Abstract
Background.
Although weight-related reasons for smoking and vaping have been examined in adults, research in adolescents is lacking. Thus, we examined the prevalence and correlates of using flavored e-liquids for appetite control or weight loss in high school adolescents.
Methods.
The analytic sample included 529 students who completed a school-based survey in Connecticut in Spring 2017 (50.6% female, 79.5% White, mean age 16.27 [SD=1.18], range 13–19 years). Inclusion criteria were past-30-day vaping, using ≥1 flavored e-liquid (past month), and having non-missing data on flavored e-liquid use for appetite control and weight loss. Participants reported on sex, age, race, past-30-day vaping and smoking frequency, nicotine e-liquid use, flavored e-liquid use (e.g., tobacco, mint, fruit, candy), and flavored e-liquid use for appetite control and/or weight loss.
Results.
Adolescent e-cigarette users (past 30-days) reported vaping flavored e-liquids for appetite control (13.8%) and weight loss (9.3%). Using flavored e-liquids for appetite control or weight loss, respectively, was associated with more frequent vaping (OR = 1.21; 1.21) and using more flavored e-liquids (OR = 1.33; 1.28, p-values < .01). Vaping candy-flavored e-liquids (OR = 1.16, p = 0.02) uniquely was associated with vaping for appetite control.
Conclusions.
A subset of adolescents reported using flavored e-liquids for weight-related reasons. These adolescents reported vaping more frequently than their counterparts, raising concerns about increased nicotine exposure. Research is needed to understand where adolescents learn about weight-motivated vaping (e.g., friends, social media) and whether weight-related motives promote e-cigarette initiation among e-cigarette naïve individuals or continued/escalating use among current users.
Keywords: adolescent, e-cigarette, vape, weight, diet, appetite
1.0. Introduction
E-cigarettes are the most commonly used tobacco product among adolescents; recent estimates suggest that 20.8% of high school students have used e-cigarettes (i.e., “vaped”) [1]. In 2016, the United States Surgeon General identified youth vaping as a major public health concern and called for efforts to develop programs to deter youth use [2]. To inform effective program development, we must understand adolescents’ motivations for vaping.
Although numerous vaping motivations have been identified in youth [3], weight-related motives have not yet been examined. However, there are several reasons to believe that weight-motivated vaping is occurring in youth. First, developmental and social factors may confer risk [4–7]. Adolescence is a developmental period when weight and body image become increasingly salient [4]. Coupled with the fact that more than one third of American adolescents are overweight [5], concerns about weight [6], “fat-talk” (i.e., negative conversations about body-related issues [6]), and weight-related bullying increase during adolescence, often prompting negative body image and dieting (especially among girls) [4,7]. Collectively, these factors may set the stage for weight-motivated vaping.
Second, research demonstrates links between adolescents’ weight and both smoking and vaping behavior [8–10]. Regarding smoking, adolescents who have a higher Body Mass Index (BMI), perceive themselves as overweight, and/or who are trying to lose weight are more likely to smoke [8]. Regarding vaping, obese male (but not female) adolescents are at increased risk for past-30-day vaping compared to healthy-weight boys [9]. Further, college student e-cigarette users with weight concerns have been shown to vape more frequently than those without weight concerns [10], although weight-related vaping was not assessed explicitly.
Third, adult research suggests that a number of features of e-cigarettes, themselves, including nicotine content and the availability of flavored e-liquids, may promote weight-motivated vaping [11,12]. Nicotine may appeal to individuals who are trying to lose weight because it serves as an appetite suppressant, reduces cravings for sweet foods, and increases the body’s resting metabolic rate and daily caloric burn [13–14]. Although data from non-clinical samples are lacking, a recent study of adults with eating disorders [11], a population that also is at increased risk for weight-motivated smoking [15], highlights the link between nicotine and weight-motivated vaping. This study found that 32.0% of participants reported vaping for weight loss/control and that these individuals were more likely to use high nicotine concentrations [11].
In addition to nicotine, which also is available through smoking tobacco cigarettes, e-cigarette e-liquids uniquely are available in thousands of flavors, some of which mimic high-calorie or high-fat foods and beverages that likely are avoided when dieting (e.g., candy, alcohol [3,16]). Individuals who are trying to lose weight or control their weight may find these flavors particularly appealing as they allow users to have the experience of tasting the flavor without consuming calories. Two studies highlight the link between flavored e-liquid use and weight-motivated vaping. In a community sample of adult e-cigarette users who were attempting to lose or control their weight, 13.5% of participants reported vaping for weight loss/control (a single variable); correlates of vaping for weight loss/control included more frequent vaping, being overweight, restricting calories, having poor impulse control, and preferring coffee or vanilla-flavored e-liquids [12]. Further, within the study of adults with eating disorders referenced above, vaping for weight loss/control also was associated with the use of sweet e-liquid flavors [11]. Although the following was not assessed explicitly in the study, the use of sweet flavors reduces the harshness of using high concentrations of nicotine [17], which may increase the efficacy of weight-motivated vaping.
