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ARTICLES: Literature Review

Knowledge, Attitudes, and Perceptions of Young Adults About Electronic Nicotine Delivery Systems in the United States

An Integrative Review

Tremblay, Beth MSN, RN; Turk, Melanie T. PhD, RN; Cooper, Maria R. PhD; Zoucha, Richard PhD, PMHCNS-BC, CTN-A, FAAN

Author Information
The Journal of Cardiovascular Nursing: 1/2 2022 - Volume 37 - Issue 1 - p 86-97
doi: 10.1097/JCN.0000000000000731
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Abstract

Problem Identification

The popularity of electronic cigarettes (e-cigarettes) is rapidly increasing, with the highest rates of usage among young adults.1,2 Most Americans know about e-cigarettes. One study indicated that awareness of e-cigarettes reached 94.3% of the population in 2014.3 Yet, the long-term health risks of e-cigarette use are unknown. However, studies using biomarkers that indicate inflammation and oxidative stress raise concern for cardiovascular and lung health. A causal link between cigarette smoking and endothelial dysfunction associated with cardiovascular disease has been established.4 The same pathophysiological events are being examined in association with e-cigarette use. A recent study examined the acute effects of flavored e-cigarette liquids (e-liquids) compared with cigarette use on endothelial health and endothelial cell-dependent macrophage activation.5 Results indicated that the inflammatory cytokines interleukin-1β and interleukin-6, known to be factors in cardiovascular disease pathogenesis, were elevated in sera of both e-cigarette and cigarette users 3 hours post use. Higher levels of reactive oxygen species, such as hydrogen peroxide, were produced by cells exposed to flavored e-liquids, which led to increased cytotoxicity.

Adding to the evidence of the acute proinflammatory effects of e-cigarette flavored liquid is a retrospective analysis of e-cigarette users and occurrence of myocardial infarction. Data from 2014 and 2016 indicated a positive association between daily e-cigarette use and having experienced an myocardial infarction that was independent of the association between traditional cigarette use and MI occurrence.6 Although this was a cross-sectional, observational study and prospective studies are needed, it demonstrates that e-cigarette users had a higher prevalence of MI than did non–e-cigarette users. Another study measured the alterations in vascular function with combustible and e-cigarette use. The study indicated that endothelial cells of combustible and e-cigarette users produced less calcymycin (A23187) stimulated nitric oxide than nonusers did.7 The authors noted that the lower nitric oxide, important in vasodilation, may be attributed to nitric endothelial nitric oxide synthase expression. This study was cross-sectional; thus, including vascular function of e-cigarette users in prospective cohort studies is needed.

Cardiovascular function is also impacted by pulmonary function. Although aerosol from e-cigarettes contains less toxicants than combustible cigarettes, they are not harmless.8 Using human airway samples, tests have indicated that innate defense proteins associated with chronic obstructive pulmonary disease were significantly elevated among e-cigarette users.9 An acute exposure of unflavored vaporized e-liquids has been shown to cause apoptosis and necrosis of alveolar macrophages in vitro.10 These findings indicate that exposure to e-cigarette liquids in the vaporized state causes inflammation and death to the cells, which capture inhaled dust and microorganisms, and the long-term impact of e-cigarette liquids on human lung function is unknown. These new studies add to existing evidence of the known deleterious effects of nicotine, formaldehyde, and diacetyl, which are found in vaporized liquid (e-liquid). Diacetyl, found in 39 of 51 e-liquids tested in a study, is used as a flavoring agent and can cause the irreversible lung disease bronchiolitis obliterans, or “popcorn lung.”11,12

