Associations between e-cigarette and combustible cigarette use among U.S. cancer survivors: implications for research and practice

  • Godfred O. AntwiEmail author
  • David K. Lohrmann
  • Wasantha Jayawardene
  • Angela Chow
  • Cecilia S. Obeng
  • Aaron M. Sayegh



Prior studies established significant associations between e-cigarette use and combustible cigarette smoking in the general population; however, little is known about such associations among cancer survivors. Thus, the current study examined possible associations between e-cigarette use and combustible cigarette smoking among U.S. cancer survivors.


Cross-sectional data were drawn from the 2016 Behavioral Risk Factor Surveillance System Survey. Binary logistic regression was used to analyze the associations between e-cigarette user status and combustible cigarette-smoking status in a sample of 4680 cancer survivors, controlling for alcohol use and sociodemographic factors. Analyses were weighted for unequal probability of sample selection to reflect national cancer survivor population estimates.


Prevalence for current e-cigarette use and combustible cigarette smoking for cancer survivors was 2.57% and 16.16%, respectively. In the adjusted analyses, cancer survivors who reported current e-cigarette use, compared to never-users, had greater odds of being current combustible cigarette smokers (odds ratio [OR] = 11.81, 95% confidence interval [CI] = 5.38–25.93). Likewise, former e-cigarette users, compared to never-users, had greater odds of being current combustible cigarette smokers (OR = 15.90, 95% CI = 10.68–23.36).


Among cancer survivors in the USA, e-cigarette use had a positive and highly significant association with combustible cigarette smoking.

Implications for Cancer Survivors

In order to prevent multiple and substitute use of nicotine-delivery products, prevention interventions and cessation programs designed for cancer survivors should specifically target both current combustible cigarette smokers and non-smokers who report former and current e-cigarette use.


Cancer survivors Electronic cigarettes Combustible cigarettes Nicotine 


Compliance with ethical standards

Conflict of interest

None of the authors has a conflict of interest to disclose.

Ethical approval

The Indiana University Institutional Review Board verified the current study as a non-human subject study.


