“If Someone Has It,I’m Gonna Hit It”: Lessons Learned From Minnesota Teens About Vaping

Abstract

Youth e-cigarette use or “vaping” has increased substantially in the past few years, an escalation attributable to flavored “pod mod” e-cigarette devices that deliver higher levels of nicotine compared with free-base nicotine found in other types of e-cigarettes. Use rates, addiction, and harms are alarming as negative effects from nicotine on adolescent brain development are well documented, and e-cigarette use is predictive of cigarette smoking initiation. This qualitative study examined what drives the appeal of these products through 10 focus groups conducted in 2019 with 67 Minnesota high school students. Focus groups aimed to understand students’ personal experiences and contextual factors that may contribute to current vaping trends and explore opportunities for improved prevention messaging. Study results revealed participants’ divergent perceptions of tobacco products (i.e., vaping vs. e-cigarettes vs. cigarettes) and the benefits and harms of each product. Participants provided insights into why youth vape, describing vaping as an easily accessible coping method to help teens manage stress and anxiety. Peer normalization and invincibility beliefs about harms were also present. Participants generated ideas about prevention messaging, describing the ineffectiveness of prevention messages they currently receive, and expressing the need for accurate information about e-cigarette health risks presented in personalized, nonjudgmental contexts by people they know care about them. These results have clear implications for prevention initiatives and can be used to inform effective prevention strategies, messaging, programming, and policies, some of which are specific to e-cigarette prevention and others that align with the theory of positive youth development.

Keywords

child/adolescent health tobacco prevention and control health promotion qualitative research health research behavior change theory theory

Background

The popularity of e-cigarette use—or “vaping”—among young people grew astronomically in the past few years, leading the U.S. Surgeon General to declare e-cigarette use among youth an epidemic in December 2018 (Centers for Disease Control and Prevention [CDC], 2019). E-cigarettes are electronic nicotine delivery systems (“ENDS”) that deliver a mixture of flavoring, liquid nicotine, and other chemicals to the user through an inhaled aerosol (CDC, 2019). This escalation began in 2015, fueled by the advent of “pod mod” e-cigarette devices (Barrington-Trimis & Leventhal, 2018) and synchronic social media-focused marketing (Lee et al., 2020) to young people, particularly by the e-cigarette brand Juul (Huang et al., 2019). Pod mods are sleekly designed e-cigarettes that promote discrete use, offer fruit and candy flavors, and associate vaping with young people being cool and having fun (Lee et al., 2020). Pod mods use nicotine salts that deliver higher levels of nicotine compared with the free-base nicotine found in other types of e-cigarettes (Barrington-Trimis & Leventhal, 2018). Youth e-cigarette use continued its rapid upward trajectory, and by 2019, more than 32% of high schoolers were current users (Creamer, 2020). Simultaneously, new pod mod e-cigarette products continued to flood the market (Kaplan, 2019).

Since this study was conducted in 2019, e-cigarette devices and brands have continued to evolve, including the introduction of cheaper, disposable devices that contain high nicotine salt levels, come in myriad flavors and colors, and are often shaped like a Juul device (e.g., Puff Bar) (Delnevo et al., 2020); (Williams, 2020). Along with many other types of e-cigarette products (e.g., refillable pod mods, menthol pod mods, and more than 15,000 flavored nicotine e-liquids), disposable e-cigarettes were left out of the early 2020 U.S. Food & Drug Administration policy that removed only certain pod mod device flavor pods from the market (U.S. Food & Drug Administration, 2020). All of these factors may make disposable e-cigarettes even more appealing to youth (Williams, 2020).

In 2020, youth e-cigarette use remained high; pod mods remained the most popular e-cigarette device, and use of disposable e-cigarettes increased (CDC, 2020; Gentzke, 2020) despite data from the 2020 National Youth Tobacco Survey indicating that 1.73 million fewer youth used tobacco products than in 2019. These findings prompted the National Youth Tobacco Survey authors to call out the critical urgency of keeping up with a “rapidly dynamic” e-cigarette landscape and related emerging public health challenges of youth e-cigarette use (Wang et al., 2021).

