Electronic nicotine delivery systems (ENDS) use and its association with low academic achievement among 9th-12th grade students in the US – 2017 Youth Risk Behavior Survey (YRBS) Open Access

Russell, Olivia (Summer 2020)

Permanent URL: https://etd.library.emory.edu/concern/etds/sx61dn50m?locale=en


Objective. In 2018, the United States (US) Surgeon General declared adolescent electronic nicotine delivery systems (ENDS) use an epidemic and called for aggressive steps to reduce ENDS use among adolescents. There is ample evidence how tobacco smoking impacts academic achievement among adolescents; however, there is a need to explore the association of ENDS use with low academic achievement in high school students in the US, to guide translational research on ENDS use and its prevention programs. 

Methods. We used self-administered questionnaire response data from the 2017 Youth Risk Behavior Survey (YRBS), a nationally representative cross-sectional survey of 14,765 US high school adolescents (9th-12th grade). Low academic achievement was defined as receiving mostly Cs, Ds, and Fs in the previous 12 months. Multiple logistic regression was performed to estimate crude and adjusted prevalence odds ratios (cPOR and aPOR, respectively) and associated 95% confidence intervals (CI) to examine the association. Adjusted analyses were stratified by gender, and controlled for year in school, race/ethnicity, and cigarette use.

Results. In 2017, 13.2% of adolescents reported current ENDS use in the past 30 days of YRBS survey, 21.5% reported past use, and 65.2% never used ENDS. Our stratified adjusted analysis showed that among females, current ENDS users had 2.3-times (95% CI: 1.5 – 3.4) higher odds for low academic achievement compared to never ENDs users, and  among males, past ENDS users had 1.3- times (95% C.I.: 1.1 – 1.5) higher odds of low academic achievement, relative to those who reported never ENDS use.

Conclusions. In our study examining a nationally representative sample of high school adolescents in the US, ENDS use was positively associated with lower academic achievement in both genders, however the association was stronger in females. Prevalence of ENDS use fluctuates in the adolescent population, and hence knowledge of gender’s differential effect on the association between ENDS use and academic achievement should be examined in future analyses. 

Table of Contents

Chapter 1: Literature Review 1

Public Health Significance 2

Electronic Nicotine Delivery Systems (ENDS) 3


ENDS Design 3

ENDS Emission 4

History of ENDS 4


Health Effects of ENDS 7

Tobacco Use Prevalence 9

Youth Risk Behavior Survey (YRBS) 9

National Youth Tobacco Survey (NYTS) 10

Population Assessment of Tobacco and Health (PATH) 11

Monitoring the Future (MTF) 11

Reasons for Use 12

Trends in Tobacco Use Among Adolescents 12

ENDS Use 12

Cigarette Use 13

Tobacco Dual Use 14

ENDS Risk Factors 14

Age/grade 15

Gender 16

Race/Ethnicity 16

Socioeconomic Status (SES) 16

Academic Achievement 16

Alcohol Use 17

Substance Use 17

Mental Health 18

Sexual Activity 19

Violence and Injury 19

Diet and Physical Activity 19

Psychosocial Characteristics 19

Susceptibility to ENDS use 20

Flavorings 20

ENDS Marketing 21

Perceived Addictiveness and Harmfulness 21

Academic Achievement Trend Data 22

Academic Achievement 23

SAT Scores 23

Drop-out Rates 24

Academic Achievement Risk Factors 24

Gender 24

Race/Ethnicity 25

SES 25

Tobacco Use 26

Alcohol Use 26

Substance Use 27

Mental Health 27

Sexual Activity 27

Violence and Injury 28

TV and Device Use 28

Diet 29

Physical Activity 29

Study Rationale 29

Chapter 2: Manuscript 32

Abstract 33

Introduction 34

Methods 36

Results 39

Tables 46

Table 1 46

Table 2 49

Table 3 53

Table 4 57

Chapter 3: Discussion 57

Findings 58

Recommendations 58

Future Analysis 58

ENDS Prevention Policy 60

References 63

Appendix 76

Tables 77

Table 5 77

Table 6 81

Table 7 84

Table 8 86

Table 9 87

Table 10 90

YRBS Survey Questions 94

ENDS Use 94

Academic Achievement 94

Year in School 95

Gender 95

Race/Ethnicity 95

Cigarette Use 96

Alcohol Risk 97

Substance Use Risk 97

Sexual Activity Risk 100

Mental Health Risk 101

Violence Risk 102

Injury Risk 102

Diet Risk 103

Physical Inactivity Risk 104

Screen Time Risk 105

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