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Published in final edited form as: Addict Behav. 2024 Sep 23;160:108174. doi: 10.1016/j.addbeh.2024.108174

How Stress Influences E-cigarette Health Message Perceptions and Intentions to Abstain from Vaping among Young Adults who Vape

Donghee N Lee 1, Hye Min Kim 2, Elise M Stevens 1
PMCID: PMC11577494  NIHMSID: NIHMS2025999  PMID: 39321718

Abstract

Purpose:

While most U.S. young adults attribute e-cigarette use (vaping) to stress coping, it is relatively unknown how young adults’ stress levels influence their e-cigarette health message responses and vaping abstinence intentions.

Methods:

In an online crowdsourcing study, young adults who currently vape (N=346, Mage=25.24) were assessed for their past-30-day stress levels. Then, they saw a message about the health effects of vaping and were asked questions about the messages and their vaping abstinence intentions. We performed multiple regressions to examine the main effects of stress levels on message evaluation (message perceptions, effects perceptions) and intentions to abstain from vaping. We then examined the indirect effects of stress levels on abstinence intentions mediated by each message outcome, respectively. Models controlled for sociodemographic characteristics, mental health status, and past-30-day e-cigarette use and cigarette smoking.

Results:

Participants with higher stress levels reported more negative message evaluation (ps<0.05). Additionally, participants with higher stress levels reported lower abstinence intentions via more negative message perceptions (b=−0.02, SE=0.01, 95% CI= −0.041, −0.004). Likewise, participants with higher stress levels reported lower abstinence intentions via more negative effects perceptions (b=−0.03, SE=0.01, 95% CI=−0.046, −0.008).

Conclusions:

Higher stress levels were associated with negative message evaluation among young adults who vape. Additionally, the association of stress levels and abstinence intentions was mediated by negative message evaluation. Public health officials may need to account for stress levels in young adults to increase the effects of e-cigarette health messages on their intentions to abstain from vaping.

Keywords: Stress, vaping, young adults, e-cigarette health messages

Introduction

Young adults in the U.S. are currently using e-cigarettes (vape) at a high rate (11% vaping every day or on some days in 2021).1 This is a public health concern, as vaping at a young age is associated with negative health effects2 and uptake of smoking combustible cigarettes in the future.3 Stress is a driving force for vaping in young people, with 81% citing stress as the main reason they started vaping, and 50.3% of those who vape almost daily (more than 20 days in the past 30 days) attribute vaping to stress coping.4 To date, public health campaigns targeting young adults have focused on messaging that highlight the negative effects of both physical (e.g., The Real Cost campaign5) and mental health (e.g., Breath of Stress Air campaign6) of vaping. However, it is relatively unknown how stress levels may influence how young adults who currently vape respond to e-cigarette health messages.

Evidence has been well-established on how stress influences vaping among young adults. Studies using self-report and qualitative methods have demonstrated that coping with stress and seeking relaxation are the main reasons that young adults vape.7–10 Furthermore, stress levels have been associated with greater risk of vaping progression and continuation among those who currently vape.11 In a laboratory experiment, young adults who currently vaped (18 to 24 years old) and who engaged in stress-inducing tasks (e.g., complex math calculations) purchased and consumed more e-cigarette puffs than those not assigned to stress-inducing tasks.12 Others found a greater likelihood of anxiety, stress, and depression among those who vape,9,13,14 suggesting the cyclical effects of stress and vaping in this population.

Limited research has examined the perceptions of anti-tobacco messages focusing on the mental health effects among those with mental health symptoms. For example, studies found that anti-smoking messages highlighting the mental health benefits of quitting were associated with greater quit attempts15 and quitting motivations16 among adults with a lifetime history of mental health conditions (vs. those without conditions). A systematic review of studies (n=8) suggests that anti-smoking messages highlighting the negative mental health effects of smoking were generally perceived as effective, elicited greater message recall, and were associated with higher abstinence intentions among those with a lifetime history of a mental health diagnoses.17 However, these studies have focused on adults who were clinically diagnosed with a mental health condition and smoked combustible cigarettes. Given the high prevalence of vaping1 and high stress in young adults (vs. older adults),18 it is important to examine how young adults, who have high stress levels and currently vape, respond to e-cigarette health messages, and how their message responses may influence their abstinence intentions.

