Journal of Community Health

, Volume 42, Issue 3, pp 624–631 | Cite as

The Use of E-cigarettes Among School-Going Adolescents in a Predominantly Rural Environment of Central Appalachia

  • Daniel Owusu
  • Jocelyn Aibangbee
  • Candice Collins
  • Crystal Robertson
  • Liang Wang
  • Mary A. Littleton
  • Rafie Boghozian
  • Vicki Casenburg
  • Hadii M. Mamudu
Original Paper


E-cigarette use among youth in the United States (U.S.) continues to increase. In the rural Northeast Tennessee, where prevalence of tobacco use is higher than national and state averages, there is no literature on e-cigarette use to inform policies and programs. This study aimed to estimate the prevalence of e-cigarette use and examine association of e-cigarette use with two tobacco products among school-going adolescents. Data from 894 participants of a school-based survey conducted in 2016 in Northeast Tennessee were analyzed. Descriptive statistics and logistic regression analyses were conducted to estimate the prevalence and delineate the associations between e-cigarette use and other tobacco products. Approximately 11% of the participants currently used e-cigarettes, and 35% had ever used e-cigarettes. About 6% of the participants were current users of both e-cigarettes and cigarettes; 4% were current users of e-cigarettes and smokeless tobacco; 3% were current users of all three products, and 15% had ever tried all three products. More than one-half of current e-cigarette users (52%) also smoked cigarettes. Adjusting for covariates, current e-cigarette use was positively associated with cigarette smoking [Odds Ratio (OR) 27.32, 95% confidence interval (CI) 14.4–51.7] and smokeless tobacco use [OR 7.92, 95% CI 3.8–16.5]. E-cigarette use was more common among the high school students than cigarette and smokeless tobacco use, and a significant proportion of users either smoked cigarettes, used smokeless tobacco, or both. Thus, there is a critical need for preventive policies and programs to address dual and poly-use of these products.


E-cigarette Dual use Poly-use Northeast Tennessee High school students 



The Sullivan County Department of Health in Northeast Tennessee conducted the survey and we would like to thank them for sharing the data with us and giving us the permission to publish. Additionally, although the agreement with the participating schools restricts us from publicizing their names, we would like to thank them for the voluntary participation. Further, we would like to thank the Department of Health Services Management and Policy and the College of Public Health at East Tennessee State University for their logistical support. Finally, we would like to thank all the students, particularly Olivia Luzzi, Ashley Dowrick, and Guy Holdon for helping us with the edition of the manuscript.

Compliance with Ethical Standards

Conflict of interest

None to declare.


