Assessing the Social Influences, Self-Esteem, and Stress of High School Students Who Vape

Abstract

Adolescent vaping is rapidly rising in Canada, and e-cigarettes have become the most widely used tobacco product among high school students; 29% of students in grades 10 to 12 reported e-cigarette use in 2019. Vaping among adolescents is a problem because the long-term health consequences of e-cigarettes remain unknown, large numbers of teens are becoming addicted to the harmful drug nicotine, and vaping has been shown to increase risk of initiation of combustible tobacco product use. To address the gaps in the current understanding of adolescent e-cigarette use, this study aims to examine the role of social peer and family influence, self-esteem, and stress on teen vaping. Seventy-nine students in grades 10 to 12 at an independent, co-ed high school in Toronto, Ontario completed an online survey about factors that influence them to vape, and about their perceived self-esteem and stress. Survey data was analyzed using Chi-Square tests and T-tests. Common motivations for vaping included stress relief (70%) and peer influence (60%). Family history of smoking or vaping and the ability to vape indoors also influenced vaping habits. Notably, e-cigarette users reported higher stress levels than non-users, but self-esteem levels were comparable. Our findings suggest that high school vaping prevention strategies should focus on stress reduction and encourage healthy coping strategies. Similar research studies should be conducted in other high schools, and future research should further explore the correlation between stress and adolescent vaping.

Introduction

The use of e-cigarettes has increased rapidly among high school students in Canada and the US [1]. In Canada, e-cigarette use in grades 10 to 12 tripled from 9% to 29% between 2017 and 2019 [2]. Similarly, in the US, e-cigarette use among high school students rose from 12% to 21% between 2017 and 2018 [3]. Electronic nicotine delivery systems, more commonly known as e-cigarettes or vapes, often contain flavorings, which have been shown to appeal to adolescent users more than traditional cigarettes [4]. However, e-cigarettes also contain several other chemicals, and many contain nicotine, an addictive and harmful substance [5]. Since vapes were first launched in 2003, more than 460 different e-cigarette brands have been introduced [5].

Increased vaping among adolescents is a societal and public health concern because the long-term health effects of vaping are mostly unknown. Research conducted on the short-term health effects of vaping have shown that vaping can cause lung injury and tissue destruction [6]. Many vapes also contain the addictive drug nicotine, which can lead to a nicotine dependence [7], excessive vaping [8], and cardiovascular complications [9], even without using other nicotine products. Additionally, adolescent use of e-cigarettes has been shown to increase the risk of initiating combustible tobacco product consumption, which poses many well established and serious health risks [10].

The growing literature on what motivates young adults to vape cite external factors such as peer influence, social image, and perceived lower health risks of vapes compared to cigarettes [1,11,12]. By contrast, there are fewer studies on the intrinsic characteristics, such as mental health and stress levels, of teens who vape. Studies conducted among university students found correlations between impulsivity, low self-esteem, and e-cigarette use [13], as well as high anxiety and e-cigarette dependence [14]. As best as we can determine, similar studies have not been conducted at a high school level. Additionally, studies on adolescent vaping in conjunction with stress have not been conducted.

This study aims to assess the vaping patterns of teen vapers at a Toronto high school, and examines the role of peer and family influence, self-esteem, and stress. The study adds to the growing literature surrounding adolescent vaping and mental health and is the first study to explore the relationship between teen vaping and stress. A greater understanding of motivations for teen vaping can inform preventative strategies to curb vaping among teens.

Methods

We conducted the survey within an independent, co-ed high school in Toronto, Ontario with 360 students in grades 10 to 12. The only inclusion criterion was being enrolled in high school; both vapers and non-vapers were surveyed. Within this population, 79 students (22%) agreed to participate in the study. Students completed an informed consent form and a 5-part close-ended survey (see Appendix A) on Google Forms using their personal laptops. Their anonymous responses were automatically recorded on a Google Sheets database. This survey was approved by the University of Toronto Schools’ Ethics board.

We adapted survey questions from the 2019 Environics Research and Health Canada “Vapers Panel Survey” [15]. The survey had five sections. Sections II to IV were completed by vapers only. Section I assessed demographics and family history of smoking or vaping. Section II assessed vaping habits, including details of vaping location and vaping patterns, to better understand the population of vapers. Section III asked participants to choose from a list of factors that influenced them to vape such as social image, stress relief, and peer or family influence. Participants also rated each factor’s influence on a five-point Likert Scale. Section IV asked participants about peer vaping patterns to assess the influence of peers. Section V measured self-esteem and stress using the Rosenberg Self-Esteem Scale [16] and the American Psychological Association (APA) Perceived Stress Scale [17]. We defined “regular vaping” as per the 2019 Health Canada definition: at least once a week for a period of 4 weeks in the past year [15]. We calculated medians, averages, and standard deviations for all quantitative variables, used Chi square tests to assess demographic differences between vapers and non-vapers, and used T-tests to assess the difference in stress and self-esteem levels of vapers and non-vapers. All tests used a critical value of p < 0.05.

