Rutgers University

Testing Rutgers University Students About their Knowledge of the Health Effects of Electronic Cigarettes vs. the Health Effects of Tobacco

Cigarettes

Joanne Strand

September 4, 2016

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Abstract

This study examines and evaluates the knowledge level of young college- age persons on scientific information about e-cigarettes and tobacco cigarettes via an online test. Also, this study determines whether or not those who never smoked or smoked tobacco cigarettes a year ago would smoke e-cigarettes now due to its high popularity and its public belief that it helps to quit tobacco smoking. Data was collected by administering a 15-question multiple-choice test via an online test based on a literature review of e-cigarettes and tobacco cigarettes, to 17-23 year old college students attending Rutgers University. The participants were categorized into four groups: non-smokers, tobacco cigarette smokers, e-cigarette smokers, and both tobacco and e-cigarette smokers. The results were statistically analyzed and compared via chi square. The data period collection was 3 weeks and 150 persons (males and females) participated in the study. After calculating comparing expected quiz results to observed quiz results with the chi square, determining the significance level of 5%, and using a chi square distribution table to find the p-value, the p value was found to be between 0.05 and 0.025. Because the p-value is lower than the significance value (0.05), it is highly likely that there is a correlation between the variables and the results observed. The group with the highest score on the quiz was the non-smoking group with a 70% average. This study has numerous findings. There is a significant finding that students in this study who smoked tobacco cigarettes were more likely to try e-cigarettes in hopes of quitting. Whether or not they failed or succeeded is not known or tested. It is also significant to find the non-smokers had the highest quiz scores. This supports the hypothesis that knowledge leads to better decision making, such as choosing healthier lifestyle habits. Out of 22 tobacco smokers, 13 also used e- cigarettes, strongly suggesting that they were using e-cigarettes to quit tobacco smoking. Finally, an encouraging finding was that tobacco smokers made up only 14.7% of the participants compared to the Centers for Disease Control and Prevention data, which shows about 16.8% of the population. This may reflect the fact that a smaller proportion of educated persons smoke tobacco.

Introduction

According to the publication entitled “The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General”, the author states that, “In the United States, smoking causes 87 percent of lung cancer deaths, 32 percent of coronary heart disease deaths, and 79 percent of all cases of chronic obstructive pulmonary disease. This report finds that in addition to causing multiple serious diseases, cigarette smoking diminishes overall health status, impairs immune function, and reduces quality of life” (US Department of Health and Human Services, 2014). Tobacco smoking is a very harmful habit that costs the lives of many, including nearly 6 million deaths per year (US Department of Health and Human Services, 2014). Electronic cigarettes, also known as e – cigarettes, were introduced into our society in 2003. They are battery-operated devices devised to deliver nicotine with flavorings and other chemicals in vapor instead of smoke. While e-cigarettes are often promoted as safer alternatives to traditional cigarettes, which deliver nicotine by burning tobacco, little is actually known yet about the health risks of using these devices. In this research project, I assessed and analyzed the knowledge of

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college students at Rutgers University about the health effects of using e – cigarettes vs. tobacco cigarettes. It took many years for scientists to recognize that tobacco cigarettes were dangerous to our health after they were first introduced to the market. It may take decades of epidemiologic and scientific studies to determine if e-cigarettes are beneficial or harmful to humans and to determine if e-cigarette use increases the likelihood of smoking tobacco cigarettes in later life because researchers believe that knowledge should help people make intelligent decisions about habits such as smoking tobacco or e-cigarettes. Thus, it was decided to assess the knowledge level of college students about the health effects of tobacco cigarettes and electronic cigarettes by the administering a 15 – question quiz. This study also examines and evaluates whether or not those who never smoked or smoked tobacco cigarettes a year ago would smoke e-cigarettes now due to its high popularity and its public belief that it helps to quit tobacco smoking.

