Abstract
Eating disorders (EDs) are associated with e-cigarette use, but the mechanisms and sex differences in this association are unclear and could reflect hypersensitivity to appealing e-cigarette sensations in EDs. In this secondary analysis of clinical-experimental research involving self-administration of varying flavored e-cigarettes, we examined whether associations of a product’s perceived sensory attributes (i.e., sweet, smooth, bitter, and harsh) with its respective appeal differed by ED symptoms (i.e., body dissatisfaction and binge eating) and sex. Adult tobacco product users (N=160; 52.5% men; Mage=34.92±13.50) were recruited online and puffed standardized doses of 8 or 20 different e-cigarette products and rated each product’s sensory attributes and appeal. Multilevel models examined three-way interactions of sex, ED symptoms, and sensory attributes with appeal ratings, using analysis that partitioned between-subjects variance from within-subjects variance. Three-way interactions between sex, ED symptoms, and within-subjects sensory ratings in predicting e-cigarette appeal revealed: (1) Higher sweetness increased appeal more strongly in women with elevated body dissatisfaction (B=0.15, p<.001); (2) Lower smoothness reduced appeal more strongly among women with elevated body dissatisfaction (B=0.10, p=.005).; (3) Higher bitterness reduced appeal more strongly among women with elevated body dissatisfaction (B=−0.15, p<.001). E-cigarettes with sweet flavors and other desirable sensory attributes could potentially be hyper-valued as appealing among women with elevated ED symptoms, but more work among individuals with well-characterized ED symptoms is needed. Regulatory strategies and interventions for reducing nicotine addiction that address flavored e-cigarettes may be especially important for the vulnerable population of women with ED symptoms.
Keywords: eating psychopathology, eating disorders, e-cigarette appeal, sex differences
E-cigarette use has increased in the past decade across both sexes (Bandi et al., 2023; Fadus et al., 2019; Lau et al., 2023; Neczypor et al., 2022). E-cigarettes play an important role in public health because they emit several toxins that may be hazardous to health, but they do so at levels lower than combustible cigarettes and could reduce harm for individuals using e-cigarettes to quit smoking (National Academies of Sciences, Engineering, and Medicine, 2018). Drivers of nicotine use and addiction vary by sex, with men potentially being more motivated by nicotine’s pharmacological effects and women being more sensitive to the non-pharmacological sensory drivers of tobacco products (Perkins et al., 1999). As such, it is of paramount importance to investigate the differential correlates of e-cigarette appeal for both men and women, particularly as this may inform targeted prevention and policy efforts to address specific vulnerabilities within these populations.
Sensory attributes related to the perceived taste (e.g., sweetness and bitterness) or respiratory effects (e.g., harshness and smoothness) of an e-cigarette are related to how appealing users find a particular e-cigarette product, and such sensory attributes mediate the association between type of flavor of the e-cigarette and the perceived appeal of the product (Leventhal et al., 2020). Sex has been shown to moderate the association of sensory experiences and appeal, with female participants showing stronger associations between sensory properties of e-cigarettes and appeal (Davis et al., 2024; Pang et al., 2020), but studies have yet to look at psychiatric symptoms as an e-cigarette appeal modulator, despite the strong association between e-cigarette use and psychiatric symptoms (Becker et al., 2021) and that men and women may express psychopathology differently.
Eating disorder (ED) symptoms, such as binge eating and body dissatisfaction, are psychiatric symptoms that are associated with e-cigarette use (Mason et al., 2022; Smith et al., 2024) and may have relevance to e-cigarette appeal. Individuals with ED diagnoses as well as subclinical ED symptoms related to binge eating and body dissatisfaction often have difficulty controlling food intake and a strong drive to consume highly palatable food (e.g., foods high in sugar and/or fat content; di Giacomo et al., 2022; Wierenga et al., 2014). In addition, EDs and their associated symptoms are related to alterations in sensory processing (Cobbaert et al., 2024). Studies have shown that individuals with bulimia nervosa and binge-eating disorder (which are characterized by recurrent binge eating and body image disturbance) show higher preference for sweet taste compared to controls as well as increased brain activation in reward regions in response to sweet taste administration (Chao et al., 2019; Goodman et al., 2018). Because e-cigarettes are available in flavors that simulate palatable foods (e.g., candy, desserts, fruit) yet are calorie-free and contain nicotine, a known appetite-suppressant, e-cigarettes may be appealing to individuals with ED symptoms to reduce cravings and consumption of palatable food (Kechter et al., 2022). Consistently, meeting criteria for an ED or showing elevated ED symptoms on self-report measures (including binge-eating frequency and body dissatisfaction) are positively associated with use of e-cigarettes (Smith et al., 2024) and have been posited as maintenance factors for ED symptoms (Mason et al., 2022). E-cigarettes may be used to reduce urges to binge by satisfying cravings for palatable foods. However, while e-cigarettes may limit binge-eating urges in the moment, they could increase palatable food craving and binge urges through increasing incentive salience and failing to satisfy physiological hunger (Mason et al., 2022).
Given that ED symptoms are associated with risk for e-cigarette use as well as alterations in gustatory and olfactory attributes, an important next step is to examine ED symptoms as a moderator of sensory attributes and e-cigarette appeal as individuals with elevated ED symptoms may be more vulnerable to product manipulations designed to increase addictive liability. Therefore, the current study examined how ED symptoms (i.e., binge eating and body dissatisfaction) influenced the association of sensory attribute ratings (i.e., sweet, smooth, bitter, and harsh) of e-cigarettes and their respective product appeal. While EDs are characterized by various different symptoms and diagnoses, this study specifically focuses on body dissatisfaction and binge eating because they (1) represent transdiagnostic symptoms that are common to multiple EDs (American Psychiatric Association, 2013) and (2) are among the most common ED symptoms in non-clinical samples that may be representative of appreciable cross-sections of the overall population (Striegel-Moore et al., 2009). In addition, because ED symptoms vary by sex (Smith et al., 2017) and the association of sensory attributes and e-cigarette appeal differs by sex (Pang et al., 2020), we included sex as a secondary moderator in models.
