Prevalence and Factors Associated With Youth Vaping Cessation Intention and Quit Attempts

The NYTS is a school-based survey conducted annually to produce a nationally representative sample of US middle school (grades 6–8) and high school (grades 9–12) students. The 2020 NYTS was conducted by using a stratified, 3-stage cluster sampling procedure, and 14 531 students from 180 schools completed the questionnaire. The school participation rate was 49.9%, and the student response rate was 87.4%, yielding an overall response rate of 43.6%.¹⁷  A detailed description of the 2020 NYTS survey can be found on the NYTS Web site.¹⁸  Given the use of public data with deidentified information, this study is treated as nonhuman subjects research.

Students who reported having used e-cigarettes ≥1 day in the past 30 days were classified as current e-cigarette users¹⁹  and were asked the question, “Are you seriously thinking about quitting e-cigarettes?” Those who responded “Yes, during the next 30 days,” “Yes, during the next 6 months,” and “Yes, during the next 12 months” were classified with “an intention to quit vaping in the next 12 months.”

Past-year vaping quit attempt among current e-cigarette users was measured by responding ≥1 time to the question, “During the past 12 months, how many times have you stopped using e-cigarettes for one day or longer because you were trying to quit using e-cigarettes for good?” with response options “I did not try to quit during the past 12 months,” “1 time,” “2 times,” “3 to 5 times,” “6 to 9 times,” and “10 or more times.” Among those who responded with ≥1 past-year vaping quit attempt, the frequency of quit attempts was coded as a continuous variable in the range from 1 to 10 (1, 2, 3–5 [recoded = 4], 6–9 [recoded = 7.5], ≥10 times [recoded = 10]).

Current e-cigarette users were categorized as “occasional” (≤5 days), “moderate” (5–19 days), and “frequent users” (≥20 days) on the basis of the frequency of e-cigarette use in the past 30 days.²⁰  Current e-cigarette users who reported using e-cigarettes that tasted like menthol, mint, clove or spice, alcohol, candy, fruit, chocolate, or any other flavor were classified as “flavored e-cigarette users.” On the basis of the difference between the age when respondents first used an e-cigarette and their current age, vaping duration was created as 4 mutually exclusive groups: <1 year, 1 year, 2–3 years, and >3 years. Vaping products used in the past 30 days and perceived harm of e-cigarette use were also analyzed.

Current other tobacco users were defined as those who reported using ≥1 nonelectronic-cigarette tobacco products (ie, cigarettes, cigars, smokeless tobacco products, hookahs, pipe tobacco, bidis, and heated tobacco product) on ≥1 day in the past 30 days.⁷  Those who reported only using e-cigarettes currently were defined as “sole e-cigarette users,” and those who reported co-use of e-cigarettes and cigarettes or other tobacco products were defined as “dual or poly users.” Nicotine craving within 30 minutes of waking up was measured by the question, “How soon after you wake up do you want to use a tobacco product?”²¹ 

Participants were asked, “What are the reasons that you have used e-cigarettes?” This study analyzed motivation to quit smoking (ie, “To try to quit using other tobacco products, such as cigarettes”) and the other 3 top reasons for youth vaping (ie, “A friend used them,” “I was curious about them,” and “I can use them unnoticed at home or at school”). To avoid multicollinearity in regression models, I excluded reasons with low prevalences (eg, “They cost less than other tobacco products”) and reasons highly correlated with existing covariates (eg, “They are less harmful than other forms of tobacco”). Demographic variables and other covariates are described in Table 1.

Sampling weights, survey strata, and primary sampling units were included in the analysis to account for the complex survey design. After descriptive analyses, weighted estimates and 95% confidence interval (CI) of the prevalence of intention to quit vaping and past-year vaping quit attempts among current e-cigarette users were reported. Among those who reported past-year vaping quit attempts, the weighted frequency and SE of vaping attempts were also reported. Multivariable logistic (dichotomous outcomes: intention to quit vaping and past-year vaping quit attempt) or linear (continuous outcome: frequency of vaping quit attempts) regression models were conducted to examine factors associated with vaping cessation behaviors, yielding adjusted odds ratios (aORs) or regression coefficients (b’s) with 95% CIs, respectively. Unadjusted logistic or linear regressions were also reported. Missing data in the explanatory variables (n range: 0–187) were managed by multiple imputation with 20 multiply imputed data sets.²²  Statistical analyses were performed by using SAS 9.4 (SAS Institute, Inc, Cary, NC), and P values <.05 were considered statistically significant.

Of 1769 current e-cigarette users in 2020, this study excluded 109 subjects lacking responses to the outcome variables (intention to quit vaping and past-year vaping quit attempts). The final analytical sample (n = 1660) included 47.9% female individuals, 85.0% high school students, 63.1% non-Hispanic white individuals, 5.7% non-Hispanic Black individuals, and 26.7% Hispanic individuals (Table 1). Approximately 40.2% reported dual or poly use of e-cigarettes and other tobacco products, 55.5% perceived e-cigarette use to be harmful, and 42.0% reported using e-cigarettes due to curiosity.

