Changes over time in reasons for quitting vaping among treatment-seeking young people from 2019 to 2022

Highlights

• •Quit vaping reasons from young people were collected in 2019 and 2022 and themes were compared.
• •Treatment seeking young people who vape reported health as their top reason for quitting in 2022.
• •Percentage point increases in current health (+13.9) and mental health concerns (+7.6) were noted.
• •Other top reasons for quitting in 2022 include social influence, cost, and freedom from addiction.
• •Increase in Other category may indicate emergence of new reasons for quitting not reported in 2019.

Abstract

Objectives

The landscape of availability, policies, and norms around e-cigarette use and cessation has changed rapidly in the last few years. There is also high interest in quitting vaping among teens and young adults. Understanding the motivation of those who want to quit vaping is important for effective intervention development. This analysis compares user-submitted reasons for quitting (RFQ) vaping from 2022 to a previous analysis from 2019 to determine whether motivations have shifted among young people.

Methods

We reviewed 2000 RFQ submissions from users who enrolled in a vaping cessation text message program in 2022. Each response was coded by ≥ 2 researchers and categorized into one of 16 themes. Findings were compared to the 2019 analysis using item-wise comparisons.

Results

The most frequent RFQ in 2022 were health (56.1%), social influence (15.8%), and other (11.7%). In comparison to 2019, health remained the top reason, but the rank order of all other reasons shifted. Theme prevalence changed significantly, with cost decreasing and health increasing. Among health-related sub-categories, current and mental health increased compared to 2019 submissions.

Discussion

RFQ among young people shifted between 2019 and 2022. We observed greater concern about current and mental health, possibly from experiencing negative health impacts from vaping or from increased awareness of these impacts. The lower prevalence of cost may reflect the widespread availability of cheaper e-cigarettes. RFQ likely change rapidly with the fluctuating e-cigarette landscape and should be considered in cessation interventions, promotional campaigns, and policy.

1. Introduction

E-cigarettes are the most common tobacco product used by teens and young adults in the U.S., with over 18.0 % of high school students (Oliver et al., 2023) and 11.0 % of young adults ages 18–24 (Cornelius et al., 2023) reporting current use in 2021. While e-cigarette use is widespread, interest in quitting vaping among young people is also high, with more than half of current e-cigarette users reporting intention to quit in national surveys (Dai, 2021, Cuccia et al., 2021) and marked increases in treatment-seeking behaviors among young people who vape (Williams et al., 2023) in recent years. Understanding the motivations of young people who want to quit vaping is important for reaching and engaging them with effective treatments.

A previous study of the reasons for quitting (RFQ) vaping among young people found that they are motivated by many factors, including health concerns, financial cost, social influence, and performance in academics, athletics, and the arts (Amato et al., 2021). Since that study was conducted in 2019, the discussion around vaping has changed significantly, impacted by the widespread media attention surrounding EVALI (e-cigarette, or vaping product, use associated lung injury) (Centers for Disease Control and Prevention, 2020, East et al., 2022, Rebuli et al., 2023), changes in regulations around e-cigarette products (Center for Tobacco Products, 2023), and the COVID-19 pandemic (Cai et al., 2021). This study examined RFQ prevalence among young people seeking treatment to quit vaping in 2022. These analyses aim to answer the following research questions: (1) What were the most common RFQ for treatment-seeking young people in 2022? (2) How did their prevalence change since 2019?

2. Methods

2.1. Intervention

Data for the current analysis were collected from users of This is Quitting, a free quit vaping text message intervention developed by Truth Initiative. This is Quitting (TIQ) is a fully automated, interactive text message program designed to help teens and young adults ages 13–24 quit vaping nicotine. Its development was informed by evidence-based smoking cessation practices for young people as well as formative research with teens and young adults. It is anchored in constructs from social cognitive theory (Bandura, 1986) and acceptance and commitment therapy (Hayes & Wilson, 1999). Many of the messages feature tips and encouraging statements submitted by previous users of the program. TIQ is promoted nationally through the truth® campaign, a public health campaign run by Truth Initiative, as well as through local and national media and outreach efforts and partnerships. As of September 2023, TIQ had more than 630,000 enrolled users.

TIQ is tailored based on age, device type, and quit date. Users who set a quit date typically receive 60 days of intervention post their target quit date. All users are asked to respond to a message prompting them for their reason for quitting. Submitted by a previous user, the prompt reads: “Abigail says ‘Giving yourself a reason to quit is a good motivator.’ Reply why you’re thinking about quitting.” Respondents text back an open-ended free text response. Since the program launched in 2019, more than 100,000 responses have been received.

No Institutional review board oversight was solicited as using user-provided data for research purposes only is part of the terms of service for using the quit vaping cessation resource (“This is Quitting”) used in the study.

2.2. Data Sources

A total sample of 4000 responses was randomly selected from 2019 and 2022. Of these, 2000 responses were collected from January to June 2022: 1000 from adolescents (13–17 years of age) and 1000 from young adults (18–24 years of age). The remaining 2000 RFQ submissions were collected in 2019, with findings summarized in a previous publication (Amato et al., 2021). All responses were manually coded by investigators.