The health belief model (HBM)19 posits that individuals’ psychological factors, such as stress, influence one’s perceived benefits and harms of a preventive behavior, which in turn influences the intentions to perform the behavior. The main objectives of the study were to explore how stress levels influenced responses to e-cigarette health messages among young adults who currently vape. According to the HBM, individuals’ stress levels would influence their perceptions of the message (message and the health behavior endorsed in the message) and the likelihood of performing the health behavior, as endorsed by the message. Therefore, we hypothesized that 1) higher stress levels would be associated with negative message evaluation and lower intentions to abstain from vaping, and 2) the association of stress levels and abstinence intentions would be mediated by negative message evaluation among young adults who currently vape. Results from our study can inform the design of public health interventions targeting young adults to discourage vaping that account for their stress levels.

Methods

Participants

A convenience sample of young adults (N=500) were recruited from an online behavioral research platform, Prolific (Prolific.com) in September 2023 for a message intervention study. The study examined the effects of communication strategies (framing and format) on how young adults responded to e-cigarette health messages. The eligibility criteria included age (18–30 years old), country of residence (U.S.), and vaping status (vaping at least once per day). For this study, we used a subset of participants who were assigned to the intervention group who received messages about the health effects of vaping (n=346).

Procedures

This study is a secondary data analysis of a study that tested the effects of e-cigarette health messages. The main outcomes of the study are being reviewed elsewhere.20 Potential participants reviewed a brief description about the study on Prolific and were directed to Qualtrics to take the survey. After providing consent, participants first completed questions about their stress levels and e-cigarette use. Then, they were randomized to an e-cigarette health message condition and answered questions about the messages and their demographics. The goal of this study was to examine how young adults’ general stress levels might influence their responses to e-cigarette health messages. Therefore, in the current study, we examined the association of participants’ past-30-day stress levels and their post-message exposure outcomes including message evaluation and behavioral intentions, while controlling for message framing or format. Participants who completed the study were thanked and compensated $4.00 via Prolific policies. All procedures were approved by the host institution’s Institutional Review Board.

Stimuli

Participants in the intervention group were randomly assigned to one of four message conditions manipulated for framing (physical health, mental health) and format (testimonial, non-testimonial). The message conditions consisted of: 1) mental health testimonial (i.e., “Here is Alex’s story about the dark truth about vaping…vaping increased my anxiety.”); 2) physical health testimonial (i.e., “Here’s Alex’s story about the dark truth about vaping…vaping increased my risk of lung damage.”); 3) mental health non-testimonial (i.e., “Here’s the dark truth about vaping…vaping increases your anxiety.”); 4) physical health non-testimonial (i.e., “Here’s the dark truth about vaping…vaping increases the risk of lung damage.”).

Measures

Demographics.

Participants reported their age (in years), gender, race, ethnicity, education.

E-cigarette use.

Participants were asked on how many days in the past 30 days they used an e-cigarette (between 0 to 30 days).21

Cigarette smoking.

Participants were asked on how many days in the past 30 days they smoked a cigarette (between 0 to 30 days).21

Stress levels.

Stress levels were measured using four items from the Perceived Stress Scale (PSS-4),22 which assessed their perceived stress experienced in the past month. Participants were asked about how often they felt and thought during the last month about their ability to control important things in life, confidence in their ability to handle personal problems, things going their way, difficulties piling up on a scale from 0 (Never) to 4 (Very often). We used the recommended guidelines to compute the PSS-4 scale. The total scores ranged from 0 to 16, with higher scores indicating greater levels of stress (Cronbach’s α=0.83).

Anxiety.

