Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 4 - Oct/Dec - 2017

Original Article Imprimir 

Páginas 121 a 132


Experimentation and use of E-cigarette in adolescence

Experimentación y uso de cigarro electrónico en la adolescencia

Experimentação e uso de cigarro eletrônico na adolescência

Autores: Carla Marisa de Oliveira Ferreira1; Diana Sofia Antunes Bordalo2; Cláudia Raquel Ferrao de Melo3; Filipe José Vaz Duarte Oliveira e Sá4; Fernanda Maria de Jesus Carvalho5; Paula Maria Rodrigues da Fonseca Coutinho6

1. Licenciatura and Masters degree integrated in Medicine. Internal Pediatric Specific Training of the Pediatric Service of the Hospital da Senhora da Oliveira - Guimarães. Guimarães, AC, Portugal
2. Licenciatura and Masters degree in Medicine. Internal Formac will Specifies Pediatric Servic the Pediatric Hospital of Eastern Ave. Vila Nova de Famalicão, Portugal
3. Health Assistant of Pediatrics of the Pediatric Service of the São João Hospital Center, Porto, Portugal
4. Pediatric hospital Wizard Servic the Pediatric Hospital of Eastern Ave. Vila Nova de Famalicão, Portugal
5. Orderly Pediatrician of Servic the Pediatric Hospital of Eastern Ave. Vila Nova de Famalicão, Portugal
6. Master Graduate Assistant in Servic of adolescent health the Pediatric Hospital of Eastern Ave. Vila Nova de Famalicão, Portugal

Correspondência:
Carla Marisa de Oliveira Ferreira
Hospital da Senhora da Oliveira - Guimarães, Serviço de Pediatria
Rua dos Cutileiros, 114, Creixomil
Guimarães, Portugal. CEP: 4835-044
carlamf85@hotmail.com

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How to cite this article

Keywords: Adolescent, smoking, cannabinoids, tobacco.
Palabra Clave: Adolescente, hábito de fumar, canabinoides, tabaco.
Descritores: Adolescente, hábito de fumar, canabinoides, tabaco.

Abstract:
OBJECTIVE: Analyze e-cigarette experimentation in adolescents and determinate risk factors associated with its experimentation.
METHODS: A community based study target at high school students, to whom it was applied a selfreport questionnaire. There were evaluated adolescents' biopsychosocial features, their knowledge about e-cigarettes, their experimentation and use of e-cigarette, tobacco and cannabinoids.
RESULTS: Were included 360 students with a mean aged of 16.4±1.2years. Almost all knew e-cigarettes. However, the presence of nicotine in e-cigarette composition was unknown by 33%, and 24% were unaware of e-cigarette health consequences. The e-cigarette experimentation was 35% and 5.3% of adolescents maintained its use. The current double consumption (e-cigarette and tobacco) was present in 5% of the sample. The multivariate analysis demonstrate that being male (OR:3,2;IC95%[1.6-6.4]) having a self-perception of early pubertal timing (OR:3.1;IC95%[1.1-8.9]), feeling adventurous (OR:6.6;IC95%[2.0-21.4]), being current tobacco (OR:6.3;IC95%[2.8-14.1]) and cannabinoids smokers (OR:4.5;IC95%[1.3-15.2]) were associated with an increased risk of e-cigarette experimentation.
CONCLUSION: In this contemporary study, about one-third of adolescents tried e-cigarettes. Being male, current tobacco or cannabinoid smoker were the major risk factors associated with e-cigarette experimentation. Further studies are important to better understand factors responsible for addiction to e-cigarettes in adolescence and to develop prevention strategies to this growing experimentation.