As shown in Table 2, 53.4% of current e-cigarette users reported intention to quit vaping. The prevalence of intention to quit vaping was lower among female individuals than among male individuals (50.6% vs 56.1%, aOR = 0.7 [0.5–0.8], P = .0004). Students who reported using a modifiable system in the past 30 days had a lower prevalence of intention to quit vaping than disposable e-cigarette users (33.1% vs 61.0%, aOR = 0.4 [0.2–0.9], P = .0204). Dual and poly users of e-cigarettes and other tobacco products had a lower prevalence of intention to quit vaping than sole e-cigarette users (aOR = 0.7 [0.6–0.9], P = .0144), and students who perceived e-cigarette use to be harmful (versus no or little harm) had a higher prevalence of intention to quit vaping (aOR = 2.2 [1.7–2.8], P < .0001). Current e-cigarette users who reported using e-cigarettes because a friend used them had a higher prevalence of intention to quit vaping (aOR = 1.5 [1.2–1.9], P = .0003), whereas those who reported using e-cigarettes for concealing had a lower prevalence of intention to quit vaping (aOR = 0.4 [0.3–0.6], P < .0001). Current e-cigarette users who reported having seen or heard “The Real Cost” campaign (versus no or not sure) had a higher prevalence of intention to quit vaping (aOR = 1.5 [1.0–2.1], P = .0375).

As shown in Table 3, 67.4% of current e-cigarette users reported ≥1 past-year vaping quit attempt. Concurrent users of e-cigarettes and other tobacco products had a lower prevalence of past-year quit attempts than sole e-cigarette users (63.3% vs 70.2%, aOR = 0.7 [0.5–0.9], P = .0144). Perceiving e-cigarette use to be harmful was associated with an increased likelihood of vaping quit attempts (aOR = 1.6 [1.2–2.1], P = .0037). Individuals who used e-cigarettes to disguise vaping at home or school were less likely to report past-year quit attempts (aOR = 0.7 [0.5–0.9], P = .0126) whereas individuals who used e-cigarettes because of curiosity had higher odds of reporting past-year quit attempts (aOR = 1.4 [1.0–1.9], P = .0306). Current e-cigarette users who reported speaking a language other than English at home (versus not doing so) also had a higher prevalence of past-year quit attempts (aOR = 1.6 [1.7–2.5], P = .0068).

Table 4 is limited to current e-cigarette users who reported ≥1 past-year vaping quit attempt (n = 1117). On average, the subjects reported 5.3 vaping quit attempts in the past 12 months. The number of vaping quit attempts was lower among female individuals than among male individuals (5.0 vs 5.6, adjusted b [SE] = −0.6 [0.3], P = .0149). Subjects who reported using an e-cigarette with prefilled pods or cartridges (eg, JUUL) had a lower number of vaping quit attempts than those reporting the use of a disposable e-cigarette (adjusted b (SE) = −0.8 (0.3), P = .0111). The number of vaping quit attempts was lower among frequent e-cigarette users (versus occasional, b (SE)= −0.8 (0.3), P = .0286) and those who reported nicotine craving within 30 minutes of waking up (versus those who did not) (adjusted b (SE) = −0.8 (0.3), P = .0146).

This national study estimated that more than half of middle and high school current e-cigarette users (∼1.7 million) reported intention to quit vaping, and approximately two-thirds of them (∼2.2 million) reported past-year vaping quit attempts in the United States. Both prevalences were higher than the numbers reported in an earlier study using the PATH data in 2017.⁶  Although sampling methodologic differences between the NYTS (school-based) and PATH (home-based) and the differences in survey questions phrasing vaping cessation behaviors may attribute to some of these changes, the rapidly evolving e-cigarette markets and changes in regulations and policies of vaping products may also play a role in changes of vaping cessation behaviors. For instance, there was widespread media coverage to raise awareness of potential risks of vaping²³  after the 2019 e-cigarette, or vaping, product use associated lung injury outbreak. A growing body of research studies has identified adverse health effects of vaping among adolescents, with findings widely disseminated through social media and news sites.^23,24  Vaping control policies, such as Tobacco 21 laws, and antivaping endeavors may also contribute to the increase of youth vaping cessation behaviors.

The findings from this study may inform the development of future evidence-based vaping cessation interventions. For instance, perceived harm of e-cigarette use is strongly associated with both intention to quit vaping and past-year quit attempts. As shown in the previous qualitative studies, health effect is one of the top reasons for adolescents to quit vaping.^25,26  However, it is alarming that ∼44.5% of current e-cigarette users still perceived e-cigarette use as no harm or little harm, which could dampen the motivation for vaping cessation. Because of the lack of knowledge, adolescents could be under misconceptions such as “e-cigarettes deliver just water vapor” and “e-cigarettes are not tobacco products.”²⁷  Thus, vaping cessation programs should emphasize the adverse health outcomes of vaping and deliver the message that e-cigarettes, just like cigarettes, will increase risks of nicotine addiction, respiratory injury, cardiovascular illnesses, and other tobacco-related diseases.

