Dual cigarette and e-cigarette use in cancer survivors: an analysis using Population Assessment of Tobacco Health (PATH) data

  • Yael R. SymesEmail author
  • Kurt M. Ribisl
  • Marcella H. Boynton
  • J. Lee Westmaas
  • Deborah K. Mayer
  • Shelley D. Golden



Cancer survivors who smoke cigarettes face health risks from continued smoking. Some smokers use e-cigarettes to reduce combustible cigarette use, but research on whether cancer survivors do the same is limited. Research is needed to understand whether smokers who are cancer survivors use e-cigarettes at higher rates than smokers never diagnosed with cancer, to inform provider-patient discussions about e-cigarettes.


Using cross-sectional data from current cigarette smokers in Wave 1 (2013–2014) of the Population Assessment of Tobacco Health (PATH) study, we compared cancer survivors (n = 433) and those without a prior cancer diagnosis (n = 10,872) on e-cigarette use and reasons for use.


Among smokers, 59.4% of cancer survivors and 63.2% of those without a cancer diagnosis had ever used e-cigarettes, and nearly one-quarter of both groups (23.1% and 22.3%, respectively) reported being current users. Multivariate results, however, suggest that cancer survivors might be more likely to be ever (OR = 1.28; p = .05) or current (OR = 1.25; p = .06) e-cigarette users compared to those never diagnosed, although results were marginally significant. The majority of both groups (> 71%) reported using e-cigarettes for perceived health-related reasons—including smoking reduction.


Our study found that among smokers, cancer survivors were using e-cigarettes at similar rates as never-diagnosed smokers and both groups used e-cigarettes largely for perceived health-related reasons.

Implications for cancer survivors

Clinicians who treat cancer survivors may need to routinely ask their patients who smoke about e-cigarette use and address the limited research on the efficacy of e-cigarettes as a cessation aid as compared to other evidence-based options.


Cancer survivor Smoking E-cigarette ENDS Dual use PATH 



The authors would like to thank Drs. Cathy Zimmer and Chris Wiesen of the UNC Odum Institute for their statistical assistance.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

KM Ribisl serves as an expert consultant in litigation against tobacco companies. All procedures performed in the PATH study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the PATH study.


