Adoption of Vaping Cessation Methods by US Adolescent E-Cigarette Users

The NYTS is an annual school-based survey to obtain a nationally representative sample of all regular public and private middle school (grades 6–8) and high school (grades 9–12) students in the 50 US states and the District of Columbia. A stratified, 3-stage cluster sampling approach was used to select participants. To comply with COVID-19 emergency protocols, data collection was conducted through an online survey between January and May 2021.²³  A total of 20 413 students from 279 schools completed the questionnaire. The school participation rate was 54.9% (ie, refusal rate = 45.1%), and the student response rate was 81.2% (ie, refusal rate = 18.8%), yielding an overall response rate of 44.6%.²³  Given the use of public data with deidentified information, this study is exempt from the University of Nebraska Medical Center institutional review board (IRB) approval.

Students who reported using e-cigarettes ≥1 day(s) in the past 30 days were classified as current e-cigarette users.²⁴  They were further asked, “During the past 12 months, how many times have you stopped using e-cigarettes for 1 day or longer because you were trying to quit using e-cigarettes for good?” Those who responded ≥1 time to the question were classified as current e-cigarette users with past-year quit attempts and constituted this study’s analytical sample. The frequency of quit attempts was coded as a continuous variable from 1 to 10 (Table 1 footnote).¹¹ 

Current e-cigarette users with ≥1 past-year quit attempt(s) were asked, “When you tried to quit using e-cigarettes, did you use any of the following?” Those who endorsed “I did not use any resources (exclusive)” were classified as “no use of any cessation methods” or unassisted quitting. We then coded the adoption of each cessation method (Table 1) as “1” when respondents marked the option (vs “0”), and the adoption of these cessation methods is not mutually exclusive.

We categorized current e-cigarette users as occasional users (≤5 days), moderate users (6–19 days), and frequent users (≥20 days) based on the frequency of e-cigarette use in the past 30 days.²⁵  Vaping duration is derived from the difference between the age when respondents first used an e-cigarette and their current age.¹¹  Based on the approximate midpoints of vaping frequency and duration, we created a 4-level index to measure the combination of vaping frequency (low [≤5 days] versus high [≥6 days]) and vaping duration (low [≤2 years] versus high [>2 years]).

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. Vaping product used in the past 30 days included “A disposable e-cigarette,” “An e-cigarette that uses prefilled or refillable pods or cartridges,” “An e-cigarette with a tank,” and “I don’t know the type.” Perceived harm of e-cigarette use was measured by a binary variable (0 = no harm/little harm vs 1 = some harm/a lot of harm).²⁶ 

Current “other tobacco users” were defined as those who reported using 1 or more non–e-cigarette tobacco products on ≥1 day in the past 30 days.²⁷  Those who reported only using e-cigarettes in the past 30 days were defined as “sole e-cigarette users,” and those who reported co-use of e-cigarettes and other tobacco products were defined as “dual users.”¹¹ 

The presence of nicotine dependence was a binary variable (yes versus no) measured by the question, “During the past 30 days, have you had a strong craving or felt like you really needed to use a tobacco product of any kind?”²⁸ 

Demographic variables include sex, race/ethnicity, school level, and sexual minority status. Self-reported race and ethnicity are considered as social constructs rather than as generic or biological categories. Those identified as Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, other races, or multi-racial groups are grouped as “other” category. We also include measures of tobacco use by household members (no, non–e-cigarette tobacco use, e-cigarette use)²⁹  and perceived peer use of e-cigarettes³⁰  to control for family and peer influences.

Distribution of sample characteristics, sample n, weighted population N, the weighted prevalence, and 95% confidence interval (CI) of each vaping cessation adoption are reported, along with the median and interquartile range (IQR) of the number of past-year quit attempts.

The logistic regressions estimated the factors associated with adopting each vaping cessation method, whereas multivariable models included demographic factors, vaping characteristics, and tobacco use status. We reported both unadjusted and adjusted odds ratios (ORs) for the adoption of “unassisted quitting” method and each of the most commonly used vaping cessation methods (ie, parent support, friend support, Internet, a mobile app, or text messaging). For the least commonly used vaping cessation methods (ie, advice from a teacher/coach, a doctor/health care provider, hospital/treatment, and quitline), only unadjusted ORs are reported in the exploratory analysis due to the low prevalence of cessation methods. Sampling weights, survey stratum, and primary sampling units were included in the analysis to account for the complex survey design and adjust for nonresponse. Statistical analyses were performed using SAS 9.4 (Cary, NC), and the survey procedure (eg, proc surveyfreq) was conducted to generate the weighted population estimates. Missing covariate data (n range: 0–137) were managed with multiple imputations using 20 multiply imputed data sets.³¹ P values < .05 were considered statistically significant.

Among 889 (representing population N = 1 271 000) current e-cigarette users with past-year quit attempts in 2021, 50.8% were female, 83.6% were high school students, 70.1% were non-Hispanic (NH) white, 7.4% were NH-black, and 19.1% were Hispanic. Approximately 32.5% of sample participants reported dual use of tobacco products, and 63.4% perceived vaping as harmful (Supplemental Table 5).