Materials and Methods

The researcher conducted an extensive literature review on e – cigarettes and tobacco cigarettes. Thus, it was decided to use a quiz created from the information about the health effects of tobacco and e-cigarettes ascertained from the literature. A demographic survey was created, which requested the person’s age, sex, grade, and smoking history. A 15 multiple-choice quiz was composed to assess the participants’ knowledge on the health effects of e – cigarettes and tobacco cigarettes. This 15 question quiz was administered to participants through Rutgers Facebook posts and person-to-person contact. The quiz was accessible for data collection on July 25, 2016 and data collection ceased on August 15, 2016. The 15 questions were selected to test the participants’ knowledge of the adverse health effects of smoking tobacco and the scientific knowledge currently available on smoking e- cigarettes, which is one recommended way to cease smoking tobacco cigarettes, according to some. The quiz is included in appendix A.

Results

Based on the demographic collected, the participants’ information were placed into four groups: non-smokers (A), tobacco cigarette smokers (B), e-cigarette smokers (C), and both tobacco and e-cigarette smokers (B and C). In this study, 150 participants, all students at Rutgers University in New Brunswick, NJ, volunteered to take a 15-question quiz that was posted on a Rutgers University Facebook group. Of the 150 participants, 78 were females and 72 were males, 13 were going to be sophomores in the fall of 2016, 69 were going to be juniors, 61 were going to be seniors, and 7 were graduate students, fifth year, or other. The total points distribution of all participants is shown in figure 1. The mean quiz scores for the four study groups are shown in figure 2 and the mean quiz scores, which breaks the groups down by gender, are shown in figure 3. The group scores were compared by statistical analysis, which was the chi square method to determine if there were significant differences.

Figure 1

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For all participants, the average was a 10.5 out of 15 points, which is a grade of 70%. The median was 10 out of 15 points or 67% and the range was 2 to 15 points.

Figure 2

This table shows the average quiz scores of participants in four categories. Out of 15 questions, non-smokers scored a 70%, tobacco cigarette smokers scored a 64%, and e-cigarette smokers scored a 68%. Those who smoked both tobacco cigarettes and e-cigarettes scored a 62%.

Figure 3

1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

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E- Cigarette Quiz: Quiz Score Distribution of all Participants

Points Scored

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E- Cigarette Quiz: Average Scores of Four Groups

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This table shows the average quiz scores for females and males in all four categories. Out of 15 questions, female non-smokers scored a 67%, female tobacco cigarette smokers scored a 67%, and female e-cigarette smokers scored an 80% Females who smoked both tobacco cigarettes and e-cigarettes scored a 60%. Out of 15 questions, male non-smokers scored a 73%, male tobacco cigarette smokers scored a 60%, and male e-cigarette smokers scored a 56%. Males who smoked both tobacco cigarettes and e-cigarettes scored a 63%.

Discussion

Health Problems Associated with Smoking Tobacco Cigarettes

Almost half a million Americans die prematurely from smoking each year and more than 16 million Americans suffer from a disease caused by smoking. Scientific evidence has linked smoking to many diseases that affect almost every organ of the human body. According to the Centers for Disease Control and Prevention, cigarette smoking, “harms nearly every organ of the body, causes many diseases, and reduces the health of smokers in general. Cigarette smoking causes more than 480,000 deaths each year in the United States… Smoking causes about 90% of all lung cancer deaths in men and women. About 80% of all deaths from chronic obstructive pulmonary disease are caused by smoking” (Centers for Disease Control and Prevention, 2015). In addition to this, smoking can cause cancer almost anywhere in the body and those who smoke tobacco cigarettes are more likely than nonsmokers to develop heart disease, stroke, and lung cancer. Also, “smokers are at greater risk for diseases that affect the heart and blood vessels (cardiovascular disease)… and smoking can cause lung disease by damaging your airways and the small air sacs (alveoli) found in your lungs” (Centers for Disease Control and Prevention, 2015). According to the publication entitled “The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General”, the author claims that, “The report also concludes that smoking causes diabetes mellitus, rheumatoid arthritis and immune system weakness, increased risk for tuberculosis disease and death, ectopic (tubal) pregnancy and impaired fertility, cleft lip and cleft palates in babies of women who smoke during early pregnancy, erectile dysfunction, and age-related macular degeneration” (US Department of Health and Human Services, 2014).