Anxiety was measured by using seven items from the Generalized Anxiety Disorder Scale (GAD-7).23 Participants were asked about how often during the past two weeks about they felt nervous, anxious or on edge, being unable to stop worrying, worrying about different things, trouble relaxing, being too restless to sit still, becoming easily annoyed or irritable, feeling afraid as if something awful might happen on a scale from 0 (Not at all) to 3 (Nearly every day). We used the recommended guidelines to compute the GAD-7 scale. The total scores ranged from 0 to 21: minimal anxiety (scores from 0–4); mild anxiety (scores from 5–9); moderate anxiety (scores from 10–14); severe anxiety (scores from 15–21; Cronbach’s α=0.92).

Depression.

Depression was measured by using nine items from the Patient Health Questionnaire (PHQ-9).24 Participants were asked about how often during the past two weeks about experiencing little interest or pleasure in doing things, feeling down, depressed, or hopeless; trouble falling or staying asleep or sleeping too much; feeling tired or having little energy; poor appetite or overeating; feeling bad about themselves or letting themselves or their family down; trouble concentrating on things; moving or speaking too slowly for others to notice; thinking about death or hurting themselves on a scale from 0 (Not at all) to 3 (Nearly every day). We used the recommended guidelines to compute the PHQ-9 scale. The total scores ranged from 1 to 27: minimal depression (scores from 1–4); mild depression (scores from 5–9); moderate depression (scores from 10–14); moderately severe depression (scores from 15–19); severe depression (scores from 20–27; Cronbach’s α=0.91).

Message perceptions.

Participants were asked about the extent to which they thought the messages grabbed their attention, were informative, meaningful, worth remembering, convincing, powerful on a scale of 1 (strongly disagree) to 5 (strongly agree)25 (Cronbach’s α=0.93).

Effects perceptions.

Participants were asked about the extent to which the messages made them think about the risks of vaping, how vaping could negatively affect their life, how vaping could harm their body, worry about the health effects of vaping, scared of vaping on a scale of 1 (strongly disagree) to 5 (strongly agree)25 (Cronbach’s α=0.95).

Intentions to abstain from vaping.

Participants were asked about the likelihood of refraining from using e-cigarettes completely and permanently, when they get lonely, when they are with their friends who use them in the next three months on a scale of 1 (definitely will not), 4 (definitely will)26 (Cronbach’s α=0.91).

Statistical Analysis

Descriptive statistics were used to check distributions of stress levels, message perceptions, effects perceptions, and intentions to abstain from vaping (Table 2). First, we performed multiple regressions to estimate the associations between stress levels and the message outcomes (message perceptions, effects perceptions) and the intentions to abstain from vaping outcome using SPSS v.29 (IBM, 2023). Next, we used PROCESS v.4.0 Model 4 (Hayes, 2018) to examine the mediation effects of message outcomes on the association between stress levels and the intentions to abstain from vaping outcome. All models controlled for age, gender, education, mental health status (anxiety, depression), the past-30-day use of e-cigarettes, the past-30-day cigarette smoking, and message condition random assignment. Moderating effects or group differences were not tested in these models.

Table 2.

Correlation Matrix of Variables.

Stress Levels Message Perceptions Effects Perceptions Intentions to Abstain from Vaping
Stress Levels 1 −0.11* −0.11* −0.10*
Message Perceptions 1 0.69*** 0.36***
Effects Perceptions 1 0.38***
Intentions to Abstain from Vaping 1
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Notes:

*

p<0.05,

***

p<0.00

Results

Participant Characteristics

On average, participants were 25.24 years old (SD=3.18) and mostly identified as non-Hispanic White/Caucasian (61.0%), about half identified as female (48.8%) and male (46.5%), had an associate’s degree or more (40.5%), and reported having mild mental health status (31.2% mild anxiety, 25.1% mild depression; Table 1).

Table 1.

Participant Characteristics (N=346).