When considering the extant research on weight-motivated vaping in concert with findings that flavored e-liquids are disproportionately important determinants of vaping among adolescents compared to adults [18], adolescents may be at risk for using flavored e-liquids for weight-related reasons. Thus, we examined the prevalence and correlates of using flavored e-liquids for appetite control and weight loss in adolescents. While previous studies combined vaping for appetite control with vaping for weight loss [11–12], we examined them independently because each may reflect different behavioral profiles and goals (e.g., maintaining versus losing weight). Several potential correlates of weight-motivated flavored e-liquid use were examined. Although sex-based differences in weight-motivated vaping were not observed in adults [12], sex was included as a predictor based on research showing sex differences in smoking, vaping, body satisfaction, and dieting behavior [7–9]. Further, age was included because research shows that older adolescents are more likely to vape [19] and diet [7]. We also included cigarette smoking status based on research indicating links between adolescents’ weight, dieting behavior, and smoking [8]. As an exploratory aim, we examined racial differences in weight-related vaping. Finally, vaping frequency, nicotine e-liquid use, and e-liquid flavor use were included based on research linking these constructs to weight-motivated vaping in adults [11–12].
2.0. Material and Methods
2.1. Participants
Adolescents from 4 Connecticut high schools completed school-based, paper-and-pencil surveys in Spring 2017.
2.2. Procedures
The Yale University Institutional Review Board and local school administrators approved the study. We mailed information sheets about the survey to parents/guardians, which included instructions to decline their child’s participation (2 parents declined). Prior to survey administration, students were informed that participation was voluntary and anonymous. Completing the survey served as consent/assent.
2.3. Measures
2.3.1. Demographics
Participants reported on sex at birth (male/female), age, and race. For all analyses, race was dichotomized (White/Non-White).
2.3.2. Past-30 Day Vaping and Smoking Frequency
Participants answered two questions: “Approximately how many days out of the past 30 days did you vape an e-cigarette/smoke a cigarette?” (0–30 days). Participants who vaped/smoked on ≥ 1 day in the past 30 days were considered past-month e-cigarette users and/or smokers, respectively.
2.3.3. Nicotine e-liquid use
Participants reported whether they had “vaped e-cigarettes with nicotine in the past 30 days” (no/yes).
2.3.4. E-liquid flavors
Participants reported on “which flavors [they had] used in the past 30 days” (response options: tobacco, menthol, mint, fruit, candy, vanilla, alcohol, coffee, spice, other, and I don’t know). Based on research showing that the total number of flavors used in the past month predicts more frequent vaping in youth [18], we created a variable reflecting the total number of flavors used.
2.3.5. Vaping flavored e-liquids for weight management
Participants reported on reasons for vaping flavored e-liquids via the question: “Why do you use flavored e-liquids?” (select all that apply from they taste better than regular cigarettes, they help me to cut down on smoking regular cigarettes, they help me to quit smoking, they freshen my breath, they provide a throat hit, they taste good, they help me control my appetite, they help me lose weight, and other (write-in). The current study focused on responses to: “they help me control my appetite” and “they help me lose weight.”
2.3.6. Data Analytic Plan
First, we derived the analytic sample such that included participants reported past 30-day vaping, used ≥1 flavored e-liquid, and had valid data for weight-related vaping (Figure 1).
Figure 1.
Flow chart depicting how the analytic sample was derived
To examine whether the analytic sample differed from excluded past-month e-cigarette users, we ran chi-square analyses and independent-samples t-tests. We then ran descriptive statistics within the analytic sample. Next, using MPlus 7.0, we ran two binary logistic regression models in which sex, age, race, past 30-day vaping frequency, nicotine e-liquid use, and the use of each flavor were included as potential correlates of using flavored e-liquids for appetite control and weight loss, respectively. We conducted a second set of analyses where the total number of flavors used was included in place of individual flavors.