2.3. Coding process

Each response was coded by two researchers, basing their selection of themes on the structured coding guide used in the 2019 analysis (available upon request; Amato et al., 2021). The guide encompassed 16 themes, with 4 sub-categories for health. Discrepancies between researchers were resolved through tie-breaker discussion with a third investigator. The themes were discussed in detail in the previous publication. Briefly:

• •Health concerns. Health included four sub-categories: current health and future health (health concerns that referred to RFQ temporality), and general health (health concerns with no temporality mentioned); and mental health and motivation, encompassing mental health concerns, e.g., anxiety and depression, and mentions of “motivation” as a reason.
• •Financial cost. Concerns about the financial impact or burden on e-cigarette users.
• •Performance. Impact of vaping on physical or mental performance, e.g., sports, grades, or musical talent.
• •Aesthetics. Concerns related to physical appearance, e.g., effects on skin, hair, or teeth.
• •Lack of positive reinforcement. Lack of reward gained from vaping such as lack of “buzz” or no longer making the user feel good.
• •Social influence. Any reasons mentioning another person, including but not limited to significant other, celebrity, or sibling.
• •Setting example. Wanting to be a good role model for others.
• •Freedom from addiction. Wanting to be independent from addiction, e.g., not wanting to “be tied to a vape anymore”.
• •Extrinsic motivation. Direction or pressure from other people or institutions, e.g., a direct command to quit or potential disciplinary action related to e-cigarette use.
• •Leads to smoking. Concerns that vaping would eventually lead to the use of combustible cigarettes.
• •Uncertainty about health effects. Concern about unknown health effects of vaping.
• •Value judgement. Wanting to quit vaping because it was undesirable, stupid, dumb, or not worth it.
• •Too young. Mention of a user's young age as their reason for quitting.
• •Other/none/ambiguous. Reasons that did not fit into other categories.

Responses that did not address the question (e.g., unrelated content or nonsensical text) were marked as non-response and were excluded from analysis (total 276 responses in 2019 and 174 in 2022).

2.4. Analytic plan

Item-specific prevalence were compared across time using X²(1) tests for the difference in two independent binomial proportions. P-values were adjusted for multiplicity using Holm’s sequential procedure (Holm, 1979).

3. Results

3.1. What are the most common reasons for quitting for treatment seeking young people in 2022?

As shown in Table 1, the most common reasons for quitting in 2022 were health (56.1%), followed by social influence (15.8%), other/none/ambiguous (11.7%), financial cost (10.3%), and freedom from addiction (9.9%). The health category was primarily driven by current health (25.4%) and general health (25.6%) concerns. Samples quotes from user submissions are shown in Table 2 for reference.

Table 1.

Item-wise comparisons of reasons for quitting vaping between 2019 and 2022.

	2022, N (%)	2019, N (%)	Percentage point difference	P-value
Health – any	1122 (56.1)	845 (42.3)	+13.8	0.002
Health – current	507 (25.4)	229 (11.5)	+13.9	0.002
Health – future	164 (8.2)	147 (7.4)	+0.9	1.000
Health – general	512 (25.6)	501 (25.1)	+0.6	1.000
Mental health & motivation	186 (9.3)	34 (1.7)	+7.6	0.002
Social influence	315 (15.8)	174 (8.7)	+7.1	0.002
Other/none/ambiguous	234 (11.7)	133 (6.7)	+5.0	0.002
Extrinsic motivation	93 (4.7)	70 (3.5)	+1.2	0.484
Aesthetics	16 (0.8)	13 (0.7)	+0.1	1.000
Leads to smoking	0 (0.0)	7 (0.4)	−0.3	0.118
Uncertainty of vaping health effects	7 (0.4)	17 (0.9)	−0.5	0.445
Performance	139 (7.0)	152 (7.6)	−0.6	1.000
Lack of positive reinforcement	9 (0.5)	40 (2.0)	−1.5	0.002
Too young	16 (0.8)	45 (2.3)	−1.5	0.003
Value judgment	62 (3.1)	139 (7.0)	−3.9	0.002
Freedom from addiction	197 (9.9)	276 (13.8)	−4.1	0.003
Financial cost	205 (10.3)	374 (18.7)	−8.4	0.002

Table 2.

Sample quotes.

Sample quote	Category
I’ve noticed it’s harder for me to breathe and it’s hurting me	Current health
I want to feel like I can be happy without nicotine, I have also noticed increased anxiety since I started vaping.	Mental health & motivation
i want to be more motivated and positive.	Mental health & motivation
I’m spending way too much money on nicotine and I think it’s messing with my health.	Financial cost Current health
My family wants me to quit and I don’t want to rely on it anymore.	Social influence Freedom from addiction
I want to quit because I don’t find vaping fun anymore. It doesn’t make me feel good.	Value judgment
I don’t feel like myself anymore.	Other/none/ambiguous
Because I’ve been addicted from a very young age and it has helped and ruined certain relations that I enjoy and I’m ready to be my true self without.	Social influence Freedom from addiction Other/none/ambiguous

3.2. How did reasons for quitting in 2022 differ from reasons for quitting from 2019?

Four of the top five RFQ were identical across time, with health topping the list in both years. However, the rank order of the remaining RFQ changed from financial cost, freedom from addiction, social influence, and physical or mental performance in 2019 to social influence, other/none/ambiguous, financial cost, and freedom from addiction in 2022.