Resumen:
OBJETIVO: Evaluar la experimentación de cigarro electrónico (e-cigarro) en la adolescencia y determinar factores de riesgo para su experimentación.
MÉTODOS: Estudio de base comunitaria dirigido a adolescentes frecuentando la enseñanza secundario, a quienles fue aplicado uncuestionario de auto-rellenado. Fueronevaluadas las características biopsicosociales de los adolescentes, su conocimiento sobre ele-cigarro, la experimentacióny uso de e-cigarro,y experimentacióny uso de tabaco y canabinoides.
RESULTADOS: Fueron incluidos 360 adolescentes conunpromedio de edad de 16,4±1,2 años. La mayoría admitió conocer ele-cigarro. No obstante, la presencia de nicotina en sucomposición era desconocida por 33%, y 24% desconocía las consecuencias do su uso para la salud. La experimentación de e-cigarro fue de 35% y 5,3% de los adolescentes mantuvoel consumo. El consumo doble actual (e-cigarroy tabaco) estuvo presente en 5% de la muestra. El análisis multivariado realizado demostró que ser del género masculino (OR:3,2; IC95%[1,6-6,4]) tener auto percepción de pubertad precoz (OR:3,1; IC95%[1,1-8,9]), tener espíritu aventurero (OR:6,6;IC95%[2,0-21,4]), ser consumidor de tabaco (OR:6,3;IC95%[2,8-14,1]) y ser consumidor de canabinoides (OR:4,5;IC95%[1,3-15,2]) está asociado a mayor riesgo  de experimentación dee-cigarro.
CONCLUSIÓN: En ese estudio contemporáneo, cerca de un tercio de los adolescentes experimentaronele-cigarro. Ser del sexo masculino, consumidor de tabaco y de canabinoides fueronlos factores de riesgo más importantes asociados a la experimentacióndele-cigarro. No obstante,son necesarios más estudios para entender mejor cuálesson los factores de riesgo asociadosa la adicción de e-cigarroen la adolescencia, para que se puedan diseñar estrategias preventivas dirigidas a esos grupos de riesgo.

Resumo:
OBJETIVO: Avaliar a experimentação de cigarro eletrônico (e-cigarro) na adolescência e determinar fatores de risco para sua experimentação.
MÉTODOS: Estudo de base comunitária dirigido a adolescentes frequentando o ensino secundário, a quem foi aplicado um questionário de autopreenchimento. Foram avaliadas as características biopsicossociais dos adolescentes, seu conhecimento sobre o e-cigarro, a experimentação e uso de e-cigarro e experimentação e uso de tabaco e canabinóides.
RESULTADOS: Foram incluídos 360 adolescentes com uma média de idade de 16,4±1,2 anos. A maioria admitiu conhecer o e-cigarro. No entanto, a presença de nicotina na sua composição era desconhecida por 33%, e 24% desconhecia as consequências do seu uso para a saúde. A experimentação de e-cigarro foi de 35% e 5,3% dos adolescentes manteve o consumo. O consumo duplo atual (e-cigarro e tabaco) esteve presente em 5% da amostra. A análise multivariada realizada demonstrou que ser doo gênero masculino (OR:3,2; IC95%[1,6-6,4]) ter auto perceção de puberdade precoce (OR:3,1; IC95%[1,1-8,9]), ter espirito aventureiro (OR:6,6;IC95%[2,0-21,4]), ser consumidor de tabaco (OR:6,3;IC95%[2,8-14,1]) e ser consumidor de canabinóides (OR:4,5;IC95%[1,3-15,2]) está associado ao maior risco de experimentação do e-cigarro.
CONCLUSÃO: Nesse estudo contemporaneo, cerca de um terço dos adolescentes experimentaram o e-cigarro. Ser do sexo masculino, consumidor de tabaco e de canabinóides foram os fatores de risco mais importantes associados à experimentação de e-cigarro. No entanto são necessários mais estudos para melhor compreender quais os fatores de risco associado à adição de e-cigarro na adolescência, para que se possam desenhar estratégias preventivas direcionadas a esses grupos de risco.

INTRODUCTION

In the last decade, the appearance of electronic cigarettes (e-cigarettes) has revolutionized tobacco use1. This electronic device was first introduced on the market in 2004 and in Europe in 2008, with the main attraction of reducing the harmful effects of tobacco consumption2.

Because its marketing is unregulated, the true constitution of the e-cigarette is unknown and as such, the effects of its long-term consumption are unpredictable. Some authors warn of the possibility of overdose in nicotine, although the manufacturers indicate nicotine concentration of 6 to 24mg, in some devices concentrations of 100mg3,4. The presence of propylene glycol in its composition is also of concern since its inhalation is associated with ocular irritation and irritation and obstruction of the airways5. Recently, other potentially hazardous substances such as diethyleneglycol, formaldehyde, acetaldehyde, acrolein and nitrosamines have been identified6.