We addressed this question in a secondary data analysis using a pooled dataset of two clinical laboratory experiments of adult current tobacco product users involving controlled puffing of e-cigarette products. Based on prior findings (Chao et al., 2019; Goodman et al., 2018; Mason et al., 2022), we expected stronger positive associations between rewarding sensory attributes of e-cigarettes and appeal for women with elevated ED symptoms, and stronger negative associations between aversive sensory attributes and appeal for women with elevated ED symptoms. The extent that ED symptoms would significantly modulate sensory attribute-appeal associations collapsed across sexes was exploratory given that much of the prior ED research has been in predominantly female samples. These insights hold the potential to inform public health strategies, such as the design of targeted interventions that are tailored to address both the sensory and psychological drivers of e-cigarette appeal. Such evidence can also inform whether future e-cigarette regulatory policies under current consideration (e.g., flavor restrictions) might disproportionately impact individuals with ED symptoms. Ultimately, given elevated e-cigarette use in individuals with ED symptoms (e.g., Smith et al., 2024), knowledge from the current study could have a sizeable impact on reducing problematic e-cigarette use through informing novel e-cigarette cessation and prevention strategies for individuals with ED symptoms and providing further support for the need for e-cigarette regulatory policies.
Method
Participants and Procedures
Two studies were pooled and included adults of any age who were established current users of e-cigarettes and/or cigarettes (n=116 [Han et al., 2024] and n=74 [Jafarzadeh et al., 2025]). Pooling data allowed greater statistical power for testing moderation. The two studies both involved self-administration of several e-cigarette products that experimentally varied on one or more product characteristic dimensions within the respective protocol (flavor, nicotine concentration, nicotine type; Table S1). Both studies recruited participants online through websites and social media advertisements. All procedures and measures were identical across the two studies, with the sole difference being the specific e-cigarette products included in the respective studies. Product variability across the two studies provided a diversity of products allowing for ample variability in sensory attributes. All procedures were reviewed and approved by the University of Southern California Institutional Review Board. Eligible and interested participants (assessed via phone screen) completed a study visit virtually, where they provided written informed consent, completed questionnaires assessing ED symptoms, demographics, and other participant characteristics, and the experimental e-cigarette product appeal self-administration protocol.
During the experimental protocol, participants self-administrated standardized doses of e-cigarettes: 8 or 20 (depending on which of the 2 parent studies) different e-cigarette solution products varying in flavor (i.e., fruit/candy, tobacco, or menthol), nicotine formulation (i.e., freebase, benzoate salt, or lactate salt), and product packaging. Participants completed the trials each using a different study-provided e-cigarette solution and e-cigarette device. The order of presentation of the different e-cigarette solutions was randomized using a random sequence generator and prepared prior to study completion by staff with no participant contact. All participants and staff with participant contact were blinded to the solutions administered at each trial. The devices used were pod cartridge inserts that were filled with the custom solutions. During each trial, participants viewed instructions directing them through the controlled guided puffing procedure in video format. Each solution was trialed using a 2-puff cycle, with each puff following this sequence: 10-second preparation, 4-second inhalation, 1-second hold, and 2-second exhale interval. Afterwards, sensory attribute and appeal ratings of the product were made. Participants were instructed to drink water or rinse their mouths after each trial to help prevent carry over effects. Device, e-cigarette solutions, and number of trials varied between the two studies (see Table S1).
Measures
Demographics and tobacco product use characteristics.
Demographics and vaping history questionnaires were used to measure age, sex, race/ethnicity, and e-cigarette product use characteristics.
Eating Pathology Symptoms Inventory (EPSI; Forbush et al., 2013).
The EPSI Binge Eating (e.g., “I stuffed myself with food to the point of feeling sick”) and Body Dissatisfaction (e.g., “I wished the shape of my body was different”) ED symptoms subscales were administered. Participants were asked to report how frequently they experienced each item during the past four weeks on a 5-point scale from 0 (never) to 4 (very often). Scores were generated by averaging the responses across items for each of the two subscales. The EPSI has shown excellent psychometric properties in previous research across sex and gender (Forbush et al., 2013; 2014). The Cronbach’s alphas in the current study were .89 and .83 for body dissatisfaction and binge eating, respectively.
Sensory attributes.
Participants provided ratings of four sensory attributes (i.e., sweet, harsh, bitter, and smooth) after each trial by answering the following questions: “How sweet was the e-cigarette?”; “How smooth was the e-cigarette?”; “How bitter was the e-cigarette?”; and “How harsh was the e-cigarette?” Ratings for each sensory item were provided using visual analogue scale anchored at 0 (not at all) and 100 (extremely). Sensory ratings were analyzed separately given that sensory attributes load onto distinct item-specific factors (Leventhal et al., 2020).
Appeal.
Immediately following each e-cigarette vaping inhalation trial, participants provided ratings of the product on visual analogue scales ranging from 0-100. Three items were rated including: 1) “How much did you like it?” (“not at all”-“extremely”); 2) “How much did you dislike it?” (“not at all”-“extremely”; reverse-scored); and 3) “Would you use it again?” (“not at all”-“definitely”). A composite appeal score was created for each trial by averaging the three items, with higher scores indicating greater product appeal. The appeal items and composite appeal score have evidenced excellent psychometric properties in previous laboratory tobacco appeal research (Goldenson et al., 2016; Leventhal et al., 2019).
Statistical Analyses
Analyses were conducted in SPSS version 29 (IBM; Armonk, NY). ANOVA or Pearson correlations were calculated to examine associations of demographic variables with ED symptoms. Variables that significantly differed by ED symptoms at p<.05 were included as covariates in the primary analysis. A Q-Q plot was computed to check for normality of the appeal outcome.
Multilevel linear models (MLMs) account for nested data (i.e., multiple time points per person) and do not assume that each person will have an equal number of time points, allowing for all cases to be used in analyses (Kreft & De Leeuw, 1998). MLMs were used to examine binge-eating symptoms and body dissatisfaction as moderators of the association of sensory (i.e., sweet, harsh, bitter, and smooth) with appeal ratings by sex. Because sensory experience ratings of e-cigarettes may be subjective to each individual, we disaggregated the effects of sensory attributes into within- and between-subject variance component effects (Curran et al., 2014). Between-subjects effects were calculated by separately aggregating each sensory experience variable across all trials and represent person-level differences. Within-subjects were calculated by subtracting the between-subjects mean for each sensory experience variable from the corresponding value at each trial and represent product-level differences. See supplementary text a more detailed description.