In contrast, youth cigarette smoking rates have been declining steadily since 2000 and were at a record low of less than 6% in 2019 (Creamer, 2020). Today’s youth often perceive smoking cigarettes to be riskier and less socially acceptable than youth of previous generations (McKelvey & Halpern-Felsher, 2017). However, evidence from two studies using Population Assessment of Tobacco and Health data suggests that vaping may open the door to future cigarette use. One study found that trying e-cigarettes before age 18 years is strongly associated with future daily cigarette smoking (Pierce et al., 2021). The other study found that youth who vape are four times more likely to begin smoking combustible cigarettes than their peers who do not vape (Berry et al., 2019).

These current trends may contribute to tobacco use continuing to be the leading preventable cause of death in the United States (National Center for Chronic Disease Prevention and Health Promotion, 2014). Furthermore, the long-term negative effects of nicotine on brain maturation, cognitive development, and mental health are well documented (Goriounova & Mansvelder, 2012). Recent studies indicate that e-cigarette aerosol is a source of exposure to myriad toxic chemicals (Park et al., 2019) and heavy metals (Olmedo et al., 2018). E-cigarette use is an independent risk factor for respiratory disease (Bhatta & Glantz, 2020), and in late 2019, it was associated with rapid increases in a new lung disease called “e-cigarette, or vaping, product use-associated lung injury” (EVALI), which subsequent to this study was strongly linked to vitamin E acetate, a preservative used in THC-containing vaping products (CDC’s Office on Smoking and Health, 2019).

Purpose

The growing concerns about use, addiction, and harms, in conjunction with increased availability of e-cigarette device types and brands, suggest a need to better understand the appeal of e-cigarettes for youth. Previous studies suggest that formative research is particularly useful to understand the variety of factors that motivate these behaviors in a specific priority population (Gittelsohn et al., 2006; Higgins et al., 1996). Formative research findings can inform the development of purposeful, multilevel interventions (Gittelsohn et al., 2006). Some studies have examined youth e-cigarette attitudes, behaviors, and social norms about earlier generations of e-cigarettes (Kong et al., 2015), but less is known about the appeal of newer e-cigarette products. In fact, authors of a recent systematic review of e-cigarette literature called for more research on the association between pod-based e-cigarette characteristics and youth perceptions of risk and appeal with the goal of designing effective preventive interventions (Lee et al., 2020).

The present study aimed to address this need for formative research examining youth perceptions of the latest generation of e-cigarettes. The social-ecological model (SEM) informed our study design. The SEM model examines individuals as embedded within the context of multiple social systems and how these interactive systems influence an individual’s health behavior (McLeroy et al., 1988; Stokols, 1992). Focus group methodology was used to gain insight into the personal experience and contextual factors that may influence adolescent e-cigarette use. Drawing on the SEM helped identify and understand the multiple levels of social and environmental factors influencing current youth vaping perceptions and behaviors.

Methods

Ten focus groups with 67 youth were conducted in metro and rural settings (five focus groups per setting) with Minnesota ninth to 12th graders in spring 2019 (metro) and fall 2019 (rural). The metro setting was within Ramsey and Dakota counties, covering the metropolitan St. Paul area. The rural setting was within three counties located in east central Minnesota. A convenience sample of participants was recruited in both settings by educators and community partners. Recruitment communications promoted the inclusion of all students regardless of vaping status. As shown in Table 1, 53% of participants identified as female; metro area participants were more diverse and were slightly older on average than rural participants.

Table 1

Demographics of Focus Group Participants (10 Focus Groups, N = 67)

Self-identified race	No. of participants	Grade				Self-identified gender
Self-identified race	No. of participants	9	10	11	12	Male	Female	Nonbinary
Metro
White	8	1	2	0	5	6	2	0
White/Native	1	0	0	0	1	0	1	0
Latino	6	1	1	2	2	2	4	0
Latino/White	3	0	0	2	1	3	0	0
Black	13	3	6	0	4	10	3	0
Black/White	5	0	0	1	4	1	4	0
Black/Native	1	1	0	0	0	0	1	0
Mixed	1	0	0	1	0	0	1	0
Total	38	6	9	6	17	22	16	0
Rural
White	26	4	8	6	8	12	13	1
Black	2	1	0	1	0	1	1	0
Mixed	1	0	0	1	0	0	1	0
Total	29	5	8	8	8	13	15	1
Combined total	67	11	17	14	25	35	31	1

Data Collection

The study was reviewed and approved as exempt by the institutional review boards at the University of Minnesota and the Minnesota Department of Health. The research team developed a question guide shaped by SEM. Focus group questions aimed to elicit (1) participants’ personal perceptions and knowledge about “vaping” versus “e-cigarettes” versus “cigarettes,” (2) social and environmental factors influencing why youth vape, and (3) suggestions for prevention messages and ideas of individuals who could persuasively convey this information to them. Table 2 provides focus group topics and main questions covered. One pilot focus group was conducted with 10 youth to test question development, resulting in slight modifications for clarity but no changes to the primary content of the question guide.