2.0. Results
The analytic sample comprised 529 adolescents (50.6% female, 79.5% White, mean age 16.27 [1.18], age range 13–19 years). Compared to excluded past-month e-cigarette users (n = 100), the analytic sample was more likely to use nicotine e-liquid; use all e-liquid flavors except alcohol and spice; and use a greater total number of flavors (analyses not shown, p-values < .05). Differences regarding flavored e-liquid use were expected because adolescents who did not endorse using flavors were excluded.
Adolescent e-cigarette users endorsed using flavored e-liquids for an average of 2.65 (1.80) reasons, with “good taste” being the most commonly endorsed reason (Table 1). Regarding the central study aims, adolescent e-cigarette users reported vaping flavored e-liquids for appetite control (13.8%) and weight loss (9.3%; see Table 1).
Table 1.
Descriptive statistics for 529 past-month adolescent e-cigarette users
| % or M (SD) | |
|---|---|
| Sex (Female) | 50.6 |
| Race (White) | 79.5 |
| Age | 16.27 (1.18) |
| Cigarette Smoking (Yes) | 21.0 |
| Vaping Frequency | 12.91 (11.03) |
| Nicotine E-liquid (Yes) | 81.4 |
| E-liquid Flavors | |
| Tobacco | 20.0 |
| Menthol | 16.4 |
| Mint | 53.9 |
| Fruit | 69.8 |
| Candy | 35.3 |
| Vanilla | 21.0 |
| Alcohol | 7.2 |
| Coffee | 10.8 |
| Spice | 5.1 |
| Other | 4.5 |
| I Don’t Know | 11.0 |
| Total Flavors Used | 2.79 (1.80) |
| Reasons for Flavored E-liquid Use | |
| Appetite Control | 13.8 |
| Weight Loss | 9.3 |
| Taste Good | 76.2 |
| Taste Better than Cigarettes | 68.1 |
| Provide Throat Hit | 35.0 |
| Help Cut Down on Smoking | 20.0 |
| Help Quit Smoking | 15.9 |
| Freshen Breath | 16.4 |
| Other | 10.8 |
| Total Reasons for Flavored E-liquid Use | 2.65 (1.80) |
Note. Data for categorical variables are presented in percentages. Data for continuous variables are presented as mean (standard deviation).
In the model in which demographic covariates and the use of individual e-liquid flavors were included as potential correlates of vaping flavored e-liquids for appetite control, vaping more frequently (OR = 1.20, p = 0.008) and vaping candy-flavored e-liquids (OR = 1.16, p = 0.021; Table 2) were significant. In the model in which the total number of flavors was included in place of the individual flavors, vaping more frequently (OR = 1.21, p = 0.004) and using a greater number of flavored e-liquids (OR = 1.33, p < 0.001) were associated with vaping flavored e-liquids for appetite control.
Table 2.
Correlates of using flavored e-liquids for appetite control and weight loss
| Appetite Control | Weight Loss | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| B | SE | Odds Ratio | 95% CI | B | SE | Odds Ratio | 95% CI | |||
| Individual Flavors | ||||||||||
| Age | 0.06 | 0.07 | 1.06 | 0.93 | 1.21 | 0.00 | 0.07 | 1.00 | 0.87 | 1.16 |
| Sex (Female) | −0.07 | 0.07 | 0.94 | 0.82 | 1.07 | −0.09 | 0.08 | 0.91 | 0.79 | 1.06 |
| Race (White) | −0.06 | 0.06 | 0.94 | 0.83 | 1.06 | −0.11 | 0.07 | 0.90 | 0.79 | 1.02 |
| Cigarette Smoking (Yes) | 0.10 | 0.07 | 1.11 | 0.96 | 1.28 | 0.06 | 0.08 | 1.06 | 0.37 | 1.26 |
| Nicotine E-liquid | −0.12 | 0.08 | 0.89 | 0.76 | 1.04 | −0.06 | 0.11 | 0.94 | 0.76 | 1.15 |
| Vaping Frequency | 0.18 | 0.07 | 1.20** | 1.07 | 1.36 | 0.19 | 0.08 | 1.21* | 1.04 | 1.40 |