  1. 1.
    Cancer treatment|survivor facts & figures. Am Cancer Soc Accessed June 12, 2018.
  2. 2.
    American Cancer Society. Cancer facts & figures 2018. Atlanta: American Cancer Society; 2018.Google Scholar
  3. 3.
    NIH fact sheets—cancer. National Institutes of Health. Accessed June 5, 2018.
  4. 4.
    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67:7–30.CrossRefGoogle Scholar
  5. 5.
    Park SA, Chung SH, Lee Y. Factors associated with suicide risk in advanced cancer patients: a cross-sectional study. Asian Pac J Cancer Prev. 2016;17(11):4831–6. Scholar
  6. 6.
    Phillips SM, Padgett LS, Leisenring WM, Stratton KK, Bishop K, Krull KR, et al. Survivors of childhood cancer in the United States: prevalence and burden of morbidity. Cancer Epidemiol Biomark Prev. 2015;24(4):653–63. Scholar
  7. 7.
    Peppone LJ, Mustian KM, Morrow GR, Dozier AM, Ossip DJ, Janelsins MC, et al. The effect of cigarette smoking on cancer treatment-related side effects. Oncologist. 2011;16(12):1784–92. Scholar
  8. 8.
    Zon RT, Goss E, Vogel VG, Chlebowski RT, Jatoi I, Robson ME, et al. American Society of Clinical Oncology policy statement: the role of the oncologist in cancer prevention and risk assessment. J Clin Oncol. 2009;27(6):986–93. Scholar
  9. 9.
    U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the surgeon general, 2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.Google Scholar
  10. 10.
    Cancer Trends Progress Report. Cancer survivors and smoking. Accessed May 30, 2018.
  11. 11.
    King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010-2011. Nicotine Tob Res. 2013;15(9):1623–7. Scholar
  12. 12.
    U.S. Department of Health and Human Services. E-cigarette use among youth and young adults. A report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016.Google Scholar
  13. 13.
    Wilson FA, Wang Y. Recent findings on the prevalence of e-cigarette use among adults in the U.S. Am J Prev Med. 2017;52(3):385–90. Scholar
  14. 14.
    Salloum RG, Getz KR, Tan AS, et al. Use of electronic cigarettes among CS in the U.S. Am J Prev Med. 2016;51(5):762–6. Scholar
  15. 15.
    Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, Sussman S, Riggs NR, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. 2015;314(7):700–7. Scholar
  16. 16.
    Barrington-Trimis JL, Urman R, Berhane K, Unger JB, Cruz TB, Pentz MA, et al. E-cigarettes and future cigarette use. Am Acad Pediatr. 2016;138:e20160379. Google Scholar
  17. 17.
    Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, Williams RJ. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tob Control. 2016;26(1):34–9. Scholar
  18. 18.
    Rigotti NA. E-cigarette use and subsequent tobacco use by adolescents. JAMA. 2015;314(7):673–4. Scholar
  19. 19.
    Borderud SP, Li Y, Burkhalter JE, Sheffer CE, Ostroff JS. Electronic cigarette use among patients with cancer: characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. 2014;120(22):3527–35. Scholar
  20. 20.
    Behavioral Risk Factor Surveillance System. Centers for Disease Control and Prevention Published December 6, 2017. Accessed May 21, 2018.
  21. 21.
    Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, 2016 Summary Data Quality Report. 2017. Accessed 21 Aug 2018.
  22. 22.
    Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr. 2017;171(8):788–97. Scholar
  23. 23.
    Smoking & tobacco use. Centers for Disease Control and Prevention. Published February 15, 2018. Accessed June 5, 2018.
  24. 24.
    Clearing the smoke. Nature Neuroscience. July 2014. Accessed June 15, 2018.
  25. 25.
    E-cigarettes and lung health. American Lung Association. Accessed September 5, 2018.
  26. 26.
    Xu Y, Guo Y, Liu K, Liu Z, Wang X. E-cigarette awareness, use, and harm perception among adults: a meta-analysis of observational studies. Gorlova OY, ed. PLoS One. 2016;11(11):e0165938. Scholar
  27. 27.
    Gallus S, Lugo A, Pacifici R, Pichini S, Colombo P, Garattini S, et al. E-cigarette awareness, use, and harm perceptions in Italy: a national representative survey. Nicotine Tob Res. 2014;16(12):1541–8. Scholar
  28. 28.
    Pasquereau A, Guignard R, Andler R, Nguyen-Thanh V. Electronic cigarettes, quit attempts and smoking cessation: a 6-month follow-up. Addiction. 2017;112(9):1620–8. Scholar
  29. 29.
    Farsalinos K. Electronic cigarettes: an aid in smoking cessation, or a new health hazard? Ther Adv Respir Dis. 2017;12:175346581774496. Scholar
  30. 30.
    Adriaens K, Van Gucht D, Declerck P, Baeyens F. Effectiveness of the electronic cigarette: an eight-week Flemish study with six-month follow-up on smoking. Reduction, craving and experienced benefits and complaints. Farsalinos K, ed. Int J Environ Res Public Health. 2014;11(11):11220–48. CrossRefGoogle Scholar
