

5.9 

(3.3–8.4)

1.8 

(0.3–3.2)

4.3 

(2.1–6.6)

77.2 

(72.0–82.4)

12.6 

(9.0–16.2)

4.8 

(1.5–8.0)

5.4 

(3.1–7.8)

77.3 

(73.4–81.2)

10.1 

(7.3–13.0)

7.9 

(5.4–10.4)

4.7 

(3.1–6.3)

2.5–3 86.2 

(83.3–89.1)

9.4 

(6.7–12.1)

1.8 

(0.6–3.1)

2.6 

(1.2–3.9)

81.7 

(78.3–85.2)

10.6 

(8.1–13.0)

2.5 

(1.3–3.7)

5.2 

(3.2–7.1)

75.2 

(72.4–78.1)

11.1 

(9.0–13.3)

7.2 

(5.5–8.8)

6.5 

(5.0–7.9)

3.5–4 89.6 

(87.5–91.8)

7.3 

(5.5–9.2)

1.3 

(0.3–2.3)

0.8 

(1.7–2.7)

83.5 

(80.3–86.7)

10.0 

(7.7–12.3)

2.8 

(1.7–3.9)

3.7 

(2.5–5.0)

78.7 

(75.9–81.5)

9.9 

(7.9–11.8)

4.6 

(3.6–5.6)

6.8 

(5.3–8.4)

4.5–5 91.0 

(89.1–92.8)

6.2 

(4.5–7.9)

1.3 

(0.4–2.1)

1.5 

(0.6–2.5)

86.1 

(83.5–88.8)

9.7 

(7.5–11.8)

1.4 

(0.7–2.0)

2.9 

(1.7–4.1)

78.6 

(75.7–81.5)

11.2 

(9.1–13.2)

4.4 

(3.3–5.5)

5.8 

(4.4–7.2)

5.5–6 

(High)

91.9 

(89.4–94.5)

5.2 

(3.3–7.0)

1.0 

(0.0–2.1)

1.9 

(0.4–3.4)

87.6 

(83.6–91.6)

9.2 

(6.3–12.2)

1.0 

(0.2–1.8)

2.2 

(0.7–3.7)

82.7 

(79.7–85.7)

10.4 

(8.1–12.7)

3.2 

(2.1–4.3)

3.7 

(2.2–5.2)

Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).

Notes: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four forms only.

aParental education is an average score of mother’s education and father’s education.

Table 2.5 Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 43

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 37.)

differences were observed among dual users (Table 2.5). 

For 10th and 12th graders, exclusive use of e-cigarettes 

was higher among boys than girls.

Tables 2.6a and 2.6b present data from the 2015 NYTS 

for middle and high school students. These data represent 

the percentages of tobacco users who were either lifetime 

or past-30-day users of e-cigarettes, by tobacco-use category (e.g., cigarettes only, other combustibles only). In 

these data, a correlation among the increasing levels of 

tobacco use, increasing complexity of poly-tobacco use, and 

e-cigarette use is apparent, with ever use and past-30-day

use of e-cigarettes emerging as least prevalent among never

tobacco users and most prevalent among the highest category of poly-tobacco users (conventional cigarettes plus

other combustibles and noncombustibles) for both age

groups. As an example, past-30-day e-cigarette use was

rare (2.8%) among middle school students who did not

use other tobacco products in that time period. However,

using the standard of past-30-day-use for each category, the

level of such use grew from 44.9% among those who had

used cigarettes only; to 61.3% among those who had used

cigarettes and other combustibles only; to 74.6% among

those who had used cigarettes, other combustibles, and

other noncombustibles only (Table 2.6a). These data are

consistent with results from the 2013–2014 PATH study

(n  =  13,651 youth, 12–17 years old), which showed that

52.6% of past-30-day tobacco users also used e-cigarettes

(Kasza et al. 2016).

According to the 2015 NYTS, among high school students, past-30-day use of e-cigarettes was also rare (3.4%) 

among never users of other tobacco products (Table 2.6b). 

In contrast, 18.4% of ever smokers of cigarettes only; 

36.3% of ever smokers of cigarettes and other combustible 

products only; and 55% of ever users of cigarettes, other 

combustibles, and other noncombustible products only 

had used e-cigarettes in the past 30  days. Although the 

survey found that just 7.3% of high school students were 

past-30-day exclusive users of e-cigarettes, many types of 

tobacco product users in the past 30 days were found to 

have used e-cigarettes in that period: 41.1% of cigaretteonly smokers; 58.8% of cigarette smokers and smokers of 

other combustible tobacco products only; and 77% of cigarette, other combustible, and noncombustible product 

users only. Similarly, 27.4% of high school students who 

had not used tobacco products in the past 30 days had ever 

tried e-cigarettes, as had 80.8% of past-30-day cigaretteonly smokers and 95.5% of those who had used cigarettes, 

other combustible, and other noncombustible tobacco 

products only (Table 2.6b).

Figure 2.5 presents data from the 2015 NYTS on the 

prevalence of past-30-day use of various tobacco products 

among middle and high school students. Although the 

overall level of tobacco use was lower in middle school, 

the patterns of poly-tobacco use were similar between the 

two groups, albeit with a larger proportion of poly-tobacco 

use in high school. An estimated 6.6% of high school students and 1.8% of middle school students were dual users 

of combustible tobacco products and e-cigarettes in 2015. 

Combined use of combustible tobacco, noncombustible 

tobacco, and e-cigarettes in the past 30 days was rare, 

with this pattern found for just 0.7% of middle school 

and 2.6%  of high school students in 2015 (Figure 2.5). 

Longitudinal data are needed to follow individuals over 

time, ideally for several years, to more precisely examine 

both the trajectories into and out of cigarette and 

e-cigarette use and to determine if dual use is a steady state 

or a pathway-to-persistent-use-of-combustible-tobacco

state (Cobb et al. 2015). The small number of such studies

that currently exist are discussed below.

Trends in prevalence. Tables 2.7a and 2.7b and 

Figures 2.6 and 2.7 present patterns of ever e-cigarette 

and poly-tobacco use over time, using the NYTS data 

from 2011 to 2015. Among both middle school and high 

school students, the exclusive use of combustible products declined over time, while both the exclusive use of 

e-cigarettes and the dual use of e-cigarettes with combustible products increased, especially from 2013 to 2015.

Middle school students. In 2011, an estimated 

21% of middle school students had ever used some form 

of tobacco in their lifetimes, compared to just 1.4% of 

middle school students who had ever used e-cigarettes 

(Table 2.7a). By 2015, 13.5% of middle school students 

had ever tried a tobacco product, while 3.5% had tried 

e-cigarettes. In that year, 4.5% of middle school students

were ever users of e-cigarettes only; 6.2% were ever users

of e-cigarettes and combustible products only; and 2.2%

were ever users of combustible products, noncombustible

products, and e-cigarettes. This means that 70% of middle

school students who had ever used e-cigarettes had

also experimented with a combustible tobacco product,

although which came first is unknown. In 2015, for

past-30-day use, exclusive e-cigarette use was 2.6% and

exclusive combustible tobacco use was 1.2%. Also in 2015,

the prevalence of past-30-day dual use of e-cigarettes and

any other combustible or noncombustible product was

similar to those estimates, at 2.7% (1.8% for e-cigarettes

plus combustibles only, 0.2% for noncombustibles and

e-cigarettes only, and 0.7% for e-cigarettes plus combustibles and noncombustibles only). In 2015, ever use of cigarettes in combination with combustibles (6.2%) was equal

to or higher than ever use of e-cigarettes only (4.5%) or

combustibles only (4.4%) (Table 2.7a).

High school students. In 2011, an estimated 47.2% of 

high school students had ever used other tobacco products in their lifetimes, compared to 4.7%  who had ever 

used e-cigarettes (Table 2.7b). By 2015, 50.4% of high
A Report of the Surgeon General

44 Chapter 2

Table 2.6a Lifetime and past-30-day e-cigarette use among U.S. middle school students, by other tobacco product 

use; National Youth Tobacco Survey (NYTS) 2015

Lifetime e-cigarette usea

Past-30-day 

e-cigarette useb

Nc % (95% CI) SE % (95% CI) SE

Ever other tobacco used (n = 1,757) 8,162

Never 6,942 5.3 (4.5–6.2) 0.4 1.6 (1.3–2.0) 0.2

Cigarettes only 343 54.3 (46.7–61.7) 3.8 20.8 (15.7–27.0) 2.8

Other combustibles only 261 59.0 (51.5–66.1) 3.7 24.8 (19.0–31.7) 3.2

Noncombustibles only 89 30.7 (23.2–39.3) 4.1 — —

Cigarettes + other combustibles only 300 70.6 (62.9–77.3) 3.6 35.0 (27.5–43.3) 4.0

Cigarettes + noncombustibles only 67 69.5 (54.5–81.3) 6.9 21.7 (12.7–34.6) 5.5

Other combustibles + noncombustibles only 27 80.3 (56.1–92.9) 9.2 39.4 (20.3–62.3) 11.2

Cigarettes + other combustibles + noncombustibles 

only

133 84.1 (73.3–91.1) 4.4 45.0 (34.7–55.7) 5.3

Past-30-day other tobacco usee (n = 417) 8,145

No 7,728 10.5 (9.1–12.0) 0.7 2.8 (2.3–3.4) 0.3

Cigarettes only 70 80.6 (68.3–89.0) 5.2 44.9 (32.0–58.6) 6.8

Other combustibles only 153 82.8 (74.0–89.1) 3.8 69.2 (59.1–77.8) 4.7

Noncombustibles only 50 49.0 (34.9–63.3) 7.3 23.1 (12.7–38.2) 6.4

Cigarettes + other combustibles only 63 77.3 (58.8–89.0) 7.6 61.3 (43.9–76.2) 8.4

Cigarettes + noncombustibles only 18 87.2 (65.2–96.1) 7.2 67.8 (40.0–87.0) 12.6

Other combustibles + noncombustibles only 20 87.5 (63.2–96.6) 7.7 64.8 (42.2–82.3) 10.6

Cigarettes + other combustibles + noncombustibles 

only

43 85.8 (67.5–94.6) 6.5 74.6 (43.4–91.8) 12.7

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other 

tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles. 

Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and 

Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes 

and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other 

Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes. 

Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.

aIncludes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once 

or twice?”

bIncludes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?”

cIncludes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.

dIncludes those who reported trying at least one of the following products (e-cigarettes not included in the definitions): Cigarettes Only;

Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only; 

Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.

eIncludes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the 

definitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and 

Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 45

E-Cigarette Use Among Youth and Young Adults

Table 2.6b Lifetime and past-30-day e-cigarette use among U.S. high school students, by other tobacco product use; 

National Youth Tobacco Survey (NYTS) 2015

Lifetime e-cigarette usea

Past-30-day 

e-cigarette useb

Nc % (95% CI) SE % (95% CI) SE

Ever other tobacco used (n = 5,094) 9,422

Never 5,326 13.1 (11.7–14.8) 0.8 3.4 (2.5–4.4) 0.5

Cigarettes only 675 54.7 (48.5–60.6) 3.0 18.4 (13.7–24.4) 2.7

Other combustibles only 947 60.0 (54.4–65.3) 2.7 21.7 (18.0–25.9) 2.0

Noncombustibles only 137 39.8 (30.8–49.6) 4.7 20.2 (12.5–31.0) 4.6

Cigarettes + other combustibles only 1,307 79.6 (74.7–83.8) 2.3 36.3 (31.5–41.3) 2.5

Cigarettes + noncombustibles only 131 61.5 (48.7–72.9) 6.2 25.5 (18.5–34.0) 3.9

Other combustibles + noncombustibles only 171 69.5 (57.1–79.6) 5.7 35.3 (26.1–45.8) 5.0

Cigarettes + other combustibles + noncombustibles 

only

728 89.2 (82.6–93.5) 2.7 55.0 (47.5–62.4) 3.8

Past-30-day other tobacco usee (n = 2,389) 9,416

No 7,542 27.4 (25.2–29.7) 1.1 7.3 (6.1–8.8) 0.7

Cigarettes only 288 80.8 (74.2–86.0) 2.9 41.1 (32.2–50.6) 4.7

Other combustibles only 701 77.2 (71.2–82.3) 2.8 50.4 (45.0–55.8) 2.7

Noncombustibles only 192 69.6 (54.6–81.4) 6.8 31.2 (23.0–40.9) 4.5

Cigarettes + other combustibles only 353 87.1 (77.5–93.0) 3.8 58.8 (49.1–67.8) 4.7

Cigarettes + noncombustibles only 62 76.9 (59.8–88.2) 7.2 50.8 (27.9–73.5) 12.3

Other combustibles + noncombustibles only 108 88.7 (78.8–94.3) 3.8 74.1 (61.3–83.9) 5.7

Cigarettes + other combustibles + noncombustibles 

only

170 95.9 (87.2–98.8) 2.4 77.0 (66.6–84.8) 4.6

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other 

tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles. 

Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and 

Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes 

and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other 

Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes. 

Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.

aIncludes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once 

or twice?”

bIncludes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?”

cIncludes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.

dIncludes those who reported trying at least one of the following products (e-cigarettes not included in the definitions): Cigarettes Only;

Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only; 

Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.

eIncludes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the 

definitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and 

Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
A Report of the Surgeon General

46 Chapter 2

Figure 2.5 Past-30-day use of various tobacco products among U.S. middle and high school students; National 

Youth Tobacco Survey (NYTS) 2015

Source: Centers for Disease Control and Prevention 2015b; unpublished data (data: NYTS 2015).

aIncludes exclusive use of e-cigarettes. It does not include use of any other product.

bIncludes exclusive use of smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products or 

e-cigarettes.

cIncludes the use of cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It includes participants who reported use of combustible

and noncombustible products but not e-cigarettes.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 47

Table 2.7a Percentage of middle school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Any lifetimea tobacco use 21.0 (19.2–22.9) 0.9 17.9 (15.9–20.0) 1.0 17.6 (15.6–19.9) 1.1 19.1 (16.7–21.8) 1.3 19.4 (17.0–22.0) 1.2

Any lifetime e-cigarette useb 1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9

Ever tobacco usec

E-cigarettes only 0.3 (0.2–0.6) 0.1 0.4 (0.3–0.5) 0.1 0.5 (0.3–0.9) 0.1 2.9 (2.3–3.5) 0.3 4.5 (3.9–5.2) 0.3

Combustibles and e-cigarettes only 0.4 (0.3–0.6) 0.1 1.1 (0.9–1.4) 0.1 1.5 (1.1–1.9) 0.2 4.5 (3.9–5.3) 0.4 6.2 (5.4–7.2) 0.5

Noncombustibles and e-cigarettes only ND ND — — — — 0.3 (0.1–0.6) 0.1 0.4 (0.2–0.7) 0.1

Combustibles, noncombustibles, and

e-cigarettes

0.5 (0.3–0.9) 0.1 1.1 (0.8–1.4) 0.1 0.8 (0.6–1.2) 0.1 2.2 (1.45–3.2) 0.4 2.2 (1.7–2.9) 0.3

Combustibles only 13.9 (12.5–15.4) 0.7 10.7 (9.5–12.1) 0.7 11.6 (10.1–13.3) 0.8 6.9 (5.6–8.4) 0.7 4.4 (3.7–5.2) 0.4

Noncombustibles only 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.6) 0.2 0.8 (0.6–1.1) 0.1 0.8 (0.5–1.2) 0.2 1.0 (0.7–1.4) 0.2

Combustibles and noncombustibles 

only 

4.3 (3.5–5.1) 0.4 3.4 (2.8–4.0) 0.3 2.4 (1.8–3.2) 0.3 1.5 (1.1–2.1) 0.2 0.7 (0.4–1.1) 0.2

Any past-30-day tobacco used 7.5 (6.4–8.8) 0.6 6.7 (5.8–7.7) 0.5 6.5 (5.43–7.8) 0.6 7.7 (6.7–8.9) 0.6 7.4 (6.3–8.7) 0.6

Any past-30-day e-cigarette usee 0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4

Past-30-day tobacco use

E-cigarettes onlyf 0.2 (0.1–0.4) 0.1 0.3 (0.2–0.4) 0.1 0.4 (0.2–0.8) 0.1 1.9 (1.4–2.5) 0.3 2.6 (2.2–3.2) 0.3

Combustibles and e-cigarettes only 0.1 (0.1–0.3) 0.0 0.5 (0.3–0.7) 0.1 0.4 (0.3–0.6) 0.1 1.3 (1.0–1.7) 0.2 1.8 (1.4–2.2) 0.2

Noncombustibles and e-cigarettes only — — — — — — 0.1 (0.1–0.2) 0.0 0.2 (0.1–0.3) 0.0

Combustibles, noncombustibles, and 

e-cigarettes

0.2 (0.1–0.3) 0.1 0.4 (0.2–0.5) 0.1 0.2 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1 0.7 (0.4–1.1) 0.1

Combustibles only 4.5 (3.7–5.5) 0.4 3.7 (3.2–4.3) 0.3 4.0 (3.3–4.9) 0.4 2.7 (2.1–3.3) 0.3 1.2 (0.9–1.6) 0.2

Noncombustibles only 0.9 (0.6–1.3) 0.2 0.7 (0.5–1.0) 0.1 0.6 (0.3–0.9) 0.2 0.7 (0.4–1.2) 0.2 0.6 (0.3–1.2) 0.2

Combustibles and noncombustibles 

only 

1.6 (1.3–2.0) 0.2 1.2 (0.9–1.5) 0.2 0.8 (0.5–1.1) 0.1 0.5 (0.4–0.8) 0.1 0.3 (0.1–0.6) 0.1

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard 

error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes, 

hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and 

combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.
A Report of the Surgeon General

48 Chapter 2

Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those 

who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or 

e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.

aIncludes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).

bIncludes those who reported having tried e-cigarettes in their lives.

cIncludes those who reported having tried at least one tobacco product in their lives.

dIncludes those who reported using at least one other tobacco product on at least 1 of the past 30 days.

eIncludes those who reported using e-cigarettes on at least 1 of the past 30 days.

f

Includes those who reported using e-cigarettes only on at least 1 of the past 30 days.

