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Electronic cigarette (e-cigarette) use has increased considerably since these products were introduced into the US marketplace in 2007,1 and e-cigarettes are the most commonly used tobacco product among US youths.2 In contrast to combustible tobacco products, e-cigarettes do not produce sidestream emissions from the device itself. However, aerosol is produced during activation of the device, some of which is exhaled into the environment where nonusers can be exposed through inhalation, ingestion, or dermal contact.3
Secondhand aerosol (SHA) from e-cigarettes can contain harmful and potentially harmful substances including nicotine, heavy metals, ultrafine particulate, volatile organic compounds such as formaldehyde and acetaldehyde, and other toxicants.3,4 However, to our knowledge, the extent to which US youths are exposed to SHA is unknown. This study assessed self-reported SHA exposure among US students.
Data came from the 2015 National Youth Tobacco Survey, a cross-sectional survey of US middle school and high school students (n = 17 711). National Youth Tobacco Survey uses a 3-stage sampling design (counties, schools, and classes) to yield nationally representative estimates.2 Written approval to participate in the survey was obtained from parents or legal guardians. This secondary analysis of deidentified public use data was exempt from human participants review.
Self-reported SHA exposure was assessed by asking, “during the past 30 days, on how many days did you breathe the vapor from someone who was using an electronic cigarette or e-cigarette in an indoor or outdoor public place?” Seven response options ranged from “0 days” to “all 30 days.” Respondents who indicated any response other than “0 days” were considered exposed to SHA.
Point estimates and 95% CIs were reported overall and by school level, sex, race/ethnicity, current (past 30-day) e-cigarette use, current (past 30-day) other tobacco product use (cigars, cigarillos, or little cigars; chewing tobacco, snuff, or dip; pipe tobacco; bidis; snus; dissolvable tobacco; and hookah or waterpipe used with tobacco), and past 30-day secondhand smoke (SHS) exposure from combustible tobacco products. Population counts were extrapolated from probability weights. Data were analyzed using R 3.2.3 (R Programming).
Overall, 24.2% of students (6.5 million) reported SHA exposure (Table). Exposure was 21.9% among boys and 26.7% among girls and ranged from 15.3% among non-Hispanic African American individuals to 27.0% among non-Hispanic white individuals. By e-cigarette use, exposure was 66.8% among current users, 28.9% among former users, and 16.4% among never-users. By other tobacco product use, exposure was 51.5% among current users, 32.3% among former users, and 16.8% among never-users. Secondhand aerosol exposure was reported among 40.0% of students exposed to SHS and among 8.5% of students not exposed to SHS.
Frequency of SHA exposure varied overall and by school level (Figure). Among all students, 10.9% (3.0 million) reported exposure on 1 to 2 days; 7.9% (2.1 million) on 3 to 9 days; 3.2% (0.8 million) on 10 to 29 days; and 2.2% (0.6 million) on all 30 days.
Respondents were asked “During the past 30 days, on how many days did you breathe the vapor from someone who was using an electronic cigarette or e-cigarette in an indoor or outdoor public place?” Response options included 0 days, 1 or 2 days, 3 to 5 days, 6 to 9 days, 10 to 19 days, 20 to 29 days, or all 30 days. Respondents who indicated any response other than 0 days were considered exposed to secondhand aerosol.
Distributions do not add up to 100% because percentages of those who reported 0 days were not included.
One in 4 US youths are exposed to SHA from e-cigarettes including 4.4 million who are not current e-cigarette users and 1 million not exposed to SHS from combustible tobacco. These findings underscore the importance of tobacco prevention strategies, including comprehensive policies that address both SHS and SHA, to prevent youth exposure to this public health threat.
To protect the public from both SHS and SHA, it is critical to modernize clean indoor air policies to include e-cigarettes. Such policies can maintain standards for clean indoor air, reduce the potential for renormalization of tobacco use, and prevent involuntary exposure to nicotine and other e-cigarette emissions.1 As of January 2017, 8 states and more than 500 communities have comprehensive indoor air laws that prohibit e-cigarettes.5
Efforts are also warranted to educate youths and youth influencers about the potential dangers of SHA exposure.1 Specifically, pediatricians can incorporate screening for e-cigarette use and SHA exposure into clinical practice, and counsel parents, youths, and caregivers about the potential harms of SHA and the importance of avoiding exposure.6 Further research on SHA constituents as well as prevalence, correlates, and locations of exposure, could help inform public health policy and practice.
Corresponding Author: Teresa W. Wang, PhD, MS, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS F-79, Atlanta, GA 30341 (firstname.lastname@example.org).
Published Online: March 20, 2017. doi:10.1001/jamapediatrics.2016.4973
Author Contributions: Dr Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.
Study concept and design: Wang, Agaku, King.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Wang, Agaku, King.
Administrative, technical, or material support: Wang, Agaku, King.
Supervision: Agaku, King.
No additional contributions: Marynak.
Conflict of Interest Disclosures: None reported.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Wang TW, Marynak KL, Agaku IT, King BA. Secondhand Exposure to Electronic Cigarette Aerosol Among US Youths. JAMA Pediatr. 2017;171(5):490–492. doi:10.1001/jamapediatrics.2016.4973
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