Although the health detriments of traditional cigarettes are well known, the same body of evidence is not currently available for e-cigarettes. As scientists uncover the potential harms of e-cigarettes, healthcare practitioners must disseminate the new information. Currently, e-cigarettes are often seen as a cessation tool and may be a successful method for smoking cessation for some adults.13 However, e-cigarettes may encourage future tobacco use for youth.14,15 With emerging evidence of potential harms, it is vital to population health to understand the factors that lead to use among young adults, who have the highest rates of e-cigarette use and may suffer greatly from long-term use.1,16 Among young adults 18 to 24 years of age, e-cigarette use more than doubled from 2013 to 2014,17 representing a growing population health concern.18 Further adding to the problem, flavoring in e-cigarettes is viewed favorably by young adults19 and works as a reinforcement of vaping behavior.20 The Food and Drug Administration (FDA) banned flavored tobacco products because of their potential attractiveness to children in 2009.21 A 2016 ruling known as the “deeming act” stated that electronic nicotine delivery systems (ENDS), such as e-cigarettes, can be regulated by the FDA as tobacco products, but only recently have the laws advanced to banning most flavors of e-liquids. The exceptions to the flavor ban are mint and menthol flavorings, which are favored by adults but ranked as far less popular by minors and young adults.22 This ban of certain flavorings is aimed at reducing new users among youth and young adults, while preserving an option for smoking cessation of traditional cigarettes by adults.2

The young adult years from 18 to 25 are described as emerging adulthood to capture the delayed adoption of adult roles.23 One characteristic of young adulthood is exploration, which may include health behaviors. Another attribute of this age may be poor self-regulation of emotions, which has been linked to risky health behaviors such as smoking traditional cigarettes.24 One factor associated with this dysregulation is impulsivity, which may be a risk factor in using addictive substances, including nicotine.25 The characteristics of young adults who are more inclined to use e-cigarettes are those who identify young adulthood as a time of experimentation and those who have experienced multiple “role transitions” such as gaining or losing a job or a romantic partner.1 Social and environmental factors also influence young adults' health behaviors. For example, young people who witness others using e-cigarettes are more likely to use them. Also, attitudes of acceptance of cigarette smoking among those who never smoked cigarettes were found to be higher among youth who lived with an e-cigarette user, were exposed to e-cigarette advertising, or who used e-cigarettes.26 These characteristics of the young adult years and loci of influence are vital in understanding how e-cigarette use is socially and culturally accepted during the formative years in young adulthood.

Role of Culture

Culture encompasses the internalized shared beliefs, knowledge, and behaviors through which a group views their individual and collective experiences.27,28 Culture is reflected not only in characteristics of young adults but also how those elements are transmitted from one individual to another. Adding to the complexity of identifying tacit cultural indicators of this health behavior is the cultural branding of e-cigarettes. Cultural branding intentionally builds myths or stories of experiences that lead consumers to buy a specific product so they can experience the “story” for themselves.29 Understanding cultural or subcultural process can allow health researchers to develop mediating or moderating interventions that specifically address culture as a health behavior influence.30 Thus, this integrative review seeks to uncover the tacit meanings that e-cigarettes have in the life of young adults. To explore how the role of culture within the young adult population influences this health behavior, the following questions guided the inquiry: (a) What is the meaning of e-cigarette use among young adults? (b) What are the perceptions, values, and social norms associated with e-cigarette use and are they communicated with others? The purpose of this integrative review is to explore existing research for elements of culture among young adults, including knowledge, attitudes, perceptions, social norms, and values about e-cigarettes, to guide future research.

Methods

To ensure a rigorous product, this IR was completed according to the model developed by Whittemore and Knafl.31 This model provides a framework to assess and synthesize multiple types of primary research into a single review.31 Inclusion of primary research with different methodologies is vital to understanding the problem of e-cigarette use in the young adult population. The model includes guidelines for problem identification, literature search, data evaluation, data analysis, and presentation.