Eight MLMs were computed, with each examining three-way interactions of sex, ED symptoms, and sensory attributes with appeal ratings; each sensory attribute and ED symptom was tested in a separate model. Each MLM included the main effects for between- and within-subjects sensory experience, either binge-eating symptoms or body dissatisfaction, and sex as well as all two- and three-way interactions. Significant three-way interactions were further examined using MLMs of sensory attribute and ED symptom main effects and sensory attribute x ED symptom interactions in predicting appeal, stratified by sex. Significance for interactions in the initial eight MLMs was set to p<.01 (two tailed) to correct for the number of models run.
Results
Descriptive Statistics
There were 190 participants across the two studies. As reported in Supplementary Table 2, the samples of the two studies significantly differed on education, tobacco product use, age, and average appetite ratings. Thirty participants did not complete the ED symptoms measure, leaving 160 participants for analysis (see Supplementary Figure 1 for participant flow). Participants who were included vs excluded due to not completing the ED symptoms measure did not differ on demographics or average appeal ratings (see Supplementary Table 3). Table 1 displays the descriptive statistics of the sample and associations with ED symptoms. The sample had slightly more men and most had completed some college or had a college degree. Also, most participants were dual e-cigarette+cigarette users or current e-cigarettes users but never smokers. Sex, education, race, ethnicity, age, and tobacco product use were not significantly associated with ED symptoms. BMI was significantly associated with body dissatisfaction and was included as a covariate in body dissatisfaction models. ED symptoms were unrelated to average ratings of sweet, bitter, harsh, or smooth across trials, ps>.05. According to the Q-Q plot, appeal approximated a normal distribution.
Table 1.
Descriptive Statistics of Participant Characteristics, by Eating Disorder Symptoms
| N (%) | Binge Eating | Body Dissatisfaction | |||
|---|---|---|---|---|---|
| M (SD) | p | M (SD | p | ||
| Demographics | |||||
| Sex | |||||
| Women | 76 (47.5) | 1.05 (0.69) | .74 | 1.02 (0.92) | .11 |
| Men | 84 (52.5) | 1.01 (0.75) | 1.35 (0.99) | ||
| Education | |||||
| Less than high school | 3 (1.9) | 0.86 (0.86) | .88 | 1.10 (0.95) | .30 |
| High School diploma or GED | 29 (18.1) | 0.96 (0.70) | 1.20 (0.95) | ||
| Some college | 68 (42.5) | 1.03 (0.69) | 1.08 (0.84) | ||
| College degree or higher | 59 (36.9) | 1.08 (0.79) | 1.40 (1.06) | ||
| Missing | 1 (0.6) | - | - | ||
| Ethnicity | |||||
| White | 98 (61.3) | 1.12 (0.76) | .40 | 1.32 (0.97) | .09 |
| Black | 25 (15.6) | 0.85 (0.52) | 1.37 (1.09) | ||
| Asian | 8 (5.0) | 0.68 (0.40) | 0.55 (0.55) | ||
| Hispanic | 9 (5.6) | 1.02 (0.93) | 0.83 (0.70) | ||
| Other | 4 (2.5) | 1.05 (1.32) | 1.24 (0.92) | ||
| Multi | 0.98 (0.63) | 0.95 (0.72) | |||
| Tobacco Product Use | |||||
| Current dual user | 60 (37.5) | 1.10 (0.76) | .61 | 1.18 (0.91) | .28 |
| Current e-cigarette use, former cigarette use | 16 (10.0) | 1.04 (0.55) | 1.37 (0.91) | ||
| Current cigarette use, former e-cigarette use | 17 (10.6) | 1.20 (0.95) | 1.56 (1.09) | ||
| Current e-cigarette use, never cigarette use | 43 (26.9) | 0.95 (0.68) | 1.00 (0.86) | ||
| Current cigarette use, never e-cigarette use | 24 (15.0) | 0.90 (0.60) | 1.36 (1.08) | ||
| M (SD) | Binge Eating | Body Dissatisfaction | |||
| r | p | r | p | ||
| Age, years | 34.92 (13.50) | .02 | .80 | .12 | .15 |
| BMI, kg/m2 | 26.89 (6.01) | .01 | .88 | .31 | <.001 |
| Between-subjects Sensory Attributes | |||||
| Sweet | 48.14 (17.20) | −.07 | .38 | −.02 | .76 |
| Bitter | 27.58 (17.60) | .06 | .35 | −.08 | .32 |
| Smooth | 54.29 (14.58) | −.05 | .55 | −.14 | .08 |
| Harsh | 39.32 (17.23) | .03 | .72 | .02 | .79 |
Note. SD=standard deviation; P-value from ANOVA (categorical variable) or Pearson correlation (continuous variable) test.
Main Analyses
The MLM results testing within- and between-subjects sensory experience, ED symptoms, and sex main effects and interactions on appeal ratings are displayed in Tables 2-5. There were significant within-subjects main effects indicating that products rated sweeter or smoother were also rated higher in appeal relative to other products and products rated more bitter or harsh were associated with lower appeal ratings relative to other products. Between-subjects smoothness was related to greater appeal and between-subjects harshness was associated with lower appeal, but there were no significant two- or three-way interactions for between-subjects sensory attributes. There were, however, several three-way interactions for within-subjects sensory attributes, body dissatisfaction, and gender as described below. No models were significant for binge-eating symptoms.
Table 2.
