Study overview

The current study analyzed cross-sectional quantitative and qualitative data from young adults (aged 18–34 years) participating in the ‘Vape shop Advertising, Place characteristics and Effects Surveillance (VAPES)’ study, which examines the US vape retail environment and its impact on e-cigarette use. This 2-year, 5-wave longitudinal cohort study was launched in Fall 2018 and entailed biannual assessments until Fall 2020. Participants were drawn from 6 metropolitan statistical areas (MSAs: Atlanta, Boston, Minneapolis, Oklahoma City, San Diego, and Seattle) with varied tobacco and cannabis legislative contexts¹⁴. This study is described in detail elsewhere¹⁵.

Ads posted on social media (i.e. Facebook, Reddit) recruited eligible individuals (i.e. aged 18–34 years, residing in one of the 6 aforementioned MSAs as indicated by residential zip code, English speaking). Individuals who clicked on ads were directed to a webpage with a study description and consent form and screened for eligibility. Purposive, quota-based sampling ensured sufficient representation of approximately one-third of e-cigarette and cigarette users, respectively, roughly equal numbers of men and women, and 40% of racial/ethnic minority. Recruitment was capped by MSA.

Individuals allowed to advance to the study (i.e. eligible and still being recruited in the respective MSA) were routed to complete the online Wave 1 (W1) survey (administered via Alchemer). Upon completion of the survey, participants were notified that they would be asked to confirm their participation by clicking a ‘confirm’ button included in an email 7 days later. Once participants clicked ‘confirm’, they were officially enrolled in the study and emailed their first incentive in the form of a $10 Amazon electronic gift card.

Of the 10433 Facebook and Reddit users who clicked on ads, 9847 consented, of which 2751 (27.9%) were not allowed to advance because they were either ineligible (n=1472) and/or excluded to reach subgroup target enrollment (n=1279). Of those allowed to advance to the survey, the proportion of completers versus partial completers was 48.8% (3460/7096) versus 51.2% (3636/7096). Partial completers were deemed ineligible for the remainder of the study; the majority of partial completers (n=2469; 67.9%) completed only the initial sociodemographic section of the survey. Of the 3460 who completed the W1 survey, 3006 (86.9%) confirmed participation¹⁵.

Quantitative data collection

Current quantitative analyses used sociodemographic data from W1 (Fall 2018, n=3006) and assessments of e-cigarette use characteristics and COVID-19 related factors among young adult e-cigarette users from W5 (Fall 2020, n=2476; 726 of whom were past 6-month e-cigarette users). W5 MSA data were reported to account for movement.

Measures

Sociodemographic and related factors during COVID-19

At W1, participants reported their age, gender, race, ethnicity, and sexual orientation. At W5, we also assessed their college enrollment, household composition, employment status, and nature of employment during COVID-19 (e.g. working outside of home, working from home, laid off, not working), loss of income or employment among participants and household members, and whether they were under state orders restricting activity, e.g. stay-at-home orders (Table 1).

E-cigarette use and related factors during COVID-19

At W5, participants were asked, ‘In the past 6 months, on how many days have you used e-cigarettes?’ (0=not at all; 5=almost daily, or daily). Past 6-month users were also asked to report the nature of their e-cigarette use (i.e. most common e-liquid flavors used, use of nicotine salt, device type). We also asked, ‘During COVID-19, did you experience any of the following: you tried to cut down on vaping; you tried to quit vaping; you stocked up on vaping products, such as e-liquids; you worried your vape shop would close or go out of business; you worried your source of vaping products (not from a vape shop) would be difficult to access; your vape shop went out of business; your source of vaping products (not from a vape shop) was difficult to access; you noticed more options for home delivery of vaping products.’

Qualitative data collection

Qualitative data collection and analyses were guided by the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines¹⁶. In February–April 2021, participants who reported past 30-day e-cigarette use at W5 were recruited via email to participate in semi-structured interviews. To participate in interviews, the only eligibility criterion was reporting past 30-day use on the eligibility screener during the recruitment period; however, we purposively sampled e-cigarette users with representation across the sexes, sexual orientation, and racial/ethnic backgrounds.

Of the 139 participants recruited via email, 105 (75.5%) began the eligibility screener, of whom 11 (10.5%) partially and 94 (89.5%) fully completed the screener. Of the 94, 34 (36.2%) were not eligible, and 60 (63.8%) were eligible and consented. Of the 60, 40 (66.7%) were successfully scheduled for and participated in an interview, at which point, saturation had been reached.

