Abstract
Introduction:
E-cigarette use is gaining popularity among youth, but knowledge on patterns of youth vaping different substances is limited. This study examines risk factors associated with past 30–day self-reported vaping nicotine, marijuana, and “just flavoring” among youth and the patterns (single, dual, and poly) of substances youth reported in their e-cigarettes.
Methods:
The 2017 Monitoring the Future survey was analyzed. Weighted estimates of substances that youth vaped were calculated, and multivariable logistic regressions were performed to examine risk factors associated with youth vaping these substances. Analyses were conducted in 2019.
Results:
Overall (N=14,560), 8.0% of participants reported currently vaping “just flavoring,” followed by 7.4% vaping nicotine and 3.6% vaping marijuana. Youth who were in 12th and 10th grade (versus 8th grade), male (versus female), current smokers (versus non-current smokers), and current marijuana users (versus non-current users) had increased risk of vaping nicotine, marijuana, and “just flavoring.” Non-Hispanic blacks were less likely than non-Hispanic whites to report currently vaping. Among students who reported e-cigarette use in the last 30 days (n=1,685), only 24.9% reported vaping “just flavoring” only, and a majority (75.1%) reported vaping nicotine, marijuana, or multiple substances. Higher (versus lower) grade or increasing cigarette smoking intensity was associated with a higher proportion of students reporting vaping nicotine only and a lower proportion of students reporting vaping “just flavoring” only.
Conclusions:
Youth e-cigarette use reveals a complex pattern, and youth reported vaping substances potentially addictive beyond “just flavoring.” Strategies and interventions to reduce youth e-cigarette use are needed.
INTRODUCTION
The prevalence of current e-cigarette use among U.S. youth increased dramatically during 2017–2018.1 The liquid used in e-cigarette products could contain nicotine, marijuana, and many different flavors.2 A previous study3 has found that about 60% of U.S. youth who use e-cigarettes reported vaping “just flavoring,” whereas less than 20% reported vaping nicotine. Tam and Warner4 further reported that increasing cigarette smoking intensity was associated with an increasing proportion of students reporting vaping nicotine and a decreasing proportion of students reporting vaping “just flavoring.” However, both studies3,4 were based on self-reported substances that students vaped at last use, which might underestimate the percentage of youth vaping substances other than flavoring.3,4 The recent Monitoring the Future (MTF) report provided the national estimates for vaping specific substances (nicotine, marijuana, or “just flavoring”).5 However, knowledge of the factors associated with youth vaping different substances is limited. Furthermore, no studies have reported patterns of youth vaping nicotine, marijuana, and “just flavoring.” Identifying substances vaped by youth is critical to formulating strategies and interventions to reverse the upward trend of youth e-cigarette use.
To address the gaps in knowledge, this study analyzes 2017 MTF data to examine the risk factors associated with youth vaping nicotine, marijuana, and “just flavoring” in the past 30 days and patterns of youth vaping behaviors.
METHODS
Study Sample
Data were collected from the 2017 MTF cross-sectional study. A total of 43,533 students participated in the 2017 survey with response rates of 87%, 85%, and 79% for 8th, 10th, and 12th grade students, respectively. The details of the sampling design can be found in another report.6 This study was treated as a non-human subjects study given the use of de-identified data.
Measures
A random sample of students (N=14,560) was asked about their ever vaping status and the substance (nicotine, marijuana, or “just flavoring”) they had vaped during the last 30 days. The vaping status was coded as “yes” (one or more occasion) and “no” (zero occasions) for each substance separately. Vaping patterns were classified further into seven mutually exclusive categories: “just flavoring” only, nicotine only, marijuana only, nicotine and marijuana, nicotine and “just flavoring,” marijuana and “just flavoring,” and all three substances.
Several covariates were included in the analysis to assess risk factors that influence substances vaped by youth, such as sex, race/ethnicity, grade, parental education level, geographic residence region based on Census categories, and population density.