Multilevel models of sweetness, eating disorder symptoms, and sex predicting appeal ratings
| Stratified Analyses | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Overall Sample | Men | Women | |||||||
| B | SE | p | B | SE | p | B | SE | p | |
| Binge Eating | |||||||||
| Intercept | 33.98 | 9.87 | <.001 | - | - | - | - | - | - |
| Sex | 0.03 | 15.07 | .99 | - | - | - | - | - | - |
| Binge eating | −1.66 | 8.27 | .84 | - | - | - | - | - | - |
| Sweet WS | 0.54 | 0.05 | <.001 | - | - | - | - | - | - |
| Sweet BS | 0.41 | 0.18 | .03 | - | - | - | - | - | - |
| Sweet WS x Sex | −0.08 | 0.62 | .21 | - | - | - | - | - | - |
| Sweet BS x Sex | 0.07 | 0.30 | .83 | - | - | - | - | - | - |
| Sweet WS x Binge eating | −0.02 | 0.04 | .61 | - | - | - | - | - | - |
| Sweet BS x Binge eating | 0.02 | 0.16 | .93 | - | - | - | - | - | - |
| Sweet WS x Sex x Binge eating | 0.11 | 0.05 | .03 | - | - | - | - | - | - |
| Sweet BS x Sex x Binge eating | −0.20 | 0.23 | .38 | - | - | - | - | - | - |
| Pseudo R2 | .25 | - | - | ||||||
| Body Dissatisfaction (BD) | |||||||||
| Intercept | 30.02 | 11.48 | .01 | 35.48 | 12.29 | .005 | 14.58 | 13.52 | .28 |
| Body mass index | 0.31 | 0.23 | .19 | 0.06 | 0.29 | .84 | 0.75 | 0.38 | .05 |
| Sex | −3.48 | 13.40 | .80 | - | - | - | - | - | - |
| BD | −3.88 | 5.62 | .49 | −2.84 | 5.70 | .62 | 5.90 | 6.25 | .34 |
| Sweet WS | 0.56 | 0.05 | <.001 | 0.56 | 0.05 | <.001 | 0.44 | 0.04 | <.001 |
| Sweet BS | 0.39 | 0.19 | .04 | 0.40 | 0.19 | .03 | 0.47 | 0.18 | .01 |
| Sweet WS x Sex | −0.13 | 0.06 | .04 | - | - | - | - | - | - |
| Sweet BS x Sex | 0.06 | 0.26 | .83 | - | - | - | - | - | - |
| Sweet WS x BD | −0.03 | 0.03 | .35 | −0.03 | 0.03 | .33 | 0.13 | 0.03 | <.001 |
| Sweet BS x BD | 0.02 | 0.11 | .89 | 0.01 | 0.11 | .95 | −0.19 | 0.13 | .13 |
| Sweet WS x Sex x BD | 0.15 | 0.04 | <.001 | - | - | - | - | - | - |
| Sweet BS x Sex x BD | −0.19 | 0.16 | .25 | - | - | - | - | - | - |
| Pseudo R2 | .26 | .26 | .27 | ||||||
Note. Appeal and sensory attribute ratings were 0-100 scale. Sex was coded 0=men and 1=women. Each ED symptom and sensory attribute were tested in separate models; Stratified models by sex were only run for models with significant three-way interactions. BS= between-subjects; WS=within-subjects
Table 5.
Multilevel models of harshness, eating disorder symptoms, and sex predicting appeal ratings
| Stratified Analyses | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Overall Sample | Men | Women | |||||||
| B | SE | p | B | SE | p | B | SE | p | |
| Binge Eating | |||||||||
| Intercept | 80.54 | 6.89 | <.001 | - | - | - | - | - | - |
| Sex | 3.29 | 11.03 | .77 | - | - | - | - | - | - |
| Binge eating | −5.84 | 5.50 | .29 | - | - | - | - | - | - |
| Harsh WS | −0.46 | 0.04 | <.001 | - | - | - | - | - | - |
| Harsh BS | −0.67 | 0.17 | <.001 | - | - | - | - | - | - |
| Harsh WS x Sex | −0.11 | 0.06 | .06 | - | - | - | - | - | - |
| Harsh BS x Sex | −0.06 | 0.27 | .84 | - | - | - | - | - | - |
| Harsh WS x Binge eating | −0.02 | 0.03 | .62 | - | - | - | - | - | - |
| Harsh BS x Binge eating | 0.12 | 0.13 | .38 | - | - | - | - | - | - |
| Harsh WS x Sex x Binge eating | 0.01 | 0.05 | .91 | - | - | - | - | - | - |
| Harsh BS x Sex x Binge eating | 0.13 | 0.23 | .57 | - | - | - | - | - | - |
| Pseudo R2 | .31 | - | - | ||||||
| Body dissatisfaction (BD) | |||||||||
| Intercept | 88.46 | 8.79 | <.001 | - | - | - | - | - | - |
| Body mass index | −0.07 | 0.21 | .76 | - | - | - | - | - | - |
| Sex | −13.08 | 9.41 | .17 | - | - | - | - | - | - |
| BD | −7.36 | 3.73 | .05 | - | - | - | - | - | - |
| Harsh WS | −0.51 | 0.05 | <.001 | - | - | - | - | - | - |
| Harsh BS | −0.72 | 0.15 | <.001 | - | - | - | - | - | - |
| Harsh WS x Sex | −0.01 | 0.06 | .90 | - | - | - | - | - | - |
| Harsh BS x Sex | 0.19 | 0.23 | .42 | - | - | - | - | - | - |
| Harsh WS x BD | 0.02 | 0.03 | .49 | - | - | - | - | - | - |
| Harsh BS x BD | 0.09 | 0.09 | .29 | - | - | - | - | - | - |
| Harsh WS x Sex x BD | −0.09 | 0.04 | .02 | - | - | - | - | - | - |
| Harsh BS x Sex x BD | −0.05 | 0.14 | .74 | - | - | - | - | - | - |
| Pseudo R2 | .32 | - | - | ||||||
Note. Appeal and sensory attribute ratings were 0-100 scale. Sex was coded 0=men and 1=women. Each ED symptom and sensory attribute were tested in separate models; Stratified models by sex were only run for models with significant three-way interactions. BS= between-subjects; WS=within-subjects
Sweetness models.
There was a significant three-way interaction for within-subjects sweetness, sex, and body dissatisfaction (Table 2). Stratified analyses by sex showed a significant two-way interaction of within-subjects sweetness and body dissatisfaction for female participants. Figures 1A depicts the interaction of within-subjects sweetness and body dissatisfaction for women. Higher product-specific sweetness ratings relative to a person’s mean level increased appeal more strongly among women with elevated body dissatisfaction.
Figure 1.
(A) Interaction of within-subjects sweet and body dissatisfaction in women; (B) Interaction of within-subjects bitter and body dissatisfaction in women; (C) Interaction of within-subjects bitter and body dissatisfaction in men; (D) Interaction of within-subjects smooth and body dissatisfaction in women. Estimated appeal ratings reflected on the Y-axis for each panel.
BD=body dissatisfaction; SD=standard deviation
Bitterness models.