Despite the growing concern about e-cigarette consumption, the advertising market advertises it as being healthier or healthier than tobacco and an important weapon to quit smoking7. On the other hand, the law is silent on e-cigarettes, since there is no legislation on their use, making it possible to use them in public places, as well as selling to minors under 18, both of which are prohibited for tobacco. These facts associated with the growing number of stores have led to the popularization and popularity of e-cigarette8. Indeed, at international level the growing popularity of e-cigarettes among teenagers and young adults is notorious. According to data from the US National Youth Tobacco Survey, in 2011, e-cigarette testing was 0.6%-6.2% in adults, 4.9%-7.0% in young adults and <1% -3.3% in secondary school adolescents9. However, updating these data in 2013 revealed that 11.9% of secondary school adolescents experienced e-cigarettes and 4.5% became regular consumers10.

With the increasing number of adolescents experiencing and consuming e-cigarettes, several questions remain unanswered, such as the long-term consequences of their use, whether e-cigarette smoking is beneficial to smoking cessation11,12, or on the contrary, whether its use could be a starting point for the nicotine addition of a future tobacco smoker13. Thus, the objectives of the present study were to determine the prevalence of e-cigarette experimentation in a population of adolescents, as well as to identify risk factors associated with their experimentation.


METHODS

Study Design

A cross-sectional, community-based study was carried out on secondary school adolescents through the application of a self-completion questionnaire. All the students of the 10th, 11th and 12th years of a Portuguese public school in the municipality of Famalicão were included. The response rate was 83%.

The application of the questionnaires was carried out in the classroom, having been delivered by the teachers. It was completed individually, anonymously and confidentially. The information was collected in April and May of 2015. The research was approved by the management of the school where the study was carried out and the free and informed consent of all the adolescents included, as well as of the respective legal representatives were obtained.


Variables analyzed

Due to the lack of validated questionnaires to evaluate e-cigarette experimentation and consumption, the authors constructed a questionnaire composed of 53 closed questions organized in 3 parts: 1-sociodemographic characteristics of the adolescent; 2 - consumption habits of e-cigarettes, tobacco and cannabinoids; 3 - knowledge about e-cigarettes. A pilot study was carried out prior to the application of the questionnaire, which did not reveal difficulties in the responses by adolescents.

Part 1 - Sociodemographic Characteristics

The demographic characteristics evaluated were gender, age (years), year of schooling, type of education (regular or professional) and number of disapprovals. The adolescent biossocial characteristics included the determination of protective factors for risk behaviors (group activities, sports practice, self-perception of puberty at an appropriate age), as well as determination of self-perception of behavioral characteristics ("adventurous spirit", "doing mindlessness", " mood swings throughout the day", " planning in advance", " self-control", "making friends", "liking dangerous things", "liking breaking the rules"). The family characteristics analyzed were family type, age and occupation of parents, as well as parental smoking habits (tobacco and e-cigarette). It was also determined the adolescent's self-perception about the parental requirement in relation to his education.

Part 2 - Habits of consumption

To assess consumption habits, adolescents were asked if they ever tried e-cigarettes, tobacco, and cannabinoids, and if so, they asked what age and why. The past consumption (ex-consumers) and the current regular (last 30 days) of e-cigarette, tobacco and cannabinoids were also discussed. In terms of current e-cigarette and tobacco consumption, four categories were created by cross-tabulating these variables: e-cigarette consumers, tobacco users, consumers of both (dual-use) and non-consumers. The degree of nicotine addiction among current adolescent tobacco smokers was determined through application of the Fagerstrom scale14. The habits of consumption of peers in relation to e-cigarette, tobacco and cannabinoids were determined.

Part 3 - Knowledge of adolescents about the e-cigarette

The adolescents' knowledge about e-cigarettes was determined by applying three questions: "Have you heard of e-cigarettes?", "Do you think that e-cigarette is bad for your health?" and "Does e-cigarette have nicotine in its composition?".


Data analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences®, version 21.0. In the descriptive statistical analysis, mean and standard deviation (SD) were used to report continuous variables, and absolute (n) and relative (%) frequencies to report categorical variables. The t-student test was used to compare differences between groups of continuous variables and the Pearson's chi-square (c2) or Fisher's exact test, when appropriate, to compare differences between categorical variables. To identify predictors of e-cigarette experimentation, Odds Ratio (OR), a logistic regression model was performed. A p value <0.05 was used as statistical significance.