Statistical Analysis
Weighted percentages and 95% CIs for the prevalence of past 30–day vaping nicotine, marijuana, and “just flavoring” were calculated. Separate multivariable logistic regressions were performed to assess risk factors associated with vaping each substance among youth. The authors further analyzed the substance use pattern among those who reported e-cigarette use in the last 30 days. Statistical analyses were performed using SAS, version 9.4. A p-value <0.05 was considered statistically significant. Analyses were conducted in 2019.
RESULTS
In 2017, overall, 12.0% of students reported currently vaping with 8.0% reporting vaping “just flavoring,” 7.4% vaping nicotine, and 3.6% vaping marijuana (Table 1). Current cigarette smokers (versus non-current smokers), current marijuana users (versus non-current users), 10th and 12th (versus 8th) graders, and male (versus female) students reported a higher prevalence of vaping nicotine, marijuana, and “just flavoring.”
Table 1.
Prevalence of Substances (Nicotine, Marijuana, and “Just Flavoring”) Youth Reported Vaping in the Last 30 Days Among All Students (n=14,560), 2017 Monitoring the Futurea
| Characteristics | Unweighted n | Weighted % | Vaping nicotine, marijuana, or “Just Flavoring” | Vaping nicotine | Vaping marijuana | Vaping “just flavoring” |
|---|---|---|---|---|---|---|
|
|
||||||
| Weighted % (95% CI) | ||||||
|
| ||||||
| Overall | 14,560 | 100 | 12.0 (11.3, 12.6) | 7.4 (6.9, 8.0) | 3.6 (3.2, 3.9) | 8.0 (7.4, 8.5) |
| Current cigarette useb | p<0.0001 d | p<0.0001 | p<0.0001 | p<0.0001 | ||
| No | 13,096 | 94.5 | 9.5 (9.0, 10.1) | 5.2 (4.8, 5.6) | 2.6 (2.3, 2.9) | 6.6 (6.1, 7.1) |
| <1 cigarette /day | 459 | 3.3 | 55.9 (50.3, 61.6) | 47.0 (41.3, 52.7) | 20.1 (15.7, 24.5) | 34.0 (28.4, 39.6) |
| 1–5 cigarettes/day | 202 | 1.5 | 58.2 (49.6, 66.8) | 50.1 (41.6, 58.6) | 20.2 (13.8, 26.5) | 36.1 (28.1, 44.2) |
| ≥1/2 pack/day | 91 | 0.7 | 58.5 (45.3, 71.7) | 49.9 (36.4, 63.4) | 31.7 (19.3, 44.2) | 23.0 (12.0, 34.0) |
| Current marijuana usec | p<0.0001 | p<0.0001 | p<0.0001 | p<0.0001 | ||
| No | 11,681 | 85.8 | 5.7 (5.2, 6.2) | 3.4 (3.0, 3.7) | N/Ae | 4.3 (3.9, 4.7) |
| 1–2 occasions | 786 | 5.6 | 37.9 (33.7, 42.0) | 24.2 (20.6, 27.8) | 11.0 (8.4, 13.6) | 25.1 (21.4, 28.7) |
| 3–9 occasions | 623 | 4.3 | 49.5 (44.7, 54.3) | 31.0 (26.5, 35.5) | 21.6 (17.8, 25.4) | 30.3 (25.9, 34.7) |
