Abstract
Background:
While several health risks of e-cigarette and marijuana use have been described, little is known about their associations with school-related outcomes and risky sexual behaviors in adolescents.
Objectives:
To determine the odds of adverse school outcomes and risky sexual behaviors among youth with single or dual use of e-cigarettes and marijuana.
Methods:
We used data from the 2015 and 2017 waves of the Youth Risk Behavior Survey, a nationally representative survey of high school students in the US. Participants (N=30,389) were divided into four exposure groups for single or dual use of e-cigarettes and marijuana. We compared rates of e-cigarette and/or marijuana use for different demographic characteristics using chi-square tests and performed multivariate logistic regressions exploring associations among e-cigarette and marijuana use and adverse school outcomes and risky sexual behaviors adjusting for confounding factors.
Results:
Participants reported e-cigarette-only (7.7%), marijuana-only (8.5%), and dual e-cigarette/marijuana (9.2%) use. Youth in all three use categories had higher odds of reporting grades that were mostly C’s or lower than youth with no use, but no difference was found between youth with e-cigarette-only vs marijuana-only use. Increased odds of having sex without a condom were seen in youth with marijuana-only use (vs. e-cigarette-only use or no use) but not in youth with e-cigarette-only use or dual use.
Conclusions:
We found increased odds of adverse school-related outcomes and contrasting sexual risk profiles among youth with single or dual e-cigarette and marijuana use.
Keywords: adolescent, cannabis, e-cigarette, nicotine, school, sexual health, student
Introduction
The high rates of use of nicotine-containing e-cigarettes among North American youth in recent years are well documented (Gentzke et al., 2019). Except for marijuana use, which has remained relatively stable over the past decade, this trend contrasts with decreasing rates of use of most other substances during adolescence (Johnston et al., 2020). In parallel, the perception of risk of regular e-cigarette and marijuana use remains low among youth, contributing to further acceptability of these substance use behaviors (Chadi, Levy, & Weitzman, 2020).
Single and dual use of e-cigarettes and marijuana have been associated with lower grades in school in a large cross-sectional study of US high-school students (Dai & Hao, 2017). Marijuana use during adolescence has also been associated with lower educational achievement during adulthood in a 10-year prospective cohort study (Thompson, Leadbeater, Ames, & Merrin, 2019).
E-cigarette and marijuana use have both separately been associated with increased rates of risky sexual behaviors. For instance, youth with e-cigarette-only or dual e-cigarette and cigarette use have been shown to be more likely than non-users to have four or more lifetime sexual partners (Demissie, Everett Jones, Clayton, & King, 2017). Similarly, male and female adolescents with past-year marijuana use have been shown to be more likely to report condomless intercourse in the past year adjusting for use of other substances (Chernick et al., 2020).
To our knowledge, the risks of adverse school outcomes and risky sexual health behaviors have not been described specifically in youth with single and dual e-cigarette and marijuana use since the widespread adoption of pod-based e-cigarettes in the US around the year 2015 (Fadus, Smith, & Squeglia, 2019). Building on a prior study showing similar, but increased mental health risk profiles among youth with single and dual e-cigarette and marijuana use (Chadi, Li, Cerda, & Weitzman, 2019), we test the hypothesis that youth with e-cigarette-only use will have similar adverse school outcomes and sexual risk profiles as youth with marijuana-only or dual e-cigarette and marijuana use.
Materials and methods
Study design
We used data from the two most recent waves (2015 and 2017) of the national Youth Risk Behavior Survey (YRBS) (Brener et al., 2004); the YRBS started including questions on e-cigarette use in 2015. This “pen and paper” survey was distributed to students in grades 9–12 across the majority of American states. Survey participants were selected through a three-stage cluster sample design to yield a nationally representative sample of high school students. Combined school and student response rates were 60% (Division of Adolescent and School Health, National Center for HIV/AIDS Viral Hepatitis STF and TB Prevention, & Centers for Disease Control, 2017) for a study sample size of 30,389 students, of which 26,821 (88.3%) had complete information for exposure to e-cigarettes and marijuana and basic socio-demographic characteristics. The study protocol was reviewed by the Boston Children’s Hospital Institutional Review Board (IRB) and deemed exempt.
