Psychosocial stressors and current e-cigarette use in the youth risk behavior survey

As defined by the World Health Organization, adolescence encompasses the phase of life between childhood and adulthood, from 10 to 19 years [1]. Tobacco consumption frequently commences and becomes established during this developmental period, with approximately 90% of adults who use combustible cigarette in the United States (U.S.) initiating tobacco use by age 18, and 98% by 26 years [2, 3]. Given this early onset of tobacco use, it is not surprising that cigarette smoking currently persists as a primary preventable cause of disease, disability, and mortality globally [1, 4]. Despite efforts to reduce tobacco use, the World Health Organization reports that tobacco use kills more than 8 million people yearly and causes various health problems, including cancer, cardiovascular disease, and respiratory diseases [1].

Recent data from the Youth Risk Behavior Survey (YRBS) show a decline in current cigarette smoking, cigar smoking, and smokeless tobacco use among adolescents [5]. This is a promising trend; however, the introduction of e-cigarettes and the ease at which these devices can be purchased have raised concerns about a possible reversal of years of progressive decline in tobacco consumption [6, 7]. The recently published Morbidity and Mortality Weekly Report, over two million middle and high school students reported current (past 30-day) e-cigarette use, with two in five reporting frequent e-cigarette use, and one in four reporting daily use [8]. E-cigarettes are handheld devices containing aerosols with nicotine, additives, aldehydes, formaldehyde, and other harmful or potentially harmful chemicals [9]. Nicotine in e-cigarettes can cause addiction and harm the developing brain [10, 11]. Although evidence varies, some studies suggest that e-cigarettes may act as a gateway to using other tobacco products like combustible cigarettes [12, 13]. Given these findings, ongoing monitoring of adolescent tobacco use and comprehensive strategies aimed at addressing traditional and emerging tobacco product use among youth are essential.

Psychosocial stressors encompass a wide range of short and long-term adverse life events that can impact an individual's psychological well-being and social functioning, such as experiences of trauma, loss, interpersonal conflicts, financial difficulties, academic pressures, and exposure to discrimination or marginalization [14, 15]. Such stressors can prompt the initiation and continued use of tobacco products, as has been shown among middle-aged adults [16, 17]. Prior studies have also shown that psychosocial stressors such as depression are associated with youth cigarette smoking as some youth may use smoking as self-medication for depression and anxiety [18, 19]. Psychosocial stressors may therefore influence e-cigarette use—the most common tobacco product among youth. Among youth, such stressor may include bullying, fights, and depression. A 2020 study showed that bullying was significantly associated with e-cigarette use among sexual minority youth in the U.S [20]. Furthermore, a longitudinal study conducted in 2018 demonstrated that externalizing symptoms, encompassing conduct disorder, attention-deficit/hyperactivity disorder, and oppositional defiant disorder, as well as internalizing symptoms, such as anxiety and depression, were strong predictors of nearly all forms of tobacco use, including e-cigarette consumption, in both youth and young adult populations [21].

Prior research into the association between psychosocial stressors and adolescent e-cigarette use has been constrained by a narrow focus on specific stressors and reliance on convenience samples, which may limit generalizability. Our study addresses these limitations by exploring a broader array of stressors, utilizing a nationally representative dataset, and evaluating the cumulative impact of stressors on e-cigarette use. We employed the 2019 National YRBS, which is representative of high school students in the U.S., to examine the associations and cumulative burden of diverse stressors on adolescent e-cigarette use. We hypothesized that adolescents exposed to psychosocial stressors will exhibit a higher prevalence and increased likelihood of e-cigarette use compared to their unexposed peers. The results of this study could inform targeted interventions and policies to reduce e-cigarette use among adolescents experiencing psychosocial stressors.

We used data from the 2019 YRBS, a cross-sectional nationally representative sample of U.S. high school students. The YRBS follows a three-stage cluster sampling design to generate a representative sample of students in grades 9 through 12. In 2019, the survey was administered in 78 locations across the U.S., including national and state levels, local school districts, territories, and tribal governments. A detailed description of the methodology used in the YRBS has been previously published [22].

Out of the 13,677 students who participated in the YRBS, we included only those who provided complete information on e-cigarette use, resulting in a final sample size of 12,797. The YRBS collects information every two years on health-risk behaviors that contribute to the leading causes of death and disability in students, including behaviors related to unintentional injuries and violence, substance use, unhealthy dietary habits, and insufficient physical activity. The school-level response rate for 2019 was 75.1%, while the student-level response rate was 80.3%, resulting in an overall response rate of 60.3% (i.e., [student response rate] × [school response rate]) [23]. Since we used publicly available, de-identified data, our study was exempt from institutional review board assessment.

Of the 12,767 participants, 49.5% were females, 13.4% were 18 years or older, 11.5% were African American, and 52.2% were White individuals. Approximately, 32.7% reported current e-cigarette use. Compared to individuals who reported no e-cigarette use, those who reported current e-cigarette use were more likely to be enrolled in 11^th grade or higher (55.5% vs. 43.2%), report current use of combustible cigarettes (15.9% vs 1.0%), smokeless tobacco (9.3% vs. 0.7%), cigar (14.4% vs. 0.9%), alcohol (64.8% vs. 12.2%) and marijuana (51.8% vs. 6.6%) (Table 1).