| ≥10 occasions | 596 | 4.3 | 62.3 (57.4, 67.2) | 40.7 (35.8, 45.5) | 40.2 (35.4, 45.0) | 33.8 (29.0, 38.5) |
| Grade | p<0.0001 | p<0.0001 | p<0.0001 | p<0.0001 | ||
| 8 | 5,323 | 36.6 | 6.7 (5.9, 7.5) | 3.6 (2.9, 4.2) | 1.7 (1.3, 2.0) | 5.4 (4.6, 6.1) |
| 10 | 4,724 | 32.4 | 13.1 (12.0, 14.3) | 8.2 (7.3, 9.1) | 4.3 (3.7, 5.0) | 9.1 (8.2, 10.1) |
| 12 | 4,513 | 31.0 | 17.1 (15.7, 18.4) | 11.3 (10.2, 12.4) | 5.0 (4.3, 5.8) | 9.9 (8.8, 10.9) |
| Sex | p<0.0001 | p<0.0001 | p<0.0001 | p=0.0016 | ||
| Male | 6,724 | 49.1 | 13.4 (12.4, 14.3) | 8.5 (7.7, 9.3) | 4.4 (3.8, 4.9) | 8.8 (8.0, 9.7) |
| Female | 6,815 | 50.9 | 10.5 (9.6, 11.3) | 6.4 (5.7, 7.1) | 2.7 (2.3, 3.2) | 7.1 (6.4, 7.8) |
| Race/ethnicity | p<0.0001 | p<0.0001 | p=0.0005 | p<0.0001 | ||
| NH white | 6,506 | 44.1 | 14.6 (13.6, 15.6) | 10.5 (9.6, 11.4) | 3.7 (3.2, 4.2) | 9.2 (8.4, 10.0) |
| NH black | 1,679 | 12.1 | 4.9 (3.6, 6.3) | 2.2 (1.3, 3.2) | 1.6 (0.8, 2.4) | 3.4 (2.3, 4.5) |
| Hispanic | 3,073 | 21.5 | 9.5 (8.3, 10.8) | 4.6 (3.7, 5.5) | 3.7 (2.9, 4.4) | 7.0 (5.9, 8.1) |
| Other | 3,302 | 22.4 | 12.8 (11.4, 14.3) | 6.6 (5.5, 7.6) | 4.4 (3.5, 5.3) | 9.0 (7.7, 10.2) |
| Parental education | p=0.5777 | p=0.6604 | p=0.2759 | p=0.6187 | ||
| Less than high | 1,284 | 10.8 | 11.7 (9.5, 13.8) | 7.0 (5.3, 8.8) | 4.2 (3.0, 5.5) | 8.0 (6.2, 9.9) |
| school | ||||||
| High school | 4,120 | 33.7 | 12.8 (11.6, 14.0) | 8.0 (7.0, 8.9) | 3.9 (3.2, 4.5) | 8.7 (7.7, 9.7) |
| College or higher | 7,299 | 55.4 | 12.2 (11.3, 13.1) | 7.8 (7.1, 8.5) | 3.4 (2.9, 3.8) | 8.1 (7.3, 8.8) |
| Region | p=0.0026 | p=0.0704 | p<0.0001 | p=0.0167 | ||
| Northeast | 2,562 | 16.9 | 12.1 (10.6, 13.6) | 7.1 (5.9, 8.3) | 4.4 (3.5, 5.4) | 7.9 (6.6, 9.1) |
| North Central | 3,415 | 21.6 | 13.4 (12.0, 14.9) | 8.5 (7.3, 9.7) | 3.3 (2.5, 4.0) | 9.3 (8.1, 10.6) |
| South | 4,933 | 37.8 | 10.5 (9.5, 11.5) | 6.8 (5.9, 7.6) | 2.5 (2.0, 3.0) | 7.0 (6.2, 7.9) |
| West | 3,650 | 23.7 | 12.9 (11.6, 14.1) | 7.8 (6.8, 8.7) | 4.9 (4.1, 5.7) | 8.2 (7.2, 9.3) |
| Density | p=0.2868 | p=0.0352 | p=0.0023 | p=0.1628 | ||
| Large MSA | 5,397 | 32.2 | 12.0 (10.9, 13.1) | 7.4 (6.5, 8.2) | 4.4 (3.8, 5.1) | 7.2 (6.4, 8.1) |
| Other MSA | 6,384 | 48.0 | 11.6 (10.6, 12.5) | 7.0 (6.2, 7.7) | 3.3 (2.8, 3.7) | 8.2 (7.4, 9.0) |
| Non-MSA | 2,779 | 19.7 | 12.9 (11.4, 14.4) | 8.7 (7.5, 10.0) | 2.9 (2.2, 3.6) | 8.5 (7.3, 9.7) |
Notes: Boldface indicates statistical significance (p<0.05).
