Commentary: Understanding Complexities of Adolescent E- cigarette Use to Develop Intervention Strategies

Adolescents use electronic cigarettes (ECIGs) at alarmingly high rates. Since 2014, ECIGs are the most used tobacco product among adolescents, with the prevalence of use in the past 30 days among high schoolers rising to 27.5% in 2019 (Centers for Disease Control and Prevention, 2021). High rates of ECIG use is an epidemic with serious impacts on adolescent health (Chadi et al., 2019; Farzal et al., 2019; Ross et al., 2018; Vogel et al., 2020). Evidence suggests that ECIG use harms the developing adolescent brain, increases the risk of respiratory symptoms and serious lung injury, and may lead to nicotine dependence and combustible cigarette use (Cherian et al., 2021; Reddy et al., 2021; United States. Public Health Service. Office of the Surgeon General, 2016). Although research has identified parental use, peer use, poor mental health, biological factors, and mass media advertising as predictors of teen tobacco product use (Centers for Disease Control and Prevention, 2021), fewer studies have comprehensively examined factors that may impact past compared to recent use. Enlow et al. (2021) present novel insights into adolescent ECIG use by analyzing differential predictors for never, ever, and current use. Participants were classified based on the frequency of ECIG use into never (never used an ECIG), ever (used an ECIG in a lifetime, but not in last 30 days), or current users (used an ECIG in last 30 days). Predictors were conceptualized based on problem behavior theory (PBT; Jessor, 1991), a theory of adolescent decision-making surrounding health risk behaviors. The predictors were categorized into the PBT domains of the social environment (gender, SES), perceived environment (peer ECIG use, parent ECIG use), personality (perceived costs and benefits, sensation seeking, personality characteristics), and behavior (alcohol, cannabis, and combustible cigarette use). Findings indicated that peer ECIG use, extraversion, perceiving fewer costs and greater affective benefits, and current or ever cigarette and alcohol use were associated with greater likelihood of ever compared to never use. Perceiving fewer costs and greater effective benefits, current cigarette use, and ever cannabis use were associated with a greater likelihood of current compared to ever use.

Overall, findings suggest that predictors of initiating ECIG use (ever users) may differ from predictors of more frequent or sustained ECIG use (current users). Strengths of this study include the use of a strong theoretical basis, novel investigation of predictors of current use, and a model that more accurately captures the multitude of factors that may affect adolescent ECIG use. In light of these findings, we offer two considerations below that may provide directions for future research on adolescent ECIG use: (a) risk factors in ever compared to current users and (b) directions for intervention strategies for prevention and cessation.

Risk Factors

Enlow et al. (2021) found that perceiving lower costs and greater benefits to ECIG use, specifically benefits on mood, appears to prompt adolescents to both initiate and continue vaping. These findings align with other samples of adolescents that cited “feeling relaxed” as a benefit to ECIG use (Burnley et al., 2021). Once adolescents perceive affective benefits from initial use, they may continue to use ECIGs to cope with emotional distress, potentially leading to symptoms of dependence (Kong et al., 2021; Vogel et al., 2020). Contrary to some previous research (Giovenco et al., 2019; Shih et al., 2017; Simon et al., 2017), social environment factors, specifically SES, did not predict ever or current ECIG use in this sample. Enlow et al. (2021) note that because SES was measured at the school level (percentage of students receiving free/reduced-price lunch) instead of at the individual or neighborhood level, the influences of objective or subjective SES in relation to other predictors could not be evaluated. Perception of affective benefits may exert an even stronger influence on initiating and sustaining ECIG use in adolescents who are coping with daily neighborhood stressors that are present in low SES, marginalized neighborhoods (Shih et al., 2017; Simon et al., 2017). Future research should consider emotional distress and self-efficacy for coping with distress as potential mediators of perceived affective benefits predicting current ECIG use. Environmental stressors (e.g., food insecurity, safety) could also be potential moderators of this relationship. Cannabis use, a unique predictor of current ECIG use, should also be examined further. Polysubstance use is common, and adolescent and young adult trajectories of nicotine vaping are similar to cannabis vaping (Agrawal et al., 2012; Lanza et al., 2020). As the popular opinion of cannabis becomes more positive and more states propose legislation to legalize and regulate medical and recreational cannabis use (Marijuana Policy Project, 2021) there is a need for research on multiple predictors of adolescents’ co-occurring ECIG and cannabis use.

Intervention Strategies

There is a dearth of evidence-based ECIG prevention and cessation interventions for adolescents. Smoking cessation programs may use ECIGs in combination with well-documented intervention strategies such as nicotine replacement therapies, education, and behavioral supports to help adults quit (Vickerman et al., 2021), but few strategies exist for adolescents. Enlow et al. (2021) posit that education on the harms of ECIGs and training in emotion regulation skills may be promising intervention strategies. Other work suggests that training adolescents to set implementation intentions, creating targeted communication campaigns on the harms of vaping to use in schools, and involving peers in implementation may be effective (Brown et al., 2019; Chu et al., 2021; Conner et al., 2019; Escoto et al., 2021). However, it remains unclear if the same strategies would be effective in both prevention and cessation. One consideration for intervention including peers is when and how to involve peers who are never, ever, or current users. Peer use predicted ever use but not current use in this analysis but was related to lifetime and current use, harm and benefit perceptions, and self-efficacy to resist ECIGs in another analysis by this research team (Durkin et al., 2021). Qualitative evidence demonstrates that adolescents who are current users view social influences (e.g., peer pressure, peers vaping in school) as a barrier to quitting (Kong et al., 2021), indicating that future work on how peers with different user statuses might hinder or facilitate cessation is needed. Intervention programs involving peer education and mentoring, for example, high school students teaching middle school students about tobacco harms, are particularly important to examine given the influence peers may exert on decision-making as adolescents develop (Brown et al., 2019; Chu et al., 2021; Ciranka & van den Bos, 2019).

Beyond individual and school-level interventions, regulatory strategies developed through collaboration between the federal government and scientists are sorely needed (Tackett et al., 2020). Tackett et al. (2020) recommend that FDA enforcement policy on flavors in ECIGs (one contributor to youth use, Cooper et al., 2016) expand to all tobacco products and that regulatory definitions are amended to close loopholes as new electronic tobacco products emerge. With greater insight into the risk factors for initiating and sustaining ECIG use, effective interventions tailored to adolescents’ needs and developmental stage can be tested, ultimately helping to curb the e-cigarette epidemic.

Conflicts of interest: None declared.