Utilizing the large and nationally representative data of U.S. high school students, our study highlighted a significant association between psychosocial stressor and current e-cigarette use, with higher e-cigarette use prevalence among individuals who reported experiencing stressors compared to those who did not. Additionally, the prevalence and odds of e-cigarette use increased in a graded manner with increasing psychosocial stressor burden scores. Also, in the supplemental analysis, we demonstrate significant associations between individual psychosocial stressors and combustible cigarette use, with the strength of the association comparable to that of e-cigarettes. These findings suggest that psychosocial stressors may influence adolescent e-cigarette and combustible cigarette use, further highlighting that stress reduction among adolescents could be a means to potentially reduce tobacco use in this population.

Previous research has shown a positive association between some psychosocial stressors such as bullying, family conflict, academic pressure, and e-cigarette use among adolescents [25‐28]. For example, one study demonstrated that adolescents who experienced bullying had 1.5 to 2 times higher odds of e-cigarette use than those who did not encounter bullying [28]. Our findings are consistent with this observation, indicating a 1.67 times higher likelihood of e-cigarette use among adolescents who reported that they had been bullied. Moreover, our study elucidates the significant association between stressors and e-cigarette use, showing that other forms of stressors, such as sexual assault, depressive symptoms, physical altercations, and weapon threats, are associated with 1.40 to 1.75 times significantly higher odds of e-cigarette use compared to adolescents without such experiences. Importantly, we also demonstrate a dose–response association, showing that participants with higher burden scores had a higher prevalence and 1.43 to 2.73 times higher odds of e-cigarette use compared to those with burden scores of zero. Furthermore, our study found that the strength of the association between psychosocial stressors and e-cigarette use is comparable to that of combustible cigarette use, which has been also shown in previous studies to be significantly associated with various psychosocial stressors [29, 30]. These findings highlight the intricate interactions between psychosocial stressors and adolescent tobacco use.

Adolescents frequently encounter stressors such as peer pressure, academic challenges, and family issues, which may increase their likelihood of using e-cigarettes [25‐28]. In this study, participants with higher burden scores, indicating greater exposure to psychosocial stressors, had a higher prevalence and odds of e-cigarette use than those without stressor experiences. These findings suggest that the accumulation of multiple stressors may exacerbate the association between stressors and e-cigarette use among adolescents. It is crucial to address adolescent e-cigarette use as they may turn to these products to cope with stress, which may indicate maladaptive coping mechanisms. The convenience and discreetness of e-cigarettes make them an attractive option for youth dealing with various forms of stress [31, 32]. Additionally, the lack of stricter enforcement of age-related sales restrictions making e-cigarettes easily accessible to youth, coupled with peer pressure, and the appeal of various flavors may contribute to adolescent use e-cigarettes to cope with stress [25, 33‐36]. Targeted advertising by e-cigarette companies, especially during vulnerable periods such as times of stress, has been found to increase adolescent use [35‐37]. This, compounded with some evidence suggesting that e-cigarettes may serve as a gateway to combustible cigarette use, further emphasizes the need to develop targeted intervention strategies to promote healthier coping mechanisms and prevent youth tobacco use during times of stress.

Our findings emphasize the critical need to address the intricate associations between various psychosocial stressors and high-risk behaviors such as e-cigarette use among adolescents. A comprehensive approach that includes mental health support, stringent control of e-cigarette and other tobacco product access, and marketing regulations is warranted to mitigate adolescent tobacco use. Mental health resources, including counseling and stress management programs, should be integrated into educational and community settings to facilitate adaptive coping strategies among adolescents. Concurrently, more stringent regulations may encompass enhanced enforcement of the minimum purchasing age, increased penalties for noncompliant retailers, expanded bans on flavored e-cigarettes, and tightened restrictions on youth-targeted marketing. Targeted educational campaigns, such as the Real Cost Campaign, can be beneficial in reducing adolescent e-cigarette use [38]. The Real Cost Campaign is a public health initiative that aims to prevent and reduce tobacco use among adolescents by highlighting the negative consequences of tobacco use. Thus, in addition to stricter enforcement of existing policies and educational campaigns, the findings of our study suggest that helping adolescents develop and adopt healthy ways of coping with stress may be instrumental in reducing adolescent tobacco use. This comprehensive approach can promote healthier behaviors, reduce e-cigarette use, and improve well-being within this vulnerable population.

Our study demonstrates a significant association of psychosocial stressors such as bullying, sexual assault, and safety-related absence from school with adolescent e-cigarette and combustible cigarette use, highlighting the need for a comprehensive approach that includes mental health support and school health programs in addition to stringent enforcement of access and marketing regulations as means of reducing youth tobacco use. Implementing these comprehensive measures may promote healthier behaviors and improve overall well-being among this vulnerable population.