  1. 1.
    U.S. Department of Health and Human Services. (2014). The Health consequences of smoking—50 years of progress: A report of the surgeon general, 2014, 1–978.Google Scholar
  2. 2.
    Mamudu, M. H., Littleton, A. M., & Wang, L. (2015). Regional population health improvement plan: Tobacco Cessation in Northeast Tennessee. Johnson City, Tennessee.Google Scholar
  3. 3.
    CDC. (2015). National center for health statistics: Healthy people 2020. Retrieved October 5, 2016, from
  4. 4.
    World Health Organization. (2014). Electronic nicotine delivery systems: Report by WHO. Geneva: WHO Framework Convention on Tobacco Control.Google Scholar
  5. 5.
    Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-cigarettes: A scientific review. Circulation, 129(19), 1972–1986. doi: 10.1161/CIRCULATIONAHA.114.007667.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Centers for Disease Control and Prevention (CDC) (2013). Notes from the field: electronic cigarette use among middle and high school students—United States, 2011–2012. MMWR. Morbidity and Mortality Weekly Report, 62(35), 729–730.Google Scholar
  7. 7.
    Cantrell, F. L. (2014). Adverse effects of e-cigarette exposures. Journal of Community Health, 39(3), 614–616. doi: 10.1007/s10900-013-9807-5.CrossRefPubMedGoogle Scholar
  8. 8.
    CDC Office on Smoking and Health. (2015). Electronic nicotine delivery systems: Key facts. Retrieved October 5, 2016, from
  9. 9.
    Backinger, C. L., Messiner, H. I., & Ashley, D. L. (2016). The FDA “Deeming Rule” and Tobacco Regulatory Research. Tobacco Regulatory Science, 2(3), 290–293. doi: 10.18001/TRS.2.3.8.CrossRefGoogle Scholar
  10. 10.
    Marynak, K., Holmes, C. B., King, B. A., Promoff, G., Bunnell, R., & McAfee, T. (2014). State laws prohibiting sales to minors and indoor use of electronic nicotine delivery systems–United States, November 2014. MMWR. Morbidity and Mortality Weekly Report, 63(49), 1145–1150.PubMedGoogle Scholar
  11. 11.
    Overbey, M. (2015). State of Tennessee. Public chapter no. 353: Senate bill no. 411. Substituted for: House bill no. 309. State of Tennessee. Retrieved from
  12. 12.
    Pisinger, C., & Dossing, M. (2014). A systematic review of health effects of electronic cigarettes. Preventive Medicine, 69, 248–260. doi: 10.1016/j.ypmed.2014.10.009.CrossRefPubMedGoogle Scholar
  13. 13.
    Callahan-Lyon, P. (2014). Electronic cigarettes: Human health effects. Tobacco Control, 23(Suppl 2), ii36–40. doi: 10.1136/tobaccocontrol-2013-051470.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    CDC. (2014). Best practices for comprehensive tobacco control. Atlanta: US 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.Google Scholar
  15. 15.
    Tomashefski, A. (2016). The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review. Journal of the American Association of Nurse Practitioners, 28(9), 510–515. doi: 10.1002/2327-6924.12358.CrossRefPubMedGoogle Scholar
  16. 16.
    Malas, M., van der Tempel, J., Schwartz, R., et al. (2016). Electronic cigarettes for smoking cessation: A systematic review. Nicotine and Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 18(10), 1926–1936. doi: 10.1093/ntr/ntw119.CrossRefGoogle Scholar
  17. 17.
    Zhong, J., Cao, S., Gong, W., Fei, F., & Wang, M. (2016). Electronic cigarettes use and intention to cigarette smoking among never-smoking adolescents and young adults: A meta-analysis. International Journal of Environmental Research and Public Health, 13(5), 465. doi: 10.3390/ijerph13050465.CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Loomis, B. R., Rogers, T., King, B. A., Dench, D. L., Gammon, D. G., Fulmer, E. B., & Agaku, I. T. (2016). National and state-specific sales and prices for electronic cigarettes-U.S., 2012–2013. American Journal of Preventive Medicine, 50(1), 18–29. doi: 10.1016/j.amepre.2015.05.003.CrossRefPubMedGoogle Scholar
  19. 19.
    Carroll Chapman, S. L., & Wu, L.-T. (2014). E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison. Journal of Psychiatric Research, 54, 43–54. doi: 10.1016/j.jpsychires.2014.03.005.CrossRefPubMedGoogle Scholar
  20. 20.
    Ramo, D. E., Young-Wolff, K. C., & Prochaska, J. J. (2015). Prevalence and correlates of electronic-cigarette use in young adults: Findings from three studies over five years. Addictive Behaviors, 41, 142–147. doi: 10.1016/j.addbeh.2014.10.019.CrossRefPubMedGoogle Scholar
  21. 21.
    McKee, M., Chapman, S., Daube, M., & Glantz, S. (2014). The debate on electronic cigarettes. Lancet (London, England). doi: 10.1016/S0140-6736(14)62366-7.Google Scholar
  22. 22.
    Grana, R., Benowitz, N., & Glantz, S. (2015). Response to letter regarding article, “Electronic cigarettes: A scientific review”. Circulation, 137(6), e342–e342.CrossRefGoogle Scholar
  23. 23.
    Cooke, A., Fergeson, J., Bulkhi, A., & Casale, T. B. (2015). The Electronic cigarette: The good, the bad, and the ugly. The Journal of Allergy and Clinical Immunology. In Practice, 3(4), 498–505. doi: 10.1016/j.jaip.2015.05.022.CrossRefPubMedGoogle Scholar
  24. 24.
    Oh, A. Y., & Kacker, A. (2014). Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes? Review on E-cigarette vapor versus tobacco smoke. The Laryngoscope, 124(12), 2702–2706. doi: 10.1002/lary.24750.CrossRefPubMedGoogle Scholar
  25. 25.
    Pepper, J. K., & Brewer, N. T. (2014). Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: A systematic review. Tobacco control, 23(5), 375–384. doi: 10.1136/tobaccocontrol-2013-051122.CrossRefPubMedGoogle Scholar
  26. 26.