N (%) or mean (SD)
Age (years) 25.24 (3.18)
Gender
Female 169 (48.8%)
Male 161 (46.5%)
Non-binarya 16 (4.6%)
Race and ethnicity
(Non-Hispanic) White/Caucasian 211 (61.0%)
(Non-Hispanic) Black/African American 42 (12.1%)
Othersb 50 (14.5%)
Hispanic/Latino 42 (12.1%)
Prefer not to answer 1 (0.3%)
Education
High school or less 78 (22.5%)
Vocational school or some college 128 (37.0%)
Associate’s degree or more 140 (40.5%)
Stress 8.45 (3.67)
Anxiety
Minimal anxiety 67 (19.4%)
Mild anxiety 108 (31.2%)
Moderate anxiety 87 (25.1%)
Severe anxiety 84 (24.3%)
Depression
Minimal depression 52 (16.1%)
Mild depression 87 (27.0%)
Moderate depression 80 (24.8%)
Moderately severe depression 59 (18.3%)
Severe depression 44 (13.7%)
Past 30-day e-cigarette use 22.55 (10.21)
Past 30-day cigarette smoking 5.46 (9.93)
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a

Non-binary includes trans female/trans woman, trans male/trans man, gender queer/gender non-conforming/gender expansive.

b

Others include two or more race categories, Asian, Native American or Alaskan Native, or Pacific Islander.

Main Effects of Stress Levels on Outcomes

We found a significant association between stress levels and message perceptions (b=−0.07, SE=0.03, p=0.016, 95% CI=−0.126, −0.013), such that those with higher stress levels rated message perceptions lower (i.e., thought the messages as less attention-grabbing, informative, meaningful, memorable, convincing, powerful). The association between stress levels and effects perceptions was also significant (b=−0.09, SE=0.03, p=0.002, 95% CI=−0.149, −0.035), such that those with higher stress levels rated effects perceptions lower (i.e., the messages made them think about the risks of vaping, how vaping could negatively affect their life, how vaping could harm their body, worry about the health effects of vaping, scared of vaping). The association between stress levels and intentions to abstain from vaping were not statistically significant.

Indirect Effects of Stress Levels on Outcomes

To test the indirect effects of stress levels on abstinence intentions, we ran two separate mediation analyses. First, message perceptions mediated the association between stress levels and intentions to abstain from vaping such that stress levels and message perceptions were negatively associated (b=−0.07, SE=0.03, p=0.016, 95% CI=−0.126, −0.013), which in turn, showed message perceptions to be positively associated with intentions to abstain from vaping (b=0.30, SE=0.04, p<0.001, 95% CI=0.219, 0.381), indirect effects: b=−0.02, SE=0.01, 95% CI=−0.041, −0.004. The total effects were not significant (b=−0.03, SE= 0.02, p=0.169, 95% CI=−0.070, 0.012). The direct effects were not significant (b=−0.01, SE=0.02, p=0.676, 95% CI=−0.046, 0.030; Figure 1), suggesting a full mediation model.

Figure 1.

Figure 1.

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Models illustrating indirect effects of stress on abstinence intentions via message perception and effects perception, respectively.

Notes: *denotes p<0.05, ***p<0.001; Model 1: Indirect effects: b=−0.02, SE=0.01, 95% CI= −0.041, −0.004; Model 2: Indirect effects: b=−0.03, SE=0.01, 95% CI=−0.046, −0.008.

Additionally, effects perceptions also significantly mediated the association between stress levels and intentions to abstain from vaping. Stress levels and effects perceptions were negatively associated (b=−0.09, SE=0.03, p=0.002, 95% CI=−0.149, −0.036), which in turn, showed effects perceptions to be positively associated with intentions to abstain from vaping (b=0.27, SE=0.04, p<0.001, 95% CI=0.191, 0.355), indirect effects: b=−0.03, SE=0.01, 95% CI=−0.046, −0.008. The total effects were not significant (b=−0.03, SE=0.02, p=0.169, 95% CI=−0.070, 0.012). The direct effects were not significant (b=−0.004, SE=0.02, p=0.847, 95% CI=−0.043, 0.035; Figure 1), suggesting a full mediation model.

Discussion

In this study, we examined how stress levels influenced young adults’ responses to e-cigarette health messages and how those responses impacted their intentions to abstain from vaping. We found that young adults with higher stress levels reported more negative message evaluation (message perceptions and effects perceptions) of e-cigarette health messages after message exposure compared to those with lower stress levels. Additionally, we found that the association between stress levels and intentions to abstain from vaping was mediated by negative message evaluation (message perceptions and effects perceptions, respectively). Our findings suggest that young adults’ stress levels may serve as an underlying factor that potentially compromises the effects of e-cigarette health messages on their intentions to abstain from vaping.