| E-liquid Flavors | ||||||||||
| Tobacco | 0.11 | 0.06 | 1.12 | 0.99 | 1.00 | 0.02 | 0.07 | 1.02 | 0.89 | 1.15 |
| Menthol | 0.07 | 0.06 | 1.07 | 0.95 | 1.20 | 0.10 | 0.07 | 1.11 | 0.96 | 1.27 |
| Mint | −0.02 | 0.08 | 0.98 | 0.84 | 1.15 | 0.11 | 0.10 | 1.12 | 0.92 | 1.35 |
| Coffee | 0.02 | 0.06 | 1.02 | 0.92 | 1.14 | 0.07 | 0.06 | 1.07 | 0.95 | 1.20 |
| Fruit | 0.07 | 0.09 | 1.07 | 0.90 | 1.27 | −0.02 | 0.10 | 0.98 | 0.80 | 1.20 |
| Candy | 0.15 | 0.07 | 1.16* | 1.02 | 1.32 | 0.03 | 0.07 | 1.03 | 0.90 | 1.19 |
| Vanilla | 0.07 | 0.06 | 1.08 | 0.96 | 1.21 | 0.07 | 0.06 | 1.07 | 0.95 | 1.22 |
| Alcohol | 0.09 | 0.05 | 1.10 | 0.99 | 1.22 | 0.08 | 0.05 | 1.08 | 0.97 | 1.20 |
| Spice | 0.03 | 0.06 | 1.03 | 0.92 | 1.16 | 0.09 | 0.06 | 1.09 | 0.97 | 1.22 |
| Other | 0.03 | 0.06 | 1.03 | 0.92 | 1.16 | −0.05 | 0.08 | 0.95 | 0.83 | 1.11 |
| Don’t Know | 0.05 | 0.08 | 1.05 | 0.90 | 1.23 | 0.01 | 0.10 | 1.01 | 0.82 | 1.23 |
| Total Flavors Used | ||||||||||
| Age | 0.06 | 0.07 | 1.06 | 0.93 | 1.20 | 0.03 | 0.07 | 1.03 | 0.90 | 1.18 |
| Sex (Female) | −0.08 | 0.07 | 0.92 | 0.81 | 1.06 | −0.10 | 0.08 | 0.90 | 0.78 | 1.06 |
| Race (White) | −0.07 | 0.06 | 0.93 | 0.15 | 1.05 | −0.12 | 0.07 | 0.89 | 0.78 | 1.01 |
| Cigarette Smoking (Yes) | 0.13 | 0.07 | 1.14 | 1.00 | 1.30 | 0.07 | 0.08 | 1.07 | 0.92 | 1.25 |
| Nicotine E-liquid | −0.14 | 0.08 | 0.87 | 0.75 | 1.02 | −0.05 | 0.10 | 0.95 | 0.79 | 1.15 |
| Vaping Frequency | 0.19 | 0.07 | 1.21** | 1.06 | 1.38 | 0.19 | 0.08 | 1.21* | 1.05 | 1.40 |
| Total Flavors Used | 0.28 | 0.06 | 1.33*** | 1.19 | 1.49 | 0.25 | 0.07 | 1.28*** | 1.13 | 1.45 |
Note. Vaping frequency, nicotine e-liquid use, and flavors reflect past 30-day use.
p < .05
p < .01
p < .001
Regarding weight loss, the first model (individual flavors) showed that vaping more frequently was significantly associated with vaping flavored e-liquids for weight loss (OR = 1.21, p = 0.014). In the second model (the total number of flavors), vaping more frequently (OR = 1.21, p = .010) and using a greater total number of flavors (OR = 1.28, p < 0.001) were associated with vaping flavored e-liquids for weight loss.
4.0. Discussion
The current study is the first to demonstrate that some adolescents are vaping flavored e-liquids for weight-related reasons; 13.8% endorsed vaping flavored e-liquids for appetite control and 9.3% for weight loss. These rates were similar to the rate of weight-related vaping (broadly defined) observed in a community sample of adult e-cigarette users who were trying to lose weight (13.5% [12]). However, while this was not the central focus of the study, the majority of adolescents indicated using flavored e-liquids for multiple reasons (especially due to good taste), and using flavored e-liquids for weight-related reasons were comparatively infrequently endorsed motives. Yet it is worth noting that, contrary to motives like “[flavors] taste good,” which are applicable to all e-cigarette users, weight-related motives only are relevant to individuals who are trying to lose or maintain weight. Given that 37.6% of adolescents ages 16–19 try to lose weight each year [20], only a portion of whom are past-month e-cigarette users, the rates of using flavored e-liquids for weight-related reasons in this subpopulation likely is considerable.