Measures
Socio-demographic characteristics were obtained for all participants: sex at birth, grade in school, race/ethnicity and sexual orientation. Sexual orientation was divided into two categories: heterosexual and non-heterosexual (Lesbian, Gay, Bisexual, “I don’t know”, or having reported sexual intercourse with a partner of the same sex). Participants were divided into four exposure groups based on current use of e-cigarettes or marijuana: (1) no use, (2) e-cigarette-only use, (3) marijuana-only use, and (4) dual use. Current use was defined as any use of e-cigarettes (at least one day of use) or marijuana (at least one occasion of use) in the past 30 days. Participants answered two separate school-related questions about their grades and ability to focus and concentrate and three separate sexual health-related questions about number of partners, having sex under the influence of alcohol or drugs and having sex without a condom which were selected based on relevance and availability in the YRBS survey. Full questions and answer categories are detailed in Table 2.
Table 2.
Associations among past month use of e-cigarette, marijuana and dual use and reports of adverse school-related outcomes and high-risk sexual behaviors
| E-cigarette-only (vs. no use) | Marijuana-only (vs. no use) | Marijuana-only (vs e-cigarette-only) | Dual use (vs. no use) | Dual use (vs e-cigarette-only) | Dual use (vs marijuana-only) | |
|---|---|---|---|---|---|---|
| Outcome | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) |
| “During the past 12 months, how would you describe your grades in school?” (Most grades C’s or lower vs mostly A’s or B’s) | ||||||
| Crude | 1.97 (1.73, 2.26) | 2.63 (2.29, 3.02) | 1.33 (1.11, 1.59) | 3.06 (2.71, 3.45) | 1.55 (1.32, 1.82) | 1.16 (1.02, 1.32) |
| Adjusted | 1.64 (1.43, 1.87) | 1.86 (1.60, 2.17) | 1.14 (0.96, 1.36) | 1.98 (1.67, 2.35) | 1.21 (1.03, 1.43) | 1.06 (0.91, 1.24) |
| “Because of a physical, mental, or emotional problem, do you have serious difficulty focusing, remembering, or making decisions” (Yes vs No) | ||||||
| Crude | 1.50 (1.29, 1.75) | 1.63 (1.40, 1.90) | 1.09 (0.90, 1.33) | 2.17 (1.90, 2.47) | 1.45 (1.22, 1.71) | 1.33 (1.13, 1.56) |
| Adjusted | 1.33 (1.11, 1.58) | 1.17 (1.02, 1.36) | 0.88 (0.73, 1.07) | 1.39 (1.15, 1.68) | 1.05 (0.89, 1.24) | 1.19 (0.98, 1.43) |
| “During the past 3 months, with how many people did you have sexual intercourse?” (Two partners or less vs three partners or more) | ||||||
| Crude | 4.30 (2.88, 6.40) | 6.80 (4.90. 9.45) | 1.59 (1.13, 2.23) | 12.69 (9.59, 16.80) | 2.96 (2.05, 4.25) | 1.87 (1.41, 2.47) |
| Adjusted | 2.23 (1.34, 3.72) | 2.65 (1.70, 4.12) | 1.19 (0.82, 1.72) | 3.52 (2.19, 5.68) | 1.58 (1.03, 2.43) | 1.33 (0.92, 1.92) |
| “Did you drink alcohol or use drugs before you had sexual intercourse the last time?” (Yes vs No)1 | ||||||
| Crude | 2.64 (1.89, 3.68) | 8.74 (6.68, 11.42) | 3.31 (2.51, 4.37) | 15.83 (12.60, 19.90) | 6.00 (4.45, 8.09) | 1.81 (1.49, 2.20) |
| Adjusted | 1.54 (1.08, 2.19) | 5.16 (3.77, 7.05) | 3.36 (2.54, 4.45) | 5.87 (4.31, 7.99) | 3.82 (2.77, 5.29) | 1.14 (0.90, 1.43) |
| “The last time you had sexual intercourse, did you or your partner use a condom?” (No vs Yes)1 | ||||||
| Crude | 0.97 (0.79, 1.20) | 1.55 (1.27, 1.89) | 1.59 (1.24, 2.03) | 1.41 (1.18, 1.67) | 1.44 (1.15, 1.81) | 0.91 (0.76, 1.09) |
| Adjusted | 0.96 (0.77, 1.19) | 1.41 (1.16, 1.71) | 1.48 (1.14, 1.92) | 1.12 (0.91, 1.38) | 1.17 (0.90, 1.52) | 0.79 (0.64, 0.98) |
Crude models represent unadjusted odds ratios. Adjusted models control for: sex, race/ethnicity, grade, sexual orientation and use of cigarettes, alcohol and illicit drugs (except marijuana). Statistically significant odds ratios are bolded.
