Full length articleE-cigarette use and respiratory disorder in an adult sample
Introduction
The use of electronic smoking devices (e-cigarettes) has increased in recent years and the prevalence of e-cigarette use is now substantial among both adolescents and adults (Jamal et al., 2017; Wilson and Wang, 2017; Zernike, 2018). Given this prevalence, it is desirable to have knowledge about the health consequences of e-cigarette use (Glantz and Bareham, 2018; Muthy, 2017). Laboratory research using animal models and cell cultures has indicated that e-cigarettes have biological effects that could lead to tissue injury (Chun et al., 2017; St. Helen and Eaton, 2018). For example, e-cigarette vapor has been shown to have cytotoxic effects on lung cells (Lee et al., 2018) and to produce physiological defects usually seen in Chronic Obstructive Pulmonary Disease (COPD; Garcia-Arcos et al., 2016). At present, however, the generalization of these findings from laboratory paradigms to epidemiological samples is unclear. There is limited knowledge on e-cigarette use with clinical or subclinical variables, and reviews have emphasized the importance of research testing such questions (US Department of Health and Human Services, 2016; Stratton et al., 2018). Accordingly, we investigated whether there was an association of e-cigarette use with diagnosed respiratory disorder in a representative sample of adults.
Previous research has provided evidence of an association of asthma with e-cigarette use, primarily from studies of adolescents. For example, a study with high school students in Hawaii found an association of e-cigarette use with asthma that was independent of cigarette smoking and marijuana use as well as several demographic variables (Schweitzer et al., 2017). This concurs with findings from adolescents in Asian countries (Cho and Paik, 2016; Wang et al., 2016) and the US state of Florida (Choi and Bernat, 2018). These results are theoretically consistent with physiological effects observed in laboratory studies (Clapp and Jaspers, 2017). While asthma may begin at earlier ages (Akinbami et al., 2014), the suggestion that e-cigarettes could maintain or exacerbate asthma (Clapp and Jaspers, 2017) led us to predict that an association of e-cigarette use with asthma would be observed among adults.
There is less evidence about chronic respiratory disorder but a study with high school students in California found an association of e-cigarette use with reports of bronchitis symptoms (McConnell et al., 2017). Yao et al. (2017) studied a US national sample of current cigarette smokers and found that e-cigarette use was associated with a higher likelihood of wheezing and having multiple colds in the past 30 days, suggesting that e-cigarette use could increase susceptibility to upper respiratory infection. A study with an adult sample in Sweden (Hedman et al., 2018) found an association of e-cigarette with respiratory symptoms (e.g., long-standing cough, recurrent wheezing) but did not assess diagnosed respiratory disorder. Hence there is still little epidemiological evidence on chronic respiratory disorder and this has been suggested as a priority for investigation (Stratton et al., 2018). The present research included a measure of chronic pulmonary disorder and based on a body of research from in vitro and animal studies (Chun et al., 2017), we hypothesized that e-cigarette use would be related to chronic respiratory disorder in adults.
To summarize, several lines of research suggest that a relation of e-cigarette use to respiratory disorder might occur among adults. Hence, we investigated whether e-cigarette use is associated with items indexing asthma and pulmonary disorder in a representative sample aged 18 years and over and whether e-cigarette use and combustible cigarette smoking could have synergistic effects for respiratory symptomatology (Cho and Paik, 2016). Because respiratory disorder is a multifactorial condition, having several different risk factors that may be correlated, we included measures of known risk factors as controls. For example, e-cigarette use and cigarette smoking tend to be correlated (Dutra and Glantz, 2014; Wills et al., 2015) so it is crucial to control for this potential confound. In addition, asthma and pulmonary symptoms are related to psychosocial factors including financial adversity (Beck et al., 2014; Kopel et al., 2014) and second-hand smoke exposure (McConnell et al., 2017) which also could be related to e-cigarette use. Obesity is a physical risk factor for asthma (Gennuso et al., 1998; von Mutius et al., 2001) so its contribution also needs to be evaluated. Thus the goal of this research was to determine the association of e-cigarette use with asthma and chronic pulmonary disorder controlling for these other factors so as to obtain a more precise test for e-cigarettes. We predicted that in this diverse sample of adults there would be positive associations of e-cigarette use with asthma and with pulmonary disorder. Because of a possibility that effects of e-cigarettes for airway irritation observed in laboratory studies could augment effects of smoking, which is not currently known (Chun et al., 2017), we also tested for an interaction of e-cigarettes and cigarette smoking.
Section snippets
Participants and procedure
This research used data from the Behavioral Risk Factor Surveillance Survey (BRFSS), an annual cross-sectional, random-digit-dialed survey that includes adult participants aged 18 years or older (CDC, 2011). The BRFSS uses a multistage sampling design to select a representative sample of the noninstitutionalized adult population in each of the 50 US states. Since 2011 the methodology has included reaching and interviewing participants on cellular telephones as well as landlines and using a
Sample characteristics
Table 1 reports the sample’s characteristics. The weighted sample was 50% female and mean age was 55 years. Proportions for primary perceived race/ethnicity were 13% Native Hawaiian, 18% Filipino, 20% Japanese, 6% Chinese, 20% Japanese, 3% Other Asian, 3% Other Pacific Islander, and 36% Caucasian. Education level was 9% less than high school, 29% high school graduate, 34% some college, and 28% college graduate.
The estimated prevalence in the overall sample was 17% for ever had asthma and 4% for
Discussion
The purpose of this research was to study the association of e-cigarette use with two indices of diagnosed respiratory disorder among adults. Findings indicated that e-cigarette use was associated with respiratory disorder independent of cigarette smoking, age, and a range of physical and psychosocial covariates. Results were similar for analyses based on relative risk and absolute risk of asthma and COPD. These results are consistent with several studies showing e-cigarette use related to
Role of funding source
Dr. Wills and Dr. Pagano were supported by grant P30 CA071789 from the National Cancer Institute. The funding agency played no role in analysis and interpretation of the data, preparation of the manuscript, and decision to submit the report for publication. The content is solely the responsibility of the authors and does not necessarily reflect official policy of the U.S. Department of Health and Human Services.
Contributors
TAW, RJW, and EKT formulated the research questions; RJW helped obtain the data; TAW and IP developed the analytic plan and performed the statistical analyses; TAW drafted and revised the manuscript; all authors reviewed and edited drafts of the manuscript critically for important intellectual content. All authors have read and approved the final manuscript.
Conflict of interest
All authors state that they do not have any financial relationships with any organizations that might have an interest in the submitted work or any other relationships or activities that could appear to have influenced the submitted work.
Acknowledgments
We thank the staff of the Hawaii State Department of Health for assisting with access to the data and providing information for the analysis.
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