Adolescent Vaping: Multiple Substance Use and Implications for School-based Prevention Programs

Abstract

Adolescent e-cigarette use (or vaping) is a prevalent behavior among adolescents. The national 2022 Monitoring the Future Survey found that past 30-day nicotine vaping was 20.7% among 12th graders and 14.2% among 10th graders. The same national survey found that past 30-day cannabis vaping was 14.8% among 12th graders and 10.3% among 10th graders. Adolescent e-cigarette use has been linked to negative health consequences, making it important to address from a population health perspective. For example, adolescent e-cigarette use has been associated with increased respiratory symptoms (such as bronchitic symptoms and shortness of breath), nicotine dependence, and involvement in other substance use. Adolescent cannabis use has been associated with impacts on mental health, poorer educational outcomes, and greater respiratory health risks, compared to those who do not engage in cannabis use. Moreover, multiple substance use, the use of two or more substances, has been associated with more severe symptoms of dependence on substances and difficulty quitting combustible cigarettes. This dissertation examines the individual sociodemographic, interpersonal, and environmental risk factors associated with adolescent multiple substance use; specifically, the dual- and poly-use of combusted tobacco, e-cigarettes, and cannabis. This dissertation defines risk factors as correlates, such as characteristics, behaviors, or environmental factors, that are associated with adolescent substance use. There is a gap in knowledge on whether different forms of vaping, solely and of multiple substances, are associated with different risk factors. School-based prevention interventions can work to change risk factors by eliminating or modifying risk factors themselves or their influence, and by promoting protective factors. Identification of these risk factors can help advocate for more resources in schools, such school counseling departments and after school programs, that provide special support for students at highest risk for multiple substance use. Study 1 measured the cross-sectional prevalence of past 30-day sole-, dual- and poly-use of e-cigarettes, all forms of cannabis, and combusted tobacco among Massachusetts high-school-aged adolescents in 2019. In addition, Study 1 identified risk factors, such as sociodemographic characteristics and social exposures for the sole-, dual- and poly-use outcomes, using weighted multinomial logistic regression. Study 1 found that adolescents who used multiple substances had different associated risk factors than those who solely-used substances, suggesting that certain adolescents may be more vulnerable than others to multiple substance use. For example, mental health correlates, such as self-reported depressed mood and self-reported emotional problems and learning disabilities (although severity and official diagnoses could not be captured), tended to be associated with dual- and poly-use outcomes. These findings provided estimates of the prevalence of multiple substance use among adolescents, and guided the approach in examining the prevalence and risk factors associated with vaping as a specific mechanism of delivery in Study 2. Study 2 assessed patterns of adolescent past 30-day dual-vaping (vaping of both nicotine and cannabis in the past 30-days) over monthly time intervals, as it accompanied the COVID-19 pandemic and school reopening for the 2021-2022 academic school year. Study 2 descriptively identified the prevalence of which substances (nicotine, THC, and CBD) adolescents self-reported vaping the most over the other substances, and whether adolescents who reported dual-vaping initiated use with nicotine or cannabis. Informed from findings from Study 1, Study 2 sought to identify risk factors associated with engaging in different forms of vaping (solely nicotine, solely cannabis, and dual-vaping). Similar to Study 1, Study 2 found that adolescents who reported dual-vaping had different associated risk factors than those who solely-vaped nicotine or cannabis, including higher self-reported impact of COVID-19 restrictions. Study 3 utilized qualitative methods to identify approaches used by school personnel to prevent student vaping. This study also sought to identify the barriers that school personnel face when introducing new resources to address student vaping on their campuses. School personnel reported already utilizing educational and alternatives-to-suspension approaches, but also expressed a need for increased resources for those approaches. Barriers to addressing vaping on school campuses included staff capacity and time, funding, and lack of mental health supports. Peer-led initiatives, parental involvement, and alternatives-to-suspension emerged as facilitators, and should be leveraged when developing and implementing vaping prevention programs in schools. These findings can inform recommendations for schools in meeting the needs of the populations of at-risk adolescents who were identified in Studies 1 and 2. Together, these studies suggest that there are different risk factors, such as paid employment, participation in organized activities, household tobacco use, mental health, and other individual and social factors, associated with different types of sole-substance use, as well as dual- and poly-use. Adolescent vaping, substance use, and mental health was further complicated by social restrictions from the COVID-19 pandemic. We found that school personnel echoed these concerns as they provided information regarding the limitations they faced in addressing the adolescent vaping-related risk factors identified in Studies 1 and 2, such as concerns for student mental health. Knowledge of risk factors for multiple substance use can help with identifying, in a school-based setting, which students may be at highest risk for multiple substance use and providing additional supports for those students, who may come from different sociodemographic backgrounds and home environments. Public health practitioners, adolescent health clinicians, policy makers, and school personnel can utilize these findings to improve approaches to prevent and reduce adolescent vaping, especially in school-based settings.