Table 2.7a Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 49

Table 2.7b Percentage of high school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Any lifetimea tobacco use 47.2 (44.0–50.4) 1.6 45.7 (43.0–48.5) 1.4 46.0 (43.3–48.7) 1.4 47.1 (44.5–49.8) 1.3 50.4 (47.9–52.9) 1.3

Any lifetime e-cigarette useb 4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2

Ever tobacco usec

E-cigarettes only 0.1 (0.1–0.2) 0.0 0.2 (0.2–0.4) 0.0 0.3 (0.2–0.6) 0.1 3.7 (2.9–4.8) 0.5 7.4 (6.6–8.4) 0.5

Combustibles and e-cigarettes 

only

1.6 (1.3–2.0) 0.2 4.2 (3.5–5.0) 0.4 6.0 (5.2–6.9) 0.4 14.5 (13.2–16.0) 0.7 20.0 (18.6–21.6) 0.8

Noncombustibles and e-cigarettes 

only

— — — — — — 0.3 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1

Combustibles, noncombustibles, 

and e-cigarettes

2.8 (2.2–3.6) 0.4 5.2 (4.3–6.2) 0.5 5.2 (4.2–6.3) 0.5 8.3 (7.0–9.7) 0.7 9.1 (7.6–10.9) 0.8

Combustibles only 29.1 (27.3–30.9) 0.9 25.1 (23.1–27.1) 1.0 25.2 (22.7–27.8) 1.3 15.8 (14.3–17.5) 0.8 10.2 (8.8–11.8) 0.8

Noncombustibles only 1.8 (1.3–2.4) 0.3 1.3 (1.0–1.8) 0.2 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.7) 0.2 0.9 (0.7–1.2) 0.1

Combustibles and 

noncombustibles only 

 11.8 (9.8–13.9) 1.1 9.7 (8.6–10.9) 0.6 7.8 (6.6–9.3) 0.7 3.3 (2.6–4.2) 0.4 2.2 (1.6–3.0) 0.4

Any past-30-day tobacco used 24.0 (22.0–26.5) 1.2 23 (21.5–25.2) 0.9 22.9 (21.1–24.9) 0.9 24.6 (22.6–26.7) 1.0 25.3 (23.1–27.6) 1.1

Any past-30-day e-cigarette usee 1.5 (1.2–2.0) 0.2 2.8 (2.3–3.5) 0.3 4.5 (3.8–5.3) 0.4 13.4 (11.2–16.1) 1.2 16.0 (14.1–18.0) 1.0

Past-30-day tobacco use

E-cigarettes onlyf 0.1 (0.1–0.2) 0.0 0.3 (0.2–0.4) 0.1 0.7 (0.5–0.9) 0.1 4.4 (3.4–5.7) 0.6 5.9 (4.9–7.0) 0.5

Combustibles and e-cigarettes 

only

0.7 (0.5–0.9) 0.1 1.4 (1.1–1.8) 0.2 2.6 (2.1–3.2) 0.3 5.8 (4.9–6.8) 0.5 6.6 (5.7–7.7) 0.5

Noncombustibles and 

e-cigarettes only

ND ND — — — — 0.6 (0.4–0.8) 0.1 0.7 (0.5–0.9) 0.1

Combustibles, noncombustibles, 

and e-cigarettes

0.6 (0.4–0.9) 0.1 1.1 (0.8–1.4) 0.1 1.1 (0.8–1.4) 0.1 2.5 (2.0–3.2) 0.3 2.6 (2.1–3.3) 0.3

Combustibles only 15.6 (14.5–16.8) 0.6 14.4 (13.2–15.6) 0.6 13.5 (12.4–14.8) 0.6 8.1 (7.2–9.2) 0.5 6.8 (5.9–7.8) 0.5

Noncombustibles only 2.3 (1.7–3.0) 0.3 1.9 (1.4–2.4) 0.2 1.6 (1.2–2.2) 0.3 1.5 (1.1–2.0) 0.2 1.5 (1.0–2.2) 0.3

Combustibles and 

noncombustibles only 

4.9 (4.0–6.1) 0.5 4.3 (3.7–5.2) 0.4 3.4 (2.7–4.3) 0.4 1.6 (1.2–2.2) 0.2 1.1 (0.7–1.8) 0.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
A Report of the Surgeon General

50 Chapter 2

Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard 

error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes, 

hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and 

combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.

Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those 

who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or 

e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.

aIncludes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).

bIncludes those who reported having tried e-cigarettes in their lives.

cIncludes those who reported having tried at least one tobacco product in their lives.

dIncludes those who reported using at least one other tobacco product on at least 1 of the past 30 days.

eIncludes those who reported using e-cigarettes on at least 1 of the past 30 days.

f

Includes those who reported using e-cigarettes only on at least 1 of the past 30 days.

Table 2.7b Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 51

E-Cigarette Use Among Youth and Young Adults

Figure 2.6 Percentage of U.S. middle school students who have ever used tobaccoa, by type of product; National 

Youth Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: For more information see Table 2.10a. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, 

which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent 

these differences.

aIncludes those who reported having tried at least one other tobacco product in their lives.

bIncludes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who 

responded “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” to the following question: “Which of the following tobacco 

products have you ever tried, even just one time?”

cIncludes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible 

products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette 

smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you 

ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies 

Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”; 

pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did 

you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even 

just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at 

least 1 day? (CHOOSE ALL THAT APPLY).”

dIncludes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products 

or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff, 

or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the 

past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following 

tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the 

following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”
A Report of the Surgeon General

52 Chapter 2

Figure 2.7 Percentage of U.S. high school students who have ever used tobaccoa, by type of product; National Youth 

Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: For more information see Table 2.10b. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, 

which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent 

these differences.

aIncludes those who reported having tried at least one other tobacco product in their lives.

bIncludes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who 

selected “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” for the following question: “Which of the following tobacco 

products have you ever tried, even just one time?”

cIncludes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible 

products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette 

smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you 

ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies 

Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”; 

pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did 

you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even 

just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at 

least 1 day? (CHOOSE ALL THAT APPLY).”

dIncludes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products 

or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff, 

or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the 

past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following 

tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the 

following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 53

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 43.)

school students had ever tried a tobacco product, and 

37.7% had ever used an e-cigarette. In 2015, 7.4% of high 

school students had ever used e-cigarettes exclusively; 

20% were ever dual users of e-cigarettes and combustible 

products; 0.6% were ever dual users of noncombustible 

products and e-cigarettes only; and 9.1% were ever poly 

users of combustibles, noncombustibles, and e-cigarettes. 

However, the order of the use (i.e., which product came 

first) remains unknown. In 2015, 5.9% of high school students were exclusive past-30-day users of e-cigarettes; 6.6% 

were past-30-day dual users of e-cigarettes and combustible tobacco products; 0.7% were past-30-day dual users 

of e-cigarettes and noncombustible tobacco products only; 

and 2.6% were past-30-day poly users of e-cigarettes, combustible, and noncombustible tobacco products. Exclusive 

use of combustible products (6.8%) remained as prevalent 

as past-30-day dual use of e-cigarettes and combustible 

products (6.6%) among high school students (Table 2.7b).

Young Adults2

2As opposed to the situation in youth, cigarettes are the most commonly used tobacco product among young adults. Therefore, this

chapter does not assess co-use of e-cigarettes and other tobacco products among young adults.

Current prevalence. Using data from the 2013–2014 

NATS, current exclusive and combined use of e-cigarettes 

and cigarettes are presented in Figure 2.8 and Table 2.8a 

for young adults (18–24 years old), and in Figure 2.8 and 

Table 2.8b for adults 25 years of age and older. For both 

age groups, exclusive use of regular cigarettes was the 

most prevalent pattern of behavior (9.6%, young adults; 

13%, adults), followed by dual use of cigarettes and 

e-cigarettes (7.5%, young adults; 4.2%, adults), and exclusive use of e-cigarettes (6.1%, young adults; 1.6%, adults).

Among young adults, combined use of the two products

and exclusive use of e-cigarettes were both higher among

males than females; combined use was higher among

Whites than in Hispanics or Blacks; and both combined

use of the two products and exclusive use of e-cigarettes

were lowest among those with a college degree.

Figure 2.8 Percentage of young adults who currently use e-cigarettesa and conventional cigarettes; National Adult 

Tobacco Survey (NATS) 2013–2014

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

aCurrent e-cigarette use was defined as those who reported they had heard of e-cigarettes and had tried e-cigarettes, and reported 

using e-cigarettes every day, some days, or rarely at the time of the interview.

Longitudinal Studies

Understanding the role that e-cigarettes play in 

the initiation of tobacco product use, especially conventional cigarettes and other combustible tobacco products, such as cigars and hookahs, is extremely important 

for informing public health policy, planning, and practice. It is unclear what impact e-cigarette use will have 

on the overall toll of tobacco use on public health (Cobb 

et al. 2015). Some researchers and policymakers are concerned about the order in which the initiation of tobacco 

products takes place, positing that the use of e-cigarettes
A Report of the Surgeon General

54 Chapter 2

Table 2.8a Percentage of young adults (18–24 years of age) who currently use e-cigarettesa, cigarettesb, or bothc products, by gender, race/ethnicity, 

and education: National Adult Tobacco Survey (NATS) 2013–2014

Neitherd E-cigarettes onlye Cigarettes onlyf Bothc

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 76.8 (75.3–78.3) 0.8 6.1 (5.3–7.0) 0.4 9.6 (8.6–10.7) 0.5 7.5 (6.6–8.4) 0.5

Gender

Female 81.8 (79.7–83.7) 1.0 4.0 (3.1–5.2) 0.5 8.4 (7.1–9.9) 0.7 5.8 (4.7–7.2) 0.6

Male 72.3 (70.1–74.4) 1.1 8.1 (6.9–9.4) 0.6 10.6 (9.2–12.2) 0.8 9.0 (7.7–10.4) 0.7

Race/ethnicity

White 72.8 (70.7–74.8) 1.1 6.3 (5.3–7.5) 0.6 11.2 (9.8–12.8) 0.8 9.7 (8.4–11.2) 0.7

Black or African American 84.8 (80.8–88.2) 1.9 2.9 (1.7–4.9) 0.8 9.8 (7.0–13.5) 1.6 2.5 (1.4–4.4) 0.7

Hispanic or Latino 80.5 (77.0–83.6) 1.7 7.5 (5.7–9.7) 1.0 6.1 (4.3–8.5) 1.1 5.9 (4.2–8.3) 1.1

Otherg 79.8 (75.5–83.5) 2.1 5.7 (3.8–8.6) 1.2 9.4 (6.9–12.5) 1.4 5.1 (3.4–7.6) 1.0

Education

<High school 67.4 (61.7–72.6) 2.8 5.8 (3.7–9.1) 1.3 17.3 (13.4–22.1) 2.2 9.4 (6.6–13.3) 1.7

High school 74.4 (71.9–76.7) 1.2 6.5 (5.3–7.8) 0.6 10.7 (9.2–12.5) 0.8 8.5 (7.0–10.1) 0.8

Some collegeh 78.2 (75.8–80.4) 1.2 7.3 (5.9–9.0) 0.8 7.2 (5.9–8.7) 0.7 7.3 (6.1–8.8) 0.7

College degreei 92.5 (90.2–94.4) 1.1 2.3 (1.4–3.9) 0.6 3.1 (2.0–4.7) 0.7 2.1 (1.2–3.5) 0.6

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

bIncludes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.

cIncludes those who reported currently using both e-cigarettes and conventional cigarettes.

dIncludes those who reported currently using neither conventional cigarettes nor e-cigarettes.

eIncludes those who reported currently using e-cigarettes but not conventional cigarettes.

f

Includes those who reported currently using conventional cigarettes but not electronic e-cigarettes.

gIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

hIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

i

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 55

Table 2.8b Percentage of adults (≥25 years of age) who currently use e-cigarettesa, cigarettesb, or bothc products, by gender, race/ethnicity, and 

education: National Adult Tobacco Survey (NATS) 2013–2014

Neitherd E-cigarettes onlye Cigarettes onlyf Bothc

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 81.3 (80.8–81.7) 0.2 1.6 (1.5–1.7) 0.1 13.0 (12.6–13.4) 0.2 4.2 (3.9–4.4) 0.1

Gender

Female 83.4 (82.8–84.0) 0.3 1.3 (1.1–1.4) 0.1 11.5 (11.0–12.0) 0.3 3.8 (3.5–4.1) 0.2

Male 78.8 (78.1–79.5) 0.4 2.0 (1.7–2.2) 0.1 14.6 (14.0–15.3) 0.3 4.6 (4.2–5.0) 0.2

Race/ethnicity

White 82.1 (81.6–82.6) 0.3 1.6 (1.5–1.8) 0.1 11.9 (11.5–12.3) 0.2 4.4 (4.1–4.7) 0.1

Black or African American 76.2 (74.6–77.7) 0.8 0.9 (0.7–1.3) 0.2 20.0 (18.6–21.5) 0.7 2.9 (2.4–3.5) 0.3

Hispanic or Latino 83.2 (81.6–84.6) 0.8 1.5 (1.1–2.0) 0.2 12.0 (10.7–13.3) 0.7 3.4 (2.7–4.2) 0.4

Otherg 77.5 (75.6–79.4) 1.0 2.5 (1.9–3.3) 0.4 14.5 (13.0–16.1) 0.8 5.5 (4.4–6.7) 0.6

Education

<High school 71.3 (69.5–73.1) 0.9 1.0 (0.7–1.4) 0.2 23.5 (21.8–25.2) 0.9 4.2 (3.5–5.1) 0.4

High school 75.4 (74.4–76.4) 0.5 1.8 (1.5–2.2) 0.2 16.9 (16.1–17.8) 0.4 5.9 (5.3–6.5) 0.3

Some collegeh 79.2 (78.4–80.0) 0.4 2.0 (1.8–2.3) 0.1 13.4 (12.7–14.1) 0.3 5.3 (4.9–5.8) 0.2

College degreei 92.5 (92.1–93.0) 0.2 1.2 (1.0–1.4) 0.1 4.7 (4.3–5.0) 0.2 1.6 (1.4–1.8) 0.1

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

bIncludes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.

cIncludes those who reported currently using both e-cigarettes and conventional cigarettes.

dIncludes those who reported currently using neither conventional cigarettes nor e-cigarettes.

eIncludes those who reported currently using e-cigarettes but not conventional cigarettes.

f

Includes those who reported currently using conventional cigarettes but not e-cigarettes.

gIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

hIncludes some college, no degree; associate’s degree: academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

i

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
A Report of the Surgeon General

(Continued from last paragraph on page 53.)

could increase the likelihood that adolescents and young 

adults who have never used any tobacco products, but initiate e-cigarettes, will become lifetime users of conventional cigarettes or other tobacco products in sufficiently 

large numbers, resulting in a net harm to public health 

(USDHHS 2012). Other researchers suggest that the order 

of product initiation for tobacco products is unimportant 

and that experimentation with a variety of substances may 

be a marker of a common vulnerability to tobacco, alcohol, 

marijuana, and other substance-use behaviors (Vanyukov 

et al. 2012). Regardless, both of these perspectives on the 

effect of e-cigarette use on youth and young adults require 

longitudinal data to understand how current behaviors 

may affect health outcomes.