A random sample of students from 2017 Monitoring the Future (n=14,560) were asked about their ever vaping status by the question To “vape” is to use a device such as a vape-pen, an e-cigarette, an e-hookah, or e-vaporizer to inhale a mist into the lungs. Have you ever vaped? Participants who endorsed this question were further asked the substance they had vaped during the last 30 days. The current vaping status was defined by three separate questions: During the LAST 30 DAYS, on how many occasions (if any) have you vaped NICOTINE?; … MARIJUANA?; …just FLAVORING?, with response options of 0 occasions, 1–2 occasions, 3–5 occasions, 6–9 occasions, 10–19 occasions, 20–39 occasions, and 40 or more occasions. Weighted % and 95% CI were reported; national weight was applied to each student record to account for the complex survey design and adjust for nonresponse.
Students’ current cigarette smoking intensity was based on the item How frequently have you smoked cigarettes during the past 30 days?, with response options not at all, less than one cigarette per day, one to five cigarettes per day, about one-half pack per day, about one pack per day, about one and one-half packs per day, and two packs or more per day.
Current marijuana use was classified based on the item On how many occasions (if any) have you used marijuana (grass, pot) or hashish (hash, hash oil) during the past 30 days?, with response options 0 occasions, 1–2 occasions, 3–5 occasions, 6–9 occasions, 10–19 occasions, 20–39 occasions, and 40 or more occasions.
Rao-Scott χ2 test was performed to detect the group difference.
Thirty-two students reported non-current marijuana use and ≥1 occasion vaping marijuana in the past 30 days. Due to the small sample size and conflicting responses, we excluded them in the analysis of vaping marijuana.
NH, non-Hispanic; MSA, metropolitan statistical area.
Table 2 presents factors associated with substances vaped by youth in 2017. Current cigarette smoking intensity was associated with an increased risk of reporting currently vaping all three substances. Compared with 8th graders, both 10th and 12th graders had higher odds of reporting currently vaping nicotine, marijuana, and “just flavoring.” Female students had lower odds of reporting currently vaping these three substances than male students. Relative to non-Hispanic whites, non-Hispanic blacks had lower odds of reporting currently vaping nicotine and “just flavoring,” and Hispanics had lower odds of reporting currently vaping nicotine.
Table 2.
Factors Associated With Self-Reported Vaping Behaviors in the Last 30 Days Among All Students (n=14,560), 2017 Monitoring the Futurea
| Vaping nicotineb | Vaping marijuanab | Vaping “just flavoring”b | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| Explanatory variables | AOR (95% CI) | p-value | AOR (95% CI) | p-value | AOR (95% CI) | p-value |
|
| ||||||
| Current cigarette use | ||||||
| No | ref | ref | ref | ref | ref | ref |