There was a significant three-way interaction for within-subjects bitterness, sex, and body dissatisfaction (see Table 3). Stratified analyses by sex showed a significant two-way interaction of within-subjects bitterness and body satisfaction for both men and women. Figures 1B and 1C depict the interaction of within-subjects bitterness and body dissatisfaction for women and men, respectively. Higher product-specific bitterness ratings relative to the person’s mean level reduced appeal more strongly among women with elevated body dissatisfaction. Yet, this same inverse association in men was stronger for those with low body dissatisfaction.
Table 3.
Multilevel models of bitterness, eating disorder symptoms, and sex predicting appeal ratings
| Stratified Analyses | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Overall Sample | Men | Women | |||||||
| B | SE | p | B | SE | p | B | SE | p | |
| Binge Eating | |||||||||
| Intercept | 58.38 | 6.06 | <.001 | - | - | - | - | - | - |
| Sex | 11.88 | 9.80 | .23 | - | - | - | - | - | - |
| Binge eating | −1.97 | 5.15 | .70 | - | - | - | - | - | - |
| Bitter WS | −0.59 | 0.05 | <.001 | - | - | - | - | - | - |
| Bitter BS | −0.16 | 0.21 | .44 | - | - | - | - | - | - |
| Bitter WS x Sex | −0.01 | 0.07 | .91 | - | - | - | - | - | - |
| Bitter BS x Sex | −0.31 | 0.31 | .31 | - | - | - | - | - | - |
| Bitter WS x Binge eating | 0.07 | 0.04 | .09 | - | - | - | - | - | - |
| Bitter BS x Binge eating | 0.02 | 0.15 | .90 | - | - | - | - | - | - |
| Bitter WS x Sex x Binge eating | −0.09 | 0.05 | .07 | - | - | - | - | - | - |
| Bitter BS x Sex x Binge eating | 0.24 | 0.25 | .34 | - | - | - | - | - | - |
| Pseudo R2 | .23 | - | - | ||||||
| Body dissatisfaction (BD) | |||||||||
| Intercept | 63.48 | 8.55 | <.001 | 68.73 | 9.90 | <.001 | 48.34 | 12.57 | <.001 |
| Body mass index | 0.14 | 0.24 | 0.57 | −0.07 | 0.30 | .81 | 0.53 | 0.40 | .19 |
| Sex | −4.39 | 8.83 | .62 | - | - | - | - | - | - |
| BD | −6.93 | 3.28 | .04 | −6.44 | 3.38 | .06 | −3.47 | 3.87 | .37 |
| Bitter WS | −0.63 | 0.06 | <.001 | −0.63 | 0.05 | <.001 | −0.55 | 0.04 | <.001 |
| Bitter BS | −0.37 | 0.21 | .08 | −0.37 | 0.21 | .08 | −0.23 | 0.19 | .24 |
| Bitter WS x Sex | 0.08 | 0.07 | .27 | - | - | - | - | - | - |
| Bitter BS x Sex | 0.11 | 0.28 | .71 | - | - | - | - | - | - |
| Bitter WS x BD | 0.08 | 0.03 | .02 | 0.08 | 0.03 | .01 | −0.07 | 0.03 | .03 |
| Bitter BS x BD | 0.14 | 0.12 | .25 | 0.14 | 0.13 | .26 | 0.03 | 0.12 | .83 |
| Bitter WS x Sex x BD | −0.15 | 0.04 | <.001 | - | - | - | - | - | - |
| Bitter BS x Sex x BD | −0.11 | 0.17 | .52 | - | - | - | - | - | - |
| Pseudo R2 | .24 | .19 | .28 | ||||||
Note. Appeal and sensory attribute ratings were 0-100 scale. Sex was coded 0=men and 1=women. Each ED symptom and sensory attribute were tested in separate models; Stratified models by sex were only run for models with significant three-way interactions. BS= between-subjects; WS=within-subjects
Smoothness models.
There was a significant three-way interaction for within-subjects smoothness, sex, and body dissatisfaction (see Table 4). Stratified analyses by sex showed a significant two-way interaction of within-subjects smoothness and body satisfaction for women only. Figure 1D depicts the interaction of within-subjects smoothness and body dissatisfaction for women. Higher product-specific smoothness relative to the person’s mean level ratings increased appeal more strongly among women with elevated body dissatisfaction.
Table 4.
Multilevel models of smoothness, eating disorder symptoms, and sex predicting appeal ratings
| Stratified Analyses | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Overall Sample | Men | Women | |||||||
| B | SE | p | B | SE | p | B | SE | p | |
| Binge Eating | |||||||||
| Intercept | 9.25 | 8.77 | .29 | - | - | - | - | - | - |
| Sex | 5.35 | 14.10 | .71 | - | - | - | - | - | - |
| Binge eating | −3.12 | 7.64 | .68 | - | - | - | - | - | - |
| Smooth WS | 0.55 | 0.04 | < .001 | - | - | - | - | - | - |
| Smooth BS | 0.84 | 0.16 | <.001 | - | - | - | - | - | - |
| Smooth WS x Sex | 0.07 | 0.06 | .24 | - | - | - | - | - | - |
| Smooth BS x Sex | −0.11 | 0.24 | .66 | - | - | - | - | - | - |
| Smooth WS x Binge eating | 0.01 | 0.03 | .88 | - | - | - | - | - | - |
| Smooth BS x Binge eating | 0.03 | 0.14 | .82 | - | - | - | - | - | - |
| Smooth WS x Sex x Binge eating | 0.05 | 0.05 | .30 | - | - | - | - | - | - |
| Smooth BS x Sex x Binge eating | 0.11 | 0.23 | .63 | - | - | - | - | - | - |
| Pseudo R2 | .43 | - | - | ||||||
| Body Dissatisfaction (BD) | |||||||||
| Intercept | 12.48 | 9.28 | .18 | 14.90 | 9.69 | .13 | 9.16 | 11.43 | .80 |
| Body mass index | −0.11 | 0.18 | .53 | −0.22 | 0.22 | .32 | 0.08 | 0.30 | .78 |
| Sex | 0.88 | 12.55 | .94 | - | - | - | - | - | - |
| BD | −1.60 | 4.85 | .474 | −1.43 | 4.82 | .77 | −6.07 | 6.86 | .38 |
| Smooth WS | 0.55 | 0.05 | <.001 | 0.55 | 0.05 | <.001 | 0.56 | 0.04 | <.001 |
| Smooth BS | 0.86 | 0.15 | <.001 | 0.86 | 0.15 | <.001 | 0.74 | 0.17 | <.001 |
| Smooth WS x Sex | 0.01 | 0.06 | .92 | - | - | - | - | - | - |
| Smooth BS x Sex | −0.10 | 0.22 | .64 | - | - | - | - | - | - |
| Smooth WS x BD | 0.004 | 0.03 | .89 | 0.004 | 0.03 | .89 | 0.11 | 0.03 | <.001 |
| Smooth BS x BD | 0.002 | 0.09 | .98 | 0.004 | 0.09 | .97 | 0.11 | 0.13 | .37 |
| Smooth WS x Sex x BD | 0.10 | 0.04 | .005 | - | - | - | - | - | - |
| Smooth BS x Sex x BD | 0.12 | 0.15 | .45 | - | - | - | - | - | - |
| Pseudo R2 | .43 | .40 | .46 | ||||||
Note. Appeal and sensory attribute ratings were 0-100 scale. Sex was coded 0=men and 1=women. Each ED symptom and sensory attribute were tested in separate models; Stratified models by sex were only run for models with significant three-way interactions. BS= between-subjects; WS=within-subjects
Harshness models.