Consistent with the health belief model,19 we found that a psychological factor (i.e., stress) influenced how young adults perceived a health behavior (i.e., vaping), in turn influencing their behavioral intentions (i.e., abstinence intentions). Young adults with higher stress levels reported negative evaluation of e-cigarette health messages, although high stress levels were not directly associated with intentions to abstain from vaping. However, negative message evaluation from those with higher stress levels were less likely to consider abstaining from vaping after seeing the messages. Past research demonstrated that highly stressed individuals respond more negatively to persuasive health messages than those who are less stressed,27 which may also explain our findings. This is concerning as stress levels for young adults (18–34 years old) are at an all-time high compared to those of older adults.18,28 This suggests that every e-cigarette health messaging campaign targeting young adults should consider the impact of stress as they develop and test the messages. Past research suggests that addressing mental health benefits of quitting smoking in anti-smoking messages increased quitting motivations16 and intentions17 among adults diagnosed with mental health conditions and smoke cigarettes. As young adults are disproportionately experiencing high stress levels, the current e-cigarette health messages may fail to reach this group without addressing the impact of stress.

Overall, our findings suggest that stress may be a major barrier for vaping cessation in young people, consistent with the current evidence.7–10 However, our study advances this association by providing insights into how young adults’ abstinence intentions may be mediated by their negative evaluation of messages because of stress, which is in alignment with HBM. In our sample of young adults, those with higher stress levels were more likely to negatively evaluate the e-cigarette health messages. Specifically, those with higher stress levels rated lower on message perceptions (e.g., felt the messages were less attention-grabbing or meaningful), and effects perceptions (e.g., less likely to think that the messages influenced their vaping risk perceptions). This association raises an important gap that potentially impedes vaping cessation messaging efforts targeting young adults. One potential short-term strategy is to consider employing tools for stress management (e.g., guided meditation)29 in conjunction with e-cigarette health messages to aid message receipt. Future work may also consider incorporating other HBM elements, such as self-efficacy, to advance this association. Specifically, messages about self-efficacy aimed at increasing self-efficacy to cope with stress, in addition to self-efficacy for abstinence, may improve e-cigarette health message receipt in this group.

Importantly, future research should also consider the impact of stress on e-cigarette health message response and e-cigarette use among sexual and gender minoritized (SGM) young adults, as they report higher stress and lower e-cigarette harm perceptions than their heterosexual and cisgender counterparts.30,31 In addition to employing SGM-culturally targeted themes and message features,32 addressing SGM-specific stress (i.e., minority stress)33,34 may enhance the effectiveness of e-cigarette health messages for this group. Taken together, our findings suggest that it is critical to account for stress levels in young adults to increase their intentions to abstain from vaping after viewing e-cigarette health messages. To increase effectiveness of e-cigarette health messages, public health officials may also consider incorporating additional lifestyle interventions to relieve stress in young adults. Overall, our findings raise the importance of addressing stress and mental wellbeing as an important first step to combat the vaping epidemic in young adults.

Limitations

First, our study employed a cross-sectional design with a single message exposure, limiting the message effects.35 Future studies should employ a longitudinal design with repeated message exposure to test the effects of stress on young adults’ message response and the behavioral changes. Our findings indicate associations and do not imply causation, thus need to be interpreted with caution. We used self-report data, which may have biases related to social desirability or message recall. Future research should incorporate biobehavioral measures that engage young adults in stress-inducing tasks to enhance ecological validity. We did not assess e-cigarette consumption patterns (e.g., flavors, intensity), thus may be limited in capturing the nuance of e-cigarette use in this group. Our study may have limited applicability to the general young adult population because we used a convenience sample, although past tobacco research using a convenience sample has shown comparable results as using representative samples.36 Lastly, while PSS-4 has been previously used with young adults in the e-cigarette use context,30,31,37 future research should develop and validate perceived stress measures specific to tobacco use in young adults to better capture the nuance of this association in this group. Despite these limitations, findings from our study provide an important insight into how stress may influence young adults’ e-cigarette health message responses to inform the future vaping cessation campaign efforts.