  1. 1.
    Cox LS, Africano NL, Tercyak KP, Taylor KL. Nicotine dependence treatment for patients with cancer. Cancer. 2003;98(3):632–44.PubMedCrossRefGoogle Scholar
  2. 2.
    Berg CJ, Thomas AN, Mertens AC, Schauer GL, Pinsker EA, Ahluwalia JS, et al. Correlates of continued smoking versus cessation among survivors of smoking-related cancers. Psycho-Oncology. 2013;22(4):799–806.PubMedCrossRefGoogle Scholar
  3. 3.
    Mayer DK, Carlson J. Smoking patterns in cancer survivors. Nicotine Tob Res. 2010;13(1):34–40.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Warren GW, Kasza KA, Reid ME, Cummings KM, Marshall JR. Smoking at diagnosis and survival in cancer patients. Int J Cancer. 2013;132(2):401–10.PubMedCrossRefGoogle Scholar
  5. 5.
    Cooley ME, Lundin R, Murray L. Smoking cessation interventions in cancer care: opportunities for oncology nurses and nurse scientists. Annu Rev Nurs Res. 2009;27(1):243–72.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Mayer DK, Terrin NC, Menon U, Kreps GL, McCance K, Parsons SK, et al. Health behaviors in cancer survivors. Oncol Nurs Forum. 2007;34(3):643–51.PubMedCrossRefGoogle Scholar
  7. 7.
    Coups EJ, Dhingra LK, Heckman CJ, Manne SL. Receipt of provider advice for smoking cessation and use of smoking cessation treatments among cancer survivors. J Gen Intern Med. 2009;24(2):480–6.PubMedCentralCrossRefGoogle Scholar
  8. 8.
    Underwood JM, Townsend JS, Tai E, White A, Davis SP, Fairley TL. Persistent cigarette smoking and other tobacco use after a tobacco-related cancer diagnosis. J Cancer Surviv. 2012;6(3):333–44.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Bellizzi KM, Rowland JH, Jeffery DD, McNeel T. Health behaviors of cancer survivors: examining opportunities for cancer control intervention. J Clin Oncol. 2005;23(34):8884–93.PubMedCrossRefGoogle Scholar
  10. 10.
    Tseng T-S, Lin H-Y, Moody-Thomas S, Martin M, Chen T. Who tended to continue smoking after cancer diagnosis: the national health and nutrition examination survey 1999–2008. BMC Public Health. 2012;12(1):784.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Fox JL, Rosenzweig KE, Ostroff JS. The effect of smoking status on survival following radiation therapy for non-small cell lung cancer. Lung Cancer. 2004;44(3):287–93.PubMedCrossRefGoogle Scholar
  12. 12.
    Videtic GM, Stitt LW, Dar AR, et al. Continued cigarette smoking by patients receiving concurrent chemoradiotherapy for limited-stage small-cell lung cancer is associated with decreased survival. J Clin Oncol. 2003;21(8):1544–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Johnson BE. Second lung cancers in patients after treatment for an initial lung cancer. J Natl Cancer Inst. 1998;90(18):1335–45.PubMedCrossRefGoogle Scholar
  14. 14.
    Do K-A, Johnson MM, Doherty DA, Lee JJ, Wu XF, Dong Q, et al. Second primary tumors in patients with upper aerodigestive tract cancers: joint effects of smoking and alcohol (United States). Cancer Causes Control. 2003;14(2):131–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Khuri FR, Kim ES, Lee JJ, et al. The impact of smoking status, disease stage, and index tumor site on second primary tumor incidence and tumor recurrence in the head and neck retinoid chemoprevention trial. Cancer Epidemiol Biomark Prev. 2001;10(8):823–9.Google Scholar
  16. 16.
    Rice D, Kim H-W, Sabichi A, Lippman S, Lee JJ, Williams B, et al. The risk of second primary tumors after resection of stage I nonsmall cell lung cancer. Ann Thorac Surg. 2003;76(4):1001–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Richardson GE, Tucker MA, Venzon DJ, Linnoila RI, Phelps R, Phares JC, et al. Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers. Ann Intern Med. 1993;119(5):383–90.PubMedCrossRefGoogle Scholar
  18. 18.
    Tucker MA, Murray N, Shaw EG, Ettinger DS, Mabry M, Huber MH, et al. Second primary cancers related to smoking and treatment of small-cell lung cancer. J Natl Cancer Inst. 1997;89(23):1782–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Browman GP, Wong G, Hodson I, Sathya J, Russell R, McAlpine L, et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. New Engl J Med. 1993;328(3):159–63.PubMedCrossRefGoogle Scholar
  20. 20.
    Møller A, Pedersen T, Villebro N, Schnaberich A, Haas M, Tønnesen R. A study of the impact of long-term tobacco smoking on postoperative intensive care admission. Anaesthesia. 2003;58(1):55–9.PubMedCrossRefGoogle Scholar
  21. 21.
    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.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Vaporciyan AA, Merriman KW, Ece F, Roth JA, Smythe WR, Swisher SG, et al. Incidence of major pulmonary morbidity after pneumonectomy: association with timing of smoking cessation. Ann Thorac Surg. 2002;73(2):420–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Karam-Hage M, Cinciripini PM, Gritz ER. Tobacco use and cessation for cancer survivors: an overview for clinicians. CA Cancer J Clin. 2014;64(4):272–90.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Patel D, Davis KC, Cox S, Bradfield B, King BA, Shafer P, et al. Reasons for current E-cigarette use among US adults. Prev Med. 2016;93:14–20.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Rutten LJF, Blake KD, Agunwamba AA, Grana RA, Wilson PM, Ebbert JO, 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):1228–34.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Zhuang Y-L, Cummins SE, Sun JY, Zhu S-H. Long-term e-cigarette use and smoking cessation: a longitudinal study with US population. Tob Control. 2016;25(Suppl 1):i90–5.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Salloum RG, Getz KR, Tan AS, et al. Use of electronic cigarettes among cancer survivors in the US. Am J Prev Med. 2016;51(5):762–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Kruse GR, Kalkhoran S, Rigotti NA. Use of electronic cigarettes among US adults with medical comorbidities. Am J Prev Med. 2017;52(6):798–804.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    American Cancer Society. Cancer facts and figures 2017. Atlanta: American Cancer Society; 2017.Google Scholar