There were no significant interactions between harshness, ED symptoms, and gender (see Table 5).
Discussion
This study involving controlled exposure to e-cigarettes in various types of flavors and sensory-modifying agents found that products eliciting more desirable sensory attributes were more appealing, especially for females with relatively higher body dissatisfaction. Consistent with previous research (Leventhal et al., 2020), independent of ED symptoms and sex, within-subjects variation sensory attributes were significantly associated with e-cigarette appeal. Specifically, products rated as sweeter and smoother were more appealing, whereas those rated as more bitter or harsh were less appealing—a typical profile of desirable sensory attributes. These results underscore the importance of sensory attributes in shaping the appeal of e-cigarettes in the overall population of tobacco product users but especially for females with elevations on some ED symptom domains.
Notably, higher e-cigarette sweetness ratings were most robustly associated with higher appeal in women with elevated body dissatisfaction, extending the notion that individuals with body dissatisfaction (i.e., a core transdiagnostic ED symptom) may be particularly sensitive to the incentive properties of sweet tastes to e-cigarettes (Chao et al., 2019; Goodman et al., 2018). This finding aligns with previous research suggesting that individuals with ED symptoms exhibit heightened preference and neural responsiveness to sweet stimuli (di Giacomo et al., 2022; Wierenga et al., 2014). Given that e-cigarettes offer sweet flavors without caloric intake, individuals with ED symptoms may find them particularly appealing, potentially using them as an alternative to consuming high-calorie foods. Congruently, prior work has shown a positive association between sweet taste preference and greater use of e-cigarettes for weight control, particularly among adults at-risk for EDs (i.e., higher body mass index; Mason et al., 2021). The current study also found that lower bitterness and higher smoothness ratings were more strongly associated with higher appeal in women with elevated body dissatisfaction for women. These findings suggest that women with higher body dissatisfaction may be more sensitive to a variety of sensory attributes, including unpleasant sensory experiences like bitterness. This is consistent with prior literature indicating that individuals with ED symptoms often exhibit altered sensory processing, including heightened sensitivity to aversive taste stimuli (Cobbaert et al., 2024).
In contrast, among men, lower bitterness ratings were associated with higher appeal more strongly among men with low body dissatisfaction, suggesting men with low body dissatisfaction may find products that are highly non-bitter particularly appealing. Perhaps for men with high body dissatisfaction, other properties are more important than low bitterness in predicting appeal, including a combination of flavor and mouth feel. Further research is needed to understand this effect, especially given that most research on taste sensitivity in EDs has focused on women and thus much less is known about sensitivity to taste among men with ED symptoms (Chao et al., 2020).
Importantly, no significant interaction effects with sex or ED-related symptoms were observed for between-subjects sensory attributes. This suggests that an individual’s overall tendency to perceive any e-cigarette as sweet, bitter, smooth, or harsh (regardless of the constituents and flavorings in an e-cigarette product) was not differentially predictive of appeal as a function of ED symptoms or sex. Instead, it was the within-subjects variations—specific to the product and its unique sensory-modifying constituents relative to other products—that drove ED-related variation in associations with appeal differentially across sexes. This distinction highlights the complexity of sensory perception and product appeal, suggesting inter-product variation in e-cigarette constituents that drive sensory perceptions of vaping may be more influential in determining e-cigarette preference in females with EDs rather than stable individual differences in sensory perception.
These findings have important public health and policy implications. The differential effects of ED symptoms on e-cigarette appeal, especially for women, suggest that certain individuals may be particularly vulnerable to e-cigarette product manipulations that boost flavor/appeal due to psychological and sensory-related factors. Regulatory efforts, such as restrictions on e-cigarettes flavors and other sensory-modifying additives, may reduce use among women with ED symptoms, who may be drawn to sweet-flavored e-cigarettes as a substitute for palatable foods. Because the US Food and Drug Administration is prescribed by the Tobacco Control Act to consider differential impacts of regulatory activities across populations who may be more vulnerable to the adverse impacts of tobacco use and disproportionately contribute to the overall population’s tobacco-related health burden, this research helps underscore the priority of focusing regulatory activities toward sensory-modifying additives in e-cigarettes. In this general population sample, appreciable portions of women expressed ED symptoms. Hence, ramping up enforcement to clear the market of unauthorized sweet-flavored e-cigarettes may be beneficial to the vulnerable subgroup of women with elevated body dissatisfaction.
Future public health and individual-level interventions aimed at reducing e-cigarette use should consider psychiatric comorbidities and sensory preferences to develop targeted approaches for prevention and cessation. Given that sensory appeal and reward responsiveness contribute to e-cigarette use, interventions targeting these mechanisms, such as mindfulness-oriented or reward-restructuring interventions that reduce the salience of nicotine cues and enhance natural reward sensitivity (Froeliger et al., 2017), may be particularly effective when adapted for individuals sensitive to sweet or smooth sensory experiences. In addition, metabolic disorders often overlap with ED symptoms and may be important to consider in future work on e-cigarette use and appeal (Yu & Muehleman, 2023). It may be that females with ED symptoms have particular difficulty quitting e-cigarettes if they vape palatable e-cigarette products, which clinicians should be aware of. The possibility that females with ED symptoms might increase or reduce their consumption of palatable foods when trying to quit vaping sweet and smooth e-cigarettes should be considered in intervention. Furthermore, considering motives for e-cigarette use (e.g., weight and appetite control motives) may be important in clients with ED symptoms to curb use of palatable e-cigarette products.
