Background: Electronic cigarettes (e-cigarettes) have become increasingly popular, yet beyond social or technical features, the specific health-related reasons adults use e-cigarettes remain poorly understood. Objective: To explore the cross-sectional associations between perceived health and current e-cigarette use in a large population-based cohort. Methods: From the participants included in the French CONSTANCES cohort (a large general-purpose national population-based cohort) from 2015 to 2017, we included 18,300 ever tobacco smokers with data on their e-cigarette use. We used logistic regressions to estimate the associations between e-cigarette use and perceived health (global and respiratory), stratifying on participants’ smoking status and adjusting for sociodemographic characteristics. To examine the role of objective health features (reported diagnoses and measured parameters during a health examination), we adjusted for prior history of respiratory and cardiovascular diseases, diabetes, cancer, spirometry, and blood pressure. Finally, we examined the effect of additionally adjusting for several health-related behaviors. Results: Participants with poor perceived health (global and respiratory) were at greater risk of e-cigarette use. These associations remained unchanged after adjustment for objective health features and health-related behaviors (e.g., in current smokers, for global perceived health, an odds ratio of 1.10 [95% CI 1.03–1.16] per increase on an 8-point scale from very good to very poor). Conclusions: Our findings suggest that the more current and former smokers felt unhealthy, the more they tended to currently use e-cigarettes. People who regularly use e-cigarettes should obtain medical supervision that takes into account not only objective diagnoses and measurements but also perceived health. Counseling practices could include assessing perceived health status to reinforce motivation to quit smoking.

Keywords:
Electronic nicotine delivery systems, Tobacco, Respiratory health, Cardiovascular health
1.
Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report.
Am J Prev Med
. 2008 Aug;35(2):158–76.
2.
Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, Whitlock EP.
Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force. Rockville (MD)
. US: Agency for Healthcare Research and Quality; 2015 [cited 2018 Jun 28]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK321744/.
3.
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, et al. Nicotine replacement therapy for smoking cessation.
Cochrane Database Syst Rev
. 2012 Nov;11:CD000146.
4.
Hajek P, Etter JF, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit.
Addiction
. 2014 Nov;109(11):1801–10.
5.
Levy DT, Borland R, Lindblom EN, Goniewicz ML, Meza R, Holford TR, et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes.
Tob Control
. 2018 Jan;27(1):18–25.
6.
Farsalinos K. Electronic cigarettes: an aid in smoking cessation, or a new health hazard?
Ther Adv Respir Dis
. 2018 Jan-Dec;12:1753465817744960.
7.
Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, et al. A randomized ­trial of e-cigarettes versus nicotine-replacement therapy.
N Engl J Med
. 2019 Feb;380(7):629–37.
8.
Barbeau AM, Burda J, Siegel M. Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach.
Addict Sci Clin Pract
. 2013 Mar;8(1):5.
9.
Sussan TE, Shahzad FG, Tabassum E, Cohen JE, Wise RA, Blaha MJ, et al. Electronic cigarette use behaviors and motivations among smokers and non-smokers.
BMC Public Health
. 2017 Sep;17(1):686.
10.
Farsalinos KE, Poulas K, Voudris V, Le Houezec J. Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries.
Addiction
. 2016 Nov;111(11):2032–40.
11.
Patel D, Davis KC, Cox S, Bradfield B, King BA, Shafer P, et al. Reasons for current E-cigarette use among U.S. adults.
Prev Med
. 2016 Dec;93:14–20.
12.
Coleman BN, Rostron B, Johnson SE, Ambrose BK, Pearson J, Stanton CA, et al. Electronic cigarette use among US adults in the Population Assessment of Tobacco and Health (PATH) Study, 2013–2014.
Tob Control
. 2017 Dec;26 e2:e117–26.
13.
Nelson VA, Goniewicz ML, Beard E, Brown J, Sheals K, West R, et al. Comparison of the characteristics of long-term users of electronic cigarettes versus nicotine replacement therapy: A cross-sectional survey of English ex-smokers and current smokers.
Drug Alcohol Depend
. 2015 Aug;153:300–5.
14.