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E- Cigarette Quiz: Average Scores of Females vs. Males

FemalesMales

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Health Problems Associated with Smoking E - Cigarettes

Electronic cigarettes, also known as e – cigarettes, were introduced into our society in 2003. They are battery-operated devices devised to deliver nicotine with flavorings and other chemicals to users in vapor instead of smoke. Although e – cigarettes are fairly new, there have been numerous experiments and research done. E – cigarettes are seen as healthier alternatives to tobacco cigarettes because these devices deliver nicotine in water vapor instead of by burning tobacco. According to the article entitled “E-cigarette use results in suppression of immune and inflammatory-response genes in nasal epithelial cells similar to cigarette smoke” in the “American Journal of Physiology - Lung Cellular and Molecular Physiology”, the author claims that FDA approves oral consumption of e – cigarettes, but inhalation effects are unknown. Epithelial cells are found in our nasal passages and in our lungs. They are along our airways and are needed to function properly to trap and dispatch particles and pathogens so we don’t get sick. These epithelial cells are critical for normal immune defense. Smoking cigarettes decreases gene expression of 53 genes that are important for the immune response of epithelial cells. However, smoking e-cigarettes decreases the gene expression of 358 genes that are important for the immune response of epithelial cells, which includes all 53 genes that smoking normal cigarettes suppressed (Martin et al., 2016). Although some research has been done on the short-term effects of e-cigarettes, the long-term health effects are still unknown. It would take 10 to 20 years to assess the effects of e-cigs to determine if negative health effects will occur.

There are about 7,000 e – cigarette flavors that are currently marketed. However, recent studies have found that flavorings, such as chocolate, cherry, etc. are harmful. In the early 2000s, it was found that inhalation exposure of the flavoring chemical diacetyl was found to be associated with a disease that became known as “popcorn lung”, which is serious lung disease in microwave popcorn workers. There has been limited research on flavoring chemicals in e-cigarettes. According to the journal article, entitled “Flavoring chemicals in e-cigarettes: diacetyl, 2,3-pentanedione, and acetoin in a sample of 51 products, including fruit-, candy-, and cocktail-flavored e-cigarettes”, the authors claim that, “The flavoring chemicals involved were on the Generally Recognized As Safe (GRAS) list that applies only to ingestion, but exposures were occurring via inhalation and very little was known about potential inhalation hazards of these chemicals at that time. In May 2000, eight persons who had previously worked at a microwave popcorn-processing plant were reported to have severe bronchiolitis obliterans, an irreversible loss of pulmonary function that can become so severe that the only treatment option may be a lung transplant” (Allen et al., 2016). There was a strong link between lung disease and airborne exposures to the butter – flavoring chemicals in the facility. Diacetyl can cause a serious and irreversible lung disease. The most prominent chemical found in the butter flavor was diacetyl. Because of the associations between diacetyl and severe respiratory diseases observed in workers, the flavorings in e-cigarettes need to be more monitored (Allen et al., 2016). In addition to this, according to the Centers for Disease Control and Prevention, c-cigarette use tripled among middle and high school students in just one year. Findings from the 2014 National Youth Tobacco Survey show that current e-cigarette use (use on at least 1 day in the past 30 days) among high school students

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increased from 4.5 percent in 2013 to 13.4 percent in 2014, rising from approximately 660,000 to 2 million students (Centers for Disease Control and Prevention, 2015). Various studies have shown that e-cigarettes helped some people quit, but it generally encourages younger adults to try tobacco smoking after initially trying e-cigarettes. As a result, smoking e-cigarettes doesn’t necessarily help people quit tobacco smoking. There is still nicotine in e-cigarettes and it is still highly addictive.

According to the article entitled “E- cigarettes: How “safe” are they?” in the Journal of Family Practice, the author claims, “Even though e-cigarettes do not emit smoke, bystanders are exposed to the aerosol or vapor exhaled by the user, and researchers have found varying levels of such substances as formaldehyde, acetaldehyde, isoprene, acetic acid, acetone, propanol, propylene glycol, and nicotine in the air” (Smith, Brar, Srinivasan, Enja, & Lippmann, 2016). The vapor produced by electronic cigarettes can contain a surprisingly high concentration of formaldehyde — a known carcinogen. As you can see, the health effects of e-cigarettes are still unknown and research still needs to be done to assess the safety of them.