Table 2

Focus Group Topics, Main Questions, and Sample Prompts

Topics	Main questions and sample prompts
Perceptions of tobacco products (vaping, e-cigarettes, cigarettes)	Let’s start with a brainstrom. I’m going to write a word on the white board and I want you to shout out any words that you associate with this word. (Vaping, e-cigarette, cigarettes were the words written and discussed consecuetively.) What do you think are in these products? How dangerous or safe do they think these products are? Compared with not using anything? Compared with using regular cigarettes or other substances instead? Are e-cigs and vaping the same thing or different? Why?
Reactions to current youth e-cigarette use statistics	What reactions do you have? How concerning is the statistic to you? What do you think are the primary causes of the increases?
Perceptions of why teens vape	Think about peers you know who might vape. Why do you think they vape? Where do they usually vape? When do they vape? What about cigarette use? Describe why or why not you think your peers who vape would or would not use regular e-cigarettes.
Vaping prevention messaging	How would you convince just two people not to vape? How should they get the information? Where? When? By whom? What do you think would be the best way to convince young people not to vape? What types of messages do you listen to when learning about risk behavior? Who would you listen to?

All focus groups were conducted by one of two moderators from the research team. The moderator facilitated discussions using the question guide to provide consistency across focus groups while allowing for flexibility to probe and encourage participation. Focus group sessions lasted between 45 and 75 minutes, included refreshments, and were digitally audiotaped and transcribed. Each session had a designated note taker. The moderator recorded observations of participant demeanor, tone, and group dynamics after each session. These data were added to the end of each transcript and used as a reference during data analysis. All participants received a $10 gift card as an incentive for their participation. Demographic characteristics were collected via an anonymous questionnaire answered by participants at the start of each focus group session.

Data Analysis

A codebook was created from the focus group responses by EL. Two members of the research team, EL and MM, independently read three transcripts, applied the initial codes, and met to discuss their results and resolve code discrepancies. Codes were added as needed. EL and MM then systematically coded all remaining focus group transcripts. Once coding was completed, key themes were identified following Hahn’s (2008) guidelines for qualitative data analysis. Findings were compared across rural and metro settings.

Results

The focus group data analysis yielded three to five main themes from each of the three key questions asked. Themes were present across focus groups unless otherwise specified. Table 3 contains categories and main themes with example quotes.

Table 3

Main Themes Generated on Youth Perceptions of Tobacco Products, Use, and Prevention

