Sports Team Participation and Vaping Among High School Students: 2015–2019

This was a secondary analysis of data from the 2015, 2017, and 2019 cycles of the national YRBS. The Centers for Disease Control and Prevention distributes the national YRBS, a self-administered questionnaire that is completed in the classroom, to a sample of noninstitutionalized high school students grades 9 through 12 every 2 years and uses a 3-stage cluster sample design to create a nationally representative sample of these students. The YRBS methodology has been described in greater detail elsewhere.²³ 

Current EVP and cigarette use were assessed with the questions “During the past 30 days, on how many days did you use an electronic vapor product?” and “During the past 30 days, on how many days did you smoke cigarettes?” For both questions, respondents were given 7 response options: “0 days,” “1 or 2 days,” “3 to 5 days,” “6 to 9 days,” “10 to 19 days,” “20 to 29 days,” and “all 30 days.” Students who did not smoke cigarettes but did use an EVP in the past 30 days were defined as current exclusive users of EVPs, henceforth referred to as EVP users. Similarly, those who did not use an EVP but did smoke cigarettes in the past 30 days were defined as current exclusive users of cigarettes, henceforth referred to as cigarette users. Those who used both EVPs and cigarettes in the past 30 days were classified as dual users. Those who did not use cigarettes or EVPs in the past 30 days were classified as nonusers. Among EVP users and cigarette users, frequency of EVP use and cigarette use, respectively, was dichotomized as intermittent (ie, 1-19 days in the past 30 days) and frequent (ie, ≥20 days in the past 30 days), consistent with the definition for “frequent use” as operationalized in the Morbidity and Mortality Weekly Report.²⁴ 

Sports team participation was assessed with the question “During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups.),” with response options ranging from “0 teams” to “3 or more teams.”

Participants were included in the analytic cohort if they had complete responses for questions assessing EVP use, cigarette use, and sports team participation, and could be classified as an EVP user, cigarette user, dual user, or nonuser. Weighted prevalence figures for population subgroups defined by grade, sex, and sports team participation were calculated for nonusers, cigarette users, and EVP users. These measures were compared between cigarette users and EVP users using second-order Rao-Scott adjusted χ² tests.

Multinomial logistic regressions were used to evaluate associations between sports team participation and EVP use, cigarette use, and dual use, comparing students who participated on 1, 2, or 3 or more sports teams against those who did not participate on any sports teams; multinomial logistic regression was also used to examine associations between EVP/cigarette use and a binary measure representing “any” sports team participation. Additionally, logistic regressions were used to determine whether, among EVP users and cigarette users, frequency of EVP use and cigarette use, respectively, was associated with sports team participation. Logistic regressions were adjusted for respondent sex, grade in school, and survey year. Given the low rate of incomplete responses for covariates included in our models and the low number of demographic measures available for multiple imputation, missing data were handled using listwise deletion when fitting adjusted models.

Analyses and calculations were performed using R (version 4.0.5) and packages survey (version 4.1-1) and svyVGAM (version 1.0) and accounted for the complex survey design of the YRBS. All analyses were conducted at an α of .05 and 95% confidence intervals (CIs) were derived for all odds ratios. This study consisted of secondary analysis of public use data, such that it does not constitute human subjects research and did not require institutional review board review or informed consent per Northwell Health institutional policy.

Of the 44 066 students in the combined 2015, 2017, and 2019 waves of the YRBS, 4972 and 9437 were missing data for cigarette/EVP use and sports team participation, respectively, such that 30 762 (80.4%) students met criteria for inclusion. Weighted to represent the national population of high school students, these participants were 50.1% female. A total of 23 326 (75.1%) were nonusers, 737 (2.3%) were cigarette users (of whom 166 [26.7%] were frequent users), 4853 (16.1%) were EVP users (of whom 886 [19.8%] were frequent users), and 1846 (6.5%) were dual users. A total of 13 972 (43.7%) participated on no sports teams, 8037 (25.4%) on 1 team, 5154 (17.4%) on 2 teams, and 3599 (13.5%) on 3 or more teams. Among students participating on 1 or more sports teams (n = 16 790), 74.5% were nonusers, 1.7% were cigarette users, 18.3% were EVP users, and 5.5% were dual users. Among students who did not participate on any sports teams in the past 12 months (n = 13 972), 75.9% were nonusers, 3.1% were cigarette users, 13.4% were EVP users, and 7.6% were dual users. Additional sample characteristics are shown in Table 1.