RESULTS

Characteristics of the population

We included 360 adolescents with a mean age of 16.4 ± 1.2 years and a similar distribution between genders. Attending to school performance, 51% attended professional education and 49% attended regular education, with 39% attending the 10th grade, 35% the 11th grade and 26% the 12th grade. The majority (72%) never disapproved (Table 1).




Regarding the characteristics of adolescents associated with risk behavior protection, 33.9% attended group activities and 62.4% practiced regular extracurricular sports. Regarding self-perception of behavioral characteristics, 13.3% admitted to being very impulsive and 52.9% to have a very adventurous spirit (Table 1).

The majority of adolescents were from a nuclear family (75%), 15% from a large family and 10% from one-parent families. The father was considered the main progenitor to use tobacco (26.9%), and 5.8% of the adolescents reported that both parents (father and mother) were smokers (Table 2).




Consumption habits

The experimentation of e-cigarette, tobacco and cannabinoids was 35%, 57.5% and 24.2%, respectively (Table 2). Tobacco experimentation occurred predominantly at 13/14 years, and the experimentation of e-cigarette and cannabinoids at 15/16 years. Taking into account only adolescents who admitted to having tried e-cigarettes, it was found that 37% experimented with e-cigarettes and tobacco at the same age, 43% experienced first tobacco, and 20% experienced first e-cigarettes.The main reason cited for this experimentation was curiosity. In the analysis of adolescent characteristics associated with e-cigarette experimentation, it was found that being male (p. 000), attending professional education (p 0.002), self-perceived precocious puberty (p .01) and practicing activities (p 0.008) were associated with e-cigarette experimentation. Having a rebellious spirit (0.002) and adventurer (p. 000), being impulsive (p. 0.002) and having less facility in making friends (p. 0.006) were behavioral characteristics associated with further experimentation. With respect to adolescent and peer smoking habits, it was found that current smoking of tobacco and cannabinoids (p. 000), as well as having friends using e-cigarettes (p. 0.024), were associated with the experimentation of e-cigarette (Table 3).




On the other hand, no familial characteristics were associated with e-cigarette experimentation (Table 3). According to the logistic regression model, adolescents of the masculine gender (OR 3.2), adolescents with self-perception of precocious puberty (OR 3.1), adolescents with a more adventurous spirit (e. OR 6.6), tobacco users (OR 6.3) and cannabinoids (OR 4.5) (Table 4).




Regarding current consumption, it was verified that 24.5% of adolescents consumed tobacco, 12.9% consumed cannabinoids and 5.3% consumed e-cigarettes (Table 2). The double consumption of e-cigarettes and tobacco was 5% and only 0.3% consumed only e-cigarettes. Most reported that their friends consumed tobacco and cannabinoids (Table 2). The application of Fagerstrom scale to current smokers revealed a moderate nicotine dependence of 8.7%, a high dependence of 4.3% and a very high dependence of 4.3%.


Knowledge about e-cigarette

The vast majority of adolescents (98%) were familiar with e-cigarettes. Regarding the consequences of their use in health, 68.8% confirmed and 6.7% denied the harmful effects of the e-cigarette for health, and 24.5% were unaware of the consequences of its use for health. Considering the e-cigarette content, 54.5% confirmed and 12.4% denied the presence of nicotine in the e-cigarette, and 33.1% were unaware that the e-cigarette had nicotine in its composition. It was found that e-cigarette experimentation was associated with a correct knowledge about e-cigarette, namely on its health consequences and nicotine content (p <0.05) (Table 5).




DISCUSSION

The experimentation of e-cigarette in adolescence is an emerging phenomenon, and it is extremely important to understand how adolescents view this novelty. It is necessary to see if adolescents are attracted to the e-cigarette, whether their experimentation is increasing, whether those who experiment continue to consume, and whether there are consistent risk factors for experimentation and continued use.