As shown in Table 1, 63.7% (weighted N = 810 000) of current vapers with past-year quit attempts reported they did not use any resources (“unassisted quitting”). Peer support (14.2%, N = 181 000), help on the Internet (6.4%, N = 82 000), a mobile app or text messaging (5.9%, N = 76 000), and parent support (5.8%, N = 73 000) were the top 4 cessation methods used by adolescent vapers, followed by getting help from a doctor or health care provider (3.9%, N = 50 000), getting help from a teacher or coach (2.4%, N = 30 000), using a quitline (1.7%, N = 21 000), and getting treatment from a medical facility (1.5%, N = 19 000). Overall, participants using a quitline and those getting treatment from a medical facility had the highest number of past-year quit attempts (median [IQR] = 5.1 [2.2–7.3]) and 4.5 [1.0–6.9], respectively).

Table 2 presents the prevalence and correlates with adopting the “unassisted quitting” method. Females (versus males) were more likely to report not using any resources (69.2% vs 57.5%; AOR [95% CI], 1.7 [1.1–2.6]), whereas Hispanic (versus NH Whites) were less likely to report unassisted quitting (49.3% vs 67.9%; AOR [95% CI], 0.4 [0.3–0.7]). E-cigarette users who reported higher vaping frequency/vaping duration and those dual/poly users were less likely to report unassisted quitting (AOR [95% CI], 0.5 [0.3–0.9]) and AOR [95% CI], 0.7 [0.44–0.97], respectively).

The prevalence and AORs of correlates with adopting the 4 most commonly used vaping cessation methods are presented in Table 3, and the unadjusted ORs are presented in Supplemental Table 6. Females (versus males) were less likely to report using parental support as a vaping cessation method (2.8% vs 8.9%; AOR [95% CI], 0.2 [0.1–0.5]). Meanwhile, as compared with NH whites, Hispanics were more likely to report using parent support (10.9% vs 4.4%; AOR [95% CI], 2.7 [1.2–6.3]) and peer support (21.7% vs 12.1; AOR [95% CI], 2.1 [1.1–3.9]). Current e-cigarette users who reported higher vaping frequency/vaping duration were more likely to report using a mobile app or text messaging. Perceived harmfulness of e-cigarette use was associated with lower odds of getting peer support (10.8% vs 20.9%; AOR [95% CI], 0.6 [0.32–0.97]) and higher odds of using a mobile app or text messaging (8.3% vs 3.3%; AOR [95% CI], 2.4 [1.1–5.3]). Nicotine-dependence symptoms were positively associated with using peer support and getting help or advice on the Internet.

Table 4 presents the prevalence and unadjusted ORs of specific correlates with the least commonly used vaping cessation methods. Overall, sexual minorities (versus heterosexuals) were more likely to report getting help from a teacher/coach and a doctor/health care provider. Compared with heterosexual vapers, gay/lesbian users and unsure individuals were more likely to seek treatment from a medical facility, whereas gay/lesbian and bisexual users were more likely to get help from a doctor/health care provider or use a quitline. Participants with high vaping frequency and/or high vaping duration were more likely to use these cessation methods. Dual use (versus sole e-cigarette use) was associated with higher odds of getting help from a teacher/coach (OR [95% CI], 3.7 [1.1–12.2]) and a doctor/health care provider (OR [95% CI], 6.2 [2.8–13.7]) as well as seeking treatment from a medical facility (OR [95% CI], 7.5 [2.2–26.2]). However, because of the small sample cells, some estimates with the least commonly used cessation methods had wide CIs, so the results should be interpreted cautiously.

To the best of our knowledge, this is the first study to provide timely evidence on the cessation methods used by e-cigarette users by analyzing a nationally representative youth sample. Overall, a majority of adolescent vapers with past-year quit attempts reported unassisted quitting. Assisted tobacco cessation is generally considered more effective than unassisted tobacco cessation for youth because it provides additional resources and support to help youth quit.³²  Given that peer influence plays a crucial role in youth e-cigarette use^33,34  and the popularity of digital platforms used by adolescents,³⁵  it is not surprising to see that nearly 1 in 7 adolescent vapers with past-year quit attempts asked for peer support, and help on the Internet, mobile apps, or text messaging ranked as the top cessation methods used by adolescent vapers. Our study also shows that parental support continues to be an important resource. By providing a supportive and open environment, parents can help their children quit tobacco by engaging in conversations about the negative effects of tobacco, setting a good example by not using tobacco themselves, and offering emotional and practical support throughout the quitting process.³⁶ 

Importantly, this study identified several demographic differences with the adoption of vaping cessation methods. As compared with male vapers, females were more likely to report unassisted quitting, whereas they were less likely to ask for help from their parents. Meanwhile, Hispanic (versus white) vapers were less likely to report unassisted quitting but were more likely to seek peer or parental support in vaping cessation. Our study also shows differences in the adoption of vaping cessation methods by sexual minority status, with gay/lesbian (versus heterosexual) vapers being less likely to report using unassisted quitting. These differences underscore the heterogeneous preference for the adoption of vaping cessation methods by key demographic groups and the importance of developing tailored cessation interventions to increase youth vaping cessation success.