Discussion of Results

After receiving 150 participants, 97 were non-smokers, 8 were tobacco smokers, 31 were e-cigarette smokers, and 13 smoked both tobacco cigarettes and e-cigarettes. The table that compares the average scores of the four groups shows that the group with the highest score on the e-cigarette and tobacco quiz was the non-smokers with a 70%. After calculating comparing expected quiz results to observed quiz results with the chi square, determining the significance level of 5%, and using a chi square distribution table to find the p-value, the p value was found to be between 0.05 and 0.025. Because the p-value is lower than the significance value (0.05), it is highly likely that there is a correlation between the variables and the results observed. This study has numerous significances. There is a significant discovery that students in this study who smoked tobacco cigarettes were more likely to try e-cigarettes in hopes of quitting. Whether or not they failed or succeeded is not known or tested. However, those who never smoked tobacco cigarettes a year ago did not smoke e-cigarettes now even due to its high popularity. It is also significant to find the non-smokers had the highest quiz scores. This supports the hypothesis that knowledge leads to better decision making, such as choosing healthier lifestyle habits. The large number of e-cigarette smokers may reflect a disproportionate number of them attracted to the quiz because there is no evidence that 21% of Rutgers University students use e-cigarettes. Also, females scored slightly better than males on the quiz with a 10 out of 15 (67%) as compared to the males score of 9.5 out of 15 (63%). Future public health researchers may expand in this research and determine how people can learn about e-cigarettes and tobacco cigarettes at a young age before experimenting with smoking either of them. Also, it would be helpful in public health research to measure the knowledge in various groups of persons to assess the knowledge verse personal decision-making, such as type of diets, weight status of participants, etc.

References

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Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton P, Stewart JH, Christiani

DC. 2016. Flavoring chemicals in e-cigarettes: diacetyl, 2,3-pentanedione, and

acetoin in a sample of 51 products, including fruit-, candy-, and cocktail-flavored

e-cigarettes. Environ Health Perspect

124:733-739;http://dx.doi.org/10.1289/ehp.1510185

Centers for Disease Control and Prevention. E-cigarette use triples among middle

and high school students in just one year. Press release, 16 Apr

2015. www.cdc.gov/media/releases/2015/p0416-e-cigarette-use.html.

Centers for Disease Control and Prevention. (2015, October 1). Health Effects of

Cigarette Smoking. Retrieved from

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/

effects_cig_smoking/

Martin, E. M., Clapp, P. W., Rebuli, M. E., Pawlak, E. A., Glista-Baker, E., Benowitz, N.

L., . . . Jaspers, I. (2016, July 12). E-cigarette use results in suppression of

immune and inflammatory-response genes in nasal epithelial cells similar to

cigarette smoke. Am J Physiol Lung Cell Mol Physiol American Journal of

Physiology - Lung Cellular and Molecular Physiology, 311(1).

doi:10.1152/ajplung.00170.2016

Smith, L., MD, Brar, K., MD, Srinivasan, K., MD, Enja, M., MD, & Lippmann, S., MD.

(2016, June). E-cigarettes: How “safe” are they? The Journal of Family Practice,

65(6), 380-385. Retrieved from https://www.google.com/url?

sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwi

LyJbtuPHNAhWFkh4KHTsUDdQQFggcMAA&url=http://www.jfponline.com/

the-publication/issue-single-view/e-cigarettes-how-safe-are-they/

02d46801d77b4f61250337877812aff6.html&usg=AFQjCNHHG7CIC0U2rzCr5D

EG5Q_dy3luCA&sig2=XGSEuQi4yaDUjFoNm7PFMg

US Department of Health and Human Services. (2014, January 17). The Health

Consequences of Smoking—50 Years of Progress: A Report of the Surgeon

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General. Retrieved July 10, 2016 from

http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fact-

sheet.html

Appendix A Researcher: Joanne Strand

What is your gender? o Male ○

What is your age?o 17 ○

22o Over 22

What grade will you be in the fall of 2016?o Freshman o Senior

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Researcher: Joanne Strand

What is your gender? o Male ○

What is your age?o 17 ○

22o Over 22

What grade will you be in the fall of 2016?o Freshman o Senior

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