Literature Search

The literature review was conducted with the help of an experienced health sciences librarian and 3 databases were searched, CINAHL, PubMed, and Scopus, for relevant articles published between 2010 and 2018. To determine the timeframe for the literature search, factors for availability and awareness of the product were assessed. Electronic cigarettes did not become available to the US market until 2007, and awareness and use of e-cigarettes were not immediate. In a preliminary search on the topic of knowledge, perceptions, and attitudes of the young adult population, no related articles were found before 2011. Therefore, a date of 2010 was selected for the purposes of this search to ensure inclusion of possible earlier articles. The age of 18 to 25 years is a commonly used age range to define “young adults” for tobacco research in the United States16 and was used for the purposes of this review. Search terms included key words and controlled vocabulary to include 3 areas. First, the area for the population included “young adults,” “emerging adults,” “college students,” and “university students.” Second, the behavior of e-cigarette use was targeted by using the following terms: “e-cigarettes,” “vaping,” “electronic nicotine delivery systems,” and “juul.” And third, key words and controlled vocabulary to capture elements of culture were “perception,” “attitude to health,” “health belief,” “culture,” and “acculturation.” Inclusion criteria for this integrated review were peer reviewed articles written in English in the United States that examined adults aged 18 to 25 years with study participants who used e-cigarettes. Articles that expand beyond ages 18 to 25 years had a minimum of 90% of their sample population within the target age range for this review. Qualitative, quantitative, and mixed-method studies were included, as well as articles that addressed characteristics of the population such as beliefs, language, values, social norms, attitudes, and perceptions toward “vaping,” e-cigarettes, or use of electronic nicotine delivery systems. Exclusion criteria were studies that explored the effects of marketing and advertising, a sole focus on e-cigarette initiation, and studies where data on e-cigarette use is compiled with other alternative tobacco products.

The study selection process followed the PRISMA guidelines (see the Figure) and included removal of duplicate studies, followed by an abstract and title review (n = 895). Articles that were not peer reviewed, not primary research, or not relevant were removed (n = 824). Seventy-one full-text studies were assessed for eligibility. Fifty-six studies were removed because they did not meet inclusion criteria. Articles that did not have a focus on an age range between 18 and 25 years, had a mean age outside of that range, or did not specify age were removed (n = 39). Another 9 studies were removed that focused on the influence of social media, advertising, or exposure to specific e-cigarette flavors. Studies that had a primary outcome of initiation of e-cigarettes were also excluded (n = 6). One study was removed because information on e-cigarettes and vaping could not be separated from the information exploring perceptions about other alternative tobacco products. Because this IR was focused on the general young adult population, 1 study that correlated use with a subgroup having a mental health diagnosis was removed (n = 1). Ultimately, 15 articles were analyzed according to the research questions.

FIGURE
FIGURE:
PRISMA flowchart.

Data Evaluation

A quality scoring instrument, the Quality Assessment Tool for Studies with Diverse Design (QATSDD) provided evaluation criteria. The QATSDD, a 16-item scoring instrument, was tested for reliability by health services researchers.32 The face validity was established through contributions of 9 researchers. Interrater reliability was measured using Cohen κ coefficient and was established through agreement of 3 researchers on 3 research papers applying the instrument (κ = 71.5%). Last, test-retest reliability was established by the results of instrument application to the same articles tested 6 weeks apart.32 The instrument is ideal for this IR as it includes criteria for evaluating quantitative, qualitative, and mixed-method studies, all of which are included in an IR. The 16 criteria within the instrument are each scored on a 4-point (0–3) scale, with 0 being missing and a 3 demonstrating excellence. Fourteen of the criteria apply to quantitative studies, and 14 criteria apply to qualitative studies. Mixed-methods studies are assessed on all 16 criteria. Thus, the total possible scores for quantitative or qualitative studies range from 0 to 42; a mixed-method study has a potential high range score of 46. Higher scores represent higher quality.

Data Analysis

The QATSDD instrument and a table for organization aided in the systematic extraction of each study's data, the synthesis of information, and assessment of study quality. Elements included in the Table are the author and year the article was published, the sample characteristics, sample size, study setting, the aims, limitations, study outcomes, and the quality assessment. Extracted data were clustered by similarities. Clusters were further coded by the author using the guiding research questions, and categories were formed. These categories were reflected upon, synthesized, and reduced to identify 3 main themes within the literature.