The key strength of the current study was use of an experimental laboratory appeal paradigm with a variety of e-cigarette flavors combined with the disaggregation of within- and between-subject ratings of sensory effects. Although, it is important to consider several limitations. While the experimental design allowed for a well-controlled study of e-cigarette product appeal, it remains to be seen whether the associations observed in our lab task are present in real-world vaping. Use of naturalistic methodologies (such as ecological momentary assessment) in future research could provide important information about the role of sensory attributes on product appeal and use of e-cigarettes. Also, the study does not allow us to make causal interpretations about the role of ED symptoms in the sensory attribute-appeal relationship. The study sample consisted of current users of e-cigarettes and/or cigarettes, which may limit generalizability to non-users or those at risk of initiating e-cigarette use. Future research should examine whether similar patterns emerge in non-users or individuals with a history of ED symptoms who have not used e-cigarettes. Although we focused on binge eating and body dissatisfaction as key ED symptoms, future studies should investigate additional ED-related factors, such as dietary restraint, compulsive exercise, and purging behaviors, to provide a more comprehensive understanding of the relationship between ED symptomatology and e-cigarette appeal. In addition, future work should examine e-cigarette sensory attributes and appeal among individuals with diagnosed EDs. Also, biopsychological factors such as genetic variations in taste sensitivity and neural and behavioral sensitivity to reward should be explored as potential contributors to individual differences in sensory perception and product appeal. Finally, it is important to mention that we assessed sex only in this study, and future studies should conduct a more comprehensive assessment of sex and gender identity.
This study adds to a burgeoning body of research on ED symptoms and e-cigarettes. Findings provide new evidence on how the association of sensory attributes on e-cigarette appeal ratings differ by ED symptom severity, particularly for women. E-cigarette appeal was more strongly elevated among women with greater body dissatisfaction when products were rated sweeter and smoother and less bitter compared to women with lower body dissatisfaction. This study does not provide insight into mechanisms that explain the findings. Yet, physiological and psychological differences related to taste and olfaction associated with EDs could be plausible mechanisms (e.g., Chao et al., 2020; Cobbaert et al., 2024), which should be explored in future research. These findings may have relevance to understanding e-cigarette use patterns and dependence potential in women and men with ED symptoms, but more research will be needed to determine the real-world impact and relevance of the current study results.
Supplementary Material
Role of Funding Sources:
This project was supported in part by grants U54CA180905 from the National Cancer Institute (NCI) and Food and Drug Administration (FDA) and K24DA048160 from the National Institute on Drug Abuse (NIDA). The content is solely the responsibility of the authors and does not necessarily represent the official views of NCI, FDA, or NIDA. The funding agencies 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 decision to submit the manuscript for publication.
Footnotes
Declaration of interests: The authors have no conflicts of interest to disclose.
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.
Data availability:
Data is available by request from the corresponding author.
References
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 10.1176/appi.books.9780890425596 [DOI] [Google Scholar]
- Bandi P, Star J, Minihan AK, Patel M, Nargis N, & Jemal A (2023). Changes in E-cigarette use among US adults, 2019–2021. American Journal of Preventive Medicine, 65(2), 322–326. 10.1016/j.amepre.2023.02.02 [DOI] [PubMed] [Google Scholar]
- Becker TD, Arnold MK, Ro V, Martin L, & Rice TR (2021). Systematic review of electronic cigarette use (vaping) and mental health comorbidity among adolescents and young adults. Nicotine and Tobacco Research, 23(3), 415–425. [DOI] [PubMed] [Google Scholar]
- Chao AM, Roy A, Franks AT, & Joseph PV (2020). A systematic review of taste differences among people with eating disorders. Biological Research for Nursing, 22(1), 82–91. 10.1177/1099800419872824 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cobbaert L, Hay P, Mitchell PB, Roza SJ, & Perkes I (2024). Sensory processing across eating disorders: A systematic review and meta-analysis of self-report inventories. International Journal of Eating Disorders. 10.1002/eat.24184 [DOI] [PubMed] [Google Scholar]
- Curran PJ, Howard AL, Bainter SA, Lane ST, & McGinley JS (2014). The separation of between-person and within-person components of individual change over time: a latent curve model with structured residuals. Journal of Consulting and Clinical Psychology, 82(5), 879–894. 10.1037/a0035297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Davis DR, Buta E, Green B, & Krishnan-Sarin S (2024). Sex differences in appeal, reward, and sensory experience of E-cigarette flavors among adults who smoke cigarettes. Preventive Medicine, 185, 108040. 10.1016/j.ypmed.2024.108040 [DOI] [PMC free article] [PubMed] [Google Scholar]
- di Giacomo E, Aliberti F, Pescatore F, Santorelli M, Pessina R, Placenti V, … & Clerici M (2022). Disentangling binge eating disorder and food addiction: a systematic review and meta-analysis. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 27(6), 1963–1970. 10.1007/s40519-021-01354-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Doran N, Brikmanis K, Petersen A, Delucchi K, Al-Delaimy WK, Luczak S, … & Strong D (2017). Does e-cigarette use predict cigarette escalation? A longitudinal study of young adult non-daily smokers. Preventive Medicine, 100, 279–284. 10.1016/j.ypmed.2017.03.023 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Drazen JM, Morrissey S, & Campion EW (2019). The dangerous flavors of e-cigarettes. New England Journal of Medicine, 380, 679–680. doi: 10.1056/NEJMe1900484 [DOI] [PubMed] [Google Scholar]
