Abstract
Introduction/Objectives:
This study analyzed the relationship between social media use, perceptions of harm, demographic factors, and the likelihood of electronic cigarette use in middle and high school students in the United States, using data from the 2023 National Youth Tobacco Survey (NYTS).
Methods:
A total of 22 069 students participated in the 2023 NYTS, with 16 845 included in the final analysis after excluding those with missing data. The survey collected self-reported data on e-cigarette use, social media engagement, perceptions of harm and addictiveness, and environmental exposure to e-cigarettes. Adjusted odds ratios (OR) were calculated to assess the association between these factors and e-cigarette use.
Results:
Two thousand four hundred ninety-eight students (14.8%) reported ever using e-cigarettes, with older students showing significantly higher odds of e-cigarette use than younger students. Non-Hispanic Black and other racial groups had lower odds of e-cigarette use compared to non-Hispanic White students. Adolescents who perceived e-cigarettes as more harmful or more addictive than cigarettes were less likely to have used them. Social media behaviors were also strongly associated with e-cigarette use, with students who used social media less frequently having lower rates of e-cigarette use. Other social media related findings showed that students who frequently saw, posted, or interacted with e-cigarette-related content were significantly more likely to try e-cigarettes. Exposure to e-cigarette use at home and in vehicles further increased the likelihood of use.
Conclusion:
This study highlights the influence of social media exposure, perceptions of harm, and demographic factors on adolescent e-cigarette use. Older students and those with greater exposure to e-cigarette-related content on social media are at higher risk for e-cigarette experimentation. Public health efforts should focus on addressing social media influences, correcting misperceptions about peer use, and educating adolescents on the risks of e-cigarette use to mitigate this growing public health concern.
Introduction
Social media has become an integral part of adolescents’ lives, with the overwhelming majority of teens going online daily and 24% reporting that they are online “almost constantly.” 1 With young audiences increasingly accessing social media sites, it’s important to question what they are being exposed to and interacting with on those platforms. Multiple studies have shown that adolescents are frequently exposed to content online that includes the use of alcohol, tobacco, marijuana, and other illicit substances.2 -6 Furthermore, it has been reported that the majority of substance-related content on social media sites depicted substance use positively. 7 Studies have already shown that adolescents who are regularly active on social media have a higher chance of tobacco or cannabis use initiation; these studies have found associations between engagement with e-cigarette related content and lower perceived danger of e-cigarette use.8,9
As adolescents continue to engage with social media, it is crucial to investigate how these exposures may influence their substance use behaviors. With the inclusion of social media use questions in national surveys like the National Youth Tobacco Survey (NYTS), it is now possible to track social media use behaviors in adolescents and draw associations between these behaviors and the use of e-cigarettes. This study uses the data collected by the NYTS in the year 2023 and its first-time data collection on social media use to determine the relationships between self-reported social media behaviors and e-cigarette use in adolescents. The findings of this study and those like it can further evaluate the potential dangers and utility of social media platforms in efforts to decrease adolescent substance use.
Methods
The National Youth Tobacco Survey (NYTS) is a national school-based, self-administered survey that collects data on tobacco product use by students in the United States ranging from grades 6 to 12 (https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm). 10 These surveys always include questions about tobacco use. In addition, other questions are added to the survey to determine factors that may influence tobacco use. This particular survey included questions about social media to determine the association between social media and tobacco/e-cigarette use. These surveys have been collecting data since 1999 in U.S. public and private schools. The NYTS began electronic data collection methods starting in 2019, and this practice of electronic data collection has continued through the 2023 cycle. Surveys were conducted through a secure website in which students logged in using a unique class ID paired with the individual school ID. The median time spent on the survey was 18 min, 50 s. 2 Participation in the survey was voluntary, for both the schools and the students, with students receiving anonymity if they participated. Parents were also given the opportunity to opt their students out of participating in the survey per the Center for Disease Control and Prevention’s Institutional Review Board (CDC/IRB).
