Is Vaping a Gateway to Addiction and Stress?

During COVID-19 and the associated lockdowns, many students experienced educational, personal, and social difficulties from this sudden disruption in routine. In the United States, parents were suddenly teaching or tutoring their K-12 students at home, and college students were told to vacate their dorm rooms and pivot to online learning. Once the lockdowns were over, students returned to their classrooms under various conditions and schedules; but for many students, going to school in fall 2023 was the first return to a routine since March 2020. As respiratory therapists, we too pivoted in how we managed mechanically ventilated patients with COVID. This included early tracheostomy, awake prone positioning, and high-flow nasal cannula, and we were introduced to new disease processes resulting from COVID-19 for the first time, so-called long COVID. A quick search in Respiratory Care revealed 424 articles on COVID-19 with many of these publications addressing the after effects of COVID-19 (https://rc.rcjournal.com/search/COVID. Accessed September 14, 2023.). I want to focus on one of those publications regarding vaping behaviors in young adults during the pandemic.

In this month's issue, Henn, Martinasek, and Lange¹ provide a cross-sectional study on the prevalence and associations of vaping behaviors among college students. The focus was on the use of electronic cigarettes or electronic nicotine delivery systems (ENDS) at 2 universities, one in Tampa, Florida, and the other in Düsseldorf, Germany. Approximately 31% of all students in the study were currently using ENDS, and interestingly, most of these students stated that their vaping increased during COVID-19 lockdowns. Addiction and stress relief were found to be significant predictors of increased vaping use. As such, the authors underscore the shift from social motivation for vaping to the addictive component of vaping in seeking stress relief.

For almost 20 years, vaping in young adults has been associated with an aura of coolness and social acceptance. The common belief was that vaping could be a less harmful substitute for smoking cigarettes and assist with smoking cessation. Despite marketers advertising ENDS as an alternative to tobacco products, this delivery device is very much like a traditional cigarette in that a dependence is created.² Nicotine is the main health hazard from vaping. Furthermore, nicotine has been considered a gateway drug to alcohol and other addictive drugs. The gateway or stepping-stones theory originated in the 1970s as a popular explanation of the observed sequence from cannabis use to other illicit drug use.³ The Centers for Disease Control and Prevention has not made a declaration that nicotine inhaled via vaping is a gateway drug. But if nicotine is a gateway drug, evidence may be directing us to this conclusion. A study by Littlefield and colleagues⁴ found that e-cigarette use was more common among college students who already drink and use nicotine products. Dutch researchers Martinelli and colleagues,⁵ replicated the findings from an American study on the relationship between e-cigarette use and tobacco use. Their findings affirmed the relationship between e-cigarette use and subsequent tobacco smoking and the opposite relation but caution that it is not yet known if the gateway hypothesis best explains the relationship between e-cigarette use and tobacco smoking.⁵ However, evidence is available that speaks to associations, as the study by Henn, Martinasek, and Lange does in relation to addiction; college-age individuals do not use e-cigarettes as a means to quit smoking traditional cigarettes but to relieve stress.

These findings add to a growing body of studies that indicate a link between e-cigarette use, tobacco smoking, and unintended consequences in young adults. More work is needed to better understand why there are such associations and whether these may be causal relationships. ENDS and vaping research typically requires a validated construct survey instrument, recruitment of participants, and self-reported answers that assess various behaviors and attitudes. One of the coauthors, Dr Mary Martinasek, is to be commended for her expertise and tireless efforts in this important area of research. There are 2 other articles in Respiratory Care that relate to smoking, vaping, and college students that are very good examples of survey methods.^6,7 Other research designs that examine ENDS and vaping from different aspects are needed, too. For example, the authors mention addiction counseling and mental health counseling and the need for increased accessibility in reaching college students. Support groups who can advise and inform how to eliminate barriers to addiction counseling are needed. Lastly, health promotion and interventions targeted to ENDS users and to those who are prone to relapse are needed in understanding addiction and stress on college campuses. Respiratory therapists can take an active role in this area, especially those who are on college campuses.