Among youth reporting sexual activity in the past 3 months.
Analyses
We compared rates of e-cigarette and marijuana use based on socio-demographic characteristics and sexual orientation using chi-square tests. We then performed multivariable logistic regression analyses to explore the associations among single and dual e-cigarette and marijuana use and answers to questions about adverse school related outcomes and risky sexual behaviors. Based on previous literature using YRBS data, regression models were adjusted for survey year, school grade, sex assigned at birth, race/ethnicity, sexual orientation, and use of cigar/cigarettes, alcohol and illicit drugs (except marijuana) in the past 30 days, using indicator variables for each (Chadi et al., 2019; Nelon et al., 2019). Missing values for grade, sex assigned at birth, race/ethnicity and exposure to e-cigarettes and marijuana were not considered to be missing at random. As such, using domain analysis, we included only participants with complete data on basic socio-demographic characteristics and exposure to marijuana and e-cigarettes for descriptive and regression analyses, but included participants with missing data to estimate variance and confidence intervals, consistent with precedent practice (Vanderbroucke, 2017), as shown in Supplemental Figure 1. For outcomes of sex after using alcohol or drugs, and sex without a condom, responses from people who reported having no sex during the past 3 months were treated as missing values, thus not included in the corresponding regression analyses. Missing indicators (labelled “unknown”) were created for all other covariates and were included in the regression analyses.
All analyses were performed using SAS 9.4 (SAS Institute Inc., North Carolina). Survey procedures were used to account for the complex sampling design and results were weighted to reflect national estimates.
Results
Participant characteristics by single/dual use of e-cigarettes and marijuana are shown in Table 1. Past month frequency of e-cigarette and/or marijuana use among youth with single and dual use is illustrated in Figure 1.
Table 1.
Participant socio-demographic characteristics by exposure to e-cigarette and marijuana use
| Total | No use | E-cigarette-only use | Marijuana-only use | Dual use | P- value1 | |
|---|---|---|---|---|---|---|
| Characteristic | N (%) | N (%) | N (%) | N (%) | N (%) | |
| Total | 30389 (100.0) | 19504 (64.2) | 2334 (7.7) | 2569 (8.5) | 2807 (9.2) | |
| Grade | ||||||
| 9 | 8219 (27.0) | 5849 (30.0) | 551 (23.6) | 432 (16.8) | 546 (19.4) | <.0001 |
| 10 | 7743 (25.5) | 5070 (26.0) | 578 (24.8 | 624 (24.3) | 637 (22.7) | |
| 11 | 7216 (23.7) | 4361 (22.4) | 576 (24.7) | 728 (28.3) | 721 (25.7) | |
| 12 | 6960 (22.9) | 4093 (21.0) | 615 (26.4) | 772 (30.1) | 864 (30.8) | |
| Sex2 | ||||||
| Female | 14978 (49.3) | 9944 (51.0) | 1041 (44.6) | 1257 (48.9) | 1231 (43.9) | <.0001 |
| Male | 15178 (49.9) | 9415 (48.3) | 1286 (55.1) | 1301 (50.7) | 1551 (55.2) | |
| Race/ethnicity | ||||||
| White | 16072 (52.9) | 10546 (54.1) | 1404 (60.2) | 1017 (39.6) | 1600 (57.0) | <.0001 |
| Hispanic | 6712 (22.1) | 4061 (20.8) | 507 (21.7) | 701 (27.3) | 640 (22.8) | |
| Asian | 1080 (3.6) | 885 (4.5) | 54 (2.3) | 26 (1.0) | 41 (1.5) | |
| Black | 4018 (13.2) | 2454 (12.6) | 188 (8.1) | 609 (23.7) | 280 (10.0) | |
| Other | 1881 (6.2) | 1180 (6.0) | 151 (6.5) | 169 (6.6) | 178 (6.3) | |
| Sexual orientation | ||||||
| Heterosexual | 24470 (80.5) | 16191 (83.0) | 1962 (84.1) | 2017 (78.5) | 2147 (76.5) | <.0001 |
| Non-heterosexual3 | 4091 (13.5) | 2239 (11.5) | 266 (11.4) | 493 (19.2) | 535 (19.1) | |
| Unknown | 1828 (6.1) | 1074 (5.5) | 106 (4.5) | 58 (2.3) | 125 (4.5) | |