Five longitudinal studies to date suggest that 

e-cigarette use among youth (Leventhal et al. 2015;

Barrington-Trimis et al. 2016; Wills et al. 2016) and youth

and young adults (Primack et al. 2015; Unger et al. 2016)

might lead to initiation of the use of combustible tobacco

products in the future. The first study to appear was by

Leventhal and colleagues (2015). In this study, a cohort of

9th graders in Los Angeles, California, was followed up at

both 6 and 12 months, into 10th grade. Those who at baseline had never used combustible tobacco, but were ever

users of an e-cigarette, were more likely to use combustible tobacco products at both follow-up points (odds ratio

[OR]  =  4.27, 95% confidence interval [CI], 3.19–5.71).

Product-specific analyses showed that e-cigarette use in

9th grade was associated with the use of cigars (OR = 4.85,

95% CI, 3.38–6.96), hookahs (OR  =  3.25, 95% CI,

2.29–4.62), and cigarettes (OR = 2.65, 95% CI, 1.73–4.05)

in 10th grade. It was also associated with the number

of different combustible products used in 10th  grade

(OR  =  4.26, 95% CI, 3.16–5.74) (all ORs presented here

were averaged across the two time points). In these

analyses, Leventhal and colleagues (2015) adjusted for

demographic characteristics (age, gender, race/ethnicity,

highest parental education), social factors (peer smoking,

parental smoking), and intrapersonal factors (depression,

impulsivity, delinquent behaviors) linked with cigarette

smoking in previous research.

Primack and colleagues (2015), in a national cohort 

study, followed youth and young adults, 16–26 years of age, 

for 1 year. At baseline, only 16 participants (2.3%) had ever 

used e-cigarettes. In adjusted models that included only 

those who did not use conventional cigarettes at baseline and adjusted for gender, age, race/ethnicity, maternal 

educational level, sensation seeking, parental cigarette 

smoking, and peer cigarette smoking, baseline e-cigarette 

use was independently associated with progression to cigarette smoking (OR = 8.3, 95% CI, 1.2–58.6) and susceptibility to cigarette smoking (OR = 8.5, 95% CI, 1.3–57.2). 

Susceptibility was defined as a lack of a firm commitment 

56 Chapter 2

not to smoke using established measures of this construct 

(Evans et al. 1995; Pierce et al. 1996).

Wills and colleagues (2016) followed a cohort of 

2,338 students in grades 9 and 10 in Hawaii for 1 year. At 

baseline, 31% of the sample had ever used an e-cigarette, 

and 15% had ever used a conventional cigarette. One 

year later, these increased to 38% and 21%, respectively. 

Of those who had not used either of these products at 

baseline, 10%  initiated exclusive e-cigarette use 1 year 

later; 2% initiated exclusive conventional cigarette use; 

and 4% initiated use of both products. Students who 

had never smoked a conventional cigarette at baseline 

but had used an e-cigarette at baseline were three times 

more likely to smoke conventional cigarettes 1 year later 

(adjusted OR  =  2.87, p  <0.001). By comparison, among 

those who smoked conventional cigarettes at baseline, 

use of e-cigarettes at that same point in time was not 

related to any reduction in the use of conventional cigarettes 1  year later (p  >0.05). Moreover, students were 

more likely to transition from never use to dual use of 

both products 1 year later if they were older, Caucasian 

or Native Hawaiian (compared with Asian-American), 

more rebellious, and perceived e-cigarettes as healthier 

(adjusted OR  =  2.05, 2.15, 3.10, 3.32, 2.59, respectively, 

all p <0.001).

Barrington-Trimis and colleagues (2016) followed a 

cohort of 11th and 12th grade students in California for 

more than 1 year (median 15.6 months). In this cohort, 

at baseline, 146 were ever e-cigarette users and 152 were 

never e-cigarette users; none had ever smoked a cigarette. 

Among never e-cigarette users at baseline, 16 participants 

(10.5%) reported using cigarettes at follow-up; among 

ever e-cigarette users at baseline, 59 participants (40.4%) 

reported the same (OR = 6.17; 95% CI, 3.30–11.60). 

After adjusting for cigar, pipe, or hookah use at baseline, 

the relationship attenuated only somewhat (OR = 5.48; 

95% CI, 2.69–11.20). When stratified by susceptibility to 

cigarette smoking at baseline (defined, like Primack and 

colleagues [2015], as the lack of a firm commitment not 

to smoke using established measures of this construct 

[Evans et al. 1995; Pierce et al. 1996]), the relationship 

was actually stronger among those who were not susceptible (OR = 9.69; 95% CI, 4.02–23.40) compared to those 

who were susceptible (OR = 2.12; 95% CI, 0.79–5.74). The 

latter relationship was not statistically significant. In additional analyses that were restricted to those who reported 

no use of any combustible tobacco product at baseline, 

e-cigarette users were more likely to initiate use of any

combustible tobacco product at follow-up (OR  =  4.98;

95%  CI, 2.37–10.4), including the use of cigarettes

(OR  =  4.29; 95% CI; 1.84–10.0), hookahs (OR  =  2.86;

95% CI, 1.21–6.78), cigars (OR = 4.39; 95% CI, 1.72–11.2),

and pipes (OR = 8.21; 95% CI, 1.20–56.2). The models used 
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 57

E-Cigarette Use Among Youth and Young Adults

by Barrington-Trimis and colleagues (2016) adjusted for 

a variety of demographic characteristics (grade, gender, 

race/ethnicity, highest parental education) and social factors (peer and parental smoking). Additionally, gender, 

race/ethnicity (Hispanic White, non-Hispanic White, 

other), grade (11th or 12th), and ever use of hookahs were 

tested as potential effect modifiers of these associations, 

but no evidence was found for the same.

Unger and colleagues (2016) followed a cohort of 

1,332 Hispanic young adults in California who provided 

survey data in 2014 and 2015. At baseline, these participants were an average of 22.7 years old. E-cigarette 

use at baseline was significantly associated with cigarette smoking (OR  =  3.32; 95% CI, 1.55–7.10, among 

non-cigarette smokers at baseline) and marijuana use 

(OR  =  1.97; 95% CI, 1.01–3.86, among non-marijuana 

users at baseline) at follow-up. Among those who did not 

smoke cigarettes at baseline (n = 1,056), 42 reported past 

month e-cigarette use in 2014; 26% of those who smoked 

e-cigarettes at baseline became cigarette smokers in 2015,

compared to 7% of those who did not smoke e-cigarettes.

Further, among those who did not smoke marijuana at

baseline (n = 1,028), 68 reported past month e-cigarette

use in 2014; 24% of those who smoked e-cigarettes at

baseline became marijuana smokers in 2015, compared to

12% of those who did not smoke e-cigarettes. Moreover,

in this study, e-cigarette use at baseline was not associated with cessation of cigarette smoking (OR = 1.31;

95% CI, 0.73– 2.36) or marijuana use (OR = 1.05; 95%

CI. 0.54–2.01) at follow-up. Among those who did smoke

cigarettes at baseline (n = 276), 76% reported past month

e-cigarette use in 2014; and 63% of those who smoked

e-cigarettes at baseline were still smoking cigarettes at

follow-up, compared to 58% of those who did not smoke

e-cigarettes. Covariates in these regression models

included age, gender, past month use of alcohol, and past 

month use of other tobacco products (hookah, cigars, 

little cigars, smokeless tobacco).

Despite the several strengths of these studies, 

including their longitudinal nature, they had weaknesses 

as well. Rigotti (2015) notes, for example, that the study 

by Leventhal and colleagues (2015) could not distinguish between those who merely began experimenting 

with a combustible product and those who became regular smokers at follow-up. The same could be said for 

the studies by Barrington-Trimis and colleagues (2016), 

Primack and colleagues (2015), and Wills and colleagues 

(2016). Similarly, the single exposure measure of the 

independent variable (i.e., any e-cigarette use) in these 

studies did not allow the authors to assess whether there 

was a dose–response relationship between the extent of 

prior e-cigarette use and subsequent use of combustible 

tobacco products. In addition, the studies by Primack and 

colleagues (2015) and Wills and colleagues (2016) did not 

assess prior use at baseline of other tobacco products, 

marijuana, or alcohol. Though it is not highlighted prominently in their article, Leventhal and colleagues (2015) 

showed a bidirectional relationship between e-cigarette 

use and other combustible tobacco product use in their 

study: Use of other combustible tobacco products at 

baseline was significantly associated with the onset of 

e-cigarette use in two follow-ups. This hypothesis was not

tested by Barrington-Trimis and colleagues (2016), Wills

and colleagues (2016), or Primack and colleagues (2015).

However, at the 1-year follow-up, Wills and colleagues

(2016) did consider other demographics, personality, and

psychosocial predictors of exclusive e-cigarette use and

dual use of conventional cigarettes and e-cigarettes.

Concerns about the samples for the two studies 

can be raised as well. The samples in the studies by 

Barrington-Trimis and colleagues (2016) and Leventhal 

and colleagues (2015) were limited to youth in California; 

the study by Primack and colleagues (2015) suffered 

from a small sample size, with only 16 e-cigarette users 

at baseline (Leventhal et al. 2015; Primack et al. 2015); 

and the study by Wills and colleagues (2016) was limited 

to 9th- and 10th-grade students in Hawaii. Additional 

studies are still needed in the future to further elucidate 

any causal relationship in either direction between the use 

of e-cigarettes and other types of tobacco products, such 

as combustibles.

E-Cigarette Use and Other

Substance Use

Few studies have investigated the co-occurrence 

of e-cigarette use and other risk behaviors in adolescents and young adults. The available evidence suggests 

that e-cigarette use is associated not only with the use of 

other tobacco products, but also with alcohol and other 

substance use, such as marijuana. This is consistent with 

the common liability model for substance use and other 

risky behaviors (Vanyukov et al. 2012). Because nearly all 

currently available studies on this topic focus on regional, 

international, and at-risk samples, the conclusions from 

most studies cannot be generalized to the U.S. population 

as a whole, however.

In the only nationally representative study examining the associations between e-cigarettes, alcohol, and 

other drug use in young adults 18–24 years of age, the 

odds of alcohol use were nine times as high and the odds 

of everyday/some-day marijuana use were three-and-a-half 

times as high among past-30-day e-cigarette users as 

they were for those who had not used these products in 
A Report of the Surgeon General

58 Chapter 2

that period (Cohn et al. 2015). Elsewhere, in a nonprobability sample of college students 17–25 years of age, 

66% of current e-cigarette users and 67% of current dual 

users were heavy drinkers, defined as consuming at least 

once, five or more drinks (men) or four or more drinks 

(women) in a single sitting during the course of 1 month 

(Littlefield et al. 2015). In another study, this one of college students in New York, past-30-day use of e-cigarettes 

was positively associated with current binge drinking and 

tobacco product use, and it was less common among those 

20–23 years of age (versus those 18 years of age), females, 

non-Hispanic non-Whites (compared with non-Hispanic 

Whites), and those reporting better-than-average school 

performance (Saddleson et al. 2015).

Data from a longitudinal cohort study of children 

with alcoholic parents found that adolescents (both middle 

and late adolescence) who used cigarettes, marijuana, or 

alcohol were significantly more likely to have ever used 

e-cigarettes. Among those who had used marijuana,

e-cigarette use was associated with greater use of marijuana during the previous 30 days (Lessard et al. 2014).

In a cross-sectional pilot study of seventh-grade students

in Southern California, ever use of e-cigarettes was 11%,

compared to 6.8% for cigarettes, 38.1% for alcohol, and

39% for cigarettes or alcohol. In this study, 80% of ever

users of e-cigarettes had used alcohol, and 42.2% had used

conventional cigarettes (Pentz et al. 2015).

In a 2013 sample of students (n = 2,002) in two states 

in the southeastern United States, 53.4% of e-cigarette 

users also used marijuana (Berg et al. 2015). Elsewhere, 

in a sample of young adults (18–23 years of age) at colleges and universities that was taken in 2013 in upstate 

New York (n = 1,437), 54.2% of past-30-day marijuana 

users, 23.9% of past-30-day alcohol users, and 40.3% of 

past-30-day binge drinkers had ever used e-cigarettes 

(Saddleson et al. 2015). In Switzerland, among a sample 

of eighth graders, nearly 60% of regular e-cigarette users 

“had been drunk” at least once in the past 30 days (defined 

as an affirmative response to the question, “have you been 

drunk in the previous 30 days”), and 44.8% had used marijuana at least once during that period (Suris et al. 2015).

There are several limitations to these observational 

studies. For example, when considering the associations 

derived from these observational studies, the order of initiation of the products of interest cannot be inferred. In 

addition, some biases cannot be ruled out because of the 

nature of the samples, and patterns of associations may 

reflect an underlying common liability to use substances 

and take part in other risky behaviors. Some studies 

adjusted for risk taking, sensation seeking, and impulsivity, while others did not.

E-Cigarettes and Marijuana

Because of their design, e-cigarettes may facilitate 

drug use among youth and young adults, as these products can be used as a delivery system for cannabinoids 

and other illicit drugs (Giroud et al. 2015; Morean et al. 

2015; Schauer et al. 2016). The aerosolization of cannabis 

is a relatively new technology used to deliver inhaled tetrahydrocannabinol (THC) and other cannabinoids while 

reducing the toxic byproducts of smoked cannabis, which 

are primarily caused by combustion (Abrams et al. 2007). 

Laboratory studies of prototype aerosolizers have 

demonstrated that they can provide a relatively effective 

mode of delivering THC, with plasma THC concentrations 

similar to those obtained from smoking a standard marijuana cigarette (Abrams et al. 2007; Giroud et al. 2015). 

In addition, thermal metered-dose cannabis inhalers 

have been developed for medical applications; their technology is similar to that of e-cigarettes (Eisenberg et al. 

2014). While the first generation of cannabis aerosolizers 

was developed to aerosolize dry cannabis, the widespread 

availability of e-cigarettes and rapid advances in their 

technology have led to the development of liquid/oil forms 

of cannabis/THC that can be used with e-cigarettes in a 

fashion similar to that employed when they are filled with 

nicotine (Giroud et al. 2015). Articles explaining how to 

acquire and use THC-containing liquid using e-cigarette 

technology are accessible on the Internet and are strongly 

suggestive of relatively widespread awareness and use 

(Gray 2013).

The actual prevalence of users of marijuana aerosolizers and their experiences remain unclear and understudied (Van Dam and Earleywine 2010; Malouff et al. 

2014). In one of the few published studies on this issue 

specific to youth, Morean and colleagues (2015) found 

that, among high school students in Connecticut, vaporizing cannabis was common among ever e-cigarette users 

(18%), ever cannabis users (18.4%), and ever dual users 

(26.5%). This finding suggests a need for more specific 

surveillance measures that take into account the use of 

drugs other than nicotine in e-cigarettes.