Ooms GI, Bosdriesz JR, Portrait FR, Kunst AE. Sociodemographic Differences in the Use of Electronic Nicotine Delivery Systems in the European Union.
Nicotine Tob Res
. 2016 May;18(5):724–9.
15.
Farsalinos KE, Romagna G, Voudris V. Factors associated with dual use of tobacco and electronic cigarettes: A case control study.
Int J Drug Policy
. 2015 Jun;26(6):595–600.
16.
Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies.
J Health Soc Behav
. 1997 Mar;38(1):21–37.
17.
Mossey JM, Shapiro E. Self-rated health: a predictor of mortality among the elderly.
Am J Public Health
. 1982 Aug;72(8):800–8.
18.
Mavaddat N, Parker RA, Sanderson S, Mant J, Kinmonth AL. Relationship of self-rated health with fatal and non-fatal outcomes in cardiovascular disease: a systematic review and meta-analysis.
PLoS One
. 2014 Jul;9(7):e103509.
19.
Schnittker J, Bacak V. The increasing predictive validity of self-rated health.
PLoS One
. 2014 Jan;9(1):e84933.
20.
Zins M, Goldberg M; CONSTANCES team. The French CONSTANCES population-based cohort: design, inclusion and follow-up.
Eur J Epidemiol
. 2015 Dec;30(12):1317–28.
21.
DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question. A meta-analysis.
J Gen Intern Med
. 2006 Mar;21(3):267–75.
22.
Doyle F, Rohde D, Rutkowska A, Morgan K, Cousins G, McGee H. Systematic review and meta-analysis of the impact of depression on subsequent smoking cessation in patients with coronary heart disease: 1990 to 2013.
Psychosom Med
. 2014 Jan;76(1):44–57.
23.
Wiernik E, Airagnes G, Lequy E, Gomajee R, Melchior M, Le Faou AL, et al. Electronic cigarette use is associated with depressive symptoms among smokers and former smokers: cross-sectional and longitudinal findings from the Constances cohort.
Addict Behav
. 2019 Mar;90:85–91.
24.
Morin AJ, Moullec G, Maïano C, Layet L, Just JL, Ninot G. Psychometric properties of the Center for Epidemiologic Studies Depression Scale (CES-D) in French clinical and nonclinical adults.
Rev Epidemiol Sante Publique
. 2011 Oct;59(5):327–40.
25.
Ruiz F, Goldberg M, Lemonnier S, Ozguler A, Boos E, Brigand A, et al. High quality standards for a large-scale prospective population-based observational cohort: constances.
BMC Public Health
. 2016 Aug;16(1):877.
26.
Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early ­Detection of Persons with Harmful Alcohol Consumption–II.
Addiction
. 1993 Jun;88(6):791–804.
27.
van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate Imputation by Chained Equations in R.
J Stat Softw
. 2011;45(3):1–67.
28.
R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2015. Available from: http://www.R-project.org/.
29.
Amato MS, Boyle RG, Levy D. E-cigarette use 1 year later in a population-based prospective cohort.
Tob Control
. 2017;26:e92–6.
30.
Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library.
BMJ
. 2000 Aug;321(7257):355–8.
31.
Rothman KJ, Gallacher JE, Hatch EE. Why representativeness should be avoided.
Int J Epidemiol
. 2013 Aug;42(4):1012–4.
32.
Morjaria JB, Mondati E, Polosa R. E-cigarettes in patients with COPD: current perspectives.
Int J Chron Obstruct Pulmon Dis
. 2017 Nov;12:3203–10.
33.
Kalkhoran S, Kruse GR, Chang Y, Rigotti NA. Smoking-Cessation Efforts by US Adult Smokers with Medical Comorbidities.
Am J Med
. 2018 Mar;131(3):318.e1–318.e8.
34.
Polosa R, Morjaria JB, Caponnetto P, Caruso M, Campagna D, Amaradio MD, et al. Persisting long term benefits of smoking abstinence and reduction in asthmatic smokers who have switched to electronic cigarettes.
Discov Med
. 2016 Feb;21(114):99–108.
35.
Biener L, Hargraves JL. A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit.