| <1 cigarette/day | 11.9 (9.0, 15.6) | <0.0001 | 9.3 (6.6, 12.9) c | <0.0001 | 6.6 (5.0, 8.8) | <0.0001 |
| 1–5 cigarettes/day | 14.1 (9.4, 21.2) | <0.0001 | 9.5 (6.0, 15.1) | <0.0001 | 8.0 (5.4, 11.8) | <0.0001 |
| ≥1/2 pack/day | 15.0 (8.0, 28.1) | <0.0001 | 18.6 (10.0, 34.3) c | <0.0001 | 3.8 (2.0, 7.5) | <0.0001 |
| Grade | ||||||
| 8 | ref | ref | ref | ref | ref | ref |
| 10 | 1.9 (1.5, 2.4) | <0.0001 | 2.3 (1.6, 3.1) | <0.0001 | 1.5 (1.3, 1.9) | <0.0001 |
| 12 | 2.4 (1.9, 3.0) | <0.0001 | 2.1 (1.5, 2.9) | <0.0001 | 1.4 (1.2, 1.8) | 0.0006 |
| Sex | ||||||
| Male | ref | ref | ref | ref | ref | ref |
| Female | ||||||
| Race/ethnicity | 0.7 (0.6, 0.8) | <0.0001 | 0.6 (0.5, 0.8) | <0.0001 | 0.8 (0.7, 0.9) | 0.0015 |
| NH white | ref | ref | ref | ref | ref | ref |
| NH black | 0.2 (0.1, 0.3) | <0.0001 | 0.6 (0.3, 1.0) | 0.0526 | 0.3 (0.2, 0.5) | <0.0001 |
| Hispanic | 0.5 (0.4, 0.6) | <0.0001 | 1.1 (0.8, 1.5) | 0.6801 | 0.8 (0.7, 1.1) | 0.1593 |
| Others | 0.9 (0.6, 1.3) | 0.5915 | 1.3 (1.0, 1.8) | 0.0487 | 1.1 (0.9, 1.3) | 0.5293 |
| Parental education | ||||||
| Less than high school | ref | ref | ref | ref | ref | ref |
| High school | 0.9 (0.6, 1.3) | 0.5915 | 0.9 (0.6, 1.4) | 0.6880 | 1.0 (0.7, 1.3) | 0.8127 |
| College or higher | 0.9 (0.6, 1.3) | 0.5704 | 0.9 (0.6, 1.4) | 0.5371 | 0.9 (0.7, 1.2) | 0.4588 |
| Region | ||||||
| Northeast | ref | ref | ref | ref | ref | ref |
| North Central | 1.2 (0.9, 1.6) | 0.1310 | 0.7 (0.5, 1.0) | 0.0663 | 1.2 (0.9, 1.5) | 0.1486 |
| South | 1.2 (0.9, 1.5) | 0.2848 | 0.6 (0.4, 0.8) | 0.0016 | 0.9 (0.7, 1.1) | 0.3771 |
| West | 1.4 (1.1, 1.9) | 0.0092 | 1.1 (0.8, 1.5) | 0.6746 | 1.1 (0.8, 1.4) | 0.6020 |
| Density | ||||||
| Large MSA | 1.2 (1.0, 1.6) | 0.1027 | 1.7 (1.2, 2.4) | 0.0017 | 1.0 (0.8, 1.3) | 0.9731 |
| Other MSA | 1.1 (0.9, 1.4) | 0.3090 | 1.4 (1.0, 1.9) | 0.0533 | 1.1 (0.9, 1.4) | 0.2320 |
|
| ||||||
| Non-MSA | ref | ref | ref | ref | ref | ref |
Notes: Boldface indicates statistical significance (p<0.05).
A random sample of students from 2017 Monitoring the Future (n=14,560) were asked about their vaping status.
Multivariable logistic regression was performed in which vaping nicotine, marijuana, and ‘just flavoring’ were separately analyzed as dependent (yes versus no) variables.
Post-hoc comparisons show that heavy smokers (≥1/2 pack/day) had significantly higher odds of reporting currently vaping marijuana (AOR=2.0, 95% CI=1.0, 3.9) compared with occasional smokers (<1 cigarette/day), p=0.0376.
NH, non-Hispanic; MSA, metropolitan statistical area.
Among those who reported vaping in the last 30 days in 2017, only 24.9% reported vaping “just flavoring” only, whereas a majority (75.1%) reported vaping nicotine, marijuana, or multiple substances (Table 3). Students in 10th or 12th (versus 8th) grade and cigarette smokers with a high (versus low) intensity had higher odds of reporting vaping nicotine only and lower odds of reporting vaping “just flavoring” only.
Table 3.