Use of Flavored E-Cigarettes

The liquid that is vaporized in an e-cigarette is available to consumers in a wide variety of flavors, including 

tobacco, mint/menthol, and fruit flavors. Although characterizing “flavors” are prohibited in cigarettes (with the 

exception of menthol and tobacco) by the Family Smoking 

Prevention and Tobacco Control Act of 2009, this practice is not currently prohibited in other tobacco products, like e-cigarettes. Retail sales data suggest that the 
59

consumption of flavored e-cigarettes and tobacco products, such as flavored cigars, has increased in recent years 

(Delnevo et  al. 2015; Giovenco et al. 2015), and recent 

studies show that youth and young adults may find these 

flavored products more appealing than their unflavored 

counterparts (Table 2.9) (Ambrose et al. 2015; KrishnanSarin et al. 2015; McDonald and Ling 2015).

Data on the use of flavored e-cigarettes among 

youth and young adults is presented in Table 2.9. In the 

2015 NYTS, participants were asked about any current use 

of e-cigarettes that were “flavored to taste like menthol 

(mint), alcohol (wine, cognac), candy, fruit, chocolate, or 

other sweets” (CDC 2015a, 1066). Among middle and high 

school students who were past-30-day users of e-cigarettes, 

1.26 million, or 44.6%, had used a flavored e-cigarette in 

that timeframe (CDC, unpublished data [NYTS 2015]); 

this included 42.6% of middle school students and 45.1% 

of high school students (Table 2.9) (CDC 2015a). The use 

of flavored e-cigarettes did not differ by gender and was 

lowest among Blacks (Table  2.9) (CDC  2015a). The use 

of flavored e-cigarettes was highest among young adults, 

according to the 2013–2014 NATS (Table 2.9): among 

those who reported using e-cigarettes every day or some 

days, 91.6% of young adults (18–24 years old) reported 

using an e-cigarette flavored to taste like menthol, mint, 

clover, spice, candy, fruit, chocolate, or other sweets. 

On the other hand, 66.6% of adults (≥25  years of age) 

who reported using e-cigarettes every day or some days 

had used flavored e-cigarettes. No gender differences were 

noted for young adults, but Blacks, as with middle and 

high school students, reported the lowest rate of using flavored e-cigarette products.

Data from the 2013–2014 wave of the PATH 

study revealed that a majority of adolescents who used 

e-cigarettes use flavors. Of those who had ever tried

e-cigarettes, 81% used flavors the first time they tried an

e-cigarette; of past-30-day users, 85.3% regularly used

flavored e-cigarettes (Ambrose et al. 2015). Ambrose and

colleagues (2015) also reported that 81.5% of respondents aged 12–17 reported that they used e-cigarettes

because “they come in flavors I like.” Elsewhere, among

8th, 10th, and 12th graders in the 2015 MTF study, about

40% said that the primary reason they used e-cigarettes

was “because they tasted good.” In contrast, about 10%

said they used e-cigarettes to quit smoking conventional

cigarettes (University of Michigan 2015). In the 2015 MTF

study, about two-thirds of 8th-, 10th-, and 12th-grade

students said that they used “just flavouring” in their

vaporizer when they “last used” a vaporizer, while only

20% reported that they used nicotine (Miech et al. 2016).

While the findings specific to nicotine are unexpected, it

is important to note that these data are self-reported. It

is questionable whether youth know what nicotine is, let

alone whether it is contained in the e-cigarette products 

that they are using. Moreover, even if youth were accurately reporting nicotine strength according to the label 

on the package, a study by Buettner-Schmidt and colleagues (2016) found that more than half of the labels on 

assessed e-cigarette products did not accurately reflect 

actual nicotine content in the product. Therefore, further 

research on nicotine content using objective measures 

(e.g., retail sales data) is warranted. Both the PATH and 

MTF studies, however, reinforce that flavorings may play 

an important role in the initiation of e-cigarette use.

Other regional studies have reinforced the popularity of flavored e-cigarette use among youth. Table 2.10 

summarizes these data on the use of flavored e-cigarettes 

among youth and young adults. Krishnan-Sarin and colleagues (2015), for example, found that sweet-flavored 

e-cigarettes were popular among middle and high school

students. In another study, which examined nonsmoking

middle and high school students and college-aged adults

in New Haven County, Connecticut, Kong and colleagues

(2015) found that “appealing flavors” was the second most

common reason cited for experimenting with e-cigarettes,

and in a qualitative study of young adults living in New

York City, flavors were identified as an attractive aspect of

e-cigarettes (McDonald and Ling 2015). In a study examining nonsmoking teens and adult smokers, the e-cigarette 

flavors tested appealed more to adults than to teens; nonsmoking teens demonstrated equally low levels of interest

in tobacco, fruit, and candy flavors (Shiffman et al. 2015).

It should be noted, however, that this study was funded by

NJOY, an e-cigarette company and, therefore, may have

suffered from commercial bias. Additional concerns about

this study concerning selection bias, validity of the survey

measures, and reliability of the findings have been raised

(Glantz 2015).

Consumer Perceptions of 

E-Cigarettes

Perceived Harm of E-Cigarettes

In the general population of U.S. adults, e-cigarettes 

have been perceived to be generally less harmful (Pearson 

et al. 2012; Czoli et al. 2014; Gallus et al. 2014; Richardson 

et al. 2014; Berg et al. 2015; Pokhrel et al. 2015) and less 

addictive (Dockrell et al. 2013; Li et al. 2013; Brown et al. 

2014; Farsalinos et al. 2015; Harrell et al. 2015; Hendricks 

et al. 2015; Kadimpati et al. 2015; Wackowski and Delnevo 

2015) than conventional cigarettes. The perceived harm 

of e-cigarettes relative to conventional cigarettes was 

lowest among those who were current smokers, followed 

by former smokers and then nonsmokers (Pearson et al.
A Report of the Surgeon General

60 Chapter 2

Table 2.9 Percentage of youth (middle and high school students), young adults (18–24 years of age), and adults (≥25 years of age) using tobacco 

products who reported using flavored e-cigarette products, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)a and 

National Adult Tobacco Survey (NATS)b

NYTS 2015a (youth): 

Middle school students

NYTS 2015a (youth): High 

school students

NATS 2013–2014b (young 

adults): 18–24 years of age

NATS 2013–2014b

(adults): ≥25 years of age

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 42.6 (36.1–49.3) 3.3 45.1 (40.4–49.9) 2.4 91.6 (87.0–94.6) 1.9 66.6 (63.4–69.5) 1.6

Gender

Female 45.5 (36.2–55.2) 4.8 46.8 (40.5–53.2) 3.2 90.1 (78.6–95.7) 4.1 68.2 (63.7–72.3) 2.2

Male 40.2 (32.2–48.7) 4.2 44.0 (39.3–48.8) 2.4 92.2 (87.0–95.4) 2.1 65.2 (60.7–69.4) 2.2

Race/ethnicity

White 52.5 (42.0–62.8) 5.3 51.4 (45.7–57.0) 2.9 90.9 (84.7–94.7) 2.5 61.2 (57.5–64.8) 1.9

Black or African American 32.9 (18.5–51.6) 8.6 20.4 (12.8–31.0) 4.5 100 (100–100)c 0.0c 92.0 (82.1–96.6) 3.5

Hispanic or Latino 28.5 (20.5–38.1) 4.4 38.8 (32.7–45.3) 3.2 89.8 (75.3–96.2)c 5.0c 85.9 (76.6–91.9) 3.8

Otherd 57.3 (39.4–73.5) 8.9 34.1 (24.8–44.9) 5.1 94.4 (82.1–98.4)c 3.5c 67.4 (57.0–76.3) 5.0

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015; NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aFlavored e-cigarette product use in NYTS was determined by the response to the question, “Which of the following tobacco products that you used in the past 30 days 

were flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate, or other sweets?” Participants could select from a list of options to designate the 

flavored tobacco product(s) they used. (Among those who reported any use of e-cigarettes in the preceding 30 days.) Those who selected e-cigarettes were coded as “yes” 

for flavored e-cigarettes. Those who did not select e-cigarettes were categorized as “no” for flavored e-cigarettes. Excludes 82 current e-cigarette users whose answers were 

missing for all flavored tobacco response options.

bFlavored e-cigarette product use in NATS was determined by the response to the question, “Were any of the electronic cigarettes that you used in the past 30 days flavored 

to taste like menthol, mint, clover, spice, candy, fruit, chocolate, or other sweets?” (Among those who reported using e-cigarettes every day or some days.) Those who selected 

“yes” were categorized as “yes” for flavored e-cigarettes. Those who selected “no” were categorized as “no” for flavored e-cigarettes. Excludes five every-day or some-day 

users who reported not using any noncigarette tobacco product in the past 30 days.

cSample size <50. No estimates had a relative SE >.40.

dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native. For young adults and adults, this group 

also includes multiracial.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 61

Table 2.10 Summary of studies on e-cigarette flavors among youth and young adults

Study Design/population Measures Outcomes/findings

Ambrose et al. (2015) • Cross-sectional

• Wave 1 of PATH study

• Household-based, nationally representative survey

of 13,651 youth 12–17 years of age

• For each product ever used, youth

were asked if it was flavored to

taste like menthol, mint, clove,

spice, candy, fruit, chocolate,

alcohol (such as wine or cognac),

or other sweets

• 81% of e-cigarette ever users used a

flavored product at first use

• 85.3% of past-30-day e-cigarette users

used a flavored product

• 81.5% of past-30-day users cited “because

they come in flavors I like” as a reason for

using e-cigarettes

Berg et al. (2015) • Cross-sectional

• Recruitment through Facebook targeting of

tobacco and marijuana users and nonusers

• 2014

• 1,567 participants, 18–34 years of age, living in the

United States

• E-cigarette use (ever tried,

number of days in past 30 days)

• Flavors used or of interest

• Most commonly used flavor was fruit

flavors (67%), which was most commonly

reported by never cigarette smokers.

• Current smokers were most likely to

report using tobacco flavors, but least

likely to report using caramel, vanilla,

chocolate, cream, or candy flavors.

CDC (2015a) • Cross-sectional

• 2014 NYTS data

• Three-stage cluster sampling procedure

• Nationally representative sample of 22,007 U.S.

middle and high school students

• Participants were asked about any

current use of tobacco products

that were “flavored to taste like

menthol (mint), alcohol (wine,

cognac), candy, fruit, chocolate, or

other sweets”

• Participants could select from a

list of options

• Among current e-cigarette users,

63.3% used a flavored product

Kong et al. (2015) • Cross-sectional

• 18 focus groups, schoolwide survey

• Recruitment by flyers and active recruitment

sessions

• Years sample drawn: 2012–2013

• New Haven County, Connecticut

• Youth: Middle and high school students; focus

group n = 127 (youth); survey n = 4,780

• Young adults: New Haven County, Connecticut,

college students; focus group n = 127

(young adults); survey n = 625

• Why did you try an e-cigarette? • 43.8% of e-cigarette ever users

experimented with e-cigarettes for the

availability of appealing flavors

• School-level differences:

χ2(2, N = 1,157) = 18.63, p ≤0.001

• Compared with college students, high

school students were more likely to

experiment with e-cigarettes because of

flavors (47% vs. 32.8%):

χ2(1, N = 1,116) = 13.61, p ≤0.001
A Report of the Surgeon General

62 Chapter 2

Study Design/population Measures Outcomes/findings

Krishnan-Sarin et al. (2015) • Cross-sectional

• School-based survey

• Recruitment by selected district reference groups

• Year sample drawn: 2013

• Youth: Connecticut middle (n = 1,166) and high

school (n = 3,614) students

• Young adults: n/a

• Which of the following flavors of

e-cigarettes have you tried?

• Most e-cigarette ever users preferred

sweet flavors:

– Sweet flavors: 56.8%

– Menthol: 8.7%

– Combos: 7.7%

– Tobacco: 3%

– Other: 2.8%

• Menthol and tobacco flavors used mostly

by e-cigarette users who were also

cigarette smokers.

– Menthol preference:

| 3.5% (never smokers)

| 5.5% (ever smokers)

| 18.6 (current smokers)

– Tobacco preference:

| 0.5% (never smokers)

| 2.4% (ever smokers)

| 7.1% (current smokers)

McDonald and Ling (2015) • Focus groups and semistructured interviews

• Recruitment from bars through screener surveys

• Years sample drawn: 2012–2013

• Youth: n/a

• Young adults: 87 young adults, 18–27 years of

age, in the boroughs of Manhattan, Brooklyn, and

Queens in New York City

• Attraction to flavors • Flavors were an attractive e-cigarette

characteristic

Shiffman et al. (2015) • Cross-sectional

• Participants drawn from online research panel

• Year sample drawn: 2014

• Youth: Nonsmoking teenagers, 13–17 years of age

• Young adults: n/a

• Interest in e-cigarettes paired with

various flavor descriptors

• Nonsmoking teens’ interest in

e-cigarettes was very low

(mean = 0.41 ± 0.14 [SE] on 0–10 scale).

• Teen interest did not vary by flavor

(p = .75)

Table 2.10 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 63

Study Design/population Measures Outcomes/findings

Ford et al. (2016) • Cross-sectional in-home survey

• Wave 7 of the Youth Tobacco Policy Survey (YTPS)

• Random location quota sampling

• 1,205 youth, 11–16 years of age, in the United

Kingdom

• Awareness of e-cigarettes

• E-cigarette use

• E-cigarette flavor awareness

• Perceptions of harm

• 12% had tried e-cigarettes

• 2% were regular users (confined to

adolescents who had also smoked

tobacco)

• 82% were aware of at least one

promotional channel (82%)

• 69% were aware that e-cigarettes came in

different flavours

• Brand awareness was low

• E-cigarettes were perceived as harmful

(mean = 3.54, SD = 1.19)

Vasiljevic et al. (2016) • Randomized controlled trial

• Participants exposed to advertisements of candylike flavored e-cigarettes, non-flavoured cigarettes,

or control

• Youth: 598 English children, 11–16 years of age

• Appeal of using e-cigarettes

• Appeal of e-cigarette ads

• Interest in buying and trying

e-cigarettes following ad exposure

• Exposure to e-cigarette ads did not seem

to increase the appeal of tobacco smoking

in children.

• Exposure to flavoured e-cigarette ads

(compared with non-flavoured ads)

increased the appeal and interest in

buying and trying e-cigarettes in children.

Note: NYTS = National Youth Tobacco Survey; PATH = Population Assessment of Tobacco and Health Study; SD = standard deviation; SE = standard error.

Table 2.10 Continued
A Report of the Surgeon General

64 Chapter 2

(Continued from last paragraph on page 59.)

2012; Richardson et al. 2014). In a nationally representative sample of U.S. adults, young adults 18–34 years of age 

were more likely than their older counterparts to perceive 

e-cigarettes as being less harmful than conventional cigarettes (Tan and Bigman 2014).

Common theories of health behavior, such as 

the Theory of Reasoned Action and the Health Belief 

Model, posit that perceptions of harm influence tobaccouse behavior, with lower perceived harm encouraging 

higher levels of experimentation and current tobacco 

use (Primack et al. 2008). Monitoring both absolute perceived harm and perceived harm relative to conventional 

cigarettes could be an indicator of later product adoption. Table 2.11 presents studies of the perceived harm of 

e-cigarettes among adolescents and young adults that are

included in this chapter.

Youth

Table 2.12a presents NYTS data from middle 

school and high school students on the perceived harm 

of using e-cigarettes on some days but not every day. 

In 2015, 61.9%  of these students, overall, believed that 

e-cigarettes caused “little or some harm” under such conditions; 14.5%, “no harm”; and 23.6%, “a lot of harm.”

However, when these data are stratified by students’ history of e-cigarette use, important differences become

clear. Notably, 34.2% of past-30-day e-cigarette users

believed e-cigarettes cause “no harm,” compared with

22.4% of ever e-cigarette users and only 9.5% of never

e-cigarette users. Conversely, 29.4% of never e-cigarette

users believed that e-cigarettes cause “a lot of harm,”

compared with 8.3% of ever e-cigarette users and 6.8% of

past-30-day e-cigarette users. These important differences

by e-cigarette use status, which suggest perceptions of no

harm related to e-cigarette use, were consistent for both

middle school students and high school students (Tables

2.12b and 2.12c).

Three studies that used data from the 2012 NYTS 

examined the correlates of U.S. adolescents’ opinions about 

the perceived harm of e-cigarettes relative to the harm of 

conventional cigarettes. Non-Hispanic Whites, students 

who lived with a smoker (Cardenas et al. 2015) or had 

a family member who used tobacco (Amrock et al. 2015), 

and past-30-day users of tobacco products other than cigarettes were more likely to believe that e-cigarettes were 

safer than conventional cigarettes (Amrock et al. 2015). 