TABLE - Article Evaluations With Quality Assessment Tool for Studies With Diverse Design
Author(s) Design Sample, Sample Size, and Setting Aims Limitations Outcomes Quality Rating
Berg et al (2016) Prospective mixed methods Age: 18–25
N = 3418
Female: 64.3%
E-cig users: n = 372, 10.9% past 30-day e-cig use
7 higher education campuses in Georgia
Exploration of psychographic characteristics of tobacco-product use using market research methods. Document tobacco use over time Restriction to 7 colleges and universities in Georgia may cause selection bias
Low response rate
Characteristics associated with e-cig use: male, nonblack, technical college, novelty seeking, not a socially conservative thinker. 31
Case et al (2016) Qualitative
Structured interviews
Age: 18–26
College students
N = 30, equal number of e-cig ever-users and nonusers; 3 (10%) past 30-day e-cig users
Female: 53.3%
One southwestern university
Explored theoretical constructs relevant to e-cig use. Intent-to-use information for future health communication campaigns Low number (n = 3) of current e-cig users recruited from single setting. Structured interview focused on Health Belief Model and could have excluded other relevant information Perceived e-cigs as less harmful than traditional cigarettes. Reported concern about health and addiction with e-cig use. 20
Cooper et al (2017) Cross-sectional Age: 18–26 (nontobacco users); n = 3663
Age: 18–29 (current tobacco users); cigarette: n = 633
N = 5482
past 30-day e-cig users: n = 429 (7.8%)
Female: 63.4%
Dual user: n = 478
24 colleges
Explore the relationship between dual cigarette and e-cigarette use. To compare perceptions of harm and addictiveness of both products among groups Cross-sectional
Limited to Texas
Perceptions of harm and addiction of e-cigs are lower than those for conventional cigarettes. Perceptions of harm and addiction were lower among exclusive and dual users, compared to nonusers. 32
Copeland et al (2017) Cross-sectional Mean age: 20.7
College students
N = 734
Female: 78.1%
White: 76.4%
Daily e-cig use: 3%
Developed the Risks and Benefits of E-cigarettes (RABE) instrument to assess the perceptions about e-cig use among college students Outcome expectancies not assessed. Questions were based on small amount of literature. No clear age-range
Cross-sectional
RABE is a reliable instrument to measure college student's perceived risks and benefits of e-cigs. 28
Hart et al (2017) Cross-sectional Age: 18–37, mean age: 20.5;
College students
N = 652
Current e-cig users: n = 42 (6.4%)
Female: 65.7%
Compared perceptions of e-cig safety among 3 groups: (1) never tried, (2) tried, and (3) current e-cig users Limited to 1 college campus in the Midwest
Cross-sectional
“Tried” or “current users” have more positive view of devices; 87% of participants were aware of e-cigs.
Current use associated with being male.
19
Hess et al (2017) Qualitative Age: 18–25
Young black adults
N = 36
Male: n = 22, female: n = 24 (52%)
Current tobacco users: n = 25; 12 (33%) had reported e-cigarette use in the past year
Examined perceptions of e-cigs among black young adults to explore the meanings ascribed to e-cigs and the role that identity plays in how these devices are viewed Lacked reporting on past 30-day e-cig use
Open-ended questions about e-cigs introduced after 10 interviews were completed
Limited to San Francisco area
Black youth perceive e-cigs as a smoking cessation tool and as a way to demonstrate unique social identity. Participants saw e-cig users in terms of race and class identity. 26
Lee et al (2017) Cross-sectional Age: 18–25
College students
N = 1198
Female: 52%
White: n = 853, black: n = 58, Hispanic: n = 48, Asian/Pacific Islander: n = 180
40% ever-users
Past 30-day e-cig users: no data
Investigated the characteristics of potential and current e-cig users based on 4 levels of use-acceptability and factors that promote acceptability of use Self-report questionnaire
Convenience sample
Single Midwestern university
Early adopters reported that e-cigs are more socially acceptable than traditional cigarettes.
Flavors promoted use. Reasons for use: positive sensory feeling, caring more about appearance than health.
36
Maglalang et al (2016) Cross-sectional Age: 18–25
Asian American and Pacific Islanders in California
N = 501
Female: 57%
LGBTQIA: 15%
Ever-users: 44%
Current e-cig users: 11%
Explored patterns of use, differences between ENDS users and nonusers, especially initiation of use Convenience sample
Cross-sectional
Learning about e-cigs from friends was linked to trying e-cigs (not current use). Current use was 2 times higher among the following groups: men, LGBTQIA, associate/vocational degree, employed. 28
Martinasek etal (2018) Cross-sectional Age: ≥18 y
College students
N = 989
