Predictors of polysubstance vaping in emerging adults

Vaping is the inhaling of a vapor created by an electronic vaporizer, which typically contain flavorings and substances such as nicotine or cannabis (Lanza et al., 2020). Vaping has become a relatively new mode of delivery for substances and its prevalence has substantially increased during the last few years in North America (Dugas et al., 2020, Lanza et al., 2020). Polysubstance vaping has become common from late adolescence to young adulthood, particularly among more frequent vapers (Lanza et al., 2020). As polysubstance users in general are at higher risk of negative health outcomes as a result of substance use including cognitive deficits, mental health issues, and earlier mortality (Connor et al., 2014, Schulte and Hser, 2014), examining the co-use of substances in this new and increasingly popular delivery method is crucial for prevention and harm reduction.

Previous research has already shown that the use of nicotine and cannabis – the two most frequently vaped substances – increases the likelihood of using both substances concurrently (Audrain-McGovern et al., 2018), while the co-occurring use of nicotine and cannabis has been linked to higher nicotine dependence and higher risk for cannabis problems (Jayakumar et al., 2021). In addition, in a recent study, past-year e-cigarette use was the only predictor of the co-use of the two substances (Jayakumar et al., 2021), which highlights the connection between vaping and polysubstance use and raises the question of how vaping may contribute to risk for increased polysubstance use. With the use of an electronic vaporizer, vapers can easily vape both nicotine and cannabis using the same delivery method, which may increase the probability of co-use. Previous research has demonstrated that e-cigarette nicotine users have higher risk for initiating the use of substances other than nicotine (Lanza et al., 2020). In addition, the same data revealed that e-cigarette vaping was associated with co-use of substances more than using substances via combustible methods (e.g., smoking cigarettes or cannabis). While there is an empirically demonstrated risk of vaping facilitating polysubstance use above and beyond combustible means, the extant literature does not offer an explanation for why that may be. Since the mechanisms through which vaping may contribute to polysubstance use are not yet clear, it stresses the importance of examining contributing factors to polysubstance use that can be linked specifically to vaping as a delivery method. Moreover, e-cigarette vaping is highly prevalent among emerging adults i.e., individuals between 18 and 30 years (Dugas et al., 2020, Dai and Leventhal, 2019), who are in a period of life that involves an extended duration of learning and experimentation making them more vulnerable to substance use including co-occurring substance use (Arnett and Tanner, 2006, Arnett, 2015, Haardörfer et al., 2016) and substance misuse (Sussman and Arnett, 2014). With the increase in popularity of vaping among young people, it is crucial to examine what factors may contribute to this higher likelihood of co-use of substances among vapers to prevent a rise of polysubstance use in future generations.

Theoretically, the integrative model of behavioral addiction (IMBA) (Fishbein and Yzer, 2003) provides a comprehensive framework for evaluating the potential risk factors for polysubstance vaping. This model suggests that there are three proximal determinants of behavioral intention: the attitude toward the behavior (i.e., overall positive or negative feeling about performing the behavior), the perceived norms concerning the behavior (i.e., perception that important others perform or do not perform the behavior (descriptive norms) or important others think that they should or should not perform the behavior (injunctive norms)) and one’s self-efficacy with respect to performing the behavior (i.e., perception that they can perform the behavior) (Fishbein and Yzer, 2003). More favorable attitudes, more perceived approval, and lower self-control are predictive of stronger intentions to use and increased substance use behaviour (Malmberg et al., 2012). Critically, the model also indicates that proximal factors (those most imminently predictive of the behavior occurring) are all functions of underlying beliefs which are influenced by distal (i.e., more removed) determinants such as demographics, or cultural and personality factors, mood and emotion patterns (Fishbein and Yzer, 2003). The highlighted distal predictive factors of substance use are relevant because some cultures are more tolerant of the use of specific substances than others (Westermeyer et al., 2004); and there are personality traits that are linked to higher risk for substance use, such as hopelessness, anxiety sensitivity, sensation seeking or impulsivity (Conrod et al., 2000). Mood and emotion patterns can also influence personal attitudes toward the behavior, as individuals having low mood or negative emotions are more likely to have positive expectancies related to the substance if that improves their mood or emotions (Blume et al., 2000). Therefore, highly prevalent co-morbid symptoms that significantly impact mood and emotion patterns such as depression and anxiety (Grant et al., 2004, Lai et al., 2015) should also be considered as distal factors when predicting the use of substances.

Evaluating this theoretical model empirically for vaping is of importance since current gold standard interventions for substance use such as cognitive behavioral therapy (CBT) (McHugh et al., 2010) assume that the proximal factors are relatively more influential on addictive behaviors than background individual differences and they are modifiable via cognitive restructuring by changing the beliefs related to the proximal factors. However, cognitive interventions may only be effective if these assumptions are met; therefore, examining the relative importance of the proximal, more modifiable factors and distal, less modifiable determinants, in developing polysubstance use is necessary to know whether cognitive interventions may be effective in curbing polysubstance vaping. It is also crucial to analyse which factors have the most impact on polysubstance vaping because current CBT treatments are least effective in polysubstance user groups (McHugh et al., 2010).

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