Nicotine Tob Res
. 2015 Feb;17(2):127–33.
36.
Harrell PT, Simmons VN, Piñeiro B, Correa JB, Menzie NS, Meltzer LR, et al. E-cigarettes and expectancies: why do some users keep smoking?
Addiction
. 2015 Nov;110(11):1833–43.
37.
Pokhrel P, Little MA, Fagan P, Kawamoto CT, Herzog TA. Correlates of use of electronic cigarettes versus nicotine replacement therapy for help with smoking cessation.
Addict Behav
. 2014 Dec;39(12):1869–73.
38.
Rutten LJ, Blake KD, Agunwamba AA, Grana RA, Wilson PM, Ebbert JO, et al. Use of E-Cigarettes Among Current Smokers: Associations Among Reasons for Use, Quit Intentions, and Current Tobacco Use.
Nicotine Tob Res
. 2015 Oct;17(10):1228–34.
39.
Lehmann K, Kuhn S, Reimer J. Electronic Cigarettes in Germany: Patterns of Use and Perceived Health Improvement.
Eur Addict Res
. 2017;23(3):136–47.
40.
Gibson LA, Creamer MR, Breland AB, Giachello AL, Kaufman A, Kong G, et al. Measuring perceptions related to e-cigarettes: important principles and next steps to enhance study validity.
Addict Behav
. 2018 Apr;79:219–25.
41.
Lee HY, Lin HC, Seo DC, Lohrmann DK. Determinants associated with E-cigarette adoption and use intention among college students.
Addict Behav
. 2017 Feb;65:102–10.
42.
Roberts ME, Doogan NJ, Stanton CA, Quisenberry AJ, Villanti AC, Gaalema DE, et al. Rural Versus Urban Use of Traditional and Emerging Tobacco Products in the United States, 2013–2014.
Am J Public Health
. 2017 Oct;107(10):1554–9.
43.
Polosa R, Cibella F, Caponnetto P, Maglia M, Prosperini U, Russo C, et al. Health impact of E-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked.
Sci Rep
. 2017 Nov;7(1):13825.
44.
Stewart SH, Connors GJ. Perceived health status, alcohol-related problems, and readiness to change among medically hospitalized, alcohol-dependent patients.
J Hosp Med
. 2007 Nov;2(6):372–7.
45.
Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis.
Lancet Respir Med
. 2016 Feb;4(2):116–28.
46.
Stenholm S, Kivimäki M, Jylhä M, Kawachi I, Westerlund H, Pentti J, et al. Trajectories of self-rated health in the last 15 years of life by cause of death.
Eur J Epidemiol
. 2016 Feb;31(2):177–85.
47.
Hayes AJ, Clarke PM, Glasziou PG, Simes RJ, Drury PL, Keech AC. Can self-rated health scores be used for risk prediction in patients with type 2 diabetes?
Diabetes Care
. 2008 Apr;31(4):795–7.
48.
Wennberg P, Rolandsson O, van der A DL, Spijkerman AM, Kaaks R, Boeing H, et al. Self-rated health and type 2 diabetes risk in the European Prospective Investigation into Cancer and Nutrition-InterAct study: a case-cohort study.
BMJ Open
. 2013 Mar;3(3):e002436.
49.
Wennberg P, Rolandsson O, Jerdén L, Boeing H, Sluik D, Kaaks R, et al. Self-rated health and mortality in individuals with diabetes mellitus: prospective cohort study.
BMJ Open
. 2012 Feb;2(1):e000760.
50.
Clergue-Duval V, Mary-Krause M, Bolze C, Fombonne E, Melchior M. Early Predictors of Trajectories of Tobacco Use Level from Adolescence to Young Adulthood: A 16-Year Follow-Up of the TEMPO Cohort Study (1999–2015).
Eur Addict Res
. 2019;25(1):2–9.
51.
Gomajee R, El-Khoury F, Goldberg M, Zins M, Lemogne C, Wiernik E, et al. Association Between Electronic Cigarette Use and Smoking Reduction in France.
JAMA Intern Med
. 2019, Epub ahead of print.
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