Topic	Qualitative themes	Illustrative quotes
Perceptions of tobacco products	Positive vaping perception	“You don’t get the gross tobacco feel when vaping. It’s just like a fresh, fruity smell and . . . you can do it anywhere you want.”
	Neutral e-cigarette perception	“We [youth] don’t see e-cigarettes often. I think I’ve seen an e-cig once in my lifetime.”
	Negative cigarette perception	“Companies are making [vaping] appealing to a younger audience. If they [tobacco companies] put cigarettes in front of us, nobody would take them. But you put vape in front of us it looks like a brand-new toy.”
Why youth vape	Stress and anxiety	“I mean [stress] is always there, but you can be like, ‘Damn, I’m tired as hell at school, I can go home though and I can hit this shit.’ It’s mostly just because of all the schoolwork that we have, and all the pressure that we get on our grades . . . There’s just constant pressure all the time.”
	Perceived peer pressure and normalization (i.e., everybody vapes)	“Vaping is like putting on shoes—everyone does it.” “They’re so used to seeing people doing it that it just doesn’t really phase them anymore.”
	Nicotine impact (buzz and addiction)	“There’s the thrill seekers at our school that are like, ‘People are going to get in trouble for this. Let’s see how long I can go with this and not get in trouble.’ . . . There’s a lot of people who didn’t mean to get addicted to it but did it to see how far they could go without getting in trouble, and actually got addicted to it.”
	Easy access	“During passing, I went to use the bathroom, there was some kid, and I knew this kid, and he hasn’t touched one his whole life. The kid’s like, ‘Hey, you want to try this?’ He just grabbed it, took it, and took a couple hits off it. It’s just so easy to get people hooked on it.”
	Invincibility	“Some kid’s lung collapsed that’s supposedly because of vaping. Which I believe it but like I feel like that’s also a thing say that could happen with cigarettes to the same kid. Maybe they just have something wrong. Or he wasn’t as strong. Like my cousin, he’s been vaping constantly for three years, not a thing wrong with him.”
E-cigarette prevention
Prevention messaging	Facts about products and risk of harms	“I don’t wanna just hear some bullshit excuse, ‘Oh you know what it’s doing to you, right?’ No, I need to actually know. Is it killing my brain cells? Is it actually making my life shorter? I need to know.”
Prevention messaging	Nonjudgmental, personalized communication	“I think it would be really good to have a class that kids can speak with an audience because it feels really good to speak and know that someone is listening to you. I think a lot of kids these days feels like no one is listening to them.”
Prevention messengers	Delivered by someone they can trust	“Teachers should have better relationships with students that smoke, because I feel like a teacher could have a really big impact.” “Counseling service would be helpful. Peer pressure is really hard.”
Prevention messengers	Personal stories	“I would listen to someone who was affected by it. Like a cancer survivor.”

Differing Perceptions of Tobacco Products

As shown in Figure 1, word association themes for “vaping,” “e-cigarettes,” and “cigarettes” revealed vastly divergent perceptions of each term and the benefits and harms they associated with each product. Participants reported a generally positive perception of vaping. For example, most participants associated the word “vaping” with fruit and candy flavors and smells, often in descriptive detail: “Juicy apple, oh my God. Juicy Apple is my favorite.” Participants rattled off types of “vape tricks” they or their friends performed or saw on social media while giggling over vape trick names like “Os, ghost inhale, tornado, zeroing, and jellyfish,” to name a few. The same slang words (e.g., “juuling,” “fiending”) and associations with vaping (e.g. “hit that shit,” “hit it”) were frequently reported.

Figure 1

Most Common Themes Generated From Tobacco Product Word Association in Descending Order

These positive associations were consistently identified despite participants reporting knowledge that vapes contain nicotine and may be harmful. More rural than metro participants perceived vaping as dangerous and discussed health impacts, though this may have been a function of timing as media reports of youth EVALI cases emerged after metro focus groups took place and prior to rural focus groups.

Conversely, when participants were prompted to provide words they identified with “e-cigarettes,” the first few moments were often met with silence as they struggled to find words they associated with this term. Some were unable to describe e-cigarettes at all; others perceived them to be different from vaping. “Is that the same as vaping?” was asked by at least one participant in every focus group. One participant confidently reported that e-cigarettes “were around before Juul and all the vapes.” Some participants described e-cigarettes as a tobacco cessation tool for adults.

Finally, participants were quick to identify words they associated with “cigarettes,” consistently reporting disgust, bad smells, and dangerous health effects from smoking. As one participant surmised, “I would never smoke [cigarettes]. They’re nasty as hell. They smell bad. People know they can die from it. I don’t want to be associated with that shit.” A few rural participants believed that cigarettes are healthier than vaping, including one who opined, “Vaping and e-cigarettes are worse [than cigarettes] because they contain a lot more carcinogens.” This perception may have been influenced by media reports on EVALI cases at the time the rural focus groups were conducted. In every focus group, at least one person associated cigarettes with “old people.” Participants also pointed out positive beliefs about vaping compared with cigarettes. For example, one participant noted, “Vaping you can be a lot more discreet.” Responded another, “Yeah, you can hide it.”

Why Youth Vape

According to participants, vaping is an easily accessible coping method to help teens manage stress and anxiety. Participants described the ease of obtaining vapes from a variety of sources. Some reported that certain convenience store clerks sell them to underage youth or that older peers sell vapes at school. One participant explained,

If you go up to an upper classman and you were a middle schooler and you asked them, “Hey bro, you got a vape? Can I buy one off of you?” Nine times out of ten they’re going to be like, “Yeah, I got you.” And who’s going to turn down some money?