Odds ratios for associations between sports team participation and cigarette use and EVP use are presented in Table 2. Relative to high school students who did not participate on any sports teams, those that participated on at least 1 team were at lower odds of cigarette use (adjusted odds ratio [aOR], 0.58; 95% CI, 0.48-0.71). Similar associations with cigarette use were identified for participation on 1 sports team, 2 sports teams, and 3 or more sports teams. Conversely, participation on any sports team was positively associated with EVP use (aOR, 1.43; 95% CI, 1.30-1.58). Positive associations between EVP use and all measures of sports team participation were also noted. Notably, participation on at least 1 sports team was associated with lower odds of dual use (aOR, 0.75; 95% CI, 0.64-0.89), mirroring the direction of the association between sports team participation and exclusive cigarette use.

Among cigarette users, sports team participation was associated with lower odds of frequent versus intermittent cigarette use in all models (Table 3). Similarly, among EVP users, sports team participation was associated with lower odds of frequent versus intermittent EVP use in 2 of the 4 models (ie, any participation and ≥3 sports teams; Table 3).

This study demonstrates that sports team participation is broadly positively associated with EVP use in a cohort of US high school students. Moreover, our findings indicate that, among EVP users, those with any sports team participation are at lower odds of frequent versus intermittent EVP use. Our finding that adolescents participating on sports teams are more likely to use EVPs extends associations identified in provincially representative cohorts of Canadian youth to a nationally representative cohort in the United States.^15,16 

In terms of studies using cohorts of US high school students, Veliz et al analyzed responses from 12th-grade students in the 2014 and 2015 MTF cohorts (n = 4450), but did not find that EVP use was broadly associated with sports participation or with 11 of the individual 13 sports examined.¹⁷  Additionally, Lee et al did not detect an association between sports team participation and EVP use in the 2017 YRBS.²²  Although the newly observed relationship between EVP use and sports team participation in the current study could be a reflection of behavioral changes among US adolescents between the 2014-2015 MTF cohorts and the 2015-2019 YRBS cohorts, this is unlikely because analyses of provincially representative cohorts of Canadian youth from parallel timeframes consistently showed associations between e-cigarette use and sports team participation.^15,16  Instead, it is likely the larger sample size of the current study (n = 30 762) conferred greater statistical power, enabling us to detect the higher prevalence of EVP use among US high school students who participated on at least 1 sports team. With respect to the differences between the current study’s findings and those of Lee et al, the most likely explanation stems from the inclusion of dual users in the EVP user group of Lee et al.²²  Given our finding that the association between sports team participation and exclusive EVP use is in the opposite direction from the association between sports team participation and dual use, the inclusion of dual users by Lee et al in their exposed group without adjusting for cigarette use may have attenuated associations examined in their study. Another explanation for the differences in findings between the current study and Lee et al relates to sample size. Whereas Lee et al relied on a single-year cohort of the YRBS, the current study used 3 cohorts, improving our statistical power to detect associations of interest.²²  Notably, although the findings of Lee et al relating to sports team participation were not statistically significant, the directions of their associations were similar to those in the current study (ie, negative for cigarette use and positive for EVP use).

Interestingly, the associations observed in the current study between sports team participation and EVP use are the inverse of those identified between sports team participation and cigarette use. This phenomenon is likely explained by the substantial differences in health perceptions relating to EVPs and cigarettes among high school students, as well as the theory of peer group effect, which states that homophilic relationships established within peer groups tend to enhance the preexisting habits that align with the group’s shared interests.²⁵  Students who participate on sports teams tend to have better health practices and are more likely to abstain from behaviors they perceive to be unhealthy,^26,27  such as cigarette smoking. This was observed in the 1997 YRBS cohort, where Pate et al found that athletes were more likely to have healthier eating habits and less likely to engage in cigarette smoking and illegal drug use.¹⁹  However, adolescents’ perceptions regarding EVPs are generally more positive than those regarding cigarettes.^5,6,28,29  For example, in the 2014 National Youth Tobacco Survey, 73% of US adolescents believed that EVPs were less harmful than cigarettes and 47% believed that EVPs were less addictive.²⁸ 

Within sports teams, members often share similar health perceptions and interests, allowing the peer group effect to mediate behavior.³⁰  For example, abstinence from cigarette smoking is often highly prevalent and homogeneous within sports teams, so a newcomer to a sports team is less likely to initiate or continue smoking.^31,32  Conversely, given the low perceptions of health risks associated with vaping, we hypothesize that EVP use does not deviate substantially from the common interests and health perceptions shared by sports team members. Perhaps unsurprisingly, the associations noted between sports team participation and EVP use in the current study mirror those noted between sports team participation and smokeless tobacco product use in the 2001-2013 YRBS.³³  We speculate that perceptions regarding the impact of different forms of nicotine products on athletic performance may be driving the associations in the current study. As seen by trends observed in smokeless tobacco use, athletes may be more likely to use forms of tobacco that are deleterious to health as long as these tobacco products are not generally thought to have a negative impact on athletic performance.