Patterns of Substances Youth Reported in Their E-cigarettes Among Those Who Reported Vaping in the Last 30 Days, 2017 Monitoring the Future (n=1,685)a
| Not “just flavoring”b | ||||||||
|---|---|---|---|---|---|---|---|---|
|
|
||||||||
| Patterns of vapingc | n | “Just flavoring” only) | Nicotine only | Marijuana only | Nicotine and marijuana | Nicotine and “just flavoring” | Marijuana and “just flavoring” | Nicotine and marijuana and “just flavoring” |
|
|
||||||||
| Weighted % (95% CI) | ||||||||
|
| ||||||||
| Overall | 1,68 | 24.9 (22.5, | 17.7 (15.5, | 8.1 (6.7, 9.5) | 7.5 (6.0, 9.0) | 27.6 (25.1, | 4.6 (3.4, | 9.6 (8.0, |
| 5 | 27.4) | 19.9) | 30.2) | 5.7) | 11.2) | |||
| Current cigarette use | ||||||||
| No | 1,262 | 31.2 (28.1, 34.2) | 16.1 (13.6, 18.5) | 8.9 (7.1, 10.6) | 5.6 (4.2, 7.1) | 25.5 (22.7, 28.3) | 5.4 (3.9, 6.9) | 7.4 (5.8, 8.9) |
| <1 cigarette/day | 234 | 6.7 (3.0, 10.5) | 20.0 (14.2, 25.8) | 6.0 (3.1, 8.8) | 13.1 (7.9, 18.3) | 37.4 (29.5, 45.2) | 2.5 (0.4, 4.6) | 14.3 (8.9, 19.6) |
| 1–5 cigarettes/day | 109 | 5.8 (0.9, 10.7) | 26.4 (15.7, 37.1) | 3.4 (0.4, 6.4) | 8.4 (2.6, 14.3) | 33.4 (23.0, 43.8) | 2.4 (0.0, 5.3) | 20.1 (11.7, 28.5) |
| ≥1/2 pack/day | 42 | 2.9 (0.0, 8.5) | 29.0 (12.5, 45.5) | 9.8 (0.0, 19.7) | 23.7 (9.0, 38.3) | 14.9 (4.0, 25.8) | 0.3 (0.0, 1.0) | 19.3 (5.5, 33.2) |
| p-valued | <0.0001 | 0.0376 | 0.1223 | <0.0001 | 0.0021 | 0.0238 | <0.0001 | |
| Current marijuana use | ||||||||
| No | 668 | 38.3 (33.9, 42.7) | 22.1 (18.3, 25.8) | N/Ad | N/Ad | 35.6 (31.2, 40.0) | N/Ad | N/Ad |
| 1–2 occasions | 288 | 24.9 (18.8, 31.0) | 16.1 (11.2, 21.0) | 7.6 (4.3, 10.8) | 9.0 (4.8, 13.2) | 29.9 (23.8, 36.1) | 3.6 (1.0, 6.2) | 8.9 (5.3, 12.4) |
| 3–9 occasions | 292 | 15.5 (10.6, 20.4) | 15.9 (10.4, 21.4) | 13.0 (8.6, – 17.5) | 10.1 (6.5, 13.8) | 25.1 (19.3, 30.9) | 8.9 (5.3, 12.5) | 11.4 (7.1, 15.7) |
| ≥10 occasions | 336 | 9.9 (6.0, 13.8) | 12.4 (8.4, 16.5) | 16.6 (12.4, 20.8) | 17.1 (12.2, 22.0) | 13.2 (8.9, 17.5) | 8.0 (4.3, 11.6) | 22.8 (17.7, 27.9) |
| p-valued | <0.0001 | 0.0098 | <0.0001 | <0.0001 | <0.0001 | <0.0001 | <0.0001 | |
| Grade | ||||||||
| 8 | 344 | 37.0 (30.8, 43.2) | 8.8 (4.9, 12.8) | 5.2 (2.7, 7.6) | 5.8 (3.0, 8.5) | 29.3 (23.2, 35.4) | 4.3 (2.3–6.4) | 9.5 (5.8, 13.3) |
| 10 | 629 | 23.4 (19.3, 27.5) | 15.2 (11.9, 18.6) | 8.9 (6.4, 8.4) | 6.3 (4.1, 11.5) | 28.4 (24.3, 32.5) | 5.0 (2.9–7.0) | 12.8 (9.9, 15.7) |
| 12 | 712 | 20.5 (17.1, 24.0) | 23.9 (20.2, 27.6) | 8.7 (6.6, 10.9) | 9.3 (6.8, 11.9) | 26.2 (22.4, 30.0) | 4.3 (2.4–6.2) | 7.0 (4.9, 9.2) |
| p-valued | <0.0001 | <0.0001 | 0.1205 | 0.0877 | 0.6066 | 0.8696 | 0.0087 | |
Notes: Boldface indicates statistical significance (p<0.05).