The 2023 NYTS used a stratified, 3-stage cluster sample design meant to produce a sample of middle and high school students in the United States that was nationally representative. Sampling was done in stages with Primary Sampling Units (PSUs) consisting of counties, groups of small counties, or parts of larger counties within strata. Secondary Sampling Units were schools within selected PSUs, and finally classes of students within each selected middle or high school. Survey administration began in March 2023 and concluded in June 2023. The 2023 NYTS had a final sample consisting of 420 schools, with participation from 179 of those schools, yielding a participation rate of 43.0%. The 2023 NYTS produced a total of 22 069 completed student questionnaires out of the 31 108 students sampled, resulting a student participation rate of 70.9%.
In the NYTS analysis, questions focusing on e-cigarette use, perception of harm related to e-cigarette use, and both physical and social media exposure to e-cigarettes were compared between students who reported e-cigarette use and those who reported having never used e-cigarettes. These variables were chosen as previous research conducted abroad has shown a possible association between social media use and e-cigarette use. 3 The robust and comprehensive nature of the NYTS allows for this analysis to be done involving children in the United States. Descriptive statistics were used to describe study participant characteristics. Categorical variables were summarized by frequencies, and continuous variables were summarized using means, standard deviations, medians, and ranges as appropriate. Adjusted odds ratios with 95% confidence interval were used to determine significance of statistical findings. The samples were weighted by the NYTS managers to account for unequal probabilities of selection response, and to match the sample demographic characteristics to the national population of middle and high school students. Statistical significance was set at .05. Analyses were performed using the statistical program R version 4.0.2 (https://cran.r-project.org/).
Results
There were 22 069 students originally participating in the 2023 NYST survey (Table 1). A total of 16 845 students were included in the data analysis after excluding students with missing answers. There is no consistent explanation for failing to complete the survey, but this problem occurred in all age groups. The actual number of the students in the data analysis included 2498 (14.8%) students who reported ever having used an e-cigarette and 14 347 (85.2%) of students who reported never having used an e-cigarette (Table 1).
Student Characteristics.
Demographic Variables
When comparing the likelihood of ever having used e-cigarettes among students of different age and race categories, statistically significant differences were found. Older students had a higher likelihood of trying e-cigarettes, with increasing odds as age increased, particularly among 15-, 16-, 17-, and >18-year-olds compared to those under 11 (Table 2). The highest likelihood was observed among 17- and >18-year-olds in the white non-Hispanic racial groups,
Risk Factors for e-cigarette Smoking.
Adjusted for all other covariates; numbers in a bold font are statically significant.
Perceptions of Substance Use Among Peers and Perceived Harm
When comparing the likelihood of ever having used e-cigarettes between students with differing perceptions of e-cigarette harm and their addictive potential compared to cigarettes, differences were observed. Adolescents who viewed e-cigarettes as equally and more addictive than cigarettes were less likely to try them compared to those who viewed e-cigarettes as less addictive, with OR (95% CI) as 0.52 (0.31, 0.88) and 0.47 (0.26, 0.85), respectively. Adolescents who believed that low nicotine cigarettes were much more harmful than typical cigarettes were also less likely to have used e-cigarettes compared to those who thought they were much less harmful with an OR of 0.57 (95% CI = 0.35, 0.93). In addition, students who perceived a higher number of their peers as e-cigarette users were more likely to have tried e-cigarettes themselves, with an odds ratio of 1.10 (95% CI = 1.07, 1.14) for each additional peer they believed had used e-cigarettes.