Ever-user: 51.4%
Female: 67.7%
White: n = 709, black: n = 54, Hispanic: n = 107, Asian/Pacific Islander: n = 38, multiracial: n = 45
Florida university
Past 30-day use of e-cigs: 35%
To explore social and behavioral perceptions, patterns of use, and first encounters with e-cigarettes among college students Only 6.8% were ≥23 y old—no clear age cutoff
Cross-sectional
Limited to college students at a single university
About half reported ever using e-cigs and other tobacco.
Men more likely to use e-cigs. Using multiple tobacco products was more prevalent among those who had tried e-cigs.
Harm from vapor perceived to be less than that of traditional cigarettes.
Peers were primary influencer of initial use. Tobacco use categories were nonusers (70%), hookah users only (14%), e-cigs only (11%), and polytobacco users (4%).
27
McDonald and Ling (2015) Qualitative
17 focus groups by 12 semistructured interviews
Age: 18–27
N = 87
New York City
Past 30-day e-cig users: 32%
Female: 44%
To explore the use of ENDS among young adults in New York City to understand the related beliefs, opinions, and practices Limited to New York City Reported experimenting with e-cigs often. Limited knowledge came from e-cig ads. Used bodily sensations to judge risks and benefits of e-cigs. Perceived e-cigs as a “toy,” like other technologies. 29
Pokhrel et al (2018) Cross-sectional Age: 18–25
N = 470
Female: 65%
White: 27.3%, Asian: 38.4%, Filipino: 16%, other: 18.1%
Never user: 42.5%, experimenter: 33%, current user: 24.5%
To develop a survey to assess e-cig outcome expectancies among college students. Determine dimensions of e-cig use expectancies and associations with e-cig use and use expectancies Cross-sectional
Predominantly Asian and PI population limits external validity
Only college students included, thus limiting generalizability
Some missing data
Replicated previous findings. Positive outcome expectancies linked to ENDS use dependence.
Higher outcome expectancies related to greater nicotine dependence.
36
Pokhrel et al (2014) Cross-sectional Mean age: 23.5
College students
N = 307
Female: 65%
One 4-y and two 2-y colleges in Oahu, Hawaii
Past 30-day e-cig use: not reported
Develop a survey to assess e-cig outcome expectancies among college students. Determine dimensions of e-cig use expectancies and associations with e-cig use and use expectancies Cross-sectional;
Expectancy survey items were adapted from previous ENDS research
Convenience sample
Limited to Hawaii
Self-report
Being a current smoker was positively related to (+) expectancies and inversely related to (−) expectancies.
Higher (+) expectancies linked to greater chance of past 30-day e-cig use. In e-cig never-users, (+) expectancy was related to greater intention to use.
35
Saddleson et al (2016) Cross-sectional Age: 18–23
Female: 56.5%
Undergraduate students
E-cig ever-users: n = 429; past 30-day e-cig users: n = 15 (3.5%)
4 universities
To discover what drives college students to use e-cigs Cross-sectional
New York only
Convenience sample
Only 15 current users
Using e-cigs for enjoyment was linked to current use. More daily users reported use for smoking cessation compared with nondaily or discontinued users. 30
Trumbo and Harper (2015) Cross-sectional Age: 18–24
National sample
Male: 51%, female: 49%;
14% tried e-cig, 84% aware of e-cig
Past 30-day e-cig use: not reported
To examine channels through which information about e-cigarettes has flowed, public perception of e-cigarettes as an innovation, and how these may influence use Self-report, online survey
Cross-sectional
Television ranked first for exposure to e-cig information. Information exposure and favorable perception as an innovation predicted use. The high degree of e-cig awareness, combined with depiction of the devices as a favorable innovation, may contribute to their wider adoption and may argue for regulation of e-cig advertising. 38
Trumbo and Harper (2016) Cross-sectional
Secondary data analysis
Age: 18–24
N = 874
Students: n = 465, nonstudents: n = 409
Female: 49.9%
National survey
Daily e-cig users: 1.2%
To explore the attitudes and use of e-cigs among college-going and straight-to-work young adults and to examine the behavior associated with e-cig use Low percentage of current vapers; 19.7% reported “former vaper” status, but it is unclear if this is based on ever trying vaping or sustained daily use
Self-report
Cross-sectional design
Attitude, norms, innovation, and information have medium to strong associations with behavioral intention to use an e-cig and acceptability of public use of e-cigs. 38
Abbreviations: e-cig, electronic cigarette; ENDS, electronic nicotine delivery systems; LGBTQIA, lesbian, gay, bisexual, transgender, queer, intersexual, asexual; PI, Pacific Islanders.