Another participant illustrated how teens vape as a coping method: “People get so stressed. Then, they think once they hit the JUUL, and then get that next new buzz, that they feel good, and they’re ready to go on.” Others referred to typical adolescent beliefs of invincibility: “The kids who vape, they think that they’re untouchable, and that it’s not going to harm them.”

Participants described the relaxing “buzz” after “hitting it” yet were well aware that nicotine caused the “buzz” they described. Reports of the “buzz” and subsequent “nicotine addiction” often went hand in hand. One participant shared, “I used to only vape at school for the buzz but then things got a little bit rough in life, then I got a little bit addicted and it just kind of went downhill from there.” At the same time, a common theme was willingness to continue vaping because, as one participant described, “that’s the curse of the teenagers. They have the knowledge, but they don’t care.”

Finally, participants noted perceptions of peer normalization and connection as reasons for youth vaping. When presented with the statistic that one in four Minnesota 11th graders vaped in the past month (Evered, 2018), almost all participants perceived this statistic to be low. This perception that “everyone vapes” was further confirmed as participants consistently pointed to vaping as a way teens think they can fit in with their peers. Said one participant, “I think a lot of kids think if they start doing it, they’ll become cool and popular.” Participants also consistently portrayed vaping as fun, a “pretty dope” social activity engaged in by most of their peers.

Prevention Messaging

Participating teens asked for accurate information about vaping health risks presented in personalized, nonjudgmental contexts by people they know care about them. Participants suggested that providing facts about dangerous chemicals and harms associated with vaping will help youth make informed decisions: “The more facts we have, and more negative things get [sic] out there would help. We were all told negative things about cigarettes and none of us would touch them.” A few metro participants had diverging opinions and were pessimistic that even when presented with facts, youth may not listen to prevention messaging. One teen noted, “I mean, there’s no real way to convince someone not to do it, because teenagers are stubborn. If they wanna do it, they’re gonna find a way to do it.”

Many participants reported that teens often feel judged by adults, even those with good intentions, and stressed that prevention messaging cannot feel admonitory for teens to hear it. One teen stated, “If you could kind of find a way not to be judgmental, but still tell them what’s best, I think you’d get a better reaction.” A number of participants mentioned “hypocritical” adults in their lives who warn them not to vape, yet vape or smoke themselves. Noted one participant, “My dad talked to me about vaping and then I found a JUUL pod in his car, so I ignored everything he said.”

Participants described the ineffectiveness of prevention messages delivered through large group presentations or posters. For example, teens will tune out large school presentations: “The presentations don’t always work because there are still some people vaping even in the auditorium during it.” Participants reported that their peers make fun of vaping prevention material displayed at school: “I’ve seen people laughing at the posters in the bathroom. I’ve watched people rip them down and put them in the garbage . . . they just think it’s funny.”

A trusted adult messenger was a consistent theme. “Someone who we could build trust with . . . everyone needs that one person they can talk to,” surmised one participant. The “trusted messengers” described ranged from scientific experts, like a physician or public health professional, to school counselors, teachers, coaches, and parents. Many participants noted that teens are often uncomfortable talking with their parents about risk behavior, describing the fear of getting into trouble and pressure not to disappoint them: “People are scared to ask for help, because if they ask for help, then they’re going to get in trouble.”

Other suggested messengers varied. Hearing personal stories was important to some participants: “I think, when we have public speakers coming to speak, I feel like kids would relate more to personal stories, rather than just presentations of what’s so bad about it.” Many said that they would not take advice from authority figures such as a principal warning students about vaping harms and punitive consequences. Observed one teen, “When you tell teenagers not to do something, they want to do it twice as much.” A few recommended older peers who they look up to as role models. Conversely, others indicated that they would not trust prevention messages from older peers.

