ABSTRACT Title of dissertation: THE ASSOCIATION BETWEEN ELECTRONIC CIGARETTE USE AND CIGARETTE SMOKING BEHAVIOR AMONG YOUNG ADULTS IN THE UNITED STATES Blair N. Coleman, Doctor of Philosophy, 2015 Dissertation directed by: Associate Professor Kerry M. Green Department of Behavioral and Community Health The prevalence of electronic cigarette (e-cigarette) use is rapidly increasing in adults and youth; however, little is known about the public health impact of their use. A debate over e-cigarettes has emerged in the literature; one side recognizes the potential benefit of e-cigarettes as a harm reduction tool, while others argue e-cigarette use may delay or deter smoking cessation due to dual use or increase the risk of initiation of conventional cigarettes among previous nonsmokers. Drawing on the Theory of Planned Behavior, this dissertation focused on attitudes, beliefs, and perceived social norms of e- cigarettes, as well as openness to conventional cigarette smoking among young adult users of the product. Using a mixed methods approach, this dissertation analyzed secondary data from the 2012-2013 National Adult Tobacco Survey (NATS) as well as focus group data collected in five cities across the U.S. to better understand the relationship between e- cigarette use and cigarette smoking among young adults. In Study 1, quantitative analyses found non-cigarette smoking young adults who have tried e-cigarettes were more likely to report openness to cigarette smoking in the future compared to those who have not tried e-cigarettes (AOR= 2.4; 95% CI= 1.7-3.3). In Study 2, qualitative findings suggest that young adult exclusive e-cigarette users were less interested in conventional cigarette smoking, and overwhelmingly described negative aspects to cigarette smoking that appeared to become more salient as a result of their e-cigarette use. In Study 3, focus group participants expressed many positive attitudes towards e-cigarettes, and simultaneously reported a lack of information and knowledge about the products. The relationship between e-cigarette use and cigarette smoking is complex and multifaceted, and influenced by a myriad of individual and social factors. Although quantitative findings suggest young adults who have used e-cigarettes compared to those who have not used e-cigarettes were more likely to report openness to future cigarette smoking, qualitative findings did not support the notion that young adult e-cigarette users (who may have prior experience with cigarette smoking) are open to future cigarette smoking. These findings provide a basis for further exploration of the association between e-cigarette use and cigarette smoking. THE ASSOCIATION BETWEEN ELECTRONIC CIGARETTE USE AND CIGARETTE SMOKING BEHAVIOR AMONG YOUNG ADULTS IN THE UNITED STATES By Blair N. Coleman Dissertation submitted to the Faculty of the Graduate School of the University of Maryland, College Park in partial fulfillment of the requirements for the degree of Doctor of Philosophy 2015 Advisory Committee: Associate Professor Kerry M. Green, Chair Dr. Benjamin J. Apelberg Assistant Professor Craig S. Fryer Professor Dr. Sally A. Koblinsky Dr. Jessica M. Rath © Copyright by Blair N. Coleman 2015 Dedication This dissertation is dedicated first and foremost to the participants who shared their opinions and candid thoughts during the focus group study. Thank you for helping me understand your experiences, and by doing so, making this research possible. Also, to my grandmother, Dorothy Coleman, who inspired and encouraged me to pursue my dreams. ii Acknowledgements Throughout my doctoral program I have had incredible support from mentors, friends and family, and faculty members—a heartfelt thank you to each of you for helping me reach this accomplishment. To my dissertation committee Chair (and all-star mentor!), Dr. Kerry Green. Words cannot express how thankful I am to you for your guidance and encouragement throughout my doctoral program. From working as your TA, to quals preparations, and now to my dissertation you have always provided support and guidance in a way that challenged me and made me a better student. I have learned so much from you over the years—thank you. To Dr. Pamela Clark, for believing in me and giving me the incredible opportunity to work with the “dream team” during the first two years of my doctoral program. You have always challenged and inspired me to be a better writer, researcher, and person. Your support throughout my doctoral program has meant so much to me. Thank you. To Dr. Benjamin Apelberg, the opportunity you gave me to join your team at CTP back in 2012 was one of the best things to happen in my professional career. The ability to gain practical experience in tobacco regulatory science as a doctoral student shaped the type of public health professional I want to become. I continue to be inspired by your patience, passion, and dedication to public service. Thank you for guidance over the past three years, and for all of your support on this project. I am sincerely grateful to the rest of my dissertation committee for their time and support for this research—Dr. Jessica Rath, Dr. Sally Koblinsky, and Dr. Craig Fryer. The depth of knowledge and guidance each of you provided to this project was essential in helping me reach this stage. A special thank you to Dr. Jessica Rath, for your professional guidance and on-going support over the past several years. To my unbelievably talented and passionate colleagues at CTP—particularly Drs. Sarah Johnson and Bridget Ambrose—who have provided incredible support and guidance to me over the past three years. Working with you and sharing your passion created a situation where I enjoy coming to work every day. For that and for the incredible amount I have learned from you, thank you. Thank you to the faculty in the Department of Behavioral & Community Health who have guided me and provided unrelenting support—particularly Dr. Kathy Sharp and Dr. Robert Feldman. Also to my cohort—Erica, Alyssa, Krishna, Erin, Luciana, Daisy, Bina, and Tim—who have been incredibly supportive and caring since we started this journey together back in 2011. To the two mentors who made everything possible: Drs. Elbert Glover and Steven Pokorny. Dr. Glover, thank for your believing in me and giving me the incredible opportunity to complete my doctoral studies at the University of Maryland. I promised I would make you proud! Dr. Pokorny, over the years I have learned so much from you personally and professionally. I’m so grateful for the countless hours you have spent providing professional advice and guiding me every step of the way. You both have challenged me and encouraged me to accomplish things at times I thought were impossible. Thank you for always believing in me. iii Lastly, but certainly not least, to all of my friends and family—particularly my parents and Tom Nesmith—who have always encouraged and supported me, despite many moves across the country, work-filled weekends, and dare I say it—temper tantrums(!). Your love and support is what kept me going through the many years of undergraduate and graduate school, and is undoubtedly the main reason I was able to achieve this accomplishment—thank you. iv TABLE OF CONTENTS Dedication .................................................................................................................................... ii Acknowledgements ................................................................................................................... iii List of Figures and Tables ...................................................................................................... vii CHAPTER ONE: INTRODUCTION ................................................................................... 1 1.1 Background ..................................................................................................................................... 1 1.1.1 Regulation of E-Cigarettes ................................................................................................................ 3 1.1.2 Use of E-Cigarettes among Young Adults .................................................................................... 4 1.1.3 Debate over the Population Impact of E-Cigarettes ................................................................. 5 1.2 Conceptual Framework of the Study ........................................................................................ 6 1.3 Statement of the Problem ............................................................................................................. 9 1.4 Purpose of the Study .................................................................................................................. 10 1.5 Specific Aims, Hypotheses, and Research Questions ......................................................... 11 1.6 Summary ....................................................................................................................................... 12 1.7 Definition of Terms ..................................................................................................................... 13 CHAPTER TWO: LITERATURE REVIEW ................................................................... 16 2.1 Background on E-Cigarettes and Emergence in the U.S. Marketplace ......................... 16 2.1.1 Background and Diversity of E-Cigarette Products ............................................................... 16 2.1.2 Marketing and Sales of E-Cigarettes ..........................................................................................