Although the peer group effect and differences in health perceptions may explain the disparate risk profiles for cigarette use and EVP use, they fail to explain this study’s finding that, among EVP users, sports team participation is associated with less frequent EVP use. A possible explanation for this relationship is that students participating in sports may have less time available for EVP use, resulting in less frequent use than among students who do not participate on any sports teams. However, if this were the case, we would expect to see associations of differing magnitudes between frequency of EVP use and participation on 1 versus 3 or more sports teams. Qualitatively, this was not observed, suggesting that some other factors may be responsible for this finding. Further research is needed to better understand the role of sports team participation in potentially predisposing adolescents to EVP use while simultaneously protecting EVP users from more frequent use.

It has been previously shown that engaging in 60 minutes of physical activity fewer than 7 days per week is associated with increased odds of cigarette smoking and decreased odds of EVP use.³⁴  It is difficult to disentangle which components of sports participation (eg, physical activity, peer interactions, health perceptions) are most directly responsible for EVP use risk given that this is a cross-sectional study. This is especially challenging because, for many students, participation in sports likely constitutes much of their total physical activity.

Despite the statistical power and generalizability conferred by the study’s use of 3 years of YRBS data, our findings must be interpreted in the context of several important limitations. First, the YRBS did not assess the type or timing of sport participation. Some research has suggested that participation in noncontact sports (eg, gymnastics, swimming) is associated with a lower risk of cigarette use, whereas participation in high-contact sports (eg, football, wrestling) has the opposite association³⁵ ; it has been shown that traditionally male contact sports (eg, lacrosse, wrestling) are associated with increased risk of substance use.³⁶  Furthermore, because of the seasonal availability of specific sports, it is possible that EVP use or cigarette use could vary seasonally for high school students that participate in 1 or more sports teams; therefore, the timing of YRBS survey distribution and response collection, as well as the YRBS only inquiring about cigarette/EVP use within the 30 days before survey administration, could have introduced measurement error. Additionally, EVP use and cigarette use may have been underreported, potentially resulting in the misclassification of some participants and underestimation of vaping/smoking prevalence and frequency. Similarly, the YRBS did not sample youth who dropped out of school or were institutionalized; failure to capture data for these youths, as well as our exclusion of those with incomplete responses for EVP or cigarette use, had the potential to introduce selection bias to our analyses and may have led to further underestimation of smoking/vaping behavior among older teenagers.³⁷  Also, the use of 3 YRBS survey waves during a period in which vaping trends and patterns were in flux likely introduced heterogeneity into the sample; regressions attempted to account for this by controlling for the survey year, but residual confounding may have affected findings. Finally, as with any other cross-sectional analysis, this study could only investigate associations, but not causality, between sports team participation and EVP/cigarette use.

Our finding that sports team participation, a classic protective factor against cigarette smoking, is associated with higher odds of EVP use highlights the notable variation between patterns of EVP use and cigarette use among high school students in the United States as they relate to sports team participation. Moreover, our novel finding that student athletes that use EVPs do so less frequently than other EVP users may have implications for efforts to promote cessation or reduction of EVP use, warranting further research.

Given the known pulmonary health risks associated with EVP use,¹⁰  as well as the consequences of these health issues on athletic performance, aggressive efforts must be taken to educate student athletes, particularly those participating in high-contact sports, about the demonstrated (and suspected) health risks of EVP use.³⁸  Hopefully, just as communitywide efforts highlighting the health risks associated with cigarette smoking have been effective in substantially reducing cigarette smoking, targeted educational efforts about the health risks of EVP use will be able to mitigate the use of EVPs among high school students.³⁹ 

aOR

adjusted odds ratio

CI

confidence interval

EVP

electronic vapor product

MTF

Monitoring the Future

YRBS

Youth Risk Behavior Survey