INTRODUCTION

Recent data indicate that American youths’ use of electronic nicotine delivery systems (ENDS) exceeds that of other tobacco products¹. As of 2017, 11.7% of high schoolers and 3.3% of middle schoolers used ENDS in the past 30 days¹. Research examining sociodemographic differences in ENDS use indicates that males², adolescents of higher socioeconomic status³, and non-Hispanic White youth⁴ may be more likely to use ENDS. Although ENDS have been positioned as potential harm reduction tools for combustible cigarette smokers⁵, their use among adolescents remains problematic as ENDS solutions and aerosols contain numerous toxicants and carcinogens⁶, in addition to nicotine, an addictive substance with neurotoxic effects on the developing brain⁷.

Studies have identified several reasons for ENDS’ increasing popularity among adolescents, including greater visibility in the media⁸, combustible cigarette smoking cessation⁹, interest in flavors¹⁰, and peer influence¹¹. Like other tobacco products¹², motivations for ENDS use may vary with sociodemographic characteristics. Studies of US adults demonstrate that appealing flavors are more likely to be a reason for use among young adults¹³, and adult women are more likely to report using e-cigarettes because of their use by friends or family members¹⁴.

Limited research has examined differences in motivations for ENDS use among sociodemographic subgroups of adolescents. A clear understanding of these variations is valuable to help ensure that messages, interventions and policies are relevant to populations most vulnerable to ENDS use and are culturally tailored as needed. This study examines how adolescents’ motivations for ENDS use vary by sociodemographic characteristics, including age, gender, race/ethnicity and household income.

METHODS

RESULTS

Table 1 presents full descriptive statistics for the analytic sample. The most commonly selected reasons for ENDS use were: appealing flavors (77.9%), ‘they might be less harmful to me than cigarettes’ (75.0%) and ‘they might be less harmful to people around me’ (74.1%). Bivariate analyses revealed several differences across sociodemographic characteristics in motivations for ENDS use (Table 2). Among females, 82.9% reported using ENDS because the product comes in appealing flavors (compared to 74.0% of males), 31.3% reported using ENDS because the product feels like smoking cigarettes (compared to 20.5% of males), and 43.3% reported using ENDS because people who are important to them use them (compared to 28.2% of males). Just over half (53.6%) of non-Hispanic Black youth reported use due to appealing flavors, compared to non-Hispanic Whites (78.8%), Hispanics (76.6%), and those of other non-Hispanic ethnicities (89.3%). Among older adolescents (15–17 years old), 56.5% reported using ENDS because the products do not smell bad, compared to 42.8% of younger adolescents (12–14 years old). Among those with household incomes of less than $10000 a year, 16.3% reported using ENDS because the advertising appealed to them, compared to 26.4% of those with household incomes of $10000– $24999, 15.0% of those with household incomes of $25000–$49999, 11.5% of those with household incomes of $50000–$99999 and 4.34% of those with household incomes of $100000 or more.

Logistic regression analyses (Table 3) indicated that variations in use behavior were associated with several motivations for ENDS use. These analyses indicate that compared to non-Hispanic Whites, those of non-Hispanic ethnicities other than non-Hispanic White or Black had a higher likelihood of reporting using ENDS because they are affordable (AOR=2.684, 95% CI: 1.044–6.899), and females had a higher likelihood of reporting using ENDS because people important to them use ENDS (AOR=1.895, 95% CI: 1.128–3.184) and a lower likelihood of reporting using ENDS because they are affordable (AOR=0.538, 95% CI: 0.296–0.976). Combustible tobacco users had a higher likelihood of reporting using ENDS, because they compared favorably to cigarettes in that they do not smell, can be used in places cigarettes are not allowed, and feel like smoking a cigarette. Flavored ENDS users had a higher likelihood of reporting using ENDS due to the appealing flavors, reduced harm perceptions, and use in socialization or because people important to them use ENDS. Adolescents who use ENDS more intensely had a higher likelihood of reporting socialization, reduced harm to others, and not bothering other people as reasons for use.

DISCUSSION

Appealing flavors was the most commonly reported motivation for using ENDS, but was mentioned more often among females. It is possible that flavors may be especially attractive to adolescent girls, as similar preferences for flavored products are observed in other products such as alcohol¹⁶. Perceptions of reduced harm to self and to others were the next most commonly reported reasons for ENDS use across all youth. This reason did not differ across sociodemographic groups, indicating that perceptions of reduced harm are important for most adolescent ENDS users, regardless of sociodemographic characteristics. Advertising was not commonly reported as a reason for ENDS use.

Logistic regression analyses revealed that similarity or exchangeability with cigarettes is an important reason for ENDS use among combustible tobacco users. Further research should explore whether ENDS are being used as an alternative to combustible tobacco among this group. More intense ENDS use was associated with reasons involving other people, indicating that social benefit may encourage more intense use.

These findings offer several insights that could be helpful for policy and practice. First, given flavor’s importance in motivating product use, limiting appealing flavors may be an important approach to reduce use among youth, particularly female youth. Second, measures to increase the price of ENDS may have more of an effect on those of other non-Hispanic ethnicities compared to non-Hispanic Whites, as this group had a higher likelihood of reporting affordability as a reason for ENDS use. Conversely, price-increasing measures may have less of an effect on females compared to males, as females were less likely to report affordability as a motivation for ENDS use. Additionally, given the high number of youth overall who report using ENDS because they believe they are less harmful to them than cigarettes, education campaigns should communicate the potential harms of ENDS. Finally, given the prevalence of youth reporting using ENDS because people who are close to them use them, campaigns or interventions that leverage the role of important people in youths’ lives may be a useful strategy.

Several limitations must be considered when interpreting our findings. First, individuals may be more likely to select those motivations that come quickly to mind. With no opportunity to report motivations outside those included in the PATH study questionnaire, other important motivations may not be reflected in the study and this analysis. Second, only youth who had used ENDS in the past 30 days were asked questions about motivations for use. Therefore, we cannot draw conclusions about motivations for use among individuals outside this group. Moreover, this sample size was relatively small. While weighting procedures were employed, future work should be done with larger samples. Finally, data on specific racial/ethnic groups other than non-Hispanic White, non-Hispanic Black and Hispanic were not available in the data file, so we are unable to draw conclusions about motivations for ENDS use among these specific populations.

CONCLUSIONS

A long history of health disparities in tobacco product use¹⁷ underscores the need for tobacco control policies and interventions that effectively reduce ENDS use among vulnerable subpopulations of adolescents. Understanding the motivations for use among sociodemographic subgroups is an initial step towards informing the development of policies and interventions with equally distributed benefits.

CONFLICTS OF INTEREST

The authors declare that they have no competing interests, financial or otherwise, related to the current work. M. B. Moran reports grants from National Institute on Drug Abuse/US Food and Drug Administration Center for Tobacco Products, during the conduct of the study. The rest of the authors have also completed and submitted an ICMJE form for disclosure of potential conflicts of interest.