Results

All included studies were published between 2014 and 2018. Of the 15 studies in this IR, 11 were quantitative, 3 were qualitative, and 1 was a mixed-method design. The QATSDD scores for this IR ranged from 19 to 38 (see the Table). Only 3 studies reported sample populations where less than half of participants were women (see the Table). The other 12 studies included more women than men, for example, 52% to 78.1% women.33–44 The studies included predominantly white participants, with the exception of Hess et al,38 who studied only black young adults, and Maglalang et al,43 who studied Asian American and Pacific Islander young adults in California. Several studies reported only limited demographics.37,45–47 Study participants who were current e-cigarette users ranged from 3%36 to 35%.44

Three themes emerged from the existing literature including: “Is it bad for me?,” “I just like it,” “Is it cool or not?”

Is It Bad for Me?

Data indicated that young adults felt they had limited knowledge45 and indicated a lack of evidence communicated to them. Many believed that the liquid used in e-cigarettes produced nothing more than water vapor. Although 75.8% of the participants in one study recognized e-cigarettes as a tobacco product, those who were current users were less likely to do so.37 Eight studies indicated that participants perceived a lower risk of harm from e-cigarettes than from traditional cigarettes.34,36,39,43,45,47–49 However, whereas 1 study indicated participants perceived a low risk of e-cigarettes, another indicated a lower relative risk.43,45 In other words, participants saw it as healthier, but not necessarily free of harm, or confused the idea of healthier than with healthy. Furthermore, those who use both traditional cigarettes and e-cigarettes (dual users) reported lower perception of harm by e-cigarettes in 1 study,35 and in another, no statistically significant difference in perceived harm was found between e-cigarette users, nonusers, and dual users.36 Yet, this same study did indicate that current e-cigarette-users perceived more benefits to using e-cigarettes than those who had never tried them. Interestingly, 1 study indicated that 57.1% of participants perceived e-cigarette use as unsafe.37 A more recent article reported concern of addiction.50 Another perception about e-cigarettes use was that it could be used as a quit aid,43 particularly for older people.38

I Just Like It

The theme of “I just like it” uncovered the underlying reasons why young adults like using e-cigarettes and illuminated motivation for use. For many young adults who use e-cigarettes, it is linked to a positive sensory experience.51,52 Study participants identified that taste was an important factor in using e-cigarettes.42,45 The evidence of flavor as a motivator to e-cigarette use is now well documented and is beginning to drive policy.2,22 However, taste was not the only aspect important to e-cigarette users.

Other aspects of e-cigarettes are also attractive to young adults. One study reported 72.1% of current e-cigarette users did so for enjoyment,41 but that enjoyment did not entirely revolve around flavor and taste of e-cigarettes. Young adults identified values such as interest in e-cigarettes due to personal interests in the mechanics of it.33 Furthermore, e-cigarettes were found to be an interesting innovation that drew some young adults to use them.53 Other young adults identified e-cigarettes as a “toy,” which may speak to the culture of technology.45 Young adults reported attitudes of novelty-seeking behavior and engaging in self-focused thinking; these attitudes more frequently present in e-cigarette users than non-e-cigarette users.33 Study participants even expressed valuing appearance over health.42

Is It Cool or Not?