Conclusions

We examined how stress levels influenced responses to e-cigarette health messages and abstinence intentions among young adults who currently vape. Those with higher stress levels reported more negative message evaluation, in turn lowering their intentions to abstain from vaping. Our findings suggest that stress may potentially compromise the effects of e-cigarette health messages on the behavioral intentions in young adults who vape. Therefore, public health officials may consider the effects of stress levels among young adults when deploying e-cigarette health messages to aid in their message receipt.

Highlights.

  • Most U.S. young adults repot using e-cigarettes (vaping) to stress coping, but it is relatively unknown how young adults’ stress levels influence their e-cigarette health message responses and vaping abstinence intentions.

  • Little is known about the associations of stress, evaluation of e-cigarette health messages, and vaping abstinence intentions.

  • In our study, young adults with higher stress levels negatively evaluated messages, which was in turn, associated with lower vaping abstinence intentions.

  • Stress levels in young adults should be considered to increase the effects of e-cigarette health messages on young adults who vape to influence behavioral changes.

Funding:

This data reported in this publication were supported by the National Institute on Drug Abuse award R00DA046563 (PI: EMS). Data analysis and manuscript preparation were additionally supported by the National Cancer Institute (NCI) and FDA Center for Tobacco Products (CTP) under award 1K99CA281094-01A1 (PI: DNL).

Declaration of Interest and Role of Funding Source

The work reported here was supported by the National Cancer Institute (NCI) and FDA Center for Tobacco Products (CTP) under award 1K99CA281094-01A1 (DNL, PI) and the National Institute on Drug Abuse of the National Institutes of Health (NIH) under award R00DA046563 (EMS, PI). Content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Footnotes

Competing Interests Statement

No, there are no competing interests.

Author Agreement Statement

We the undersigned declare that this manuscript is original, has not been published before, and is not currently being considered for publication elsewhere.

We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

We understand that the Corresponding Author (Donghee N. Lee) is the sole contact for the editorial process. She is responsible for communicating with the other authors about progress, submissions of revisions, and final approval of proofs.

Signed by all authors as follows:

Donghee N Lee, PhD

Hye Min Kim, PhD

Elise M Stevens, PhD

Conflicts of interest: The authors have no conflicts of interest to report.

Disclosure: Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or Food and Drug Administration.