Results

Demographics

Table 1 displays survey demographics. Of the 79 participants, 20 (25%) had vaped regularly in the past year, while 59 (75%) were non-vapers or vaped infrequently. The mean age was 16.4 overall and similar between the vapers and non-vapers. Twelve of the 20 (60%) vapers were female, but sex differences were not statistically different (p = 0.32). Family members’ history of smoking or vaping was more common in vapers (9 or 45%), compared to 15% (9) for non-vapers (p = 0.006).

Table 1. Age, Gender, and Family History of Vapers and Non-Vapers.

Variable	Total (N=79)	Non-Vapers (N=59)	Vapers (N=20)	Chi square (vapers vs non-vapers)
Mean Age	16.38 (0.91)	16.60 (0.96)	16.70 (0.66)
Gender
Male	36 (46%)	29 (49%)	7 (35%)
Female	41 (52%)	29 (49%)	12 (60%)
Other	2 (2%)	1 (2%)	1 (5%)	1.639*
Family history of smoking or vaping
No	61 (77%)	50 (85%)	11 (55%)
Yes	18 (23%)	9 (15%)	9 (45%)	7.512**

Note: Data are presented as mean (SD) for age and as N (%) for categorical variables. * p>0.05, 2 degrees of freedom, not significant. ** p<0.05 1 degree of freedom, significant.

Vaping Habits

In order to understand underlying factors that may influence teenagers to vape, participants who vaped were asked about their vaping habits. Nineteen of the 20 (95%) vapers started vaping within the past year. Nine vapers (45%) vaped primarily after school, and 13 vapers (65%) vaped primarily inside their home. Every respondent’s vape contained nicotine. Notably, 10 (50%) of the vapers had recently quit, either temporarily or permanently. An additional 6 (30%) planned to quit in the near future.

When asked about peer vaping habits, 13 vapers (65%) had used a friend’s vape before buying their own, and 3 (15%) continued to use a peer’s vape regularly without buying their own. Additionally, 12 (60%) respondents had peers who tried using the respondent’s vape before buying their own.

Reasons for Vaping

Participants were asked to choose from a list of factors that may influence them to vape and rate each factor on a scale of 1 to 5: “1” meaning no influence and “5” meaning maximum influence (Figure 1). “Stress relief” and “friends vaping” (or peer influence) were the most popular reasons for vaping, each listed by 70% and 60% of participants, respectively. These factors were followed by “use indoors” (45%) and “flavor choice” (35%). Few respondents listed “Use on social media” as a contributing factor (20%), and “Family vaping” was not a popular factor (15%). No respondents vaped in order to quit cigarettes.

Figure 1.

Reasons for Vaping and Relative Importance of Factors.

Self-Esteem and Stress

All participants completed the Rosenberg Self-Esteem Scale and the APA Perceived Stress Scale to investigate if vaping correlated with mental health traits. There was no significant difference in the self-esteem scores between vapers and non-vapers (p = 0.6356) (Figure 2). However, there was a difference in the stress scores: vapers were more stressed than non-vapers (p = 0.0409) (Figure 3).

Figure 2.

Rosenberg Self-Esteem Scale Scores.

Figure 3.

APA Perceived Stress Scale Scores.

We explored this correlation further by dividing the vaping group into current vapers and vapers who quit (N=10 for each). We then compared stress scale scores between the three groups in three different t-tests (Figure 3). None of the comparisons yielded a significant difference, most likely due to small sample size.

Discussion

This study aimed to assess the influences and mental health characteristics of adolescent vapers. We found that adolescents who vape at this high school are primarily motivated to vape by peer influences and for stress relief. Notably, teens who vape reported higher stress levels than non-vapers. The highest levels of reported stress were among teens who quit vaping recently. Family history of smoking or vaping or the ability to vape indoors also influenced their vaping habits. There was no significant difference in the self-esteem levels of vapers and non-vapers. This observation differs from previous findings among college age vapers, which found that vapers had lower self-esteem than non-vapers on the Rosenberg Self-Esteem Scale [13].

Stress relief was the most commonly cited reason for vaping and had the second highest rated influence (Figure 1). This finding suggests a strong connection between vaping and stress among adolescents. Interestingly, very few studies consider stress relief as a factor when assessing why teens vape. However, stress is a well-established determinant of cigarette uptake among teens [18-21]. Finkelstein et al. found that higher perceived stress among students in grades 7 to 12 was significantly correlated with smoking initiation [20]. Booker et al. found similar results among 6th graders, where stress and stressful life events were associated with intention to smoke [21]. This may be the case among teenage vapers as well. Future studies should continue assessing the linkage between stress relief and vaping.