Discussion and Implications

This formative research study examined e-cigarette perceptions among metro and rural Minnesota youth to inform development of strategies, tools and material for youth e-cigarette prevention, and interventions. Results showed vastly different associations for e-cigarettes and combustible cigarettes, insight into social and environmental factors for why youth vape, and ideas about prevention messages and messengers. These results point to important implications for practice, policy, and research, including using language tailored to the current context and developmental stage of adolescence, and addressing social and environmental contexts of e-cigarette use. Although the focus groups were conducted during the height of Juul’s popularity and just as disposable devices were making their debut, the increased popularity of disposable vaping devices, and their striking similarity to pod mod products like Juul, provides support that these results may be relevant to youth perceptions about these newer vaping products. Additionally, findings are aligned with the theory of positive youth development (PYD), which provides an effective framework to develop youth-focused prevention efforts. PYD literature emphasizes that effective prevention programs with youth aim to mitigate risk and promote protective factors and positive assets in the lives of teens (Catalano et al., 2004; DuBois & Karcher, 2014; Resnick, 2005; Stephenson & Johns Hopkins Bloomberg School of Public Health, 2009).

Tailoring Language and Messaging

An important finding was the consistency of associations made about the three tobacco terms discussed. Participants perceived vaping favorably while they were ambivalent about the term e-cigarettes and perceived combustible cigarettes negatively. Participants did not associate pod mods with the term e-cigarettes, which is consistent with a recent literature review (Lee et al., 2020) and pod mod social media marketing campaigns targeting youth (Huang et al., 2019). Some participants associated the term e-cigarettes with smoking cessation when, in fact, they are not regulated as cessation tools (U.S. Preventive Services Task Force, 2021). Perceptions that most teens vape and that vaping is ubiquitous across social media—which is consistent with the tobacco industry’s history of attracting youth with appealing flavors and targeted advertising (Brown et al., 2014)—suggest that public health is currently losing the battle against these dangerous new products.

These findings may have important implications for prevention campaigns and future research. For example, the word “e-cigarettes” alone is often used to describe these products, but results of this study indicating perceived differences between “e-cigarettes” and “vapes” can inform how questions are asked in youth tobacco use surveys or how medical practitioners talk with youth about tobacco use. Future studies should test the efficacy of prevention campaigns referring to these products collectively or separately and seek to further understand the value of identifying that these are the same products marketed to different audiences by the tobacco industry. Studies that seek to develop prevention messaging should also prospectively address the rapidly evolving, diverse e-cigarette landscape and evaluate the potential appeal of new products to youth (Lee et al., 2020).

Furthermore, as perceived social norms are important determinants of health behavior (Dempsey et al., 2018), results suggest testing prevention messaging that directly confronts the idea that “everyone vapes” and the perceived peer pressure to engage in this activity, especially given that a strong predictor of teen smoking is having friends or peers who smoke (Hoffman et al., 2007). Messaging that challenges social norms misperceptions around vaping is aligned with the Social Norms Approach, a widely used behavior change strategy to promote positive health behaviors and reduce negative health behaviors (McAlaney et al., 2010).

Prevention campaigns may also want to find ways to associate vaping with negative images. The finding that these teens view cigarettes as “disgusting” is compelling. While young people noted the danger of cigarettes, their repulsion was also visceral in terms of smells and other socially relevant, negative associations. These findings are consistent with previous research demonstrating that negative social consequences are one of the most effective ways to frame messages aimed at curbing youth risk behavior (Kingsbury et al., 2015).

Beyond clarity of language, findings also illuminated strong opinions about effective prevention messaging and messengers. Participants preferred trusted adults providing factual information in a nonjudgmental manner to help them build healthy life skills. Talking with youth instead of at them creates the space for youth to share their thoughts and questions about risk behavior (Wickman et al., 2008). Participants had even stronger opinions about messaging that does not work for them stating clearly that they will not listen to hypocritical adults or authority figures lecturing while threatening punishment. They reported that adult-driven prevention efforts like posters and lectures make teens want to rebel and do the opposite of what they are being told. This finding is consistent with a recent study where youth found certain prevention ads unappealing because they looked like an adult made them for teens while parents thought that these same ads would be effective with youth (Popova et al., 2021). Youth participants suggested engaging teens to lead antivaping campaigns that could increase message authenticity and trust.

Finally, the idea that teens do not intend to get addicted and underestimate the risk was uniformly found across focus groups despite the EVALI outbreaks occurring immediately prior to and during the rural focus group sessions. Adolescents appear to not accurately assess risk, resulting in perceptions of invincibility (Wickman et al., 2008). Teen brains are also primed for positive chemical reactions from risky behavior, making them prone not only to engage in risk behavior but also to develop addiction (Petit et al., 2013). Therefore, prevention campaigns focused solely on warning youth about the dangers of vaping may not be sufficient to address the youth vaping epidemic. Vaping prevention messaging should be carefully designed and tested to communicate risks in a way that will reduce youth e-cigarette use and change misperceptions about addiction and harms.