Conversely, girls and students 17  years of age or older 

were more likely to believe that e-cigarettes were more 

harmful than regular cigarettes (Amrock et al. 2015). The 

perceived harm of e-cigarettes decreased with increasing 

levels of cigarette smoking, such that in 2012, 25% of adolescent never smokers, 41.3% of adolescent ever smokers, 

and 54.2% of adolescent past-30-day smokers believed that 

e-cigarettes were less harmful than cigarettes (Ambrose

et al. 2014). Prior use of e-cigarettes was also associated

with perceived harm of that product. Among students

who had ever tried e-cigarettes in 2012, 71.8% believed

that they were less harmful than cigarettes, 12.1% equally

harmful, and 5% more harmful. These estimates were

similar to those for students who had used e-cigarettes in

the past 30 days (Amrock et al. 2015). In addition, susceptibility to cigarette smoking among never smokers was

associated with perceptions of low harm for e-cigarettes

(Ambrose et al. 2014).

Although not all studies reviewed in this section 

included “don’t know” as a response option for questions on the harms of e-cigarettes, those that did, found 

that a large number of students were unsure of the relative harmfulness of e-cigarettes compared to conventional cigarettes (Ambrose et al. 2014; Amrock et al. 

2015). In fact, among U.S. adolescents responding to the 

2012 NYTS, “don’t know” was the most common response 

(41.1–53.3%) across all the demographic subgroups 

examined (gender, age, and race/ethnicity) (Amrock et al. 

2015). In this sample, more never smokers (57.4%) than 

ever smokers (37.5%) or past-30-day smokers (24%) had 

not heard of or did not know enough about e-cigarettes to 

make a judgment of harm (Ambrose et al. 2014). Future 

studies will benefit from examining the effect of harm perception on the use of e-cigarettes and other tobacco-use 

behaviors among adolescents.

Young Adults

Table 2.12d presents data from the 2013−2014 

NATS on beliefs about harm from e-cigarettes among 

young adults (18–24 years old). Just over half (53.8%) of 

young adults believed that e-cigarettes were “moderately 

harmful,” 26.8% believed they were “very harmful,” and 

19.4% believed they caused “no harm.” Levels of belief in 

moderate harm were quite similar by type of e-cigarette 

use: 52.8% of never users, 56.8% of ever (but not current) users, and 53.6% of current users. Ever and current 

users were more likely than never users to report that 

e-cigarettes were “not at all harmful,” while never users

were more likely than the other two groups to report that

e-cigarettes were “very harmful.”

Published studies on perceived harm of e-cigarettes 

from regional samples, primarily of college and university students, are presented in Table 2.11. A large survey 

(n = 4,444) of college students in North Carolina conducted 

in 2009 found that, as with adolescents, perceived harm 

of e-cigarettes, compared with conventional cigarettes, 

was lower among college students who had ever used 

e-cigarettes (45%) than among those who had never used
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 65

Table 2.11 Summary of studies on perceptions of e-cigarette harm among youth and young adults

Study Design/population Measures Outcomes/findings Comments

Choi et al. (2012) • Focus groups

• Recruitment by (1) online

advertisements, (2) flyers on one

4-year and two 2-year college

campuses, (3) announcements in

student life newsletter at a 2-year

college, and (4) recruitment booth on

a 2-year college campus

• Year sample drawn: 2010

• Youth: n/a

• Young adults: Individuals in

Minneapolis-St. Paul, MN, enrolled

in or who had graduated from

4-year colleges, or those who were

enrolled in or had graduated from

2-year colleges, or those who had not

enrolled in postsecondary education;

N = 66

• Perceived harmfulness relative

to cigarettes

• No consensus among participants

• Lack of information on

(1) ingredients, (2) health impact,

and (3) mechanism used to vaporize

nicotine

• Some noted e-cigarettes to be as

harmful as cigarettes (“all one

product, in different forms”)

• Generalizability

• Limited sample size

Adkison et al. (2013) • Parallel prospective cohort

• Telephone interview and web-based

surveys

• Probability sampling methods

(random-digit dialing)

• Years sample drawn: 2010–2011

(Wave 8), 2008–2009 (Wave 7, where

available)

• Youth: n/a

• Young adults: current smokers,

≥18 years of age; N = 5,939 (Canada:

n = 1,581; United States: n = 1,520;

United Kingdom: n = 1,325;

Australia: n = 1,513)

• Are electronic cigarettes more

harmful than, less harmful

than, or equally harmful as

regular cigarettes to one’s

health?

• Not explicitly reported for young

adults

• Inclusion of only

current and former

cigarette smokers

• Limited set of

questions
A Report of the Surgeon General

66 Chapter 2

Study Design/population Measures Outcomes/findings Comments

Faletau et al. (2013) • Qualitative exploratory

• Structured focus groups and

individual interviews

• Recruited from two low

socioeconomic primary schools

in East and South Auckland, New

Zealand

• Year sample drawn: 2011

• Youth: Maori, Tongan, Samoan,

Cook Island, and Niuean children,

6–10 years of age; N = 20

• Young adults: n/a

• Viewed tobacco cigarette and

electronic cigarette videos

• Still allows smokers to smoke,

despite its function as a cessation aid

• Generalizability

• Unknown if

saturation was

reached in

children between

focus groups

and individual

interviews

Sutfin et al. (2013) • Cross-sectional

• Web-based survey (part of a

randomized group trial)

• Stratified random sample

• Year sample drawn: 2009

• Youth: n/a

• Young adults: undergraduate students

attending eight universities in North

Carolina; N = 4,857 (completers of

e-cigarette question, n = 4,444).

• Compared with a regular

cigarette, how harmful do you

think e-cigarettes are?

– Less harmful

– As harmful

– More harmful

– Do not know

• Among the overall sample:

– 17% indicated “as harmful”

– 23% indicated “less harmful”

– 2% indicated “more harmful”

– 50% indicated “do not know”

• Among ever e-cigarette users:

– 17% indicated “as harmful”

– 45% indicated “less harmful”

– 3% indicated “more harmful”

– 23% indicated “do not know”

• Among never e-cigarette users:

– 16% indicated “as harmful”

– 22% indicated “less harmful”

– 2% indicated “more harmful”

– 51% indicated “do not know”

• Ever e-cigarette use significantly

associated with harm perceptions

(p <0.001)

• Low response rate

• Generalizability

• Inability to

differentiate former

smokers from

experimenters

• Cross-sectional

analysis

Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 67

Study Design/population Measures Outcomes/findings Comments

Ambrose et al. (2014) • NYTS

• Cross-sectional

• School-based survey

• Three-stage cluster sampling

• Year sample drawn: 2012

• Youth: U.S. middle and high school

students (grades 6–12); N = 24,658

• Young adults: n/a

• Do you believe that electronic

cigarettes or e-cigarettes, such

as Ruyan or NJOY, are less

harmful, equally harmful, or

more harmful than regular

cigarettes?

• 30.6% (CI, 29.3–31.9%)

of respondents believed

e-cigarettes are less harmful

than cigarettes: never smokers:

25% (CI, 23.9–26.2%); ever smokers:

41.3% (CI, 39.1–43.6%); current

smokers: 54.2% (CI, 51.0–57.4%)

• Female and Hispanics were less

likely to perceive e-cigarettes as less

harmful than cigarettes compared

with males and Whites, across all

smoking statuses

• Current smokers that had ever used

e-cigarettes were more than twice as

likely to perceive e-cigarettes as less

harmful, compared with smokers

who had never used e-cigarettes

(AOR = 2.48; CI, 1.87–3.29)

• Never smokers who had ever used

e-cigarettes were almost six times

as likely to perceive e-cigarettes

as less harmful, compared with

never smokers who had never used

e-cigarettes (AOR = 5.88;

CI, 3.07–11.25)

• Perceived graduated

risk

• Self-reported items

• Social desirability

bias

• Generalizability

Table 2.11 Continued
A Report of the Surgeon General

68 Chapter 2

Study Design/population Measures Outcomes/findings Comments

Czoli et al. (2014) • Cross-sectional

• Survey

• Recruitment through online panel

of commercial market research

company

• Year sample drawn: 2012

• Youth: Canadian youth recruited

from online panel, 16–30 years of age;

n = 1,188

• Young adults: Canadian young adults

recruited from same online panel (see

above)

• Is this product harmful to your

health?

• Have you ever experienced

any side-effects or adverse

outcome(s) while using

e-cigarettes?

• Mean score for agreement with

e-cigarettes as harmful to your

health (higher score indicates greater

agreement):

– Among cigarette nonsmokers:

5.5 (e-cigarette nonuser) vs. 4.4

(e-cigarette ever user)

– Among former smokers: 5.2

(e-cigarette nonuser) vs. 3.6

(e-cigarette ever user)

– Among current smokers: 2.6

(e-cigarette nonuser) vs. 3.5

(e-cigarette ever user)

• Cross-sectional

analysis

• Generalizability

Gallus et al. (2014) • Cross-sectional

• In-person survey

• Representative multistage sampling

• Year sample drawn: 2013

• Youth: n/a

• Young adults: Italians ≥15 years of

age; N = 3,000

• Indicate your opinion (true/

false) concerning e-cigarettes

on the following:

– (1) Are not harmful for health

– (2) Are less harmful than

traditional cigarettes because

they do not contain nicotine

– (3) Are less harmful

because there is no tobacco

combustion

– (4) Are less harmful because

they contain only nicotine

– (5) Are more harmful than

traditional cigarettes

– (6) Are an efficient tool to

quit smoking

– (7) Allow smoking even

where it is forbidden

• Findings not explicitly reported for

young adults

• Unstable estimates

due to small sample

of e-cigarette users

• Unvalidated survey

Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 69

Study Design/population Measures Outcomes/findings Comments

Tan and Bigman (2014) • Cross-sectional

• Health Information National Trends

Survey 4 Cycle 2

• Collected between October 2012 and

January 2013

• U.S. adults ≥18 years of age

• N = 3,630, 29.8% 18–34 years of age

• Compared to smoking

cigarettes, would you say that

electronic cigarettes are:

– Much less harmful

– Less harmful

– Just as harmful

– More harmful

– Much more harmful

– I’ve never heard of electronic

cigarettes

• Compared with younger respondents

(18–34 years of age), older

respondents had 38%–72% lower

odds of believing that e-cigarettes are

less harmful than regular cigarettes

—

Tucker et al. (2014) • Cross-sectional

• Paper-based survey

• Probability-based sampling

• Year sample drawn: not reported

• Youth: n/a

• Young adults: homeless young adults,

17–25 years of age; N = 292 (subset of

lifetime e-cigarette users, n = 83)

• Rate whether they perceive

e-cigarettes to be less harmful,

more harmful, or just as

harmful as smoking cigarettes

• 44.9% viewed e-cigarettes as less

harmful than conventional cigarettes

• 26.6% viewed e-cigarettes as just as

harmful as conventional cigarettes

• 3.7% viewed e-cigarettes as more

harmful than conventional cigarettes

• 24.8% did not know the relative

harm

• Did not collect

information on

youth’s attitudes

about alternate

tobacco products

besides e-cigarettes

• Did not collect

information on the

conditions under

which they used

various products

Amrock et al. (2015) • NYTS

• Cross-sectional

• School-based survey

• Three-stage cluster sampling

• Year sample drawn: 2012

• Youth: U.S. middle and high school

students (grades 6–12); N = 24,658

• Young adults: n/a

• Do you believe that electronic

cigarettes or e-cigarettes, such

as Ruyan or NJOY, are less

harmful, equally harmful, or

more harmful than regular

cigarettes?

• 34.2% (CI, 32.8–35.6%) of

adolescents considered e-cigarettes

to be less harmful than cigarettes

• Females were less likely than males

to perceive e-cigarettes as less

harmful than cigarettes

• Lifetime e-cigarette users were more

likely than never users to report

e-cigarettes as less harmful than

cigarettes (71.8% vs. 31%)

• Past-30-day e-cigarette users were

more likely than nonrecent users to

report e-cigarettes as less harmful

than cigarettes (73.8% vs. 33.1%)

• Missingness

• Perceived graduated

risk

• Self-reported items

• Social desirability

bias

• Generalizability

Table 2.11 Continued
A Report of the Surgeon General

70 Chapter 2

Study Design/population Measures Outcomes/findings Comments

Berg et al. (2015) • Cross-sectional

• Online-based survey

• Recruitment by random selection

• Year sample drawn: 2013

• Youth: n/a

• Young adults: U.S. university

students; n = 2,002

• How harmful to your health do

you think electronic cigarettes

are?

• How addictive do you think

electronic cigarettes are?

• How socially acceptable among

your peers do you think

electronic cigarettes are?

• Respondents considered e-cigarettes

among the least harmful

(4.26 ±1.95), addictive

(4.29 ± 2.08), and socially acceptable

(4.12 ± 2.03) of the products

considered

• Electronic cigarettes were among the

most positively perceived products

(11.56 ± 4.22)

• Predictors of more favorable

perceptions included:

– Being male (p = 0.03)

– Parental tobacco smoking

(p = 0.02)

– More friends who smoke cigarettes

(p <0.001)

– More friends who use hookah

(p <0.001)

– More friends who use electronic

cigarettes (p = 0.04)

• Recent cigarette smoking (p <0.001).

• Generalizability

• Responder bias

• Cross-sectional

analysis

Camenga et al. (2015) • Focus groups

• Purposive sampling

• Years sample drawn: 2012–2013

• Youth: middle and high school

students in Connecticut; n = 68

• Young adults: college students in

Connecticut; n = 59

• Discuss the comparison

between e-cigarettes and

cigarettes.

• Compared with nonsmokers, college

and high school smokers were

more likely to believe the use of

e-cigarettes could lead to a persistent

“craving” that would prevent

successful smoking cessation

• Compared with nonsmokers, college

and high school smokers were more

likely to believe that e-cigarette use

would maintain nicotine addiction

• Transferability

• Generalizability

• Limited definition

of e-cigarettes

Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 71

Study Design/population Measures Outcomes/findings Comments

Cardenas et al. (2015) • Cross-sectional

• School-based survey

• Three-stage cluster sampling

• Year sample drawn: 2012

• Youth: U.S. middle and high school

students; full sample size not

reported; subsample of children who

never tried smoking cigarettes,

n = 14,861

• Young adults: n/a

• Do you believe that electronic

cigarettes or e-cigarettes, such

as Ruyan or NJOY, are less

harmful, equally harmful, or

more harmful than regular

cigarettes?

• Participants who lived with a

smoker were more likely to report

e-cigarettes are less harmful than

regular cigarettes (16.2% vs. 24.8%)

• E-cigarette users were more likely to

believe e-cigarettes are less harmful

than regular cigarettes

(70.9% vs. 27.5%)

• No limitations

reported

Chaffee et al. (2015) • Cross-sectional

• Year sample drawn: 2014

• Youth: male high school students

from San Francisco; n = 104

• Participants were asked to

estimate the probability

(0–100%) that specific health

or social outcomes would

happen to them as a result

of e-cigarette use (e.g., heart

attack, lung cancer, get into

trouble, upset family, etc.)