Interestingly, although 70% of vapers said they vaped for stress relief, vapers reported significantly higher stress than non-vapers (Figure 3). Thus, even if teens are vaping for stress relief, they continue to report higher levels of stress than non-vapers. Long term cigarette use increases stress levels among adolescents, especially with frequent use [18,22]. Byrne et al. surveyed 6579 high school students and followed up with them after 12 months, finding that non-smokers who started smoking were significantly more stressed than those who remain non-smokers [19]. Although cigarette smoking is commonly believed to relieve stress, in fact long term use increases mood swings and heightens stress levels [23]. This may be due to nicotine’s ability to both stimulate and desensitize nicotinic acetylcholine receptors, which alter how stress response pathways function [24]. Since high stress levels are a common determinant of cigarette uptake, the correlation may also go the other way. The same question may be posed for vaping: do high stress levels lead to uptake of vaping or does vaping lead to high stress levels?

Peer influence was the second most cited reason for vaping and had the highest rated influence (Figure 1), consistent with other studies [1,12]. Indeed, the majority of survey respondents had shared vapes among their peers. Peer influences have also been documented as a strong determinant of teenage cigarette initiation and continuation in various countries [25].

Family history was a significant determinant of teen vaping. Family history of smoking is well recognized as a strong determinant of adolescent cigarette uptake [26]. Additionally, socio-economic status, which is connected to family history, has also been identified as a predictor of e-cigarette use among youth [27]. Thus, despite the respondents rating family history as relatively unimportant, it may be a major determinant of teen vaping decisions.

Limitations

This study expands the relatively limited number of quantitative studies on underlying factors that motivate adolescent vaping. However, there are two main limitations to this study. First, we had a small sample size of 360 and a low survey response rate of 22%. A larger sample size is required to examine differences with greater statistical reliability, or to conduct more advanced statistical tests such as multivariate linear and logistic regressions. For example, the p-value when comparing stress of ex-vapers and never vapers (p = 0.053) approached significance with a small sample size and would be confirmed or refuted with a larger number of observations. Despite the small sample size, this survey still yielded significant results and can serve as a framework for larger studies in the future.

Secondly, half of the vaping respondents reported quitting recently. Thus, we were unable to answer key questions, such as “In the past 30 days, how many days have you vaped?” or “Are you addicted to vaping”. These questions would allow us to understand if someone were a casual vaper or addicted to vaping and doing it every day. When answering questions about why they vape, they were answering in retrospect, which may have added recall bias.

Implications for Policy and Research

These findings point to possible interventions to reduce uptake of vaping by students, or to help current vapers quit. Peer influence plays a key role in teen vaping uptake, which suggests that students should be educated on how to combat peer influence and pressure when subtle or implicit.

Our findings show the connection between stress and uptake. Highly stressed teens may vape as an outlet for stress relief and then grow dependent. Thus, an important aspect of teen vaping prevention and cessation may be positive mental health initiatives, including support and guidance programs that provide students with more healthy ways of coping with their stress than vaping. This approach is related to other youth e-cigarette prevention programs, such as “CATCH My Breath,” which involves discussing motivations for vaping and exploring possible alternatives to satisfying these motivations [28]. Such an approach may benefit from a specific discussion on mental health and coping strategies.

Similar research should be conducted in other educational institutions to further understand adolescent motivations for vaping and how vaping correlates to stress and self-esteem. Further research is required to explore the correlation between stress and vaping, especially among adolescents. Along with survey-based research, clinical studies measuring cortisol levels could help quantify the stress of vapers or the impact of intervention programs. Study designs would need to consider the direction of effect: if vaping elevates stress levels in adolescents or are adolescents with higher stress levels more likely to start vaping in the first place. Studies should consider also how quitting vaping affects stress levels of adolescents and their mental health overall.

Conclusion

Our findings suggest that it would be useful for high schools to implement interventions aiming to prevent students from vaping and encourage current vapers to quit. These interventions should focus on mental health and stress levels of students, as well as addressing peer pressure. This study shows a novel correlation between high stress levels and e-cigarette use among adolescents, which should be explored further in future research. The study also expands the relatively limited number of quantitative studies on underlying factors that motivate adolescent vaping. Additionally, this study can be used as a template to inform similar studies in other schools. Such research will expand the evidence-base to help curb the rapid rise in adolescent vaping.

Glossary

NIDA

National Institute on Drug Abuse

US

United States of America

APA

American Psychological Association

Appendix A.

yjbm_94_1_95_appendix.pdf ^{(204.5KB, pdf)}