  30. 30.
    Delnevo CD, Giovenco DP, Steinberg MB, Villanti AC, Pearson JL, Niaura RS, et al. Patterns of electronic cigarette use among adults in the United States. Nicotine Tob Res. 2016;18(5):715–9.PubMedCrossRefGoogle Scholar
  31. 31.
    McMillen RC, Gottlieb MA, Shaefer RMW, Winickoff JP, Klein JD. Trends in electronic cigarette use among US adults: use is increasing in both smokers and nonsmokers. Nicotine Tob Res. 2015;17(10):1195–202.PubMedCrossRefGoogle Scholar
  32. 32.
    McQueen N, Partington EJ, Harrington KF, Rosenthal EL, Carroll WR, Schmalbach CE. Smoking cessation and electronic cigarette use among head and neck cancer patients. Otolaryngol Head Neck Surg. 2016;154(1):73–9.PubMedCrossRefGoogle Scholar
  33. 33.
    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.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    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):116–28.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Pepper JK, Brewer NT. Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review. Tob Control. 2014;23(5):375–84.PubMedCrossRefGoogle Scholar
  36. 36.
    Grana R, Benowitz N, Glantz SA. E-cigarettes a scientific review. Circulation. 2014;129(19):1972–86.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Malas M, van der Tempel J, Schwartz R, Minichiello A, Lightfoot C, Noormohamed A, et al. Electronic cigarettes for smoking cessation: a systematic review. Nicotine Tob Res. 2016;18(10):1926–36.PubMedCrossRefGoogle Scholar
  38. 38.
    McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014;12:CD010216. Scholar
  39. 39.
    Rahman MA, Hann N, Wilson A, Mnatzaganian G, Worrall-Carter L. E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis. PLoS One. 2015;10(3):e0122544. Scholar
  40. 40.
    Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382(9905):1629–37.PubMedCrossRefGoogle Scholar
  41. 41.
    Nayan S, Gupta MK, Sommer DD. Evaluating smoking cessation interventions and cessation rates in cancer patients: a systematic review and meta-analysis. ISRN Oncology. 2011;2011:849023. Scholar
  42. 42.
    Nayan S, Gupta MK, Strychowsky JE, Sommer DD. Smoking cessation interventions and cessation rates in the oncology population an updated systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2013;149(2):200–11.PubMedCrossRefGoogle Scholar
  43. 43.
    Meernik C, Goldstein AO. Should clinicians recommend E-cigarettes to their patients who smoke? No. Ann Fam Med. 2016;14(4):302–3.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Brandon TH, Goniewicz ML, Hanna NH, Hatsukami DK, Herbst RS, Hobin JA, et al. Electronic nicotine delivery systems: a policy statement from the American Association for Cancer Research and the American Society of Clinical Oncology. J Clin Oncol. 2015;33(8):952–63.PubMedCrossRefGoogle Scholar
  45. 45.
    Bhatnagar A, Whitsel LP, Ribisl KM, Bullen C, Chaloupka F, Piano MR, et al. Electronic cigarettes. Circulation. 2014;130(16):1418–36.PubMedCrossRefGoogle Scholar
  46. 46.
    Travis LB. The epidemiology of second primary cancers. Cancer Epidemiol Biomark Prev. 2006;15(11):2020–6.CrossRefGoogle Scholar
  47. 47.
    Hyland A, Ambrose BK, Conway KP, Borek N, Lambert E, Carusi C, et al. Design and methods of the Population Assessment of Tobacco and Health (PATH) study. Tob Control. 2016;26(4):371–8.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Secretan B, Straif K, Baan R, Grosse Y, el Ghissassi F, Bouvard V, et al. A review of human carcinogens—part E: tobacco, areca nut, alcohol, coal smoke, and salted fish. Lancet Oncol. 2009;10(11):1033–4.PubMedCrossRefGoogle Scholar
  49. 49.
    Westmaas JL, Alcaraz KI, Berg CJ, Stein KD. Prevalence and correlates of smoking and cessation-related behavior among survivors of ten cancers: findings from a nationwide survey nine years after diagnosis. Cancer Epidemiol Biomark Prev. 2014;23(9):1783–92.CrossRefGoogle Scholar
  50. 50.
    Hanna N, Mulshine J, Wollins DS, Tyne C, Dresler C. Tobacco cessation and control a decade later: American Society of Clinical Oncology policy statement update. J Clin Oncol. 2013;31(25):3147–57.PubMedCrossRefGoogle Scholar

Copyright information

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

Authors and Affiliations

  1. 1.Department of Health Behavior, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Behavioral Research CenterAmerican Cancer SocietyAtlantaUSA
  3. 3.School of NursingUniversity of North Carolina at Chapel HillChapel HillUSA

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