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Discordance between perceived and actual tobacco product use prevalence among US youth: a comparative analysis of electronic and regular cigarettes
  1. Israel Terungwa Agaku,
  2. Satomi Odani,
  3. David Homa,
  4. Brian Armour,
  5. Rebecca Glover-Kudon
  1. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
  1. Correspondence to Dr Israel Terungwa Agaku, Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA; iagaku{at}


Importance Two components of social norms—descriptive (estimated prevalence) and injunctive (perceived acceptability)—can influence youth tobacco use.

Objective To investigate electronic cigarettes (e-cigarette) and cigarette descriptive norms and measure the associations between overestimation of e-cigarette and cigarette prevalence and tobacco-related attitudes and behaviours.

Design Cross-sectional.

Setting School-based, using paper-and-pencil questionnaires.

Participants US 6th-12th graders participating in the 2015 (n=17 711) and 2016 (n=20 675) National Youth Tobacco Survey.

Exposure Students estimated the percent of their grade-mates who they thought used e-cigarettes and cigarettes; the discordance between perceived versus grade-specific actual prevalence was used to categorise students as overestimating (1) neither product, (2) e-cigarettes only, (3) cigarettes only or (4) both products.

Outcomes Product-specific outcomes were curiosity and susceptibility (never users), as well as ever and current use (all students). Descriptive and multivariable logistic regression analyses were performed. Statistical significance was at P<0.05. Data were weighted to be nationally representative.

Results More students overestimated cigarette (74.0%) than e-cigarette prevalence (61.0%; P<0.05). However, the associations between e-cigarette-only overestimation and e-cigarette curiosity (adjusted OR (AOR)=3.29), susceptibility (AOR=2.59), ever use (AOR=5.86) and current use (AOR=8.15) were each significantly larger than the corresponding associations between cigarette-only overestimation and cigarette curiosity (AOR=1.50), susceptibility (AOR=1.54), ever use (AOR=2.04) and current use (AOR=2.52). Despite significant declines in actual e-cigarette use prevalence within each high school grade level during 2015–2016, perceived prevalence increased (11th and 12th grades) or remained unchanged (9th and 10th grades).

Conclusions Four of five US students overestimated peer e-cigarette or cigarette use. Counter-tobacco mass media messages can help denormalise tobacco use.

  • advertising and promotion
  • denormalization
  • electronic nicotine delivery devices
  • prevention

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  • Contributors ITA conceptualised and designed the study and drafted the initial manuscript. SO helped conceptualise the study, assisted in the statistical analyses and critically reviewed and revised the manuscript. DH, BA and RG-K helped conceptualise the study and critically reviewed and revised the manuscript. All authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data used for this research are publicly available and can be accessed at