- Fadus MC, Smith TT, & Squeglia LM (2019). The rise of e-cigarettes, pod mod devices, and JUUL among youth: Factors influencing use, health implications, and downstream effects. Drug and Alcohol Dependence, 201, 85–93. 10.1016/j.drugalcdep.2019.04.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Froeliger B, Mathew AR, McConnell PA, Eichberg C, Saladin ME, Carpenter MJ, & Garland EL (2017). Restructuring reward mechanisms in nicotine addiction: A pilot fMRI study of mindfulness-oriented recovery enhancement for cigarette smokers. Evidence-Based Complementary and Alternative Medicine, 2017(1), 7018014. doi: 10.1155/2017/7018014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Han D, Wong M, Peraza N, Vogel EA, Cahn R, Mason TB, Kirkpatrick M, Tackett AP, & Leventhal AM (2024). Dose response effects of two nicotine salt formulations on electronic cigarette appeal and sensory attributes. Tobacco Control, 33, 434–440. 10.1136/tc-2022-057553 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Goldenson NI, Kirkpatrick MG, Barrington-Trimis JL, Pang RD, McBeth JF, Pentz MA, … & Leventhal AM (2016). Effects of sweet flavorings and nicotine on the appeal and sensory properties of e-cigarettes among young adult vapers: Application of a novel methodology. Drug and Alcohol Dependence, 168, 176–180. 10.1016/j.drugalcdep.2016.09.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Goodman EL, Breithaupt L, Watson HJ, Peat CM, Baker JH, Bulik CM, & Brownley KA (2018). Sweet taste preference in binge-eating disorder: A preliminary investigation. Eating Behaviors, 28, 8–15. 10.1016/j.eatbeh.2017.11.005 [DOI] [PubMed] [Google Scholar]
- Górna I, Napierala M, & Florek E (2020). Electronic cigarette use and metabolic syndrome development: A critical review. Toxics, 8(4), 105. 10.3390/toxics8040105 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Jafarzadeh NS, Han DH, Peraza N, Anderson MK, Harlow AF, Monterosso JR, Pang R, Mason TB, Hong K, Cahn R, & Leventhal AM (2025). Effect of packaging with vs. without candy-oriented marketing themes on the appeal and sensory attributes of flavored e-cigarettes. Tobacco Control. 10.1136/tc-2024-058904 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kechter A, Ceasar RC, Simpson KA, Schiff SJ, Dunton GF, Bluthenthal RN, & Barrington-Trimis JL (2022). A chocolate cake or a chocolate vape? Young adults describe their relationship with food and weight in the context of nicotine vaping. Appetite, 175, 106075. 10.1016/j.appet.2022.106075 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kreft IG, & De Leeuw J (1998). Introducing multilevel modeling. Sage. [Google Scholar]
- Lau L, Conti AA, Hemmati Z, & Baldacchino A (2023). The prospective association between the use of E-cigarettes and other psychoactive substances in young people: a systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 105392. 10.1016/j.neubiorev.2023.105392 [DOI] [PubMed] [Google Scholar]
- Leventhal A, Cho J, Barrington-Trimis J, Pang R, Schiff S, & Kirkpatrick M (2020). Sensory attributes of e-cigarette flavours and nicotine as mediators of interproduct differences in appeal among young adults. Tobacco Control, 29, 679–686. doi: 10.1136/tobaccocontrol-2019-055172 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Leventhal AM, Goldenson NI, Barrington-Trimis JL, Pang RD, & Kirkpatrick MG (2019). Effects of non-tobacco flavors and nicotine on e-cigarette product appeal among young adult never, former, and current smokers. Drug and Alcohol Dependence, 203, 99–106. 10.1016/j.drugalcdep.2019.05.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Leventhal AM, Mason TB, Kirkpatrick MG, Anderson MK, & Levine MD (2020). E-cigarette device power moderates the effects of non-tobacco flavors and nicotine on product appeal in young adults. Addictive Behaviors, 107, 106403. 10.1016/j.addbeh.2020.106403 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Mason TB, & Leventhal AM (2021). Relations among sweet taste preference, body mass index, and use of E-cigarettes for weight control motives in young adults. Eating Behaviors, 41, 101497. 10.1016/j.eatbeh.2021.101497 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Mason TB, Tackett AP, Smith CE, & Leventhal AM (2022). Tobacco product use for weight control as an eating disorder behavior: Recommendations for future clinical and public health research. International Journal of Eating Disorders, 55(3), 313–317. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Míguez-Burbano MJ, Vargas M, Quiros C, Lewis JE, Espinoza L, & Deshratan A (2014). Menthol cigarettes and the cardiovascular risks of people living with HIV. Journal of the Association of Nurses in AIDS Care, 25, 427–435. 10.1016/j.jana.2014.01.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems. (2018). Public Health Consequences of E-Cigarettes. Eaton DL, Kwan LY, Stratton K, editors. Washington (DC): National Academies Press (US). [PubMed] [Google Scholar]
- Neczypor EW, Mears MJ, Ghosh A, Sassano MF, Gumina RJ, Wold LE, & Tarran R (2022). E-cigarettes and cardiopulmonary health: review for clinicians. Circulation, 145(3), 219–232. 10.1161/CIRCULATIONAHA.121.056777 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Perkins KA, Donny E, & Caggiula AR (1999). Sex differences in nicotine effects and self-administration: review of human and animal evidence. Nicotine & Tobacco Research, 1(4), 301–315. 10.1016/j.ypmed.2024.108040 [DOI] [PubMed] [Google Scholar]
- Smith KE, Mason TB, Murray SB, Griffiths S, Leonard RC, Wetterneck CT, … & Lavender JM (2017). Male clinical norms and sex differences on the Eating Disorder Inventory (EDI) and Eating Disorder Examination Questionnaire (EDE-Q). International Journal of Eating Disorders, 50(7), 769–775. 10.1002/eat.22716 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Smith CE, Mason TB, Kechter A, Monterosso JR, & Tackett AP (2024). Eating disorder symptomatology among young adult cigarette and E-cigarette users. Substance Use & Misuse, 59(8), 1221–1227. 10.1080/10826084.2024.2330910 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Striegel-Moore RH, Rosselli F, Perrin N, DeBar L, Wilson GT, May A, & Kraemer HC (2009). Gender difference in the prevalence of eating disorder symptoms. International Journal of Eating Disorders, 42(5), 471–474. 10.1002/eat.20625 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wierenga CE, Ely A, Bischoff-Grethe A, Bailer UF, Simmons AN, & Kaye WH (2014). Are extremes of consumption in eating disorders related to an altered balance between reward and inhibition? Frontiers in Behavioral Neuroscience, 8, 410. 10.3389/fnbeh.2014.00410 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yu Z, & Muehleman V (2023). Eating disorders and metabolic diseases. International journal of Environmental Research and Public Health, 20(3), 2446. 10.3390/ijerph20032446 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data is available by request from the corresponding author.