Youth vaping behaviors, harm perception, and nicotine dependence also influence the selection of vaping cessation methods. According to our study, fewer youth vapers engage in these cessation methods before they perceive that they are addicted, indicating a potential to expand assisted cessation opportunities before it becomes more difficult for them to quit. Clinical advice to try a period of abstinence may help adolescents understand their withdrawal symptoms resulting from nicotine addiction.³⁷  Furthermore, a mobile app or text messaging was particularly preferred by those with high vaping frequency and/or high vaping duration, whereas the presence of nicotine dependence symptoms was associated with higher adoption rates of friend support or getting help on the Internet. Although those with nicotine dependence (versus without) also tended to have a higher prevalence of reporting use of a mobile app or text messaging (8.4% vs 5.3%), the statistically insignificant finding might be because this variable is measured by any tobacco products, rather than specially for e-cigarette use. Therefore, adolescents may underreport symptoms if they do not identify an e-cigarette as a “tobacco product.” Furthermore, some of the mobile apps and text messaging programming for adolescents specifically targeted e-cigarette use rather than other tobacco products, which could be why more adolescents who vaped frequently used these resources relative to those with tobacco dependence generally. Additionally, because of the dearth of evidence-based and empirically validated vaping cessation programs for youth, adolescent vapers may choose the available resources based on their individual needs. For instance, adolescent vapers with higher vaping frequency and/or longer duration might prefer a mobile app or text messaging because the program is often positioned as a nonjudgmental and supportive friend and delivered to participants through interactive text messages.¹⁹ 

Seeking professional advice from a teacher/coach, a doctor/health care provider, a medical facility, and quitline were generally less commonly used among adolescent vapers. However, the adoption of these vaping cessation methods was generally higher among those with high vaping frequency/duration as well as dual users of e-cigarettes and other tobacco products, and sexual minority vapers. Previous studies have reported higher e-cigarette use, nicotine dependence, and co-use of other tobacco products among sexual minority adolescents.^38,39  Lesser peer and parental support in these minority groups might be another plausible reason for the high utilization of professional help. Quitting vaping can be challenging, especially for those addicted to nicotine. Seeking professional help to assess the situation and provide appropriate support or treatment can overcome addiction and improve vaping cessation success.³⁷ 

Evident of fewer than 4% of adolescent vapers got support on their quit attempt from a doctor may reflect a lack of disclosure to their health care provider and/or a lack of engagement by primary care doctors with adolescents regarding their e-cigarette use. Encouraging youth to discuss their tobacco use with their doctor may yield more quit attempts, better access to available supports, medications to help cut down or at least better control of withdrawal symptoms, and ultimately a greater chance of success in quitting tobacco products.³⁷  Interventions with health care systems to ensure universal screening, motivational messaging, medications, referral to available online apps, and texting programs may also expand the percentage of adolescents who are supported in their quit attempts.

This study has some limitations. First, the adoption of vaping cessation methods is 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  In addition, the NYTS data are cross-sectional; thus, we were unable to establish causal inferences. Second, the school participation rate during the COVID-19 pandemic was lower (eg, 54.9% in 2021) compared with recent NYTS cycles (∼78.2% between 2011 and 2019 NYTS). However, the 2021 NYTS had a high student participation rate (81.2%), and the weighted sample produced nationally representative estimates. Furthermore, the 2021 survey was administered online to allow participation from various locations, and the survey format and the broad context of COVID-19 could potentially affect the adoption and prevalence estimates of vaping cessation methods.⁴¹  For instance, students with remote schooling might be less likely to report peer support in their vaping cessation than those attending school in person. Future studies should assess whether patterns of vaping cessation methods may vary after the pandemic. Finally, vaping cessation methods, except unassisted quitting, were not mutually exclusive. Indeed, approximately one-third of e-cigarette users with past-year assisted quit attempts reported utilization of 2 or more cessation methods (Table 1 footnote), signaling that many adolescent vapers are unable to quit after trying multiple methods in the current landscape of available cessation strategies.

A majority of adolescent vapers reported not using any cessation methods in their quit attempts. Of those who seek support, the 4 most commonly used vaping cessation methods include parent support, friend support, Internet, and a mobile app or text messaging. Sex differences, cultural and sexual minority background, and vaping experience were the most influential factors in adolescents’ preference for vaping cessation methods. Future studies should examine the pathways connecting these potential drivers to the adoption of cessation treatment and develop optimal strategies to increase youth vaping cessation success.

CI

confidence interval

IQR

interquartile range

NH

non-Hispanic

OR

odds ratio

NYTS

National Youth Tobacco Survey