Targeting Social and Environmental Contexts of Use

Teens repeatedly discussed enormous pressures in their lives, vaping to cope with stress, and the unanticipated addiction that often follows. Participants suggested that many of their peers do not have access to needed support and that concern about being judged by adults can prevent teens from asking for help. Teens’ desires to have better resources to cope with stress aligns with the PYD construct of emotional competence, which includes the ability to identify and manage feelings, delay gratification, control impulses, and reduce stress (Catalano et al., 2004).

These findings point to the need for holistic prevention and health promotion strategies, including mental health interventions to protect underserved youth. Schools and community programs can fill these gaps with evidenced-based policies and programs to ensure that youth have access to appropriate resources. Furthermore, the reported desire for a trusted adult guide is consistent with research that mentoring relationships can be positive resources in the lives of adolescents (Lerner et al., 2014).

Another concerning finding was the ease with which teens from both settings access e-cigarettes, a finding consistent with other research (Institute of Medicine, 2015; Roeseler et al., 2019). Easy access to tobacco products is significantly related to smoking initiation and regular use (Leatherdale & Strath, 2007). State and local governments, and more recently the federal government, raised the tobacco sales age to 21 years based on such evidence (Tobacco 21, 2020). Tobacco 21 is only one policy example, and a continued need exists to enact and enforce robust tobacco prevention laws and policies at multiple levels. We wish to emphasize the best practice recommendations for enforcement that avoid punitive responses to youth behavior, instead focusing penalties on illegal sales behavior by tobacco retailers (Public Health Law Center, 2019a) and alternative measures to suspension in schools as part of a comprehensive commercial tobacco-free schools policy (Public Health Law Center, 2019b).

These recommendations align with findings from the fields of juvenile justice (Lopes et al., 2012) and behavior management in schools (Fabelo et al., 2011) that exclusionary and punitive consequences are ineffective for youth. We encourage instead schools and other community institutions to consider that an important PYD construct is to create boundaries and community standards for positive youth behavior (Catalano et al., 2004). Positive behaviors can be promoted by activities that integrate active participation in skill building opportunities in conjunction with rewarding and supportive adult–youth relationships (Lerner et al., 2014). To clarify based on examples in our findings, it is important for schools to interrupt vaping in restrooms, but often counterproductive to suspend students for the behavior.

Our findings have limitations. The study was conducted in two geographic regions of one state and may not be generalizable to the perceptions of all youth. The two focus group sets were conducted 6 to 9 months apart and within a rapidly evolving context of increasing regulations, new research, and industry workarounds that may have influenced participant responses. For example, the rural focus groups took place right after the EVALI outbreak and subsequent national media coverage. We did not assess vaping status or evaluate perceptions of specific e-cigarette devices or brands, which may have helped contextualize findings. This study had relatively consistent findings among rural and metro youth perceptions about e-cigarettes that appear to contrast a 2011 study that found divergent tobacco perceptions between youth in urban and rural settings (Rothwell & Lamarque, 2011). Additional research on larger samples of diverse youth across geographic settings is recommended to further assess the extent to which youth e-cigarette perceptions vary by sociodemographic characteristics.

Despite these limitations, this study fills a needed gap in the literature about youth perceptions including benefits and harms associated with different tobacco products, social and environmental factors that influence vaping, and preferred strategies for prevention messaging. These findings have important implications for designing and testing prevention efforts striving to curb e-cigarette initiation, use, and nicotine addiction among youth, and also for strategies to promote healthy adolescent development.

Footnotes

Authors’ Note:

The 2020 NYTS data came out after this study was conducted, but these data provide additional support for the continued urgency to understand the products and behaviors driving youth e-cigarette use. This study was funded by a Tobacco-Free Communities grant from the Minnesota Department of Health. Additional funding was provided by the University of Minnesota School of Public Health, Division of Health Policy and Management.

ORCID iDs

Elyse Levine Less

Melissa Mady

John H. Kingsbury

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