E-Cigarette Use Among Adult Primary Care Patients: Results from a Multisite Study

  • William S. JohnEmail author
  • Kiran Grover
  • Lawrence H. Greenblatt
  • Robert P. Schwartz
  • Li-Tzy Wu
Original Research



Primary care settings provide opportunities to identify electronic-cigarette (e-cigarette) use and to implement strategies for changing tobacco use behavior. However, a better understanding of the extent and associated characteristics of e-cigarette use among primary care patients are needed to inform such efforts.


To describe patient demographic and substance use characteristics by e-cigarette use status among a large sample of primary care patients. To examine the prevalence and correlates of e-cigarette use among tobacco users in the sample.


Cross-sectional analysis from a multisite validation study of a substance use screening instrument.


Adult primary care patients aged 18 and older (n = 2000) recruited across 5 primary care clinics in the Eastern USA from 2014 to 2015.

Main Measures

Patients reported past 3-month e-cigarette use, sociodemographics, tobacco use, and other substance use. Current nicotine dependence and DSM-5 criteria for past-year substance use disorders were also assessed.

Key Results

Among the total sample, 7.7% (n = 154) adults reported past 3-month e-cigarette use. Adults who reported e-cigarette use (vs. no use) were more likely to be younger, white, or have frequent tobacco use, nicotine dependence, or past-year illicit drug use/disorders. Among past 3-month tobacco users, 16.3% reported e-cigarette use. Adjusted logistic regression indicated that odds of e-cigarette use were greater among tobacco users who had some college education or more (vs. < high school) or were daily/almost daily tobacco users (vs. not); odds were lower among Blacks/African-Americans (vs. whites). E-cigarette use among tobacco users was associated with increased odds of current nicotine dependence or tobacco use disorder as well as more severe dependence/disorder.


Enhanced surveillance of e-cigarette use among adult tobacco users in primary care, particularly among those who use tobacco frequently, may have implications for helping patients with tobacco cessation using established approaches including behavioral support, pharmacotherapy, or referral to specialized care.


primary care tobacco electronic cigarette e-cigarette vaping 



This original data source (CTN-0059) was supported by the US National Institutes of Health (UG1DA040317, UG1DA013034, UG1DA013035, U10DA013727). The secondary data analysis and preparation of this manuscript was made possible by the US National Institutes of Health (UG1DA040317 and R01MD007658). The sponsoring agency had no further role in the study design and analysis, the writing of the report, or the decision to submit the paper for publication. The opinions expressed in this paper are solely those of the authors. The authors thank the study team of the CTN-0059 and all study participants for their time and contributions. The authors thank He Zhu, PhD, for providing help with data analysis.

Compliance with Ethical Standards

Conflict of Interest

Li-Tzy Wu also has received research funding from Patient-Centered Outcomes Research Institute, Duke Endowment, and Centers for Disease Control and Prevention. William S. John also has received research funding from Patient-Centered Outcomes Research Institute. Robert Schwartz has provided consultation to Verily Life Sciences. The other authors have no conflicts of interest to disclose.