Social Media Influences
When comparing the likelihood of ever having used e-cigarettes between students with differing social media use behaviors and exposures, differences in odds ratios were found between adolescents of varying frequency of viewing posts related to e-cigarettes, varying frequency of making posts related to e-cigarette use, and frequency of interaction with e-cigarette related posts. Adolescents who use social media about 1 time per week, a few times per week and less than 1 h/day are less likely to have used e-cigarettes, compared to those who used social media less than 1 per week, with ORs of 0.30 (0.10, 0.84), 0.36 (0.14, 0.94), and 0.35 (0.13, 0.92), respectively. Parenthetically, this result would suggest that all social media use does not focus on e-cigarettes and other potentially harmful behaviors. Adolescents who had seen posts or contents related to e-cigarettes were more likely to have ever tried e-cigarettes compared to those who had never seen them. The odds ratios for about less than monthly, weekly, and daily were 1.43 (1.05, 1.94), 1.49 (1.05, 2.13), and 1.45 (1.00, 2.09), respectively. Adolescents who reported posting using e-cigarettes less than monthly were more likely to have used e-cigarettes compared to those who had never posted pictures or videos of themselves or others using e-cigarettes, with an odds ratio of 2.04 (95% CI = 1.51, 2.76). Similarly, adolescents who reported interacting with posts related to e-cigarettes at higher frequencies were more likely to have used e-cigarettes compared to those who did not interact with these posts. The odds ratios for less than monthly, monthly, weekly, and daily are 1.93 (1.63, 2.29), 2.02 (1.44, 2.83), 2.03 (1.40, 2.96), and 2.35 (1.49, 3.68), respectively.
Environmental and Household Influences
When comparing the likelihood of ever having used e-cigarettes between students with differing levels of exposure to e-cigarette use at home, in vehicles, and exposures to e-cigarette vapor both indoors and outdoors, differences were observed. Adolescents who reported that someone at home used e-cigarettes for more days in the past week were more likely to have ever used e-cigarettes compared to those who reported fewer times seeing someone at home use these products in the last week, with an OR of 1.07 (1.00, 1.15). Similarly, adolescents who reported that someone in the same vehicle with them used e-cigarettes for more days in the past week were more likely to have ever used e-cigarettes compared to those who reported fewer times seeing someone in the same vehicle using these products in the last week, with an OR of 1.08 (1.00, 1.17). Likelihoods of adolescents having ever used e-cigarettes based on indoor and outdoor exposures to e-cigarette vapor varied inconsistently between those who had more exposures and those who had fewer. The odds ratios for 10 to 19 and 20 to 29 days with indoor vapor exposure are 1.31 (1.00, 1.72) and 1.59 (1.05, 2.40), respectively.
Discussion
This study underscores the critical relationship between adolescent social media use and e-cigarette behaviors, revealing significant associations between online exposure to e-cigarette content and the likelihood of e-cigarette use. These results support prior research suggesting that increased social media engagement exposes adolescents to positive depictions of substance use, normalizing behaviors such as e-cigarette use, and potentially reducing perceptions of harm.6 -8
One key finding is the role of age in influencing e-cigarette use. Older adolescents were more likely to have tried e-cigarettes, consistent with existing literature that associates increasing age with greater access to these products. Adolescents gain more autonomy, access to financial resources, and social connections over time, which may facilitate e-cigarette experimentation and use.11 -13 In addition, older students often report higher levels of social media use, compounding their exposure to substance-related content. 1
How does exposure to e-cigarettes in social media influence student interest in these products? Lee et al 11 studied the visual materials on e-cigarette posted on the social media platforms Instagram and Pinterest. Data were collected over 5 weeks and classified into categories. The most popular categories for Instagram were marketing, customization, and juice and flavors. The most popular categories on Pinterest were customization, marketing, and memes. This study included 1800 pictures. The study had limitations because it is not possible to determine who posted these images. The age and/or gender are uncertain. In addition, some of these efforts may involve manufacturers and represent advertising. These authors suggested that this study established an overall interest in e-cigarettes in social media, and this represents an effort to increase the involvement of social media users and this particular product. The NYTS-CDC survey provides information about the race, gender, and age in survey questions. This information could help identify important subgroups who use electronic cigarettes.