Item-wise comparisons showed significant differences in prevalence between 2019 and 2022. The largest changes occurred for health (increased by 13.8 percentage points), which was primarily driven by increases in those endorsing current health concerns (increased by 13.9 percentage points) and mental health concerns (increased by 7.6 percentage points). Other significant increases were observed for social influence and other/none/ambiguous categories.

For categories that decreased since 2019, financial cost had the largest difference (decreased by 8.4 percentage points), followed by freedom from addiction, value judgment, too young, and lack of positive reinforcement. No significant differences were observed for future health, general health, extrinsic motivation, aesthetics, leads to smoking, uncertainty of vaping health effects, and performance.

4. Discussion

Reasons for quitting vaping among young people have shifted between 2019 and 2022. While health was the top reason for both 2019 and 2022, the proportion reporting health as their reason for quitting increased significantly, primarily driven by users reporting current health concerns and mental health concerns. The increases in current health concerns and mental health concerns may be due to users experiencing increased health-related consequences from vaping (potentially from longer use of e-cigarettes than in 2019, or different products now on the market) or increased prevalence of mental health co-morbidities reported in the overall population since the onset of the COVID-19 pandemic (Kessler et al., 2022). These increases may also be due to increased public education and media reports around the potential health impacts of vaping that may have led to higher awareness of these issues. Similarly, as the general public has become more aware of the potential consequences of vaping, the social norms around vaping and quitting vaping may have shifted, leading to the increased prevalence of social influence reported in the 2022 data.

Decreases in some of the top reasons from 2019 (e.g., financial cost) may be due to changes in the e-cigarette market and regulatory landscape that have led to the proliferation of disposable e-cigarette devices (Ali et al., 2023). For example, TIQ users reported a large decline in the use of pod-based devices (e.g., Juul) after Juul stopped selling most flavored products due to regulatory pressure, while disposable devices not included in flavor-restriction regulations at the federal level (e.g., Puff Bar) rose to the top (Bottcher et al., 2020). Increases in the other/none/ambiguous category may indicate the emergence of novel RFQ not previously identified in 2019. Anecdotally, many responses coded as other/none/ambiguous mentioned themes of “self-identity” or “self-improvement”. Additional research is needed to determine whether adding these topics as new themes to the coding guide used for the current study is warranted.

A few limitations should be considered. These findings encompass responses from TIQ users willing to respond to a text message prompt and may not represent all users or all young people interested in quitting vaping. Also, the 2022 data were collected after the COVID-19 pandemic, which may have led to heightened sensitivity among TIQ users around respiratory health issues.

Despite these limitations, this study shows that motivations for quitting vaping have changed over time, even within a relatively short 3-year timespan. These findings can be used to inform new promotional campaigns which lean into messaging around current and mental health concerns (rather than a vague general health concern) to be more salient to a target audience of young people. Cessation program developers may want to consider tailoring interventions on reason for quitting to maximize impact. Given that decreases in cost as a reason for quitting likely reflect shifts among young people who vape to lower-cost disposable devices, policymakers should consider potential implications of regulatory actions on a specific product type in future policies. The shifting motivations around quitting among young people and potential drivers of these changes should continue to be carefully considered and monitored for cessation intervention development, promotional campaign messaging, and policy development.

5. Role of funding sources

This study was funded by Truth Initiative. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

6. Contributors

All authors contributed to study design and development of the coding guide. SC, GE, and IB coded the data. GDP conducted post-coding analyses. SC led the first draft of the manuscript with writing contributions from all co-authors. All authors reviewed drafts and provided feedback on the final manuscript.

CRediT authorship contribution statement

Sarah Cha: Conceptualization, Methodology, Investigation, Data curation, Writing – original draft, Writing – review & editing, Project administration. Michael S. Amato: Conceptualization, Methodology, Writing – review & editing, Project administration. George D. Papandonatos: Methodology, Formal analysis, Writing – original draft, Writing – review & editing. Giselle Edwards: Conceptualization, Methodology, Investigation, Writing – original draft, Project administration. Isabel Berdecio: Conceptualization, Methodology, Investigation, Writing – original draft, Project administration. Megan A. Jacobs: Conceptualization, Methodology, Writing – review & editing. Amanda L. Graham: Conceptualization, Methodology, Writing – review & editing, Supervision, Project administration, Funding acquisition.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: SC, MSA, GE, IB, MAJ, and ALG are employees of Truth Initiative, a non-profit public health foundation that sells digital tobacco cessation programs to support its mission-driven work.

Data availability

Data may be made available on request.