US Adults' Perceptions About the Harms of Nicotine in Electronic Vapor Products on the Adolescent Brain, United States, 2016-2017.

We used data from the 2016 and 2017 SummerStyles survey (N = 4,186 and 4,066, respectively) to assess US adults’ perceptions about the harms of nicotine in electronic vapor products (EVP) to the developing adolescent brain. Of respondents in 2016, 68.5% agreed exposure to nicotine in EVP was harmful, and of respondents in 2017, 62.6% agreed (P < .001). This agreement varied by several covariates. Continued efforts are warranted to educate the public about the risks of EVP use among youth, including the harmful effects of nicotine exposure on the developing adolescent brain.

Current cigarette smokers were defined as respondents who smoked at least 100 cigarettes in their lifetime, and smoked cigarettes "every day" or "some days" when surveyed. Former cigarette smokers were respondents who smoked at least 100 cigarettes in their lifetime, and who smoked "not at all" when surveyed. Never cigarette smokers had not smoked 100 cigarettes in their lifetime.
Current EVP users were defined as respondents who ever used an EVP ("e-cigarettes, e-cigars, e-pipes, vape pens, e-hookahs, and hookah pens, such as blu, NJOY, or Starbuzz") even once and used EVP within the 30 days preceding the survey. Former EVP users were respondents who ever used an EVP, but not within the past 30 days. Never EVP users were respondents who reported never using an EVP, even just one time.

Results
In 2017, 62.6% of adults agreed ("strongly agree" = 35.7% and "somewhat agree" = 26.9%) that nicotine in EVP harmed the developing adolescent brain; 3.7% somewhat disagreed, 4.4% strongly disagreed, and 29.3% neither agreed nor disagreed (Table 1). Prevalence of agreement was higher among women (65.2%) than men (59.9%) (P < .05), and ranged from 61.1% among 25-to 44-year-olds to 65.0% among adults aged 65 years or older (Table 2). By race/ethnicity, agreement ranged from 55.1% among non-Hispanic blacks to 64.5% among non-Hispanic whites. Prevalence of agreement generally increased with greater educational attainment and annual household income. Prevalence of agreement was higher among married adults (64.2%) than single adults (58.9%). By region, prevalence of agreement ranged from 60.5% in the South to 66.0% in the Midwest. Prevalence of agreement was higher among those who lived in households with children (64.4%) compared with those who did not (62.0%). Prevalence of agreement was 42.6% among current smokers, 60.2% among former smokers, and 68.9% among never smokers. Additionally, prevalence of agreement was 34.9% among current EVP users, 50.4% among former EVP users, and 65.4% among never EVP users.

Discussion
We found that approximately two-thirds of adults in the United States agree that nicotine in EVP is harmful to the developing adolescent brain. However, variations in agreement exist across subpopulations, with lower prevalence among current and former smokers and e-cigarette users.
In 2016, the Surgeon General concluded that the use of products containing nicotine in any form among youth, including in e-cigarettes, is unsafe (2). At that time, the Surgeon General released a Public Service Announcement warning about these risks (5). Subsequently, several states and communities developed educational and media materials to reflect the growing body of scientific evidence on this issue (6). Such information is important given that current e-cigarette use increased 78% among US high school students during 2017-2018 alone (7); this increase was likely because of the recent popularity of newer e-cigarettes such as JUUL, which can be used discreetly, have a high nicotine content, and come in youth appealing flavors (4).
Prevalence of agreement varied between 2016 and 2017, both overall and across subpopulations. This difference could be due to multiple factors, including differences in exposure to media campaigns and education about the risks of nicotine among youth, or differences in respondent characteristics or sample size between the 2 surveys.
This study has limitations. First, the survey was internet-based and may not be fully representative of the US adult population; however, data were weighted to US Current Population survey proportions. Second, data were self-reported, which could lead to recall bias.
In conclusion, about one-third of adults do not agree that nicotine harms the developing brain, which continues to develop through adolescence and into young adulthood (4). Continued efforts are warranted at the national, state, and local levels to educate the public about the risks of EVP use among youth, specifically related to the risks of nicotine exposure (2-4).