An alternative approach to understanding the association between social media and students involves the use of study groups. Smith and Hilton 12 studied the exposure of youth in Scotland to e-cigarettes using focused study groups. This project involved 20 groups and 82 young people with an age range of 11 to 16 years. Forty-seven participants were female. The sample included 10 smokers and 18 teens who used e-cigarettes. The respondents knew that companies used a variety of tactics to increase e-cigarette use. This included the use of an influencer, celebrity endorsement, attractive, youthful flavors, bright colors, and emotional appeals to advertising products. They used qualitative thematic analysis of the data. This would allow information about perception, but it did not provide any information on the frequency of specific opinions. The authors concluded that this industry was using the same tactics to attract customers that the tobacco industry had used in the past.
The results from the National Youth Tobacco survey indicate that most respondents thought that e-cigarettes had a little potential to cause harm. For example, Russell et al 13 collected information on the perceptions of harm and addiction of electronic cigarettes by adolescents using an online survey. The study included 9865 adolescents aged 13 to 17 years. A very small percentage of respondents (6.1% of the and 9.3%) believed that daily use or occasional use of e-cigarettes would cause no harm. In addition, 7.3% thought it was very unlikely that they would become addicted to electronic cigarettes. Overall, a large percentage respondents thought that e-cigarettes were risk free. This perception needs to be corrected to limit the use of this nicotine product. These participants participated in the Qualtrics internet-net research panel. They were the children of adults enrolled in this panel. The exact process resulting in participation is uncertain. The study has definitely limitations in understanding exact process in identifying participants. The NYTS study is much clearer in terms of who participated.
The study also revealed notable demographic differences, with non-Hispanic White adolescents having the highest likelihood of e-cigarette use. These findings corroborate previous studies attributing racial disparities in e-cigarette use to cultural norms, variations in parental monitoring, and differences in targeted marketing strategies. For example, flavored tobacco products, which disproportionately appeal to younger users, are often marketed to specific demographic groups, potentially exacerbating usage trends among non-Hispanic White adolescents.
The influence of social media behaviors was particularly pronounced in the NYTS. Adolescents who frequently viewed, interacted with, or posted e-cigarette-related content were significantly more likely to have used e-cigarettes themselves. These findings agree with previous studies showing that exposure to substance-related content online can alter perceptions of harm and normalize use.6 -8 Adolescents’ interactions with such content likely reinforce social norms that support e-cigarette experimentation and contribute to increased feelings of peer pressure to conform to perceived normal behaviors.
In addition, the 2023 NYTS study highlights the importance of environmental and household influences. Adolescents exposed to e-cigarette use at home or in vehicles were more likely to use these products. This finding suggests that parental or peer modeling of e-cigarette use influences adolescent behaviors, a point supported by previous research demonstrating the impact of household substance availability on adolescent use patterns.14 -16
Despite its strengths, this study has limitations. The cross-sectional nature of the NYTS limits the ability to infer causality. Self-reported data could also be subject to recall bias or social desirability bias, potentially underestimating or overestimating actual behaviors. In addition, the study’s reliance on survey questions about social media interactions cannot fully capture the complexity of how adolescents engage with online content. Future longitudinal studies are needed to confirm these findings and explore causal pathways.
Conclusion
This study provides valuable insights into the complex interaction between social media use, demographic factors, and environmental influences on adolescent e-cigarette behaviors. It highlights the need for public health initiatives to address the pervasive impact of social media on youth perceptions of e-cigarette use. Strategies such as implementing stricter regulations on e-cigarette advertising, enhancing parental awareness of adolescents’ online activities, and promoting education campaigns that counteract pro-tobacco messaging on social media are essential.
In addition, targeted interventions addressing the demographic and environmental disparities identified in this study are critical. Efforts to limit adolescents’ access to e-cigarettes at home and in social settings could significantly reduce usage rates. By fostering a more comprehensive understanding of the social and environmental factors influencing e-cigarette use, these initiatives can contribute to reducing the public health burden of adolescent e-cigarette use.
Footnotes
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.