    McNeill, A., Etter, J.-F., Farsalinos, K., Hajek, P., le Houezec, J., & McRobbie, H. (2014). A critique of a World Health Organization-commissioned report and associated paper on electronic cigarettes. Addiction (Abingdon, England), 109(12), 2128–2134. doi: 10.1111/add.12730.CrossRefGoogle Scholar
  27. 27.
    McRobbie, H., Bullen, C., Hartmann-Boyce, J., & Hajek, P. (2014). Electronic cigarettes for smoking cessation and reduction. The Cochrane Database of Systematic Reviews, 12, CD010216. doi: 10.1002/14651858.CD010216.pub2.Google Scholar
  28. 28.
    de Andrade, M., Hastings, G., & Angus, K. (2013). Promotion of electronic cigarettes: tobacco marketing reinvented? BMJ (Clinical Research Ed.), 347, f7473.Google Scholar
  29. 29.
    Voigt, K. (2015). Smoking Norms and the Regulation of E-Cigarettes. American Journal of Public Health, 105(10), 1967–1972. doi: 10.2105/AJPH.2015.302764.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Dutra, L. M., & Glantz, S. A. (2014). Electronic cigarettes and conventional cigarette use among us adolescents. JAMA Pediatrics, 168(7), 610. doi: 10.1001/jamapediatrics.2013.5488.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Walley, S. C., & Jenssen, B. P. (2015). Electronic nicotine delivery systems. Pediatrics, 136(5), 1018–1026. doi: 10.1542/peds.2015-3222.CrossRefPubMedGoogle Scholar
  32. 32.
    Primack, B. A., Soneji, S., Stoolmiller, M., Fine, M. J., & Sargent, J. D. (2015). Progression to Traditional cigarette smoking after electronic cigarette use among us adolescents and young adults. JAMA Pediatrics, 1–7. doi: 10.1001/jamapediatrics.2015.1742.
  33. 33.
    Leventhal, A. M., Strong, D. R., Kirkpatrick, M. G., et al. (2015). Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA: The Journal of the American Medical Association, 314(7), 700–707. doi: 10.1001/jama.2015.8950.CrossRefPubMedGoogle Scholar
  34. 34.
    Barrington-Trimis, J. L., Urman, R., Berhane, K., et al. (2016). E-Cigarettes and future cigarette use. Pediatrics, doi: 10.1542/peds.2016-0379.Google Scholar
  35. 35.
    CDC. (2012). Smoking and tobacco use. State highlights—Tennessee. Retrieved September 16, 2016, from
  36. 36.
    Lee, Y. O., Hebert, C. J., Nonnemaker, J. M., & Kim, A. E. (2014). Multiple tobacco product use among adults in the United States: Cigarettes, cigars, electronic cigarettes, hookah, smokeless tobacco, and snus. Preventive Medicine, 62, 14–19. doi: 10.1016/j.ypmed.2014.01.014.CrossRefPubMedGoogle Scholar
  37. 37.
    CDC. (2016). Smoking & tobacco use: National Youth Tobacco Survey (NYTS). Retrieved October 5, 2016, from
  38. 38.
    CDC. (n.d.). Adolescent and School Health: Youth Risk Behavior Surveillance System (YRBSS). Retrieved October 5, 2016, from
  39. 39.
    USDHHS. (2012). Preventing tobacco use among youth and young adults. A report from the Surgeon General. U.S. Department of Health & Human Services. Retrieved from
  40. 40.
    Etter, J.-F., Bullen, C., Flouris, A. D., Laugesen, M., & Eissenberg, T. (2011). Electronic nicotine delivery systems: A research agenda. Tobacco control, 20(3), 243–248. doi: 10.1136/tc.2010.042168.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Palazzolo, D. L. (2013). Electronic cigarettes and vaping: A new challenge in clinical medicine and public health. A literature review. Front Public Health, 1, 56. doi: 10.3389/fpubh.2013.00056.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Kahan, D. M., Braman, D., Slovic, P., Gastil, J., & Cohen, G. (2009). Cultural cognition of the risks and benefits of nanotechnology. Nature Nanotechnology, 4(2), 87–90. doi: 10.1038/nnano.2008.341.CrossRefPubMedGoogle Scholar
  43. 43.
    Sutfin, E. L., McCoy, T. P., Morrell, H. E. R., Hoeppner, B. B., & Wolfson, M. (2013). Electronic cigarette use by college students. Drug and Alcohol Dependence, 131(3), 214–221. doi: 10.1016/j.drugalcdep.2013.05.001.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Nayak, P., Pechacek, T. F., Weaver, S. R., & Eriksen, M. P. (2016). Electronic nicotine delivery system dual use and intention to quit smoking: Will the socioeconomic gap in smoking get greater? Addictive Behaviors, 61, 112–116. doi: 10.1016/j.addbeh.2016.05.020.CrossRefPubMedGoogle Scholar
  45. 45.
    Pearson, J. L., Richardson, A., Niaura, R. S., Vallone, D. M., & Abrams, D. B. (2012). E-cigarette awareness, use, and harm perceptions in US adults. American Journal of Public Health, 102(9), 1758–1766. doi: 10.2105/AJPH.2011.300526.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Daniel Owusu
    • 1
  • Jocelyn Aibangbee
    • 2
  • Candice Collins
    • 3
  • Crystal Robertson
    • 4
  • Liang Wang
    • 5
  • Mary A. Littleton
    • 6
  • Rafie Boghozian
    • 7
  • Vicki Casenburg
    • 8
  • Hadii M. Mamudu
    • 9
  1. 1.Georgia State University Tobacco Center of Regulatory Science (GSU TCORS)AtlantaUSA
  2. 2.Johnson CityUSA
  3. 3.Department of Biostatistics and EpidemiologyEast Tennessee State UniversityJohnson CityUSA
  4. 4.Louisiana Department of HealthOffice of Public HealthBaton RougeUSA
  5. 5.Department of Biostatistics and EpidemiologyEast Tennessee State UniversityJohnson CityUSA
  6. 6.Department of Community and Behavioral HealthEast Tennessee State UniversityJohnson CityUSA
  7. 7.BlountvilleUSA
  8. 8.Sullivan County Health DepartmentBlountvilleUSA
  9. 9.Department of Health Services Management and Policy, College of Public HealthEast Tennessee State UniversityJohnson CityUSA

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