The current study also identified user characteristics that were associated with using flavored e-liquids for weight-related reasons. Consistent with adult research [11–12], adolescents’ use of flavored e-liquids for appetite control and weight loss was associated with more frequent vaping. Future research can evaluate whether more frequent users discover that vaping suppresses appetite and/or facilitates weight loss or whether individuals who vape for weight-related reasons use more frequently to achieve weight-related goals. Consistent with research linking the use of more e-liquid flavors to frequent vaping in youth [18], the total number of flavors used in the past month was associated with using flavored e-liquids for appetite control and weight loss. Although additional research is needed to explain this finding, using multiple flavors may allow youth to more effectively substitute e-liquid flavors for a variety of foods. Further, consistent with adult research [12], adolescents who used a sweet-flavored e-liquid (in this case, candy) were more likely to report vaping for appetite control. Additional research is needed to fully understand the relationship between using sweet-flavored e-liquids and weight-motivated vaping, especially given that candy-flavored e-liquid use was a significant correlate in the current study while using sweet flavors that have been associated with adult vaping like vanilla were not [12]. It is possible that, similar to using sugar substitutes (e.g., aspartame), using sweet-liquids may lead to reduced intake of sugary foods and promote weight loss [21]. In addition, the use of sweet flavors increases the palatability of high nicotine concentrations, which may increase the efficacy of weight-motivated vaping [17].
Contrary to our hypotheses, neither demographics, smoking status, nor nicotine e-liquid use were associated with weight-motivated vaping. The null main effect for sex was consistent with research on weight-motivated vaping in adults [12], although additional research is needed to examine potential moderating effects of sex on weight-motivated vaping. Further, the null effect for age may be linked to the limited age range of the sample. Regarding race, research is needed within a more diverse sample to better ascertain whether there are race-based effects in weight-motivated vaping. Future research also is needed to understand the null effect of cigarette smoking. It may be that cigarette smoking is not related specifically to the use of flavored e-liquids for weight-related reasons but that smoking (or smoking for weight loss) is related to weight-motivated vaping, broadly defined. Finally, regarding nicotine use, the null findings may be driven by the fact that the majority of the sample (81.4%) reported using nicotine. Future research examining relationships between e-liquid nicotine concentration(s), which would have more variability, and weight-motivated vaping may allow for a more nuanced assessment of the link between nicotine use and weight-motivated vaping.
The current findings should be considered in light of several limitations. First, we examined the use of flavored e-liquids for weight-related reasons among youth rather than the broader use of e-cigarettes for weight loss and appetite control based on the question that was included in our study (“Why do you use flavored e-liquids?”). Given the appetite suppressant effects of nicotine and evidence that weight-related vaping among adults may be linked to characteristics of e-cigarette use that are unrelated to flavor [e.g., keeping hands busy, hand-to-mouth action; 22], additional research is needed to fully establish the prevalence and correlates of weight-motivated vaping, broadly defined, among youth. Second, we only assessed two weight-related vaping motives (appetite control and weight loss). Research is needed to assess the prevalence of additional weight-motivated vaping motives (e.g., weight maintenance, weight gain). Third, weight-related data including height and weight (from which BMI can be estimated), perceived weight status (e.g., underweight, overweight), dieting history (e.g., current, past), dieting practices (e.g., calorie restriction, exercise), and eating disorder history were not collected. Future research could explicate the relationship between these factors and weight-motivated vaping in youth. Finally, data were collected in Southeastern Connecticut, and it will be important to examine the prevalence of weight-motivated vaping in national surveys.
In sum, the current study suggests that a subset of adolescents is vaping flavored e-liquids for weight-motivated reasons. Importantly, these adolescents vaped more frequently than those who did not report weight-related flavor use, raising concerns about increased nicotine exposure. Future research should evaluate where adolescents learn about weight-related vaping (e.g., friends, social media) and whether weight-related motives promote e-cigarette initiation or continued/escalating use among current users. Finally, although replication is needed within nationally representative samples, prevention and intervention efforts targeting youth vaping should consider including information on weight-motivated vaping; this unsubstantiated use of e-cigarettes may confer risk for experiencing negative consequences of nicotine exposure in youth (e.g., impaired cognitive development, impulse control, risk for dependence [23]) and developing eating disorders [11].
Highlights.
13.8% of high school adolescents vaped flavored e-liquids for appetite control
9.3% of high school adolescents vaped flavored e-liquids for weight loss
Weight-related flavored e-liquid use was associated with more frequent vaping
Weight-related flavored e-liquid use was associated with using more e-liquid flavors
Vaping candy-flavored e-liquid was associated with vaping for appetite control
Acknowledgements
The authors wish to thank all participants who contributed to this work.
Role of Funding Source
Research reported in this publication was supported by grant number PD50DA036151 from the NIDA and FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.
Footnotes
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Conflict of Interest
Dr. Morean serves as a consultant for Gofire, Inc with a restricted stock agreement. The remaining authors report no conflicts of interest.
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