Perceptions about the social acceptability of e-cigarette use varied greatly between e-cigarette users and nonusers. In 1 study, users and nonusers reported social stigma as a disadvantage to e-cigarette use and that using e-cigarettes can be a social barrier owing to friends who do not approve,34 but other studies report that e-cigarettes are used for social or recreational use.43 However, another study indicated that peer influence was a primary reason for trying e-cigarettes.39 In general, those who were early adopters of e-cigarettes reported that use is more socially acceptable.42 Two studies reported social enhancement with use,40,50 where “social enhancement” was defined as the participants' belief that they will be liked more or be more socially acceptable to others. Whereas e-cigarette users indicated that use in public was acceptable, nonusers reported the opposite.34

Beyond acceptability, several studies explored how young adults perceived their own social identity with regard to using e-cigarettes in public. One e-cigarette user reported a fear of looking silly when vaping in public,45 which was supported by reports of a negative social consequence of e-cigarette use in public as “looking awkward.”50 Nonusers reported views that those who use e-cigarettes in public are “rebellious”45; have a negative appearance40; and look like “hipsters,”38 “dorks,” or “addicts.”34

Discussion

This review synthesizes the literature and sought to illuminate elements of culture among young adults, including knowledge, attitudes, perceptions, social norms, and values about e-cigarettes, to guide future research. The research questions were as follows: (a) What is the meaning of e-cigarette use among young adults? (b) What are the perceptions, values, and social norms associated with e-cigarette use, and are they communicated with others? The first question was not fully answered in this review because meaning of e-cigarette use should come primarily from current e-cigarette users to gain the insider's perspective. The 3% to 35% of participants reporting current e-cigarette use captures some of this perspective, but future research should recruit current and regular e-cigarette users. Only 1 study actually addressed the concept of meaning,38 but the participants of the study were not screened for current e-cigarette use. Thus, the concept of meaning to the young adults who are currently engaged in e-cigarette use is still not fully explored. As the physiological effects of e-cigarette use continue to be discovered, an understanding of the behavior of people who are at highest risk for deleterious effects is also needed. Part of understanding health behaviors includes understanding the social and cultural drivers of the choices of an individual who identifies as belonging to a larger group or sub-group. Despite these shortfalls, several themes emerged which are useful to understanding the knowledge, perceptions, attitudes, and social norms held by young adults.

The first theme was “Is it bad for me?” The literature highlights that young adults who use e-cigarettes lack awareness of the potential health effects that the product may have; furthermore, young adults may not seek out health-related information because of enjoyment of using e-cigarettes and wanting to believe that they are safe and will not injure one's personal appearance or health in the way traditional cigarettes do. Young adults identified the potential harm of e-cigarettes through a lens of relative harm. If they believe it is less harmful than traditional cigarettes, they may find it more acceptable. To address harm, warning labels advising consumers of risks of nicotine addiction have been added to packaging based on current evidence54; however, warnings are limited only to the risk of nicotine addiction and not any other harmful effects. Further research will be needed to not only assess for long-term health effects but also the best way to communicate health risks to young adults. Young adults have been found to have a lessened perception of harm after exposure to advertising.55 Therefore, research that assesses the health warnings within advertisements should also be conducted to recommend advertising that aligns with current traditional cigarette advertising. Current traditional cigarette warning labels include health effects beyond the risk of just nicotine addiction.

The second theme, “I just like it,” indicates that motivations for use are often personal and include experiential motivators such as flavor, novelty seeking, and valuing appearance over health. The evidence of flavor as a motivator to e-cigarette use is now well documented and is beginning to drive policy, such as banning flavors that may increase initiation of use.2,22 Novelty seeking is consistent with other tobacco research. There is a positive correlation between novelty-seeking behavior and daily combustible cigarette smoking in young adults.56 Valuing appearance over health is consistent with other research that explores the initiation of e-cigarette among young adults.42 These motivating factors should be considered for health education and policy making. One recent advance in protecting public health with respect to e-cigarettes has been the proposed policies by the FDA in March 2019,2 which will ban all flavors in e-liquids with the exception of tobacco, mint, and menthol flavors. Although menthol flavor was found to be among the most cytotoxic, youth and young adults tend to rate attractiveness of this flavor lower than adults.22

The third theme, “Is it cool or not?,” demonstrates some underlying social influences for young adults. For the young adults who engage in this behavior, there may be a mystique of being different or separate from the mainstream crowd. Although they may feel judged at times, there is some benefit to identifying oneself as different through a health behavior such as e-cigarette use and thus being a part of a smaller group with a similar interest.45 Two studies began to look at social enhancement, which may reflect an aspect of culture, but limited exploration of the culture of e-cigarette use by young adults was evident. For example, language is used to create conceptual clarity and is vital to understanding culture.57 Alexander et al57 conducted a study of this nature in the general adult population, but no studies were found that discussed language specific to e-cigarette use in young adults. Future research should examine language and communication unique to young adults who use e-cigarettes.