This study is the first of its kind to report that dual and poly use of e-cigarettes with other tobacco products and reasons for vaping are significantly associated with youth vaping cessation behaviors. The dual and poly use of e-cigarettes and other tobacco products was also associated with reduced intention to quit and past-year quit attempts among adolescents. Multiple biospecimen studies in conjunction with national surveys have shown that dual e-cigarette and tobacco users (versus exclusive e-cigarette users) have higher concentrations of known tobacco-related toxicants^28–30  and increased symptoms of nicotine dependence and addictions.²¹  This study reveals that students using e-cigarettes because of peer influence or curiosity were more likely to report an intention to quit vaping or past-year quit attempts, whereas those choosing vaping because of the concealed use were less likely to report quit behaviors. These reasons for vaping may reflect e-cigarette use patterns and nicotine addiction. For instance, students who use e-cigarettes because of curiosity or peer pressure are more likely to be exclusive e-cigarette users³¹  and less likely to be nicotine dependent. Thus, vaping cessation programs need to tailor interventions on the basis of reasons for e-cigarette use and dual and poly use status.

This study also provides early evidence of the association between e-cigarette devices and vaping cessation behaviors among adolescents. First, current e-cigarette users of a modifiable system had a lower prevalence of intention to quit vaping than users of other devices. In February 2020, the FDA issued an enforcement action on cartridge-based e-cigarettes with flavors other than tobacco and menthol.³²  However, the modifiable system is exempt from the flavor ban. Vaping products with a modifiable system allow users to customize voltage, temperature,³³  and electronic liquids, tending to deliver nicotine to the lungs more efficiently.³³  These features may increase the appeal and nicotine uptake from vaping. Alternatively, modifiable users (versus disposable product users) are also more likely to be users of combustible tobacco products.³⁴  Therefore, they may view vaping as a positive health change, leading to a lower intention to quit vaping. Second, JUUL or other pod users reported fewer quit attempts than users of disposable e-cigarettes. JUUL contains nicotine salt with a high nicotine concentration (3% or 5%), which may increase palatability and cause nicotine dependence among youth. A recent biomarker study found a high concentration of cotinine in urine samples among JUUL and other pod users.³⁵  Sleek product design, disguised use, extensive marketing, and flavors might also reduce cessation attempts among adolescent e-cigarette users. Lastly, disposable e-cigarette use increased significantly among US youth from 2019 to 2020 and has become an emerging public health challenge.³⁶  This study found that disposable e-cigarette users reported the highest prevalence of intention to quit vaping. It is possible that new disposable pod-style devices, such as Puff Bar, may attract experimental users of e-cigarettes out of curiosity and peer influence. These users were less likely to use other tobacco products and thus more likely to quit vaping.³⁷  Future studies are needed to assess the causal relationship between e-cigarette devices and youth vaping behaviors.

The FDA has included e-cigarettes in the “The Real Cost” campaign to educate youth about vaping risks.¹⁶  This study found that students who had seen or heard about “The Real Cost” campaign had a higher intention to quit vaping. Because many adolescents are interested in quitting vaping or have tried to quit vaping in the past year, researchers face an unprecedented urgency to conduct more empirical investigations of youth vaping cessation behaviors. Nicotine can pose adverse effects to brain development, causing addiction, stress, mood disorders, and loss of attention, memory, and impulse control.^4,13  A previous cohort study reported that vaping dependence is associated with youth e-cigarette use escalation.³⁸  This study further identified that frequent e-cigarette use and tobacco craving were correlated with fewer quit attempts. Symptoms of nicotine dependence could make cessation difficult and increase the risk of relapse.³⁹  Thus, development of efficacious interventions to address nicotine dependence, withdrawal symptoms, and coping skills can prevent youth vaping addiction.

This study has some limitations. First, intention to quit vaping and past-year vaping quit attempts are self-reported, and they are subject to recall and social desirability biases.⁴⁰  However, the test and retest reliability of self-reported behaviors related to tobacco use among adolescents is high.⁴⁰  Second, the data are cross-sectional and preclude the causal inference. Third, the definition of quit attempts requiring one day or longer may inflate true quit attempts because infrequent e-cigarette users often abstain from vaping for one day or longer. Fourth, because participants were asked about the type of e-cigarette used most often in the 2020 NYTS, the association of quit behaviors and use of multiple e-cigarette devices was not assessed in this study, which merits future research. Finally, although this study included various factors related to vaping cessation in the analyses, some confounders, such as household income, parental education, and socioeconomic status, were not asked in the 2020 NYTS and may affect the outcomes.

Despite these limitations, this study reported that intention to quit and past-year quit attempts are prevalent among US adolescent e-cigarette users. Multifaceted factors, including vaping devices, multiple tobacco use, vaping reasons and harm perceptions of e-cigarette use, and nicotine dependence, are associated with youth vaping cessation behaviors. Development and dissemination of evidence-based vaping cessation programs are needed to curb the youth vaping epidemic.

HD had full access to all the data in the study and takes responsibility for the integrity of the data.

aOR

adjusted odds ratio

b

regression coefficient

CI

confidence intervale-cigarette, electronic cigarette

FDA

US Food and Drug Administration

NH

Non-Hispanic

NYTS

National Youth Tobacco Survey

PATH

Population Assessment on Tobacco and Health