• Ever use of electronic cigarettes

was associated with lower perceived

probabilities that unfavorable

outcomes would happen

—

Lotrean (2015) • Cross-sectional

• 2013

• Students 19–24 years of age from

Cluj-Napoca, Romania; n = 480

• Belief that e-cigarettes are less

dangerous than cigarettes:

agree, partially agree, disagree,

partially disagree, don’t know

• 55.9% of the total sample agreed

or partially agreed that e-cigarettes

are less dangerous, 35.8% did not

know, and 8.3% disagreed or partially

disagreed

• More smokers than nonsmokers or

ex-smokers agreed or partially agreed

that e-cigarettes are less dangerous

(62.3% vs. 58.7% and 33.3%,

respectively)

• Very small sample

• Measures not clearly

defined

Table 2.11 Continued
A Report of the Surgeon General

72 Chapter 2

Study Design/population Measures Outcomes/findings Comments

McDonald and Ling 

(2015)

• Focus groups and semistructured

interviews

• Recruitment from bars through

screener surveys

• Years sample drawn: 2012–2013

• Youth: n/a

• Young adults: young adults in the

boroughs of Manhattan, Brooklyn,

and Queens in New York City,

18–27 years of age; N = 87

• Perceived risks • Little knowledge of the devices

• Belief that e-cigarettes contain

harmless “water vapor” rather than

smoke

• Belief that “water vapor” is less

harmful or even “good” for users

• No limitations

reported

Roditis and HalpernFelsher (2015)

• Focus groups

• Recruitment from after-school

programs in urban Northern

California

• 2–6 participants in each group

• 24 adolescents: 9 female, 15 male

• Perceived risks and benefits

associated with conventional

cigarettes versus e-cigarettes

• Little knowledge of risks of

e-cigarette use

• Belief that e-cigarettes have no

nicotine

—

Cooper et al. (2016) • Cross-sectional

• Drawn from 2014 Texas Youth

Tobacco Survey, a school-based

survey

• Youth: students in grades 6–12 from

27 counties in Texas; N = 13,602

• “How dangerous do you think it

is for a person your age to use

electronic cigarettes?”

• Those in the e-cigarette-only group

viewed conventional cigarettes as

more harmful than did those in the

dual user group

• No differences in how harmful those

in the e-cigarette-only group and the

dual user group rated e-cigarettes

• Those in the cigarette-only group

rated e-cigarettes as more harmful

than did those in the dual user group

—

Note: Studies in this table are sorted by year of publication and then alphabetically. AOR = adjusted odds ratio; CI = confidence interval; NYTS = National Youth Tobacco Survey.

Table 2.11 Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 73

E-Cigarette Use Among Youth and Young Adults

Table 2.12a Percentage of middle school and high school students who reported that using e-cigarettes on some days 

but not every day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; 

National Youth Tobacco Survey (NYTS) 2015

No harm Little/some harm A lot of harm

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 2,511 14.5 (13.4–15.8) 10,471 61.9 (60.3–63.5) 4,070 23.6 (22.2–25.0)

E-cigarette use

Neverb 1,200 9.5 (8.4–10.8) 7,528 61.0 (59.4–62.6) 3,653 29.4 (28.0–30.9)

Ever, but not past 30 daysc 601 22.4 (20.3–24.6) 1,748 69.3 (66.4–72.1) 249 8.3 (7.0–9.9)

Past 30 daysd 641 34.2 (31.2–37.3) 1,089 59.0 (55.9–62.0) 126 6.8 (5.4–8.7)

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval. There were 325 youth excluded due to missing responses for e-cigarette use.

aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not 

every day?” Responses for “little harm” and “some harm” were combined.

bIncludes those who reported never trying e-cigarettes.

cIncludes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.

dIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.

Table 2.12b Percentage of middle school students who reported that using e-cigarettes on some days but not every 

day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; National Youth 

Tobacco Survey (NYTS) 2015

No harm Little/some harm A lot of harm

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 1,089 13.5 (11.9–15.4) 4,579 57.6 (56.1–59.2) 2,260 28.8 (27.1–30.6)

E-cigarette use

Neverb 658 9.9 (8.3–11.6) 3,927 58.0 (56.5–59.4) 2,141 32.2 (30.5–33.9)

Ever, but not past 30 daysc 211 31.9 (27.7–36.3) 383 60.6 (55.7–65.4) 60 7.5 (5.4–10.4)

Past 30 daysd 193 41.5 (35.6–47.6) 220 50.0 (44.3–55.7) 38 8.5 (6.0–12.0)

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval. There were 132 middle students excluded due to missing responses for e-cigarette use.

aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not 

every day?” Responses for “little harm” and “some harm” were combined.

bIncludes those who reported never trying e-cigarettes.

cIncludes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.

dIncludes those who reported using e-cigarettes, on 1 or more days in the past 30 days.
A Report of the Surgeon General

74 Chapter 2

Table 2.12c Percentage of high school students who reported that using e-cigarettes on some days but not every 

day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; National Youth 

Tobacco Survey (NYTS) 2015

No harm Little/some harm A lot of harm

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 1,422 15.3 (14.0–16.7) 5,892 65.3 (63.2–67.3) 1,810 19.4 (18.0–20.9)

E-cigarette use

Neverb 542 9.2 (7.8–10.9) 3,601 64.3 (62.0–66.7) 1,512 26.4 (24.6–28.3)

Ever, but not past 30 daysc 390 19.5 (17.5–21.8) 1,365 71.9 (68.6–74.9) 189 8.6 (6.9–10.6)

Past 30 daysd 448 32.3 (28.8–35.9) 869 61.3 (57.8–64.8) 88 6.4 (4.8–8.4)

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval. There were 166 high school students excluded due to missing responses for e-cigarette use.

aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not 

every day?” Responses for “little harm” and “some harm” were combined.

bIncludes those who reported never trying e-cigarettes.

cIncludes those who reported trying e-cigarettes but not using electronic cigarettes on 1 or more days in the past 30 days.

dIncludes those who reported using e-cigarettes, on 1 or more days in the past 30 days.

Table 2.12d Percentage of young adults (18–24 years of age) who reported that e-cigarettes were not at all harmful, 

moderately harmful, or very harmfula, by e-cigarette smoking status; National Adult Tobacco Study 

(NATS) 2013–2014

Not at all harmful Moderately harmful Very harmful

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 796 19.4 (17.9–20.9) 2,260 53.8 (51.9–55.7) 1,053 26.8 (25.1–28.6)

E-cigarette use

Neverb 359 14.3 (12.7–16.2) 1,423 52.8 (50.4–55.2) 814 32.9 (30.6–35.2)

Ever, but not currentc 210 22.9 (19.7–26.4) 520 56.8 (52.7–60.8) 186 20.3 (17.2–23.8)

Currentd 227 36.4 (31.8–41.2) 317 53.6 (48.6–58.5) 53 10.0 (7.2–13.9)

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Notes: CI = confidence interval. There were three young adults who were excluded because of missing responses for both ECIGEVER 

and ECIGNOW.

aIncludes responses to the question, “How harmful do you think using e-cigarettes are to a person’s health?”

bIncludes those who reported having never tried e-cigarettes or having never heard of them.

cIncludes those who reported having heard of e-cigarettes and tried e-cigarettes but reported using them “not at all” at the time of 

the interview.

dIncludes those who reported having heard of e-cigarettes, tried e-cigarettes, and using e-cigarettes some days, every day, or rarely at 

the time of the interview.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 75

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 64.)

e-cigarettes (22%) (Sutfin et al. 2013). Just over half of the

participants in this study who had never tried e-cigarettes,

however, said that they did not know enough to judge the

relative harm of e-cigarettes compared to conventional

cigarettes. In this study and another study, lack of knowledge about the perceived harm of e-cigarettes relative to

conventional cigarettes was associated with lower odds of

using e-cigarettes (Sutfin et  al. 2013; Choi and Forster

2014b). In the study by Choi and Forster (2014b), lower

perceived harm of e-cigarettes and the belief at baseline

that e-cigarettes can help people quit smoking were both

associated at follow-up with a higher likelihood of having

tried e-cigarettes.

Reasons for Use and Discontinuation

Reasons for Use

Table 2.13 summarizes studies of reasons for using 

and discontinuing e-cigarettes. The most commonly cited 

reasons for use by adolescent and young adult e-cigarette 

users included curiosity (Schmidt et al. 2014; Biener and 

Hargraves 2015; Biener et al. 2015; Kong et al. 2015; 

McDonald and Ling 2015; Suris et al. 2015; Sutfin et al. 

2015), flavorings/taste (Ambrose et al. 2015; University of 

Michigan 2015), use as a less harmful/less toxic alternative 

to conventional cigarettes (Peters et al. 2013; Tucker et al. 

2014; Ambrose et al. 2015; Kong et al. 2015; McDonald 

and Ling 2015; Sutfin et al. 2015), and avoidance of indoor 

smoking restrictions or disturbing people with secondhand smoke from conventional cigarettes (Tucker et al. 

2014; Ambrose et al. 2015; Kong et al. 2015; McDonald 

and Ling 2015; Suris et al. 2015; Sutfin et al. 2015). Other 

reasons youth and young adults reported trying or using 

e-cigarettes included affordability and lower cost than

conventional cigarettes (Tucker et al. 2014; Ambrose et al.

2015); accessibility and convenience (Choi et al. 2012;

Kong et al. 2015); social approval and/or offer from a

family member or friend (Peters et al. 2013; Kong et al.

2015; Suris et al. 2015; Sutfin et al. 2015); perception

that e-cigarettes are “cool,” “modern,” or “high-tech”

(Choi et al. 2012; Kong et al. 2015); avoidance of smelling

cigarette smoke (Peters et al. 2013; Tucker et al. 2014;

Ambrose et al. 2015; Kong et al. 2015; Sutfin et al. 2015);

ease of keeping hidden from parents/teachers (Peters et al.

2013; Kong et al. 2015); and weight control (Tucker et al.

2014). Young adults also perceived that e-cigarettes were

more socially acceptable than smoking conventional cigarettes in public (Trumbo and Harper 2013).

Some youth and young adults also reported using 

e-cigarettes as an aid to reducing and/or quitting their use of 

conventional cigarettes (Li et al. 2013; Schmidt et al. 2014;

Tucker et al. 2014; Suris et al. 2015; Sutfin et al. 2015; Bold

et al. 2016). Data from the 2012 NYTS, however, suggest 

that while e-cigarette use among U.S. youth may be associated with intentions to smoke conventional cigarettes, it is 

not associated with intentions to quit conventional cigarette smoking (Park et al. 2016). This is further reinforced 

by a study of young adults from Switzerland, which found 

that after 15 months of follow-up, e-cigarette use was not 

associated with either cessation or reduction in the use of 

conventional cigarettes (Gmel et al. 2016). There is some 

evidence to suggest that curiosity was a stronger driver of 

an e-cigarette trial among young adults than smoking cessation, and that smoking cessation was a stronger driver 

of such a trial among older adults (Schmidt et al. 2014). 

Other evidence suggests that reasons for use were driven 

by tobacco-use status, with regular adolescent e-cigarette 

users much more likely than adolescents who had used 

e-cigarettes just once to give the reason for use as smoking

cessation, smoking reduction, or avoidance of smoke-free

air regulations (Suris et al. 2015). Nationwide, according

to the 2015 MTF (University of Michigan 2015), “because

they tasted good” was cited as a reason to use e-cigarettes

among 40% of 8th-, 10th-, and 12th-grade users, versus

just 10% who reported they used them in an attempt to

quit smoking conventional cigarettes. In a New Zealand

study, interest in using e-cigarettes to quit using conventional cigarettes was higher among young adults than

older adults (Li et al. 2013). Finally, another study, this

one conducted among high school, middle school, and

college students in Connecticut in 2012–2013, found that

although the students were aware that e-cigarettes could

be used to aid in smoking cessation, they thought that few

smokers had successfully used e-cigarettes to quit smoking

(Camenga et  al. 2015). However, in an article published

by this group (Bold et al. 2016), trying e-cigarettes to

quit smoking was the most robust predictor of continued

e-cigarette use 6 months later, using a multivariable model

that included all reasons simultaneously, though this

reason was only endorsed at baseline by 5.9% of youth. Low

cost was the most robust predictor of more frequent use

6 months later, though only 10% of students endorsed this

reason at baseline (Bold et al. 2016). Therefore, the reasons

to experiment with e-cigarettes are likely different from the

reasons to continue using them, over time.

No randomized controlled trials specific to the efficacy of using e-cigarettes for quitting conventional cigarette smoking for young adults have been conducted to 

date. Although use of e-cigarettes as a potential cessation 

device for conventional cigarette smoking among adults is 

important to examine (e.g., McRobbie et al. 2014; McNeill 

et al. 2015), none of this evidence is included here, as it 

does not directly discuss youth and young adults. Three 

observational studies specific to this issue, however, have 

been conducted among young adults to date. Data from
A Report of the Surgeon General

76 Chapter 2

Table 2.13 Summary of studies on reasons for use and discontinuation of e-cigarettes among youth and young adults

Study Design/population Measures Outcomes/findings

Adkison et 

al. (2013)

• Parallel prospective cohort

• Telephone interview and web-based

surveys

• Probability sampling methods (randomdigit dialing)

• Years sample drawn: 2010–2011 (Wave

8), 2008–2009 (Wave 7; where available)

• Youth: n/a

• Young adults: current smokers,

≥18 years of age; N = 5,939

(Canada, n = 1,581; U.S., n = 1,520;

United Kingdom, n = 1,325;

Australia, n = 1,513)

• Four questions were asked regarding

reasons for use (yes/no):

1. Electronic cigarettes may not be as bad as

cigarettes for your health

2. Easier to cut down on the number of

cigarettes you smoke

3. Can smoke in places where smoking

conventional cigarettes is prohibited

4. Might help you quit

• Not explicitly reported for young adults

Choi et al. 

(2012)

• Focus groups

• Recruitment by (1) online

advertisements, (2) flyers on one

4-year and two 2-year college campuses,

(3) announcements in student life

newsletter at a 2-year college, and

(4) recruitment booth on a 2-year

college campus

• Year sample drawn: 2010

• Youth: n/a

• Young adults: Individuals in

Minneapolis-St. Paul, MN, enrolled in or

who had graduated from

4-year colleges, or those who were

enrolled in or had graduated from

2-year colleges, or those who had not

enrolled in postsecondary education;

N = 66

• Potential as quit aids • Ineffective as quit aids because:

– Contain nicotine

– Potential to be addicted to e-cigarettes

– Eliminate social interaction aspect

• Potential to help quit smoking because:

– Potential for gradual reduction in nicotine
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 77

Study Design/population Measures Outcomes/findings

Choi and 

Forster 

(2013)

• Population-based prospective cohort

study

• Interview

• Cluster random sampling

• Years sample drawn: 2010–2011

• Youth: n/a

• Young adults: U.S. midwestern adults,

20–28 years of age; n = 2,624 (sample

from Minnesota)

• Indicate your level of agreement:

1. E-cigarettes can help people quit smoking

2. E-cigarettes are less harmful than

cigarettes

3. E-cigarettes are less addictive than

cigarettes

• 44.5% agreed e-cigarettes can help quit smoking;

associated with the following characteristics:

– Not being non-Hispanic White (AOR = 0.60;

CI, 0.44–0.84)

– Enrolled/graduated from 2-year college (AOR = 1.47;

CI, 1.09–1.98)

– Current smoker (AOR = 1.35; CI, 1.05–1.73)

– At least one close friend who smokes (AOR = 1.27;

CI, 1.03–1.57)

• 52.9% agreed e-cigarettes are less harmful than cigarettes;

associated with the following characteristics:

– Not being non-Hispanic White (AOR = 0.73;

CI, 0.53–0.99)

– Male (AOR = 1.39; CI, 1.15–1.67)

– Current smoker (AOR = 1.42; CI, 1.11–1.83)

• 26.4% agreed e-cigarettes are less addictive than cigarettes;

associated with the following characteristics:

– Current smoker (AOR = 1.51; CI, 1.15–1.99)

– Former smoker (AOR = 1.64; CI, 1.19–2.25)

– At least one close friend who smokes (AOR = 1.28;

CI, 1.00–1.63)

Faletau et 

al. (2013)

• Qualitative exploratory

• Structured focus groups and individual

interviews

• Recruited from two low socioeconomic

primary schools in East and South

Auckland, New Zealand

• Year sample drawn: 2011

• Youth: Maori, Tongan, Samoan, Cook

Island, and Niuean children, 6–10 years

of age; N = 20

• Young adults: n/a

• Viewed tobacco cigarette and electronic

cigarette videos

• Stops people from smoking

• People won’t die

• Protects those around e-cigarette users from sickness

Table 2.13 Continued
A Report of the Surgeon General

78 Chapter 2

Study Design/population Measures Outcomes/findings

Li et al. 