All frequencies and percentages are weighted. All percentages are column percent except for the total row (row percent).
P-values for general chi-square tests for each participant characteristic.
Sex defined as sex assigned at birth.
Non-heterosexual defined as youth who self-identified as gay, lesbian, bisexual or “not sure” or reported a sexual encounter with a partner of the same sex.
Figure 1.
Past 30-day frequency of marijuana, e-cigarette and dual marijuana/e-cigarette use among adolescents reporting use. All percentages are weighted and indicate proportions of respondents within each marijuana/e-cigarette single or dual use category reporting use corresponding to one of the four frequency ranges. E-cigarette use is defined as number of times used in the past 30 days. Marijuana use is defined as the number of days of use in the past 30 days. Frequency for dual use is reported separately for e-cigarettes and marijuana. For e-cigarettes, participants were asked to report use of “electronic vapor products, such as blu, NJOY, Vuse, MarkTen, Logic, Vapin Plus, eGo, and Halo” and told that “electronic vapor products include e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens”. For marijuana, participants were asked to report use of “marijuana also called grass, pot, or weed”.
Multivariable analyses revealed that youth in all categories of single and dual e-cigarette and/or marijuana use had higher odds of reporting adverse school outcomes, when compared to youth with no use of either substance, adjusting for socio-demographic and substance use confounders as shown in Table 2. However, no differences were found between youth with e-cigarette-only vs marijuana-only use. Youth with single or dual use had higher odds of reporting three or more sexual partners in the past 3 months and having sex after using alcohol or drugs than youth with no use. While youth with marijuana-only use had higher odds of reporting sex without a condom at last sexual intercourse than youth with no use, we did not find increased odds of reporting sex without a condom among youth with single e-cigarette and dual e-cigarette and marijuana use compared to youth with no use. We also found increased odds of using alcohol or drugs before sexual intercourse in youth with marijuana-only or dual use vs e-cigarette-only use as well as increased odds of having intercourse without a condom in youth with marijuana-only vs e-cigarette-only use.
Discussion
In our study, adolescents who endorsed e-cigarette-only, marijuana-only and dual e-cigarette and marijuana use had increased odds of reporting adverse school outcomes and high-risk sexual health behaviors compared to those who denied use.
Both nicotine and marijuana have known effects on the developing brain and can affect cognitive abilities on a short- and long-term basis (Salmanzadeh et al., 2020; Squeglia & Gray, 2016). Although our study design did not allow confirming which happened first between substance use and adverse school outcomes, our results suggest that use of nicotine and/or marijuana could be associated with poor educational attainment. While only a minority of participants with e-cigarette and/or marijuana use reported use more than 20 days/times in the past 30 days, regular use of both nicotine and marijuana can lead to physiological dependence and, in some cases, significant withdrawal symptoms which can interfere with school activities (DiFranza et al., 2007; Simpson & Magid, 2016). Conducting a dose-response analysis, which could help uncover whether heavier nicotine/marijuana use is associated with worse school outcomes would be a logical next step for our research.