According to our results, 35% of adolescents experienced e-cigarettes. This value is higher than that reported by Barrington-Trimis et al. , who reported higher rates of experimentation, where 24% of adolescents in their sample tried e-cigarettes15. According to the National Youth Tobacco Survey in 2013, 11.9% of high school adolescents experienced e-cigarette10. The results obtained in the present study may reveal a growing trend of e-cigarette experimentation, however, it should be noted that despite the high experimentation found in our population, current e-cigarette consumption (5.3%) is similar to that two studies10,15. To better understand this fact, it would be important to compare the results obtained with other national data, since cultural and social factors can influence e-cigarette acceptance. However, according to the authors, this is the first study to address this problem in Portugal.

The existence of predictive factors of e-cigarette experimentation was also explored. The male gender was associated with a higher probability of experimentation, similar to that reported by other authors16. Corroborating with the results demonstrated by Babineau et al., Being a smoker was also an important risk factor for the e-cigarette experimentation in the present study, increasing the chance of e-cigarette experimentation by 6.6 times17. There was also an increased risk of e-cigarette experimentation by adolescents who consumed cannabinoids, although this association was reported less frequently although there were some authors who showed a positive association18. It is known that adolescents who mature early are more likely to be at risk, such as risky sexual behavior and consumption of additive substances19. Also in relation to e-cigarette experimentation, self-perception of precocious puberty was associated with an increase in the chance of experimentation of 3.1 times.

The use of e-cigarettes and tobacco has been widely studied in order to understand whether e-cigarette smoking could be a smoking cessation aid, or whether it could be the starting point for smoking. According to Durmowicz et al. ,adolescents using e-cigarettes also consume tobacco, as observed in our sample20. The double consumption of e-cigarettes and tobacco was 5% and only 0.3% of adolescents consumed e-cigarettes alone. These numbers, together with the fact that 43% of adolescents have previously tried e-cigarette tobacco, leads us to consider that e-cigarette has not been useful in smoking cessation. Recently, Barrington-Trimis et al. in a 16-month study of 146 adolescents found that 40.4% of e-cigarette consumers and 10.5% of those who never used e-cigarettes became tobacco users, with e- cigarette use increasing the risk of smoking 6.17 times21. The simultaneous use of e-cigarettes and tobacco raises additional concerns as there is cumulative exposure to nicotine at risk of intoxication as well as exposure to other potentially harmful products.

Regarding adolescents' knowledge about e-cigarettes, we found that although 98% claimed to be familiar with the device, most did not have adequate knowledge about e-cigarette, since only 1/3 recognized the possibility of negative effects of its use for health. Teenagers who tried e-cigarettes were those who knew their health consequences and those who recognized the presence of nicotine as one of the constituents of the e-cigarette. A possible explanation for this finding may be related to the fact that e-cigarette may be perceived as less harmful than tobacco, as demonstrated by Wills et al. who found that 67% of adolescents considered e-cigarette healthier than tobacco15,22. In the future, it would be important to introduce this theme in school education programs, similar to what happens with consumption of additive substances, so that the correct knowledge of the adolescents about these new devices is enhanced.

As limitations of the present study it is emphasized that this is a cross-sectional study, which makes it impossible to understand how the e-cigarette experimentation in this population evolved. It would be important to complement these results by conducting a longitudinal study in order to establish the evolution of this situation. It is also worth noting the use of an unvalidated questionnaire, but because it is a recent issue, there are no validated instruments to evaluate the experimentation and use of e-cigarettes in adolescence. However, we tried to reduce this fact with a pilot study.

The authors consider the results of extreme importance, since they are associated with practical applicability, allowing to know the reality of the experimentation and use of the e-cigarette by the Portuguese adolescents, unknown until the present. Thus, given the high e-cigarette experimentation, it is sensible that the approach to this subject becomes part of the adolescent HEEADSSS interview, namely in the approach of D (drugs) along with tobacco, alcohol and drugs.Simultaneous use of e-cigarettes and tobacco should also be of concern to health professionals who deal directly with adolescents, since in these cases there is cumulative exposure to nicotine as well as other harmful substances in the e-cigarette.

The present study allowed us to conclude that e-cigarette is widely tested by adolescents, particularly by boys who smoke conventional tobacco and cannabinoids. Taking into account previous studies, the high incidence of e-cigarette experimentation obtained may reveal an increasing trend of device experimentation. The current use of e-cigarettes and tobacco was 5% and the use of e-cigarettes was only 0.3%, so it is not clear if e-cigarettes are just a novelty that young people have just tried or if they have potential to compete in the market with conventional cigarettes.