1.
Office of the Surgeon General. E-cigarette use among youth and young adults: a report of the Surgeon General. Washington

4.
Office of the Surgeon General. Know the risks: e-cigarettes and young people: resources. https://ecigarettes.surgeongeneral.gov/resources.html. Accessed July 31, 2019. Abbreviations: CI, confidence interval; EVP, electronic vapor products. a Significant χ 2 test (P < .05) across favorability categories within the specified characteristic. b Current smoking was defined by having smoked at least 100 cigarettes and currently smoking "some days" or "every day." Former smoking was defined by having smoked at least 100 cigarettes and currently smoking "not at all." Never smoking was defined as not having smoked 100 cigarettes. c EVP use was defined as "Electronic vapor products (eg, e-cigarettes, e-hookahs, e-cigars, e-pipes, hookah pens, vape pens, or some other electronic vapor product)." Ever EVP use was defined as ever trying EVP, even just once; current use was any use in the past 30 days; former use was defined as ever use and no use in the last 30 days; and never use was defined as never trying.   Abbreviations: CI, confidence interval; EVP, electronic vapor products. a Significant χ 2 test (P < .05) across favorability categories within the specified characteristic. b Current smoking was defined by having smoked at least 100 cigarettes and currently smoking "some days" or "every day." Former smoking was defined by having smoked at least 100 cigarettes and currently smoking "not at all." Never smoking was defined as not having smoked 100 cigarettes. c EVP use was defined as "Electronic vapor products (eg, e-cigarettes, e-hookahs, e-cigars, e-pipes, hookah pens, vape pens, or some other electronic vapor product)." Ever EVP use was defined as ever trying EVP, even just once; current use was any use in the past 30 days; former use was defined as ever use and no use in the last 30 days; and never use was defined as never trying. www.cdc.gov/pcd/issues/2020/19_0391.htm • Centers for Disease Control and Prevention Abbreviations: CI, confidence interval; EVP, electronic vapor products. a Agree was defined as "somewhat agree" and "strongly agree" responses. b Significant χ 2 test (P < .05). c Current smoking was defined by having smoked at least 100 cigarettes and currently smoking "some days" or "every day." Former smoking was defined by having smoked at least 100 cigarettes and currently smoking "not at all." Never smoking was defined as not having smoked 100 cigarettes. d EVP use was defined as "Electronic vapor products (eg, e-cigarettes, e-hookahs, e-cigars, e-pipes, hookah pens, vape pens, or some other electronic vapor product)." Ever EVP use was defined as ever trying EVP, even just once; current use was any use in the past 30 days; former use was defined as ever use and no use in the last 30 days; and never use was defined as never trying.

PREVENTING CHRONIC DISEASE
(continued on next page) PREVENTING CHRONIC DISEASE VOLUME 17, E27 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY MARCH 2020 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.  Abbreviations: CI, confidence interval; EVP, electronic vapor products. a Agree was defined as "somewhat agree" and "strongly agree" responses. b Significant χ 2 test (P < .05). c Current smoking was defined by having smoked at least 100 cigarettes and currently smoking "some days" or "every day." Former smoking was defined by having smoked at least 100 cigarettes and currently smoking "not at all." Never smoking was defined as not having smoked 100 cigarettes. d EVP use was defined as "Electronic vapor products (eg, e-cigarettes, e-hookahs, e-cigars, e-pipes, hookah pens, vape pens, or some other electronic vapor product)." Ever EVP use was defined as ever trying EVP, even just once; current use was any use in the past 30 days; former use was defined as ever use and no use in the last 30 days; and never use was defined as never trying. www.cdc.gov/pcd/issues/2020/19_0391.htm • Centers for Disease Control and Prevention