The semi-structured interview guide was developed by the study team to explore experiences with tobacco product use. The initial interview guide was piloted through mock interviews among a sample of 4 graduate research assistants, wherein we tested question phrasing, clarity, and necessary probes. The interview guide was revised after the first 3 interviews to ensure clarity and comprehensiveness. Interview guide topics explored in the current analyses focused on how participants’ e-cigarette use changed during COVID-19 and if they made any attempt to quit or cut back on vaping during this time.

We conducted interviews via WebEx after obtaining online consent via email. The interviews, which lasted about 45 minutes, were facilitated by 4 female graduate research assistants trained in qualitative data collection. The interviews were audio-recorded for subsequent coding. Participants were debriefed and compensated with a $35 Amazon e-gift card upon interview completion. All audio-recorded interviews were uploaded to a secure, password-protected computer, and the recordings were transcribed verbatim by a contracted professional transcription service.

Statistical analysis

Survey data were analyzed descriptively to characterize participants, using SPSS 24.0. Qualitative data were analyzed using thematic analyses. Transcripts were systematically coded using QRS Software NVivo v12 and cross-checked for agreement regarding the application of the codes. Team discussions occurred regularly in which codebook themes were redefined, inclusion and exclusion criteria were set, and representative passages were identified. Discrepancies regarding code choices were resolved through discussion in a process of constant comparison and until consensus was reached (kappa=93.3%). Inter-rater reliability was calculated for each code through use of an intra-class correlation coefficient and was deemed acceptable if the coefficient was ≥0.80. Content codes were used to thematically group similar interview text; themes were organized into overarching domains compiled with representative quotations, which were edited for readability. Balancing the controversy in qualitative research regarding whether to quantify qualitative results, we indicated the frequency with which themes were provided by participants by quantizing them as ‘most’, ‘many’, ‘almost half’, ‘some’, and ‘a few’¹⁶.

Ethical approval

All human participants were treated in accord with the Principles of the Ethical Practice of Public Health of APHA, gave their informed consent to participate, and the study was reviewed and approved by the Institutional Review Boards of Emory University and George Washington University [interviews; NCR203050].

Quantitative results

This sample of past 6-month e-cigarette users at W5 (n=726) had an average age of 24.15 (SD=4.84) years, 51.1% were female, 35.5% sexual minority, 73.6% White, 4.4% Black, 10.2% Asian, and 12.1% Hispanic (Table 1). Among past 6-month e-cigarette users at W5, 34.4% were enrolled in college. Most lived with a spouse/romantic partner (43.9%), roommates/friends (29.9%), or with parents (23.8%). Regarding employment, 15.0% reported not working before the pandemic. When asked about the impact of COVID-19 on employment, 27.3% continued working outside the home, 18.6% changed to working from home, and 15.3% were laid off. Relatedly, 72.8% indicated a personal loss or loss of a household member’s income and 30.2% indicated more household financial problems. At W5, 38.7% indicated no COVID-related restrictions, 32.4% reported sheltering in place, 7.2% were experiencing a lockdown, and 28.7% were in self-quarantine.

As shown in Table 2, 616 (84.8%) of W5 past 6-month e-cigarette users reported past 30-day e-cigarette use and an average of 14.97 (SD=12.84) days of use in the past 30 days; past 30-day users used e-cigarettes 17.51 days (SD=12.17). Roughly half reported past 30-day use of cigarettes (44.4%), other tobacco (54.0%), and cannabis (60.1%). Notably, 22.6% reported attempts to cut down on vaping, 16% tried to quit vaping, 23.7% stocked up on vaping products during COVID-19, several worried their product source would close (19.6% regarding vape shops, 15.3% other sources), some reported their source closed (5.5% regarding vape shops, 7.6% other sources), and 8.8% noticed more home delivery options.

Qualitative results

Semi-structured interview participants (n=40) had an average age of 26.30 (SD=4.39) years, 35.0% were female, 45.0% sexual minority, 57.5% White, 5.0% Black, 22.5% Asian, and 12.5% Hispanic (Table 1). The proportions residing across the MSAs ranged from 7.5% in Oklahoma City to 25.0% in Minneapolis, with 5.0% residing outside the 6 MSAs (due to moving since W1). Table 3 presents themes, and selected quotes regarding: 1) the impact of COVID-19 on the accessibility of product; 2) stress; 3) boredom; and 4) changes in daily environment.

The impact of COVID-19 on accessibility of product

Many participants reported accessibility issues related to e-cigarette products and other substances during the pandemic, and many reported a decrease in e-cigarette use due to limited access to products. Many participants indicated stocking up on flavored e-liquids or obtaining flavors from alternative sources due to business closures and limitations in supply brought about by COVID-19. One participant described the impact of vape stores closing on access to e-cigarette products during the pandemic:

‘When COVID-19 first started, everything was starting to shut down and so I stocked up.’ (e-cigarette user, Seattle)

Store closures encouraged some young adult e-cigarette users to change their purchasing habits which included purchasing products through new avenues such as the Internet.