There is a well-known association between adolescent substance use and risky sexual behaviors (McAloney, 2015). Our study suggests that e-cigarette use, though considered by many as a “cleaner” and “safer” alternative to smoking or other drugs (McKelvey, Baiocchi, & Halpern-Felsher, 2018), should be considered a risk factor for certain risky sexual behaviors. Though increases in odds of reporting several sexual partners were similar between use groups, odds of having sex after using alcohol or drugs were higher among youth with marijuana-only use than among youth with e-cigarette-only use.
Our results should be interpreted considering some limitations. First, this was a cross-sectional study and recall periods were not the same for substance use and risky sexual behavior questions; therefore, it was impossible to determine the temporal relation between e-cigarette/marijuana use and adverse outcomes and risky sexual behaviors. Second, the two questions used to reflect school-related outcomes, were the most relevant questions identified in the YRBS survey but may not capture all potential impacts of e-cigarette and/or marijuana on school functioning. Specifically, the question on concentration, focus and decision-making was double-barreled; more research is needed to separately examine the potential effects of e-cigarette and marijuana use on physical and mental health problems, which may then have an impact on school-related outcomes. Third, our study did not allow exploring whether shared risk factors for both substance use and school/sexual health related outcomes (e.g. mental health conditions, attention-deficit hyperactivity disorder) could help explain some of the associations we uncovered in our analyses. Fourth, e-cigarettes and other vaping devices are used to consume marijuana by approximately one-third of adolescents who report e-cigarette use (Johnston et al., 2020). This may have blurred the lines between use of nicotine-containing e-cigarettes and marijuana and was not captured in our study. Finally, this survey was school-based and voluntary, implying that youth who were absent from school on the day the survey was administered or who were not attending school—and who may present riskier health profiles—were excluded, limiting our study’s generalizability.
Considering the high prevalence of e-cigarette and marijuana use among adolescents, there is a need for effective prevention strategies and policy measures which could help mitigate the impacts of adverse school outcomes and risky sexual behaviors among students who use e-cigarettes and/or marijuana.
Supplementary Material
Acknowledgments
Declaration of interest: The authors declare that this article content has no conflict of interest of any kind. This work was supported by the National Institutes of Health (K23DA045085 and L40DA042434 to SEH); and the Thrasher Research Fund (Early Career Award, no grant number, to SEH). The funders had no role in the study design, in data collection, analysis or interpretation, in article development, or in the decision to submit the article for publication
References
- Brener ND, Kann L, Kinchen S. a, Grunbaum JA, Whalen L, Eaton D, … Ross JG (2004). Methodology of the youth risk behavior surveillance system. MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control, 53(RR-12), 1–13. https://doi.org/rr6201a1 [pii] [PubMed] [Google Scholar]
- Chadi N, Li G, Cerda N, & Weitzman E (2019). Depressive symptoms and suicidality in adolescents using e-cigarettes and marijuana: a secondary data analysis from the Youth Risk Behavior Survey. Journal of Addiction Medicine, epub. [DOI] [PubMed] [Google Scholar]
- Chadi Nicholas, Levy S, & Weitzman ER (2020). Moving beyond perceived riskiness: Marijuana-related beliefs and marijuana use in adolescents. Substance Abuse, 41(3), 297–300. 10.1080/08897077.2019.1635972 [DOI] [PubMed] [Google Scholar]