  31. 31.
    Bullen C, Howe C, Laugesen M. Electronic cigarettes for smoking cessation: a randomised controlled trial. J Vasc Surg. 2014;59(3):872. Scholar
  32. 32.
    Van Gucht D, Adriaens K, Baeyens F. Online vape shop customers who use E-cigarettes report abstinence from smoking and improved quality of life, but a substantial minority still have vaping-related health concerns. Int J Environ Res Public Health. 2017;14(7):798. Scholar
  33. 33.
    Burke L, Miller L-A, Saad A, Abraham J. Smoking behaviors among cancer survivors: an observational clinical study. J Oncol Pract. 2009;5(1):6–9. Scholar
  34. 34.
    Toll BA, Brandon TH, Gritz ER, Warren GW, Herbst RS AACR Subcommittee on Tobacco and Cancer. Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement. Clin Cancer Res. 2013;19:1941–8.CrossRefGoogle Scholar
  35. 35.
    Huang J, Chaloupka FJ, Fong GT. Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis. Tob Control. 2014;23(0 1):i7–12. Scholar
  36. 36.
    Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database Syst Rev. 2018.
  37. 37.
    Westmaas JL, Berg CJ, Alcaraz KI, Stein K. Health behavior theory constructs and smoking and cessation-related behavior among cancer survivors of ten cancers nine years after diagnosis: a report from the American Cancer Society Study of CS-I. Psycho-Oncology. 2015;24(10):1286–94. Scholar
  38. 38.
    Kaul S, Veeranki SP, Rodriguez AM, Kuo Y-F. Cigarette smoking, comorbidity, and general health among CS of adolescent and young adult cancer. Cancer. 2016;122(18):2895–905. Scholar
  39. 39.
    Tao L, Wang R, Gao Y-T, Yuan J-M. Impact of post-diagnosis smoking on long-term survival of cancer patients: the Shanghai Cohort Study. Cancer Epidemiol Biomark Prev. 22(12):2404–11.
  40. 40.
    Park JJ, Park HA. Prevalence of cigarette smoking among adult CS in Korea. Yonsei Med J. 2015;56(2):556–62. Scholar
  41. 41.
    Health risks of smoking tobacco. American Cancer Society. Accessed May 21, 2018.
  42. 42.
    Cigarette smoking and health. Encyclopedia of behavioral hedicine. 2013;421–421.
  43. 43.
    Alzahrani T, Pena I, Temesgen N, Glantz SA. Association between electronic cigarette use and myocardial infarction. Am J Prev Med. 2018;55(4):455–61. Scholar
  44. 44.
    Jamal A, Agaku IT, O’Connor E, King BA, Kenemer JB, Neff L. Current cigarette smoking among adults—United States, 2005–2013. MMWR Morb Mortal Wkly Rep. 2014;63(47):1108–12.Google Scholar
  45. 45.
    Schnoll RA, Goelz PM, Veluz-Wilkins A, Blazekovic S, Powers L, Leone FT, et al. Long-term nicotine replacement therapy: a randomized clinical trial. JAMA Intern Med. 2015;175(4):504–11. Scholar
  46. 46.
    Prochaska JJ, Benowitz NL. The past, present, and future of nicotine addiction therapy. Annu Rev Med. 2016;67:467–86. Scholar
  47. 47.
    Song AV, Morrell HER, Cornell JL, Ramos ME, Biehl M, Kropp RY, et al. Perceptions of smoking-related risks and benefits as predictors of adolescent smoking initiation. Am J Public Health. 2009;99(3):487–92. Scholar
  48. 48.
    Aryal UR, Bhatta DN. Perceived benefits and health risks of cigarette smoking among young adults: insights from a cross-sectional study. Tob Induc Dis. 2015;13(1).
  49. 49.
    Sharma M, Khubchandani J, Nahar VK. Applying a new theory to smoking cessation: case of multi-theory model (MTM) for health behavior change. Health Promot Perspect. 2017;7(2):102–5. Scholar
  50. 50.
    Roberts NJ, Kerr SM, Smith SM. Behavioral interventions associated with smoking cessation in the treatment of tobacco use. Health Serv Insights. 2013;6:HSI.S11092. Scholar
  51. 51.
    Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville: US Public Health Service; 2008.Google Scholar
  52. 52.
    Li X, Li Q, Dong L, Sun B, Chen J, Jiang Y, et al. Risk factors associated with smoking behaviour in recreational venues: findings from the International Tobacco Control (ITC) China Survey. Tob Control. 2009;19(Supplement 2):i30–9. Scholar
  53. 53.
    Kim H, Kim M-H, Park Y-S, Shin JY, Song Y-M. Factors that predict persistent smoking of CS. J Korean Med Sci. 2015;30(7):853–9. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Godfred O. Antwi
    • 1
    Email author
  • David K. Lohrmann
    • 1
  • Wasantha Jayawardene
    • 2
  • Angela Chow
    • 1
  • Cecilia S. Obeng
    • 1
  • Aaron M. Sayegh
    • 3
  1. 1.Department of Applied Heath ScienceIndiana University School of Public HealthBloomingtonUSA
  2. 2.Institute for Research on Addictive BehaviorIndiana University School of Public HealthBloomingtonUSA
  3. 3.Department of Epidemiology and BiostatisticsIndiana University School of Public HealthBloomingtonUSA

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