Stress

Some participants reported increased stress during the pandemic, which influenced their e-cigarette and other substance use. One participant reported that stress due to work schedule changes:

‘… doubled during the pandemic’ (e-cigarette, cigarette, and cannabis user, Minneapolis)

One participant described the stress related to job loss at the beginning of the pandemic, which prompted an increase in e-cigarette use. In addition, stress due to major life changes such as job loss prompted increases in vaping during the pandemic:

‘It increased a lot. I lost my first job during this pandemic. Then I had to go hunting for a new job, and a lot of them just didn’t work out. So it’s been a lot of job-hopping, and that’s very stressful.’ (e-cigarette user, Oklahoma City)

Boredom

As a result of daily life changes brought about by the pandemic, many participants found more opportunities to vape:

‘A good part of me wanted to vape all the time, so if I went into a different room, or if I got bored, I hit my vape.’ (e-cigarette and cannabis user, Boston)

Changes in daily environment

Most participants reported an increase in e-cigarette use during the pandemic due to significant changes in daily social interactions. Social distancing restrictions and stay-at-home orders imposed by COVID-19 kept many young adults at home, and most participants who increased their e-cigarette use during the pandemic noted that they had more occasions to use e-cigarettes. In addition, school closures and teleworking schedules provided a unique opportunity to use e-cigarettes freely without constraints at home:

‘It’s probably increased during the pandemic, partially because I am at home all the time now and I vape freely in my home even when my boyfriend is trying to quit.’ (e-cigarette, cigarette, cannabis, and CBD user, Minneapolis)

Some participants noted that changes in daily work environments, such as a transition to telework, increased freedom to engage in vaping:

‘So I was working from home, and could vape all day long at my desk, instead of being somewhere in my office before having to work from home.’ (e-cigarette, cigarette, and cannabis user, Atlanta)

Pre-pandemic e-cigarette use was limited by restrictions in work or school settings; however, the pandemic left many participants homebound. This dramatic change in life provided ample time and setting to allow for unrestricted e-cigarette use:

‘So when I would go into school, we’re not supposed to vape, so definitely being able to do it freely all day long has increased my usage.’ (e-cigarette, cigarette, cannabis, and CBD user, Minneapolis)

Changes in social interactions brought upon by COVID-19 provided an opportunity for young adults to initiate e-cigarette use. One participant noted that the lack of socialization aided in reduced e-cigarette use:

‘It’s starting to reduce just because I have a little one and I’m not going out as much as I used to. So, it’s starting to decrease.’ (e-cigarette and cannabis user, Minneapolis)

Another young adult e-cigarette user described how being homebound forced reflection on use habits, which led to an overall reduction in use:

‘Honestly, I’ve become more aware of it just because I’m in the same room all day. If I get bored and hit my vape but I am in my room all day… [I’m] forced to reflect on how much I vape.’ (e-cigarette, cigarette, cannabis, and CBD user, Boston)

Limitations

Limitations include limited generalizability to young adults across the US due to the sampling strategy (e.g. recruiting a sample consisting of about one-third cigarette and e-cigarette users, via social media). Additionally, participants are likely to differ from those who chose not to participate regarding some important characteristics (e.g. preconceived positive attitudes towards screening and health-conscious behaviors). However, both for the parent study and the interview component of the study, we purposively sampled to obtain the participation of individuals of varying age, sex, and race/ethnicity, and these 6 MSAs represented a broad range of tobacco and e-cigarette policies as well as COVID-related state orders. Particularly noteworthy, the interviews were conducted among past 30-day e-cigarette users, and thus do not represent the perspectives of those who quit using e-cigarettes during the pandemic.

Implications for policy and/or practice

Understanding the effects of the ongoing and evolving COVID-19 pandemic on young adult e-cigarette use is imperative^20,21. Undoubtedly, the COVID-19 pandemic has presented young adults with unprecedented challenges pertaining to mental health and overall wellness. Results from this study and others have highlighted the importance of promoting opportunities for young adults to build relationships, particularly during a time in history when experiences of loneliness and isolation have escalated. Increasing the accessibility to mental health and social support services for young adults, and intentionally engaging them in pandemic-appropriate community-building and extracurricular activities, may decrease stress, foster a sense of belonging, and increase quality of life. Future prevention research efforts should continue to: 1) monitor young adults’ vaping behavior over the course of the pandemic; and 2) examine the relationship between the initiation of vaping, or increased vaping, during different stages of the pandemic on future substance use.