Weighted % and 95% CI were reported among those who reported vaping nicotine, marijuana, or “just flavoring” in the last 30 days.
Thirty-two students reported non-current marijuana use and ≥1 occasion of vaping marijuana in the past 30 days. Due to the small sample size and conflicting responses, they were excluded in the analysis of vaping marijuana.
The vaping pattern was classified into mutually exclusive groups based on separate questions about vaping nicotine, marijuana, and “just flavoring” in the last 30 days. For instance, “just flavoring” only is defined as students who reported vaping “just flavoring” on ≥1 occasion, vaping nicotine on zero occasions, vaping marijuana on zero occasions).
Rao-Scott χ2 test was performed to detect the group difference. N/A, not applicable
DISCUSSION
This study reported a comparable prevalence of youth reporting vaping nicotine (7.4%) and “just flavoring” (8.0%) in the last 30 days in 2017. Studies have reported a surge in e-cigarette use among youth from 2017 to 2018,1 partly due to the rising popularity of products with nicotine salt and pod-based products like JUUL, and a large number of flavors appealing to adolescents. The present findings coincide with an upward trend of youth reporting vaping nicotine, marijuana, and “just flavoring” in the 2018 MTF report.5 To counter the rising e-cigarette use among youth, the U.S. Food and Drug Adminstration launched “The Real Cost” Youth E-cigarette Prevention Campaign in 20187 to urge adolescents to understand the potential health consequences of using e-cigarettes. The Food and Drug Administration also announced a proposal to tighten restrictions on flavored e-cigarettes in March 2019.8 The educational media campaign has shown to be effective in preventing tobacco use among youth9 and restrictions on flavored e-cigarette sales might further curb youth e-cigarette use. However, restrictions on marijuana use have been relaxing in recent years, and fewer adolescents have perceived use of marijuana as harmful.10 These changes may lead to a reduction in youth vaping nicotine or “just flavoring” and an increase in youth vaping marijuana. “The Real Cost” campaign has delivered messages to educate youth that e-cigarettes, just like cigarettes, put them at risk for addiction.7 This study found that nearly 30% of past 30–day e-cigarette users reported vaping marijuana. Given that vaping marijuana may be associated with the recent spate of lung illnesses,11 educating youth about the harms of vaping marijuana in future campaigns is warranted.
This study adds to the existing literature by reporting patterns of substances used in e-cigarettes. It found that increasing cigarette smoking intensity is associated with a higher proportion of students reporting vaping nicotine only and a lower proportion of students reporting vaping “just flavoring” only. Current cigarette smokers with a high (versus low) smoking intensity have higher nicotine dependence, which could increase the risk of vaping nicotine. The findings also suggest that 8th graders and non-smokers have a high prevalence of reporting vaping “just flavoring.” This could be due to the fact that younger (versus older) adolescents and non-smokers (versus current smokers) may be less likely to know which substance they are vaping or what nicotine is.12 Parents, school educators, and health practitioners need to educate youth about substances in their e-cigarette devices and raise their knowledge about the potential harms of e-cigarette use.