(2013)

• Cross-sectional

• Telephone-based survey

• Random-digit-dial sampling

• Years sample drawn: 2011–2012

• Youth: n/a

• Young adults: current smokers and

recent quitters, ≥18 years of age, in New

Zealand; N = 840

• Indicate your level of agreement:

1. E-cigarettes are safer to use than tobacco

cigarettes (n = 317)

2. E-cigarettes can help people quit smoking

tobacco (n = 313)

• OR = 1.81 (.78–4.18) among participants 18–24 years of

age for perceived safety of e-cigarettes compared with

participants ≥45 years of age

• OR = 0.50 (0.21–1.17) among participants 18–24 years of

age for perceived efficacy of e-cigarettes compared with

participants ≥45 years of age

Pepper et 

al. (2013)

• Cross-sectional

• Web-based survey

• Recruited through parents who were

members of an online panel assembled

by random-digit dialing and addressbased sampling.

• Year sample drawn: 2011

• Youth: U.S. males, 11–17 years of age;

N = 228

• Young adults: n/a

• If one of your best friends were to offer you

an e-cigarette, would you try it?

• If one of your best friends were to offer you a

flavored e-cigarette (chocolate, mint, apple,

etc.), would you try it?

• Overall, 18% were willing to try an e-cigarette if offered by

a best friend:

– 13% willing to try a plain e-cigarette

– 5% willing to try flavored e-cigarettes or both kinds

• Willingness to try e-cigarettes by age:

– 11–13: 11%

– 14–16: 15%

– 17–19: 29%

• OR = 3.26 (CI, 1.27–8.35) among those 17–19 years of age

for willingness to try an e-cigarette, compared with those

11–13 years of age

• Willingness to try e-cigarettes by smoking status:

– Nonsmoker: 13%

– Smoker: 74%

• OR = 18.67 (6.22–55.98) among smokers for willingness to

try an e-cigarette, compared with nonsmokers

Peters et 

al. (2013)

• Focus groups

• Recruitment through large, diverse high

school in southwestern United States

• Year sample drawn: 2012

• Youth: U.S. teenage boys; N = 47

• Young adults: n/a

• Why do youth use electronic cigarettes?

• What do your friends think about electronic

cigarettes?

• Why are electronic cigarettes so popular?

• Reported reasons for use among youth:

– Expeditious consumption and concealment: 40%

– High school approval: 26%

– Healthier than cigarettes: 19%

– Odorless: 15%

• Reported perceptions of friends:

– High school approval: 49%

– Healthier than cigarettes: 36%

– Safe high: 15%

• Reported reasons for popularity:

– Accessibility: 43%

– Healthier than cigarettes: 30%

– Aesthetics: 23%

• Don’t know: 4%

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 79

Study Design/population Measures Outcomes/findings

Trumbo 

and 

Harper

(2013)

• Cross-sectional

• Web-based survey

• Recruitment by offer of extra credit to

students in a 100-level course

• Year sample drawn: 2011

• Youth: n/a

• Young adults: freshmen and sophomores

in a 100-level mass media in society

course; n = 244

• Indicate your level of agreement with

relative advantage:

1. I think e-cigarettes are safer in terms of

“secondhand” smoke compared to tobacco

cigarettes

2. I think e-cigarettes are not as harmful to

users as tobacco cigarettes

• Indicate your level of agreement with

compatibility:

1. I think e-cigarette users can easily make

use of existing smoking areas

2. I believe using e-cigarettes would fit in

well with the lifestyle of most smokers

• Indicate your level of agreement with

complexity:

1. I believe it will not be difficult for smokers

to learn how to use e-cigarettes

2. Overall, e-cigarettes are no more

complicated to use than ordinary tobacco

cigarettes

• Indicate your level of agreement with

“trialability”:

1. I think it will be easy for people to

purchase e-cigarettes

2. Smokers could easily give e-cigarettes a

try to see if they like them better than

tobacco

• Mean score (SD) of innovation items: 36.0 (4.7)

Zhu et al. 

(2013)

• Population

• Online-based surveys

• National probability sample

• Year sample drawn: 2012

• Youth: n/a

• Young adults: U.S. adults,

>18 years of age; N = 10,041

• Why did you use e-cigarettes (yes/no)?

1. Safer than cigarettes

2. Cheaper than cigarettes

3. Easy to use when I can’t smoke

4. To try to quit smoking cigarettes

5. Just because

• Not explicitly reported for young adults

Table 2.13 Continued
A Report of the Surgeon General

80 Chapter 2

Study Design/population Measures Outcomes/findings

Choi and 

Forster 

(2014b)

• Population-based prospective cohort

study

• Survey

• Cluster random sampling

• Years sample drawn: 2011–2012

• Youth: n/a

• Young adults: participants in Minnesota

Adolescent Community Cohort;

n = 1,379

• Indicate your level of agreement with the

following:

1. Using e-cigarettes can help people quit

smoking

2. Using e-cigarettes is less harmful to

health of the user than smoking cigarettes

3. E-cigarettes are less addictive than

cigarettes

• 10% agreed that e-cigarettes can help people quit smoking;

associated with e-cigarette experimentation at follow-up

(AOR = 1.98; CI, 1.29–3.04)

• 10.1% agreed that e-cigarettes are less harmful than

cigarettes; associated with e-cigarette experimentation at

follow-up (AOR = 2.34; CI, 1.49–3.69)

• 9.3% agreed that e-cigarettes are less addictive than

cigarettes

Czoli et al. 

(2014)

• Cross-sectional

• Survey

• Recruitment through online panel of

commercial market research company

• Year sample drawn: 2012

• Youth: Canadian youth recruited

from online panel, 16–30 years of age;

n = 1,188

• Young adults: Canadian young adults

recruited from same online panel

• Indicate your agreement with the following

reasons for trying e-cigarettes:

1. In places where you can’t smoke

cigarettes

2. For times when you don’t want to smoke

around others

3. To help you cut back on the amount you

smoke

4. To help you while you are trying to quit

smoking

5. As a long-term replacement for cigarettes

6. As a cheaper alternative to cigarettes

• Reasons for trying e-cigarettes among current cigarette

smokers:

– To help cut back on the amount they smoked (77.7%)

– As a long-term replacement for cigarettes (77.8%)

– For the times when they don’t want to smoke around

others (78.8%)

– To help them while they are trying to quit smoking

(80.4%)

– As a cheaper alternative to cigarettes (80.7%)

– In places where they can’t smoke cigarettes (80.9%)

Li et al. 

(2014)

• Cross-sectional

• Telephone-based survey

• Recruitment by telephone-based

omnibus survey and quitline client

database

• Year sample drawn: 2013

• Youth: n/a

• Young adults: current smokers and

recent quitters, ≥18 years of age, in New

Zealand; N = 267

• Indicate your level of agreement:

1. Electronic cigarettes are for people who

want to stop smoking completely

2. Electronic cigarettes are for people who

want to cut down on their smoking

3. Electronic cigarettes are for people who

want to still smoke in restricted public

places such as inside a cafe, restaurant,

or pub

• OR = 1.99 (CI, 0.99–3.97) among those 18–34 years of

age for agreeing that “electronic cigarettes are for people

who want to stop smoking completely,” compared with

individuals ≥35 years of age

• OR = 0.72 (CI, 0.24–2.21) among those 18–34 years of

age for agreeing that “electronic cigarettes are for people

who want to cut down on their smoking,” compared with

individuals ≥35 years of age

• OR = 0.93 (0.47–1.85) among those 18–34 years of age for

agreeing that “electronic cigarettes are for people who want

to still smoke in restricted public places such as inside a

cafe, restaurant or pub,” compared with individuals ≥35

years of age

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 81

Study Design/population Measures Outcomes/findings

Schmidt et 

al. (2014)

• Cross-sectional

• Telephone-based survey

• Random-digit-dial sampling

• Year sample drawn: 2013

• Youth: n/a

• Young adults: noninstitutionalized

adults in Montana; n = 5,000

• Select all of the reasons you initiated use of

e-cigarettes:

1. To quit smoking cigarettes

2. To reduce cigarette consumption

3. To try something new (curiosity)

4. To not disturb other people with smoke

5. To smoke in a place where cigarette

smoking is prohibited

6. To save money

7. E-cigarettes might be less harmful than

cigarettes

8. E-cigarettes taste better

9. Other

• Among those 18–34 years of age, approximately

50% reported trying e-cigarettes to quit or reduce

cigarette use

• Among those 18–34 years of age, approximately

70% reported trying e-cigarettes to try something

new (curiosity)

Tucker et 

al. (2014)

• Cross-sectional

• Paper-based survey

• Probability-based sampling

• Year sample drawn: not reported

• Youth: n/a

• Young adults: homeless young adults,

17–25 years of age; N = 292 (subset of

lifetime e-cigarette users, n = 83)

• 18-item measure of reasons for using

e-cigarettes, rating each reason on a 4-point

scale (1 = not at all true, 4 = very true)

• Most common reasons for use included:

– Not having to go outside to smoke cigarettes (38%)

– To deal with situations or places where they cannot

smoke (36%)

– To avoid bothering other people with tobacco smoke

(31%)

• Less common to report using e-cigarettes was to quit

smoking (17–18%)

Ambrose 

et al. 

(2015)

• Cross-sectional

• Wave 1 of PATH study

• Household-based, nationally

representative survey

• Youth: 12–17 years of age; n = 13,651

• Young adults: n/a

• Past 30-day e-cigarette users were asked to

report reasons for product use, including “it

comes in flavors I like”

• 81.5% of past-30-day users cited “because they come in

flavors I like” as a reason for using e-cigarettes

• Other common reasons for use were “they might be less

harmful to me than cigarettes” (79.1%); “they might be

less harmful to people around me than cigarettes” (78.1%);

and “I can smoke/use them at times when or in places

where smoking cigarettes isn’t allowed” (58.9%)

Biener et 

al. (2015)

• Cross-sectional

• Population-based mail survey

• Dual-frame sample

• Youth: n/a

• Young adults: 18–25 years of age;

n = 4,740

• Reasons for trying: curiosity, use by friends,

health risks relative to cigarettes, absence of

smell, for use where smoking is prohibited,

and to quit or cut down on smoking

• Reasons for stopping e-cigarette use: health

concerns, negative reactions to taste and

feeling sick, inferiority to other forms of

tobacco, expense, lack of availability, and

social disapproval

• Most common reason cited was curiosity, with never

smokers more likely to cite this (77.3%) than former or

current cigarette smokers (59% and 61%)

Table 2.13 Continued
A Report of the Surgeon General

82 Chapter 2

Study Design/population Measures Outcomes/findings

Camenga 

et al. 

(2015)

• Focus groups

• Purposive sampling

• Years sample drawn:

2012–2013

• Youth: middle and high school students

in Connecticut; n = 68

• Young adults: college students in

Connecticut; n = 59

• Discuss your motivations to use e-cigarettes • Maintain smoking actions while allowing individuals to use

a “healthier” nicotine product

• Maintain tactile sensations to help with conditionedsmoking cues

• College students believed e-cigarettes to be healthier than

cigarettes

Kong et al. 

(2015)

• Cross-sectional

• Focus groups, schoolwide survey

• Recruitment by flyers and active

recruitment sessions

• Years sample drawn: 2012–2013

• Youth: New Haven County, Connecticut,

middle and high school students; focus

group n = 127 (youth and young adults);

survey n = 4,780

• Young adults: New Haven County,

Connecticut, college students; focus

group n = 127 (youth and young adults);

survey n = 625

• Focus group:

– Why do you think people your age would

use e-cigarettes?

• Survey:

– Why did you try an e-cigarette?

– If you tried an e-cigarette but stopped

using it, why did you stop?

• Focus group responses:

– Reasons for use:

| Influence of family and friends

| To be “cool”

| Curiosity

| Readily available

| Flavors

– Comparison to cigarettes:

| Healthier

| Less harsh

| Cheaper

| Smells better

| More convenient

| Can hide it

| Use it indoors

– Reasons for discontinuation:

| Losing interest

| Negative physical effects (e.g., light-headed)

| Bad taste

| High cost

| Less satisfying than cigarettes

• Survey responses:

– Reasons for experimentation (among lifetime e-cigarette

users):

| Curiosity (54.4%)

| Friends’ influence (31.6%)

– Reasons for discontinuation:

| Uncool (16.3%)

| Health risks (12.1%)

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 83

Study Design/population Measures Outcomes/findings

Li et al. 

(2015)

• Cross-sectional

• 2014

• Nationwide, in-home survey in New

Zealand

• Multistage, stratified, clustered, and

random probability sampling method

(oversampling of Maori and Pacific

peoples)

• Participants ≥15 years of age; n = 2,594:

– Youth: 15–17 years of age, 3.8% of

sample

– Young adults: 18–24 years of age,

13.4% of sample

• Why did you try using an electronic

cigarette? (Multiple responses allowed—

wanted to quit smoking cigarettes

completely/wanted to replace smoking

cigarettes some of the time/wanted to smoke

in places where cigarette smoking is not

allowed/cheaper than tobacco cigarettes/

safer than tobacco cigarettes/curiosity/

recommendation/other)

• 57.1% of ever users cited curiosity as a reason for first

trying, followed by 31.3% of ever users who cited wanting

to quit smoking completely

• Current e-cigarette users were more likely than noncurrent

users to report wanting to quit smoking completely as a

reason for using e-cigarettes

McDonald 

and Ling 

(2015)

• Focus groups and semistructured

interviews

• Recruitment from bars through screener

surveys

• Years sample drawn: 2012–2013

• Youth: n/a

• Young adults: young adults in the

boroughs of Manhattan, Brooklyn, and

Queens in New York City, 18–27 years of

age; N = 87

• Bodily sensations

• Use in response to clean air laws

• Vapor described as “harsh” or “burning”

• Discontinued use because believed it would cause one to

smoke more

• Discontinued use due to fear of nicotine hangover

• Use to smoke in places where conventional smoking is not

allowed

Pokhrel et 

al. (2015)

• Cross-sectional

• Web-based survey

• Recruitment by flyers across

three college campuses

• Year sample drawn: 2013

• Youth: n/a

• Young adults: U.S. students from

a 4-year university and two 2-year

community colleges in Oahu, Hawaii;

n = 307

• Fourteen items, scored on a scale of 1 (do not

agree) to 7 (agree), address three main

beliefs. E-cigarettes:

– Are less harmful than cigarettes

– Improve the health of current smokers

– May be used to quit smoking

• Participants generally scored harm-reduction items higher

• Among health benefit items, “e-cigarettes improve

breathing and reduce coughing” received the highest

average score: mean (SD) = 3.9 (1.6)

• Among smoking-cessation items, “e-cigarettes are a good

compromise for people trying to quit smoking” received

the highest average score: mean (SD) = 4.6 (1.8)

• Across all items, “e-cigarettes cut down on the harmful

effects of secondhand smoke” was scored the highest: mean

(SD) = 5.3 (1.7)

• 69% of participants agreed with the above item

Table 2.13 Continued
A Report of the Surgeon General

84 Chapter 2

Study Design/population Measures Outcomes/findings

Suris 

(2015)

• Cross-sectional

• Data drawn from spring 2014 wave of

ado @ internet.ch, a longitudinal study

on Internet use

• Representative sample of students in

French-speaking part of Switzerland

• Sample of 621 students included

never e-cigarette users (n = 353),

experimenters (n = 120), and users

(n = 148); mean age = 16.2 years

• Reason for having used e-cigarettes?

– Curiosity

– To smoke where it is forbidden

– To reduce smoking

– To do like my friends

– To quit smoking

– Other

• Experimenters were significantly more likely to have used

e-cigarettes for curiosity while users were more likely to

use them where it is forbidden to smoke (p<.01)

Sutfin 

(2015)

• Longitudinal cohort study

• Data from the Smokeless Tobacco Use

in College Students Study

• College students from North Carolina

and Virginia

• Reasons for e-cigarette use were

evaluated at Wave 6 of the study, n = 271

• Why did you try e-cigarettes? (check all

that apply):

– “I was curious about the product”

– “It might be better for my health than

smoking cigarettes”

– “My friends use e-cigarettes”

– “I can use it in places where cigarette

smoking is not allowed”

– “To help me quit smoking”

– “To cut down on smoking”

– “It doesn’t smell bad”

• The majority (91.6%) reported curiosity as a reason for

trying e-cigarettes

• More than 70% tried e-cigarettes because their friends

used them

• About 70% tried e-cigarettes because they believed them

to be better for their health than cigarettes

• Fifty percent cited, “It doesn’t smell bad,” and “I can use

it where cigarette smoking is not allowed”

• About 31% said that they used e-cigarettes to cut down

on smoking

• Twenty percent said that they tried e-cigarettes to help

them quit smoking

University 

of 

Michigan 

(2015)

• Cross-sectional

• Data from the Monitoring the Future

Study

• School-based, self-administered, paperand-pencil questionnaire with crosssectional and longitudinal components

• Students from 8th, 10th, and 12th grades

• Weighted sample of students responding

to the “reasons for use of electronic

vaporizer” question: 603 (8th grade), 846

(10th grade), and 1,449 (12th grade)

• “What have been the most important reasons

for your using an electronic vaporizer, such

as an e-cigarette?”

