High-School Students Rarely Use E-Cigarettes Alone: A Sociodemographic Analysis of Polysubstance Use Among Adolescents in the United States

Introduction Most adolescents reporting e-cigarette use have also used combustible tobacco; however, the extent to which they use other substances is less clear. This study assessed e-cigarette use with tobacco, alcohol, or cannabis and quantified the risk of polysubstance use among adolescents overall and by sociodemographic characteristics. Aims and Methods Using 2017 Youth Behavioral Risk Factor Surveillance System data from adolescents (grades 9–12) with complete substance use information (n = 11 244), we examined e-cigarette poly-use status (none [referent], e-cigarettes only, or e-cigarettes + other substances). We estimated the prevalence of substance use and modeled odds of e-cigarette use, alone or with other substances, by several sociodemographic characteristics. Analyses were completed in Stata version 15.1 using survey procedures to account for the complex survey design. Results Approximately 12% of adolescents reported past 30-day e-cigarette use. Almost all (93%) e-cigarette users also reported other substance use; alcohol appeared most frequently in combinations. Odds of e-cigarette single use and e-cigarette poly-use (vs. no use) were higher for males and adolescents with lower grades (odds ratios [ORs] = 1.44–2.31). Racial/ethnic minorities had lower odds of e-cigarette poly-use than White peers (ORs = 0.18–0.61), and bisexual (vs. straight) adolescents were more likely to be e-cigarette poly-users (OR = 1.62). E-cigarette use increased from 9th grade (7%) to 12th grade (16%). Conclusions Polysubstance use is highly prevalent among adolescents who use e-cigarettes. Therefore, e-cigarette screening should include the assessment of other substances, especially alcohol. Early and comprehensive prevention efforts to reduce e-cigarette and other substance use could have a substantial beneficial impact on population health over time. Implications This study extends knowledge about e-cigarette use among adolescents by exploring its use with alcohol, cannabis, and other tobacco products. We found that e-cigarettes were very rarely used alone, and our analysis identified several sociodemographic factors associated with greater odds of e-cigarette polysubstance use. In response, we recommend that prevention interventions address multiple substances concurrently, screen repeatedly to detect new initiation as age increases, focus on e-cigarette use as a less stigmatized entry point to discussions of substance use, and target priority population subgroups.