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.Cornelius ME. Tobacco Product Use Among Adults – United States, 2021. MMWR Morb Mortal Wkly Rep. 2023;72. doi: 10.15585/mmwr.mm7218a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. Accessed December 15, 2021. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf [Google Scholar]
  • 3.Hair EC, Barton AA, Perks SN, et al. Association between e-cigarette use and future combustible cigarette use: Evidence from a prospective cohort of youth and young adults, 2017–2019. Addict Behav. 2021;112:106593. doi: 10.1016/j.addbeh.2020.106593 [DOI] [PubMed] [Google Scholar]
  • 4.Truth Initiative. Colliding Crises: Youth Mental Health and Nicotine Use.; 2021. Accessed December 20, 2023. https://truthinitiative.org/research-resources/emerging-tobacco-products/colliding-crises-youth-mental-health-and-nicotine-use
  • 5.Food and Drug Administration. The Real Cost E-Cigarette Prevention Campaign. FDA. September 22, 2022. Accessed September 28, 2022. https://www.fda.gov/tobacco-products/real-cost-campaign/real-cost-e-cigarette-prevention-campaign [Google Scholar]
  • 6.Truth Initiative. Breath of Stress Air is calling a vape what it truly is. March 11, 2022. Accessed October 25, 2023. https://truthinitiative.org/research-resources/emerging-tobacco-products/breath-stress-air-calling-vape-what-it-truly
  • 7.Pokhrel P, Little MA, Fagan P, Muranaka N, Herzog TA. Electronic cigarette use outcome expectancies among college students. Addict Behav. 2014;39(6):1062–1065. doi: 10.1016/j.addbeh.2014.02.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Harrell PT, Brandon TH, England KJ, et al. Vaping Expectancies: A Qualitative Study among Young Adult Nonusers, Smokers, Vapers, and Dual Users. Subst Abuse. 2019;13:1178221819866210. doi: 10.1177/1178221819866210 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Jha V, Kraguljac A. Assessing the Social Influences, Self-Esteem, and Stress of High School Students Who Vape. Yale J Biol Med. 2021;94(1):95–106. [PMC free article] [PubMed] [Google Scholar]
  • 10.Newcombe KV, Dobbs PD, Oehlers JS, Dunlap CM, Cheney MK. College Students’ Reasons for Using JUULs. Am J Health Promot. 2021;35(6):835–840. doi: 10.1177/0890117121992292 [DOI] [PubMed] [Google Scholar]
  • 11.Mantey DS, Clendennen SI, Sumbe A, Wilkinson AV, Harrell MB. Perceived stress and E-cigarette use during emerging adulthood: A longitudinal examination of initiation, progression, and continuation. Prev Med. 2022;160:107080. doi: 10.1016/j.ypmed.2022.107080 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Pericot-Valverde I, Heo M, Litwin AH, Niu J, Gaalema DE. Modeling the effect of stress on vaping behavior among young adults: A randomized cross-over pilot study. Drug and Alcohol Dependence. 2021;225:108798. doi: 10.1016/j.drugalcdep.2021.108798 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Wilson OWA, Bullen C, Duffey M, Bopp M. The association between vaping and health behaviors among undergraduate college students in the United States. Journal of American College Health. 2022;0(0):1–5. doi: 10.1080/07448481.2022.2076097 [DOI] [PubMed] [Google Scholar]
  • 14.King JL, Reboussin BA, Spangler J, Cornacchione Ross J, Sutfin EL. Tobacco product use and mental health status among young adults. Addict Behav. 2018;77:67–72. doi: 10.1016/j.addbeh.2017.09.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Prochaska JJ, Gates EF, Davis KC, Gutierrez K, Prutzman Y, Rodes R. The 2016 Tips From Former Smokers"® Campaign: Associations With Quit Intentions and Quit Attempts Among Smokers With and Without Mental Health Conditions. Nicotine & Tobacco Research. 2019;21(5):576–583. doi: 10.1093/ntr/nty241 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Steinberg ML, Rosen RL, Ganz O, Wackowski OA, Jeong M, Delnevo CD. Communicating the benefits of quitting smoking on mental health increases motivation to quit in people with anxiety and/or depression. Addictive Behaviors. 2024;149:107903. doi: 10.1016/j.addbeh.2023.107903 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Perman-Howe PR, McNeill A, Brose LS, Tildy BE, Langley TE, Robson D. The Effect of Tobacco Control Mass Media Campaigns on Smoking-Related Behavior Among People With Mental Illness: A Systematic Literature Review. Nicotine & Tobacco Research. 2022;24(11):1695–1704. doi: 10.1093/ntr/ntac079 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.American Psychological Association. Stress in America 2023: A nation recovering from collective trauma. https://www.apa.org. November 2023. Accessed May 15, 2024. https://www.apa.org/news/press/releases/stress/2023/collective-trauma-recovery
  • 19.Rosenstock IM. The Health Belief Model and Preventive Health Behavior. Health Education Monographs. 1974;2(4):354–386. doi: 10.1177/109019817400200405 [DOI] [PubMed] [Google Scholar]