This study is subject to limitations. First, self-reported information is subject to recall errors. Second, the potential for misclassification due to students’ self-reports could be large as students might not be fully aware of the substances they have vaped.12 Third, this study analyzed the 2017 MTF data, and future studies should assess whether and to what extent use patterns have changed in 2018 and beyond.
CONCLUSIONS
Despite these limitations, this study provided a more nuanced view of youth e-cigarette use behaviors. It found that youth were more likely to report vaping nicotine and marijuana than “just flavoring” only and that cigarette smoking intensity was associated with an increasing proportion of students reporting vaping nicotine only. Continuous surveillance of youth behaviors and strategies and interventions to reduce youth e-cigarette use are needed.
ACKNOWLEDGMENTS
Research reported in this publication was supported by grant number R03CA228909 (Principal Investigator: Dai) from the National Cancer Institute and U.S. Food and Drug Administration Center for Tobacco Products. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or Food and Drug Administration.
The funding agency had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.
The authors have no financial relationships relevant to this article to disclose.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REFERENCES
- 1.Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Adolescent vaping and nicotine use in 2017–2018 — U.S. national estimates. N Engl J Med. 2019;380(2):192–193. 10.1056/nejmc1814130. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.HHS. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta: HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. [Google Scholar]
- 3.Miech R, Patrick ME, O’Malley PM, Johnston LD. What are kids vaping? Results from a national survey of U.S. adolescents. Tob Control. 2017;26:386–391. 10.1136/tobaccocontrol-2016-053014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Tam J, Warner KE. Students’ cigarette smoking and the perceived nicotine content of their e-cigarettes. Am J Prev Med. 2018;55(3):376–383. 10.1016/j.amepre.2018.04.034. [DOI] [PubMed] [Google Scholar]
- 5.Johnston LD, Miech RA, O’Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the Future National survey results on drug use, 1975–2018: overview, key findings on adolescent drug use. Ann Arbor, MI: Institute for Social Research, University of Michigan; 2019. 10.3998/2027.42/150621. [DOI] [Google Scholar]
- 6.Bachman J, Johnston L, O’Malley P, Schulenberg J. The Monitoring the Future project after thirty-seven years: design and procedures. Occasional Paper #76. www.monitoringthefuture.org/pubs/occpapers/mtf-occ76.pdf. Published 2011. Accessed on September 26, 2019. [Google Scholar]
- 7.Food and Drug Administration. FDA launches new campaign: “The Real Cost” youth e-cigarette prevention campaign. www.fda.gov/tobacco-products/real-cost-campaign/fda-launches-new-campaign-real-cost-youth-e-cigarette-prevention-campaign. Updated June 4, 2019. Accessed September 16, 2019.
- 8.Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb MD, on advancing new policies aimed at preventing youth access to, and appeal of, flavored tobacco products, including e-cigarettes and cigars. www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-advancing-new-policies-aimed-preventing-youth-access. Published March 13, 2019. Accessed September 16, 2019. [Google Scholar]
- 9.Farrelly MC, Duke JC, Nonnemaker J, et al. Association between The Real Cost media campaign and smoking initiation among youths — United States, 2014–2016. MMWR Morb Mortal Wkly Rep. 2017;66(2):47–50. 10.15585/mmwr.mm6602a2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Miech R, Johnston L, O’Malley PM. Prevalence and attitudes regarding marijuana use among adolescents over the past decade. Pediatrics. 2017;140(6):e20170982. 10.1542/peds.2017-0982. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Statement from CDC Director Robert R. Redfield MD, and Acting FDA Commissioner Ned Sharpless MD, on federal and state collaboration to investigate respiratory illnesses reported after use of e-cigarette products. www.cdc.gov/media/releases/2019/s0830-statement-e-cigarette.html. Published August 30, 2019. Accessed September 16, 2019. [Google Scholar]
- 12.Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tob Control. 2019;28(1):115–116. 10.1136/tobaccocontrol-2018-054273. [DOI] [PubMed] [Google Scholar]