ACKNOWLEDGMENTS

The authors would like to thank all those who contributed to the study, especially to all adolescents who accepted to participate, as well as to all teachers.


REFERENCES

1. C. Protano, Milia L, Orsi G, Vitali M. Electronic cigarette: a threat or an opportunity for public health? State of the art and future perspectives. Clin Ter 2015; 166 (1):32-37.

2. Duffy E, Jenssen B. Electronic Cigarettes: The New Face of Nicotine. Pediatrics 2014;134 (1)

3. Rahman M, Hann N, Wilson A, Worrall-Carter L. Electronic cigarettes: patterns of use, health effects, use in smoking cessation and regulatory issues. Tobacco Induced Diseases 2014, 12:21

4. Grana R, Benowitz N, Glantz S. E-Cigarettes A Scientific Review Circulation 2014;129:1972-1986.

5. Wieslander G, Norbäck D, Lindgren T. Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respiratory effects. Occup Environ Med 2001;58(10):649-55.

6. Jensen R, Luo W, Pankow J, Strongin R, Peyton D. Hidden Formaldehyde in E-Cigarette Aerosols. N Engl J Med 2015; 372:392-394

7. World Health Organization [homepage on the Internet]. Geneva: WHO [acesso 2014 Jan 13]. Marketers of electronic cigarettes should halt unproved therapy claims [about 2 screens]. Disponível em: http://www.who.in

8. Global Advisors Smoke free Policy. Electronic smoking devices. [Available at www.njgasp.org/E-Cigs_White_Paper.pdf. Accessed Set 25 2013.]

9. Centers for Disease Control and Prevention. Notes from the Field: Electronic Cigarette Use Among Middle and High School Students - United States, 2011-2012. MMWR 2013; 62(35):729-730.

10. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students - United States, 2013. MMWR 2014; 63(45):1021-1026.

11. Bullen C, Howe C, Laugesen M. Electronic cigarettes for smoking cessation: a randomized controlled trial. Lancet. 2013; 382(9905):1629-1637.

12. Britton J. Electronic cigarettes: pro. Thorax BMJ, April 2015 ; 70(4).

13. Khan J. E-cigarettes: A gateway to nicotine addiction? J Postgrad Med Inst 2015; 29(4): 213-4.

14. Fagerstrom KO Measuring degree of physical dependence to tobacco smokin with reference to individualization of treatment. Addict Behav 1978;3(3-4):235-41

15. Barrington-Trimis J, Berhane K, Unger J, Cruz T, Huh J, Leventhal A, et al. Psychosocial Factors Associated With Adolescent Electronic Cigarette and Cigarette Use. Pediatrics 2015;136:308.

16. Czoli CD, Hammond D, White CM. Electronic cigarettes in Canada: Prevalence of use and perceptions among youth and young adults. Canadian journal of public health 2014, 105(2), e97.

17. Babineau K, Taylor K, Clancy L. Electronic Cigarette Use among Irish Youth: A Cross Sectional Study of Prevalence and Associated Factors. PLOS ONE 2015; 27.

18. Morean M, Kong G, Camenga D, Cavallo D, Krishnan-Sarin S.High School Students' Use of Electronic Cigarettes to Vaporize Cannabis. Pediatrics 2015;136:611.

19. Patton G, McMorris B, Toumbourou J, Hemphill S, Donath S, Catalano R. Puberty and the Onset of Substance Use and Abuse. Pediatrics. 2004 Set; 114(3): e300-306.

20. Durmowicz E L. The impact of electronic cigarettes on the paediatric population. Tob Control 2014;23.

21. Jessica L. Barrington-Trimis, Robert Urman, Kiros Berhane, Jennifer B. Unger, Tess Boley Cruz, Mary Ann Pentz, Jonathan M. Samet, Adam M. Leventhal and Rob McConnell. E-Cigarettes and Future Cigarette Use. PediatricsJune, 2016.

22. Wills T, Knight R, Williams R J, Pagano I, Sargent J D. Risk Factors for Exclusive E-Cigarette Use and Dual E-Cigarette Use and Tobacco Use in Adolescents. Pediatrics 2015;135;e43.
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