Demographics for race and ethnicity in the studies of this review do not fully represent those of current e-cigarette users. Most participants in the reviewed studies were white. Data from the National Adult Tobacco Survey (2013–2014) of exclusive e-cigarette users indicate that 6.3% were white, 2.9% were black, and 7.9% were Hispanic or LatinX, leaving another 5.7% reporting race/ethnicity as “other.” Dual use of e-cigarettes and traditional cigarettes was reported at nearly twice the rate among whites (9.7%) as for all other race/ethnicities (2.5% to 5.9%, CI = 95%). Although this indicates e-cigarette use is predominant in those reporting exclusive and dual use of e-cigarettes, future research should seek to include all ethnicities representative of current e-cigarette use.

Gender should also be accurately represented in future research. Women were overly represented in most of the reviewed studies. Because current e-cigarette users are more likely to be male,37,39,43 this limits the perspective of current e-cigarette-users. Twice as many men (8.1%) used e-cigarettes only compared with women (4%, confidence interval = 95%). The gap is similar for dual use, with 9% of men and 5.8% of women reporting dual use. The gender gap is substantially larger than exclusive combustible cigarette use (10.6% for men vs 8.4% for women).17 To better understand e-cigarette users and to answer the first research question that guided this review, research with a larger representation of men is needed.

Implications for nursing practice include patient education and cessation counseling. Efforts must focus on dispelling myths that e-liquid is water vapor and explaining the concept of relative risk as it pertains to tobacco products. Young adults who do not currently smoke cigarettes should be educated that e-cigarettes are not a recommended alternative to other tobacco products and that they carry unique health risks in addition to risk of nicotine addiction. Nurses should be aware of current evidence-based treatment recommended for tobacco cessation including nicotine replacement therapy and cessation counseling services. Evidence describing the values associated with e-cigarette use and viewpoints related to health is useful to nurses. In particular, nurses and other healthcare providers must use this information on young adults' health beliefs, attitudes, and perceptions to help reduce e-cigarette use and subsequent cardiovascular and cardiopulmonary health problems.

Strengths and Limitations

Limitations of the IR included that the review was restricted to English-only articles; thus, studies that examined the perspectives of young adults from non–English-speaking countries may have been missed. Second, because this topic is being aggressively evaluated, the information is rapidly changing and updated, making a completely comprehensive review difficult. These limitations were also met with strengths. An exhaustive search was conducted over the most relevant period with assistance from an experienced health sciences librarian. This was the first IR to analyze the current literature about the characteristics of e-cigarette use among young adults. Lastly, the research included in this review had overall strong quality scores.

Conclusion

This IR found that young adults continue to hold misconceptions about the health risks of e-cigarettes, that they are motivated by liking the sensation of e-cigarettes (particularly taste), and that there are some elements of social identity associated with use. The 3 themes that emerged from this IR provide information to help healthcare providers understand the relevant characteristics and motivations for e-cigarette use among young adults. Primary and secondary prevention that focuses on knowledge and intercepts harmful behavior, like e-cigarette use, has a far greater health advantage to the population than a wait-and-see approach. The damage that traditional smoking has had on generations of Americans is well documented. Moreover, 99% of the time, long-term addiction to nicotine starts before age 25.16 Preliminary studies show the proinflammatory effects of e-cigarettes on human tissue are the same as traditional smoking, thus setting up a potential trajectory for heart and lung disease. Further research is needed to fully understand the meaning of e-cigarette use to young adults to be effective health counselors and advocates for appropriate public health policy.

What’s New and Important

  • Current e-cigarette users are underrepresented in research about e-cigarette use among young adults.
  • Young adults are not armed with the appropriate knowledge to make informed choices about using e-cigarettes.
  • E-cigarette users tend to value appearance and physical sensation over health.
  • Social norms related to e-cigarette use are linked to perception of identity and the current technology-focused culture.

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Keywords:

culture; electronic nicotine delivery systems; young adult

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