  • 20.Lee DN, Stevens H, Kim HM, Stevens EM. “I vape because I am stressed”: Integrating stress and mental health in e-cigarette social media messages for young adults who vape. In: 74th Annual International Communication Association Conference.; 2024. [Google Scholar]
  • 21.National Institutes of Health, U.S. Food and Drug Administration. Population Assessment of Tobacco and Health (PATH) Study: Final Adult Baseline (Wave 1) Questionnaire. National Institutes of Health.; 2013. [Google Scholar]
  • 22.Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. Journal of Health and Social Behavior. 1983;24:385–396. doi: 10.1037/t02889-000 [DOI] [PubMed] [Google Scholar]
  • 23.Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097. doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
  • 24.Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. doi: 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Noar SM, Rohde JA, Prentice-Dunn H, Kresovich A, Hall MG, Brewer NT. Evaluating the actual and perceived effectiveness of E-cigarette prevention advertisements among adolescents. Addictive Behaviors. 2020;109:106473. doi: 10.1016/j.addbeh.2020.106473 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Maloney EK, Cappella JN. Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and Perceptions in Daily, Intermittent, and Former Smokers? Health Communication. 2016;31(1):129–138. doi: 10.1080/10410236.2014.993496 [DOI] [PubMed] [Google Scholar]
  • 27.Suka M, Yamauchi T, Yanagisawa H. Responses to persuasive messages encouraging professional help seeking for depression: comparison between individuals with and without psychological distress. Environ Health Prev Med. 2019;24(1):29. doi: 10.1186/s12199-019-0786-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.American Psychological Association. Gen Z adults and younger millennials are “completely overwhelmed” by stress. https://www.apa.org. November 2023. Accessed May 31, 2024. https://www.apa.org/topics/stress/generation-z-millennials-young-adults-worries
  • 29.Battalio SL, Conroy DE, Dempsey W, et al. Sense2Stop: A micro-randomized trial using wearable sensors to optimize a just-in-time-adaptive stress management intervention for smoking relapse prevention. Contemporary Clinical Trials. 2021;109:106534. doi: 10.1016/j.cct.2021.106534 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Patterson JG, Keller-Hamilton B, Wedel A, et al. Absolute and relative e-cigarette harm perceptions among young adult lesbian and bisexual women and nonbinary people assigned female at birth. Addict Behav. 2023;146:107788. doi: 10.1016/j.addbeh.2023.107788 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Wedel AV, Patterson JG, Lee DN, Stevens EM, Wagener TL, Keller-Hamilton B. E-Cigarette Use among Sexual Minoritized Women and Nonbinary People Assigned Female at Birth: Assessing the Roles of Discrimination, Perceived Stress, and Social Support. Subst Use Misuse. 2023;58(9):1102–1109. doi: 10.1080/10826084.2023.2212056 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Patterson JG, Keller-Hamilton B, Wedel AV, et al. Responses to e-cigarette health messages among young adult sexual minoritized women and nonbinary people assigned female at birth: Assessing the influence of message theme and format. Drug and Alcohol Dependence. 2022;231:109249. doi: 10.1016/j.drugalcdep.2021.109249 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Gamarel KE, Mereish EH, Manning D, et al. Minority stress, smoking patterns, and cessation attempts: Findings from a community-sample of transgender women in the San Francisco Bay area. Nicotine Tob Res. 2016;18(3):306–313. doi: 10.1093/ntr/ntv066 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Gordon AR, Fish JN, Kiekens WJ, et al. Cigarette smoking and minority stress across age cohorts in a national sample of sexual minorities: Results from the generations study. Annals of Behavioral Medicine. 2021;55(6):530–542. doi: 10.1093/abm/kaaa079 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Sundar A, Kardes FR, Wright SA. The Influence of Repetitive Health Messages and Sensitivity to Fluency on the Truth Effect in Advertising. Journal of Advertising. 2015;44(4):375–387. doi: 10.1080/00913367.2015.1045154 [DOI] [Google Scholar]
  • 36.Jeong M, Zhang D, Morgan JC, et al. Similarities and differences in tobacco control research: Findings from convenience and probability samples. Ann Behav Med. 2018;53(5):476–485. doi: 10.1093/abm/kay059 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Lee DN, Stevens EM, Patterson JG, Wedel AV, Wagener TL, Keller-Hamilton B. Associations of Perceived Stress and Social Support on Health Behavior Changes in Sexual Minoritized Women During the COVID-19 Pandemic. Women’s Health Reports. 2023;4(1):182–190. doi: 10.1089/whr.2022.0095 [DOI] [PMC free article] [PubMed] [Google Scholar]

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