- Chernick LS, Chun TH, Richards R, Bromberg JR, Ahmad FA, McAninch B, … Spirito A (2020). Sex Without Contraceptives in a Multicenter Study of Adolescent Emergency Department Patients. Academic Emergency Medicine, 27(4), 283–290. 10.1111/acem.13867 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Dai H, & Hao J (2017). Electronic cigarette and marijuana use among youth in the United States. Addictive Behaviors, 66, 48–54. 10.1016/j.addbeh.2016.11.005 [DOI] [PubMed] [Google Scholar]
- Demissie Z, Everett Jones S, Clayton HB, & King BA (2017). Adolescent Risk Behaviors and Use of Electronic Vapor Products and Cigarettes. Pediatrics, 139(2), e20162921. 10.1542/peds.2016-2921 [DOI] [PMC free article] [PubMed] [Google Scholar]
- DiFranza JR, Savageau JA, Fletcher K, O’Loughlin J, Pbert L, Ockene JK, … Wellman RJ (2007). Symptoms of tobacco dependence after brief intermittent use: the Development and Assessment of Nicotine Dependence in Youth-2 study. Arch Pediatr Adolesc Med, 161(7), 704–710. 10.1001/archpedi.161.7.704 [DOI] [PubMed] [Google Scholar]
- Division of Adolescent and School Health, National Center for HIV/AIDS Viral Hepatitis STF and TB Prevention, & Centers for Disease Control. (2017). Youth Risk Behavior Surveillance System (YRBSS) 2017 YRBS Data User’s Guide. Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2017/2017_YRBS_Data_Users_Guide.pdf
- 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]
- Gentzke AS, Creamer M, Cullen KA, Ambrose BK, Willis G, Jamal A, & King BA (2019). Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018. MMWR. Morbidity and Mortality Weekly Report, 68(6), 157–164. 10.15585/mmwr.mm6806e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Johnston LD, Miech RA, O’malley PM, Bachman JG, Schulenberg JE, & Patrick ME (2020). Key Findings on Adolescent Drug Use: Monitoring the future survey results on drug use 1975–2019. Ann Arbor, MI. Retrieved from http://www.monitoringthefuture.org//pubs/monographs/mtf-overview2019.pdf [Google Scholar]
- McAloney K (2015). Clustering of Sex and Substance Use Behaviors in Adolescence. Substance Use & Misuse, 50(11), 1406–1411. 10.3109/10826084.2015.1014059 [DOI] [PubMed] [Google Scholar]
- McKelvey K, Baiocchi M, & Halpern-Felsher B (2018). Adolescents’ and Young Adults’ Use and Perceptions of Pod-Based Electronic Cigarettes. JAMA Network Open, 1(6), e183535. 10.1001/jamanetworkopen.2018.3535 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Nelon JL, De Pedro KT, Gilreath TD, Patterson MS, Holden CB, & Esquivel CH (2019). A latent class analysis of the co-occurrence of sexual violence, substance use, and mental health in youth. Substance Use and Misuse, 54(12), 1938–1944. 10.1080/10826084.2019.1618337 [DOI] [PubMed] [Google Scholar]
- Salmanzadeh H, Ahmadi-Soleimani SM, Pachenari N, Azadi M, Halliwell RF, Rubino T, & Azizi H (2020, March 1). Adolescent drug exposure: A review of evidence for the development of persistent changes in brain function. Brain Research Bulletin. Elsevier Inc. 10.1016/j.brainresbull.2020.01.007 [DOI] [PubMed] [Google Scholar]
- Simpson AK, & Magid V (2016). Cannabis Use Disorder in Adolescence. Child Adolesc Psychiatr Clin N Am, 25(3), 431–443. 10.1016/j.chc.2016.03.003 [DOI] [PubMed] [Google Scholar]
- Squeglia LM, & Gray KM (2016). Alcohol and drug use and the developing brain. Curr Psychiatry Rep, 18(5), 46. 10.1007/s11920-016-0689-y [DOI] [PMC free article] [PubMed] [Google Scholar]
- Thompson K, Leadbeater B, Ames M, & Merrin GJ (2019). Associations Between Marijuana Use Trajectories and Educational and Occupational Success in Young Adulthood. Prevention Science, 20(2), 257–269. 10.1007/s11121-018-0904-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Vanderbroucke DA (2017). Not So Simple: Intervals You Can Have Confidence in with Real Survey Data (No. Paper 970–2017). Retrieved from https://support.sas.com/resources/papers/proceedings17/0970-2017.pdf
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.