  1. 1.
    McMillen RC, Gottlieb MA, Shaefer RM, Winickoff JP, Klein JD. Trends in electronic cigarette use among u.s. adults: use is increasing in both smokers and nonsmokers. Nicotine Tob Res 2015;17(10):1195-1202.CrossRefGoogle Scholar
  2. 2.
    Rutten LJ, Blake KD, Agunwamba AA, et al. Use of e-cigarettes among current smokers: associations among reasons for use, quit intentions, and current tobacco use. Nicotine Tob Res 2015;17(10):1228-1234.CrossRefGoogle Scholar
  3. 3.
    Rodu B, Plurphanswat N. E-cigarette Use among US adults: Population Assessment of Tobacco and Health (PATH) Study. Nicotine Tob Res 2018;20(8):940-948.CrossRefGoogle Scholar
  4. 4.
    Mirbolouk M, Charkhchi P, Kianoush S, et al. Prevalence and distribution of e-cigarette use among U.S. adults: Behavioral Risk Factor Surveillance System, 2016. Ann Intern Med 2018;169(7):429-438.CrossRefGoogle Scholar
  5. 5.
    Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS Data Brief 2015(217):1-8.Google Scholar
  6. 6.
    Jaber RM, Mirbolouk M, DeFilippis AP, et al. Electronic cigarette use prevalence, associated factors, and pattern by cigarette smoking status in the United States from NHANES (National Health and Nutrition Examination Survey) 2013-2014. J Am Heart Assoc. 2018;7(14).Google Scholar
  7. 7.
    Coleman BN, Rostron B, Johnson SE, et al. Electronic cigarette use among US adults in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2014. Tob Control 2017;26(e2):e117-e126.CrossRefGoogle Scholar
  8. 8.
    Sharapova SR, Singh T, Agaku IT, Kennedy SM, King BA. Patterns of e-cigarette use frequency—National Adult Tobacco Survey, 2012-2014. Am J Prev Med 2018;54(2):284-288.CrossRefGoogle Scholar
  9. 9.
    Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2016;9:Cd010216.PubMedGoogle Scholar
  10. 10.
    Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med 2016;4(2):116-128.CrossRefGoogle Scholar
  11. 11.
    Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med 2019.Google Scholar
  12. 12.
    Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in electronic cigarettes: an unrecognized respiratory health hazard? JAMA. 2014;312(23):2493-2494.CrossRefGoogle Scholar
  13. 13.
    Kosmider L, Sobczak A, Prokopowicz A, et al. Cherry-flavoured electronic cigarettes expose users to the inhalation irritant, benzaldehyde. Thorax. 2016;71(4):376-377.CrossRefGoogle Scholar
  14. 14.
    Siu AL. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2015;163(8):622-634.CrossRefGoogle Scholar
  15. 15.
    Steinberg MB, Giovenco DP, Delnevo CD. Patient–physician communication regarding electronic cigarettes. Prev Med Rep 2015;2:96-98.CrossRefGoogle Scholar
  16. 16.
    Doescher MP, Wu M, Rainwater E, Khan AS, Rhoades DA. Patient perspectives on discussions of electronic cigarettes in primary care. J Am Board Fam Med 2018;31(1):73-82.CrossRefGoogle Scholar
  17. 17.
    Nickels AS, Warner DO, Jenkins SM, Tilburt J, Hays JT. Beliefs, practices, and self-efficacy of US physicians regarding smoking cessation and electronic cigarettes: a national survey. Nicotine Tob Res 2016;19(2):197-207.CrossRefGoogle Scholar
  18. 18.
    Pepper JK, McRee A-L, Gilkey MB. Healthcare providers’ beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. J Adolesc Health 2014;54(6):678-683.CrossRefGoogle Scholar
  19. 19.
    McNeely J, Wu LT, Subramaniam G, et al. Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool for substance use screening in primary care patients. Ann Intern Med 2016;165(10):690-699.CrossRefGoogle Scholar
  20. 20.
    Chou SP, Saha TD, Zhang H, et al. Prevalence, correlates, comorbidity and treatment of electronic nicotine delivery system use in the United States. Drug Alcohol Depend 2017;178:296-301.CrossRefGoogle Scholar
  21. 21.
    Wu LT, McNeely J, Subramaniam GA, Sharma G, VanVeldhuisen P, Schwartz RP. Design of the NIDA clinical trials network validation study of tobacco, alcohol, prescription medications, and substance use/misuse (TAPS) tool. Contemp Clin Trials 2016;50:90-97.CrossRefGoogle Scholar
  22. 22.
    Humeniuk R, Ali R, Babor TF, et al. Validation of the alcohol, smoking and substance involvement screening test (ASSIST). Addiction. 2008;103(6):1039-1047.CrossRefGoogle Scholar
  23. 23.
    World Health Organization (WHO). The World Mental Health Composite International Diagnostic Interview. 2015. Accessed 12 Apr 2017.
  24. 24.
    Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991;86(9):1119-1127.CrossRefGoogle Scholar