– To help me quit regular cigarettes

– Because regular cigarette use is not

permitted

– To experiment to see what it’s like

– To relax or relieve tension

– To feel good or get high

– Because it looks cool

– To have a good time with my friends

– Because of boredom—nothing else to do

– Because it tastes good

– Because I am “hooked”—I have to have it

• More than half of all students in 8th, 10th, and 12th grades

reported that curiosity to see what they were like was a

primary reason for use

• Forty percent said that they used e-cigarettes because they

tasted good

• About 10% said they used them in an attempt to quit

smoking regular cigarettes

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 85

Study Design/population Measures Outcomes/findings

Berg 

(2016)

• Cross-sectional

• Recruitment through Facebook

targeting of tobacco and marijuana users

and nonusers

• 2014

• Youth: n/a

• Young adults: 18–34 years of age, living

in the United States; N = 1,567

• Reasons for use: For what reasons do you/

might you use e-cigarettes?

• Reasons for discontinued use: Why have you

not used recently?

• Reasons for use among current e-cigarette users:

– ‘‘They might be less harmful than cigarettes’’ (77%)

– ‘‘They do not smell’’ (77%)

– ‘‘They help people quit smoking’’ (66%)

– ‘‘They cost less than other forms of tobacco’’ (62%)

• Reasons for use among nonusers:

– “They might be less harmful than cigarettes” (41%)

– “They don’t smell” (34%)

• Reasons for discontinuation:

– ‘‘Using other tobacco products instead’’ (43%)

– ‘‘They are too expensive’’ (35%)

– ‘‘I just don’t think about it’’ (31%)

Bold 

(2016)

• Longitudinal

• Youth: New Haven County, Connecticut,

middle and high school students

• 2013–2014

• 340 e-cigarette users at baseline

• Reasons for first trying e-cigarettes:

– Curiosity

– It is cool

– Good flavors

– Does not smell bad

– Can hide it from adults

– Low cost

– My friends use it

– My parents/family use it

– Can use it anywhere

– To quit smoking regular cigarettes

– It is healthier than regular cigarettes

• In multivariable model, including all reasons

simultaneously, trying e-cigarettes to quit smoking was

the most robust predictor of current (i.e., past 30 days)

e-cigarette use 6 months later; however, this reason was

endorsed by very few youth (5.9%)

• In multivariable model, including all reasons

simultaneously, trying e-cigarettes because of low cost was

the most robust predictor of more frequent e-cigarette use

(i.e., more days/month) 6 months later; this reason was

endorsed by few youth (10%)

Note: Studies in this table are sorted by year of publication and then alphabetically. AOR = adjusted odds ratio; OR = odds ratio; PATH = Population Assessment of Tobacco 

and Health Study; SD = standard deviation.

Table 2.13 Continued
A Report of the Surgeon General

86 Chapter 2

(Continued from last paragraph on page 75.)

a population-based cohort study of U.S. young adults 

in the Midwest suggest that e-cigarettes are not effective as a technique for quitting the use of conventional 

cigarettes. In that study, 11% of cigarette smokers who 

had used e-cigarettes in the past 30 days at baseline quit 

smoking at the 1-year follow-up, compared with 17% of 

cigarette smokers who had never used e-cigarettes 

(OR = 0.93, p = 0.93) (Choi and Forster 2014a). Another 

cohort study of Swiss young adult men concluded that 

there were no beneficial effects of vaping for conventional 

cigarette smoking cessation or smoking reduction (Gmel 

et al. 2016). In this study, e-cigarette users reported lower 

cigarette smoking cessation rates at follow-up among 

those who were occasional cigarette smokers at baseline 

(OR = 0.43; 95% CI, 0.19–0.96). No differences between 

e-cigarette users and nonusers were noted among those

who were daily cigarette smokers at baseline (OR = 0.42;

95%  CI, 0.15–1.18). No differential changes between

e-cigarette users and nonusers in the number of conventional cigarettes smoked per week were noted at followup, either (Gmel et al. 2016). In a study by Unger and colleagues (2016), which focused on Hispanic young adults

in California, e-cigarette use at baseline (2014) was not

associated with cessation of cigarette smoking (OR = 1.31; 

95% CI, 0.73–2.36) or marijuana use (OR = 1.05; 95% CI, 

0.54–2.01) at follow-up (2015), though e-cigarette use 

at baseline did increase the likelihood of transitioning 

from nonuser to user of cigarettes (OR = 3.32; 95% CI, 

1.55–7.10) and marijuana (OR = 1.97; 95% CI, 1.01–3.86) 

(Unger et al. 2016). Additional research is required to 

determine any potential efficacy of e-cigarette use for conventional cigarette smoking cessation in young adults.

Reason for Discontinuation

In the small number of published studies on reasons 

for discontinuation of e-cigarette use in young users, adolescent and young adult smokers have cited lack of satisfaction and e-cigarettes’ poor taste and cost (Kong et al. 

2015) as reasons for discontinuing. Additional reasons 

have included negative physical effects (e.g., feeling lightheaded) (Kong et al. 2015) and loss of interest. In one study 

of young adults aged 18–35, former and never smokers of 

conventional cigarettes also cited the idea that e-cigarettes 

were “bad for their health” as a reason for discontinuation 

(Biener and Hargraves 2015; Biener et al. 2015).

Evidence Summary

The most recent estimates available show that 

13.5%  of middle school students (2015), 37.7% of high 

school students (2015), and 35.8% of young adults 

(2013–2014) had ever used an e-cigarette (Tables 2.1a, 2.1b, 

and 2.4a). The most recent data also show that past-30-day 

use of e-cigarettes is higher among high school students 

(16% in 2015) and young adults (13.6% in 2013–2014) 

than among middle school students (5.3% in 2015) and 

adults (25  years of age and older) (5.7% in 2013–2014) 

(Tables  2.1b, 2.4a, and 2.4b). Among youth and young 

adults, rates of ever and past-30-day use of e-cigarettes 

have increased greatly since the earliest e-cigarette surveillance efforts began in 2011. The increases among adults 

25 years of age and older, by comparison, have been less 

steep. Among middle school and high school students, both 

ever use and past-30-day use of e-cigarettes more than tripled from 2011 to 2015 (NYTS 2011–2015; Figures 2.1 and 

2.2) (CDC 2013a; Ambrose et al. 2014; Lippert 2015), and 

among young adults (18–24 years of age), the prevalence 

of ever use more than doubled from 2013 to 2014 (Styles 

2013–2014; Figure 2.3).

Among youth, past-30-day exclusive use of 

e-cigarettes among 8th, 10th, and 12 graders (6.8%, 10.4%, 

and 10.4%, respectively) was more common than exclusive

use of conventional cigarettes (1.4%, 2.2%, and 5.3%  in

those grades) or dual use of e-cigarettes and conventional

cigarettes (2.4%, 3.5%, and 5.8% in those grades) (Table 2.5; 

Figure 2.4). However, among young adults 18–24 years of 

age, the patterns were different. In that group, exclusive 

use of conventional cigarettes surpassed exclusive use of 

e-cigarettes and use of both types of products (Figure 2.8).

For example, in 2013–2014, 9.6% of young adults smoked

conventional cigarettes exclusively, 6.1% were current

users of e-cigarettes, and 7.5% currently used both. The

use of e-cigarettes and other tobacco products, such as

combustibles, appeared to co-vary among youth and young

adults (Figures 2.6, 2.7, and 2.8). Although five longitudinal studies suggest that e-cigarette use is related to the

onset of other tobacco product and marijuana use among

youth and young adults (Leventhal et al. 2015; Primack

et  al. 2015; Barrington-Trimis et  al. 2016; Unger et al.

2016; Wills et al. 2016), some studies had limitations in

their ability to distinguish experimental smokers from regular smokers at follow-up (Leventhal et al. 2015; Primack

et al. 2015; Barrington-Trimis et al. 2016; Wills et al. 2016).

Therefore, more studies are needed to elucidate the nature

of any true causal relationship between e-cigarette use and

combustible tobacco products. Investigation of whether

e-cigarette use is related to other types of substance abuse

(e.g., marijuana, alcohol) might help distinguish the extent 

to which e-cigarette use may precede or follow other forms
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 87

E-Cigarette Use Among Youth and Young Adults

of substance use in the context of the common liability/

vulnerability model (Vanyukov et al. 2012).

Although use of other tobacco products has been the 

strongest correlate of ever and past-30-day e-cigarette use 

among youth and young adults, sociodemographic characteristics have also been associated with the use of these 

products. Across both ever use and past-30-day use measures, e-cigarette use has been more common among high 

school than middle school students, a pattern similar to 

trends seen in other categories of tobacco products (CDC 

2015c). Among middle school students in 2014 and 2015 

(CDC 2016), ever e-cigarette use was highest for Hispanics 

(Table 2.1a); among high school students, ever use was 

highest among Hispanics and Whites (Table 2.1b). No differences between boys and girls were observed among middle 

school students in 2015 (Tables 2.1a, 2.1b). However, in 

2015 male high school students were significantly more 

likely to report past-30-day use than their female counterparts (Table 2.2b) (CDC 2016). For young adults, ever and 

past-30-day use of e-cigarettes were significantly higher 

among males than females (Table 2.4a). Current e-cigarette 

use was significantly lower among Blacks than in other 

racial/ethnic groups (Table 2.4a). Ever and past-30-day 

e-cigarette use was also significantly lower among those 

with a college education. Continued research is warranted 

to monitor patterns of e-cigarette use across population 

groups by gender, age, race/ethnicity, and education, as well 

as by sociodemographic characteristics for which disparities in tobacco use have been noted. Availability of data on 

e-cigarette use among youth and young adults is currently 

limited, including geography (e.g., subnational data at the 

state or local levels), sexual orientation and gender identity (e.g., lesbian, gay, bisexual, transgender), and socioeconomic status (e.g., household income, poverty status) (CDC 

2014a; Johnson et al. 2016).

Research on youth and young adults’ 

e-cigarette-related knowledge, attitudes, and beliefs is 

still developing and remains relatively sparse. Perceived 

harm is the most developed area of research. Most youth 

and young adults believe e-cigarettes are “less harmful” 

than conventional cigarettes (Table 2.11). However, up to 

50% of respondents in some of these studies felt they did 

not know enough about the potential dangers associated 

with e-cigarettes to answer questions about perceived harm 

(Ambrose et al. 2014; Amrock et al. 2015). Although relative harm compared with cigarettes is important to assess, 

equally important is determining young people’s perception of the absolute harm from e-cigarettes. National data 

show that only 23.6% of middle and high school students 

combined believed that e-cigarettes cause “a lot of harm” 

(Table  2.12a), and only 26.8% of young adults believed 

e-cigarettes are “very harmful” (Table 2.12d). However, significant differences emerge in these perceptions of harm 

when examined by whether or not youth and young adults 

use e-cigarettes. Among both middle and high school students and young adults, perceptions of “no harm” were 

much more prevalent among those with prior experience 

with e-cigarettes (Tables  2.12b–2.12d). Current e-cigarette users were two to three times more likely to report 

that e-cigarettes convey “no harm” compared to never 

e-cigarette users, for both age groups (Tables 2.12a and 

2.12d).

The most commonly cited reasons that youth and 

young adults reported using e-cigarettes included curiosity (Schmidt et al. 2014; Biener and Hargraves 2015; 

Biener et al. 2015; Kong et al. 2015; McDonald and Ling 

2015; Suris et al. 2015; Sutfin et al. 2015), flavorings/taste 

(Ambrose et al. 2015; University of Michigan 2015), use as 

a less harmful/less toxic alternative to conventional cigarettes (Peters et al. 2013; Tucker et al. 2014; Ambrose et al. 

2015; Kong et al. 2015; McDonald and Ling 2015; Sutfin 

et al. 2015), and avoidance of indoor smoking restrictions 

or disturbing people with secondhand smoke from conventional cigarettes (Tucker et al. 2014; Ambrose et al. 2015; 

Kong et al. 2015; McDonald and Ling 2015; Suris et al. 2015; 

Sutfin et al. 2015). Using e-cigarettes as an aid to conventional cigarette smoking reduction/cessation (Li et al. 2013; 

Schmidt et al. 2014; Tucker et al. 2014) was not a primary 

motivator among youth and young adults. Youth and young 

adult smokers cited lack of satisfaction, poor taste, and cost 

(Kong et al. 2015) as reasons for discontinuing e-cigarette 

use. Additional research is needed to examine how reasons 

for use, including the appeal of flavored e-cigarettes, are 

causally related to the onset and progression of e-cigarette 

use among youth and young adults. Data from the first 

wave of the PATH study suggest that flavors may play an 

important role in the initiation of e-cigarette use among 

youth (Ambrose et al. 2015), while data from the 2014 

NYTS (Corey et al. 2015) and 2013–2014 NATS (Table 2.9) 

underscore that use of flavored e-cigarettes remains prevalent among youth and young adults who currently use 

e-cigarettes.
A Report of the Surgeon General

88 Chapter 2

Conclusions

1. Among middle and high school students, both ever 

and past-30-day e-cigarette use have more than tripled since 2011. Among young adults 18–24 years 

of age, ever e-cigarette use more than doubled from 

2013 to 2014 following a period of relative stability 

from 2011 to 2013.

2. The most recent data available show that the prevalence of past-30-day use of e-cigarettes is similar 

among high school students (16% in 2015, 13.4% in 

2014) and young adults 18–24 years of age (13.6% in 

2013–2014) compared to middle school students 

(5.3% in 2015, 3.9% in 2014) and adults 25 years of 

age and older (5.7% in 2013–2014).

3. Exclusive, past-30-day use of e-cigarettes among 

8th-, 10th-, and 12th-grade students (6.8%, 10.4%, 

and 10.4%, respectively) exceeded exclusive, 

past-30-day use of conventional cigarettes in 2015 

(1.4%, 2.2%, and 5.3%, respectively). In contrast—

in 2013–2014 among young adults 18–24 years of 

age—exclusive, past-30-day use of conventional cigarettes (9.6%) exceeded exclusive, past-30-day use of 

e-cigarettes (6.1%). For both age groups, dual use of 

these products is common.

4. E-cigarette use is strongly associated with the 

use of other tobacco products among youth and 

young adults, particularly the use of combustible 

tobacco products. For example, in 2015, 58.8% of 

high school students who were current users of 

combustible tobacco products were also current 

users of e-cigarettes.

5. Among youth—older students, Hispanics, and 

Whites are more likely to use e-cigarettes than 

younger students and Blacks. Among young 

adults—males, Hispanics, Whites, and those with 

lower levels of education are more likely to use 

e-cigarettes than females, Blacks, and those with 

higher levels of education.

6. The most commonly cited reasons for using 

e-cigarettes among both youth and young adults are 

curiosity, flavoring/taste, and low perceived harm 

compared to other tobacco products. The use of 

e-cigarettes as an aid to quit conventional cigarettes 

is not reported as a primary reason for use among 

youth and young adults.

7. Flavored e-cigarette use among young adult current 

users (18–24 years of age) exceeds that of older adult 

current users (25 years of age and older). Moreover, 

among youth who have ever tried an e-cigarette, a 

majority used a flavored product the first time they 

tried an e-cigarette.

8. E-cigarette products can be used as a delivery 

system for cannabinoids and potentially for other 

illicit drugs. More specific surveillance measures are 

needed to assess the use of drugs other than nicotine 

in e-cigarettes.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 89

E-Cigarette Use Among Youth and Young Adults

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