  25. 25.
    Mwenifumbo J, Tyndale IV R. DSM-IV, ICD-10 and FTND: discordant tobacco dependence diagnoses in adult smokers. J Addict Res Ther 2011;2:1.CrossRefGoogle Scholar
  26. 26.
    Chung T, Martin CS, Maisto SA, Cornelius JR, Clark DB. Greater prevalence of proposed DSM-5 nicotine use disorder compared to DSM-IV nicotine dependence in treated adolescents and young adults. Addiction. 2012;107(4):810-818.CrossRefGoogle Scholar
  27. 27.
    Association AL. Cutting tobacco’s rural roots: tobacco use in rural communities. Disparities in Lung Health Serires 2012.Google Scholar
  28. 28.
    Anand V, McGinty KL, O’Brien K, Guenthner G, Hahn E, Martin CA. E-cigarette use and beliefs among urban public high school students in North Carolina. J Adolesc Health 2015;57(1):46-51.CrossRefGoogle Scholar
  29. 29.
    Giovacchini CX, Pacek L, McClernon FJ, Que LG. Use and perceived risk of electronic cigarettes among North Carolina middle and high school students. N C Med J 2017;78(1):7-13.PubMedGoogle Scholar
  30. 30.
    Boonn A. State cigarette excise tax rates & rankings. Washington DC: Campaign for Tobacco-Free Kids. 2015.Google Scholar
  31. 31.
    Giovenco DP, Lewis MJ, Delnevo CD. Factors associated with e-cigarette use: a national population survey of current and former smokers. Am J Prev Med 2014;47(4):476-480.CrossRefGoogle Scholar
  32. 32.
    Delnevo CD, Giovenco DP, Steinberg MB, et al. Patterns of electronic cigarette use among adults in the United States. Nicotine Tob Res 2016;18(5):715-719.CrossRefGoogle Scholar
  33. 33.
    King BA, Patel R, Nguyen KH, Dube SR. Trends in awareness and use of electronic cigarettes among US adults, 2010-2013. Nicotine Tob Res 2015;17(2):219-227.CrossRefGoogle Scholar
  34. 34.
    Courvoisier DS, Etter J-F. Comparing the predictive validity of five cigarette dependence questionnaires. Drug Alcohol Depend 2010;107(2-3):128-133.CrossRefGoogle Scholar
  35. 35.
    Ferguson JA, Patten CA, Schroeder DR, Offord KP, Eberman KM, Hurt RD. Predictors of 6-month tobacco abstinence among 1224 cigarette smokers treated for nicotine dependence. Addict Behav 2003;28(7):1203-1218.CrossRefGoogle Scholar
  36. 36.
    Japuntich SJ, Leventhal AM, Piper ME, et al. Smoker characteristics and smoking-cessation milestones. Am J Prev Med 2011;40(3):286-294.CrossRefGoogle Scholar
  37. 37.
    Kozlowski LT, Porter CQ, Orleans CT, Pope MA, Heatherton T. Predicting smoking cessation with self-reported measures of nicotine dependence: FTQ, FTND, and HSI. Drug Alcohol Depend 1994;34(3):211-216.CrossRefGoogle Scholar
  38. 38.
    Camenga DR, Kong G, Cavallo DA, et al. Alternate tobacco product and drug use among adolescents who use electronic cigarettes, cigarettes only, and never smokers. J Adolesc Health 2014;55(4):588-591.CrossRefGoogle Scholar
  39. 39.
    Miech RA, O’Malley PM, Johnston LD, Patrick ME. E-cigarettes and the drug use patterns of adolescents. Nicotine Tob Res 2016;18(5):654-659.CrossRefGoogle Scholar
  40. 40.
    Morean ME, Kong G, Camenga DR, Cavallo DA, Simon P, Krishnan-Sarin S. Latent class analysis of current e-cigarette and other substance use in high school students. Drug Alcohol Depend 2016;161:292-297.CrossRefGoogle Scholar
  41. 41.
    Breitbarth AK, Morgan J, Jones AL. E-cigarettes—an unintended illicit drug delivery system. Drug Alcohol Depend 2018;192:98-111.CrossRefGoogle Scholar
  42. 42.
    Biener L, Hargraves JL. A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit. Nicotine Tob Res 2014;17(2):127-133.CrossRefGoogle Scholar
  43. 43.
    Brose LS, Hitchman SC, Brown J, West R, McNeill A. Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with a 1-year follow-up. Addiction. 2015;110(7):1160-1168.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • William S. John
    • 1
    Email author
  • Kiran Grover
    • 1
  • Lawrence H. Greenblatt
    • 2
  • Robert P. Schwartz
    • 3
  • Li-Tzy Wu
    • 1
    • 2
    • 4
    • 5
  1. 1.Department of Psychiatry and Behavioral Sciences, Division of Social and Community Psychiatry Duke University Medical CenterDurhamUSA
  2. 2.Department of Medicine, Division of General Internal MedicineDuke University Medical CenterDurhamUSA
  3. 3.Friends Research Institute, Inc.BaltimoreUSA
  4. 4.Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA
  5. 5.Center for Child and Family Policy, Sanford School of Public PolicyDuke UniversityDurhamUSA

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