From stress to susceptibility: how COVID lockdowns shaped teen vaping risk

By Vijay Kumar MalesuReviewed by Susha Cheriyedath, M.Sc.Oct 12 2025

New research shows that pandemic stress didn’t lead teens straight to vaping, but it quietly opened the door, making them more willing to try e-cigarettes and cannabis long after schools reopened.

Study: Prospective associations of COVID-related stress with vaping nicotine and cannabis among high school students: Mediated by vaping susceptibility. Image Credit: Daisy Daisy / Shutterstock

In a recent study published in the journal PLoS One, a group of researchers at the University of Southern California, USA, tested whether coronavirus disease 2019 (COVID-19)-related stress during remote learning predicted later electronic (e)-cigarette and cannabis vaping among high-school students, and whether this link was mediated by susceptibility to use.

Background

During the pandemic, research showed mixed trends in youth substance use, with some studies reporting declines and others indicating rebounds. E-cigarettes expose the developing brain to nicotine, which can harm attention and self-control. Vaping cannabis in adolescence is tied to lower grades and higher risks of addiction and mental-health problems. The Severe Acute Respiratory Syndrome Coronavirus 2 pandemic brought online classes, isolation, and family stress, pressures that can push teens toward risky choices. Before trying any product, many teens shift from “definitely not” to “maybe,” a stage known as susceptibility. Families and schools need to spot and lower susceptibility. Long-term data were required to show how pandemic stress shaped subsequent vaping behavior.

About the study

Researchers tracked 1,316 public-school students in Los Angeles County starting in ninth grade across three yearly surveys. First was Time 1 (2020–2021) during COVID-19 school closures, then Time 2 (2021–2022) in the first year back on campus, and lastly Time 3 (2022–2023), two years after reopening. At T1, they measured COVID-related stress using a multi-item checklist with acceptable internal consistency (Cronbach’s alpha = 0.75). Although it has not been externally validated, the checklist covers family life, duties, time pressure, and social life. They also measured susceptibility, meaning students were not firmly saying “no” to e-cigarettes and cannabis at T1 and T2 using adapted, established items.

Current use (any past-30-day vaping of e-cigarettes or cannabis) was captured at T1 and T3 with Youth Risk Behavior Surveillance System (YRBSS) questions and coded yes/no. Students completed surveys on their own devices using Research Electronic Data Capture (REDCap). The University of Southern California Institutional Review Board (IRB; HS-18-00706) approved the study.

Analyses adjusted for age, biological sex, race/ethnicity, family finances, parent education, baseline susceptibility, and baseline use. The team used regression-based path models in Mplus, clustering by school, to test direct effects from T1 stress to T3 vaping and indirect impacts through T2 susceptibility. Indirect paths used Monte Carlo integration. Results appear as odds ratios (ORs) with 95% confidence intervals (CIs). Missing data were handled with full-information maximum likelihood, so all available answers contributed. This design cleanly tested whether early pandemic stress raised later vaping risk and whether growing openness to try explained that link.

Study results

The cohort was 57.8% female, and 53.4% identified as Hispanic. At Time 1, past-30-day vaping was uncommon: 3.6% reported e-cigarette use and 2.9% reported cannabis vaping. By Time 3, both increased to 6.4% for e-cigarettes and 7.4% for cannabis. Average COVID-related stress at T1 was 18.99 (standard deviation (SD) = 4.93). Openness to try (susceptibility) was widespread: at T2, 38.4% were susceptible to nicotine vaping and 19.9% to cannabis vaping, close to T1 levels (36.7% and 18.6%).

“Total-effect” models showed that each one-SD increase in T1 stress predicted higher odds of T3 e-cigarette use (B = 0.21, OR = 1.24, 95% CI: 1.04–1.49, p = .02) after adjustments. The same increase predicted higher odds of T3 cannabis vaping (B = 0.26, OR = 1.30, 95% CI: 1.10–1.54, p = .002). In short, more early stress is linked to more later vaping.

Mediation tests asked whether stress influenced teens by shifting their response from “definitely not” to “maybe.” Higher T1 stress predicted higher T2 susceptibility for both products (e-cigarette: B = 0.04, p = .02; cannabis: B = 0.04, p = .02). In turn, higher T2 susceptibility strongly raised the odds of T3 past-30-day use (e-cigarette: B = 0.98, OR = 2.67, 95% CI: 1.39–5.12, p = .003; cannabis: B = 1.62, OR = 5.04, 95% CI: 2.50–9.08, p < .001). After adding susceptibility, the direct path from T1 stress to T3 e-cigarette use dropped to non-significant (B = 0.14, OR = 1.14, 95% CI: 0.95–1.37, p = .17). The direct path to T3 cannabis vaping stayed significant but smaller (B = 0.19, OR = 1.21, 95% CI: 1.01–1.46, p = .04).

Indirect effects were significant for both outcomes (e-cigarette: Bindirect = 0.04, 95% CI: 0.01–0.08, p = .04; cannabis: Bindirect = 0.06, 95% CI: 0.02–0.10, p = .01), explaining 15.9% of the total effect for e-cigarettes and 24.9% for cannabis. In simple terms, stress during remote schooling nudged some teens from a firm “no” to a “maybe,” which made later vaping more likely, especially for cannabis. The authors suggested this stronger mediation for cannabis may reflect its greater perceived taboo and lower normalization compared to e-cigarettes, which are more widely accepted. Sensitivity checks (E-values) suggested only unmeasured factors with moderate-to-large links could fully erase these patterns. However, influences like peer use or mental-health history may still play a role.

Additional context and limitations

Findings may not generalize beyond Southern California public high schools, and students who remained in the study differed in sex and ethnicity from those lost to follow-up. Pandemic phases, including overlaps with later COVID-19 surges such as Omicron, may blur the timing of stress, susceptibility, and use. Although E-values indicate moderate robustness, unmeasured factors such as peer or parental vaping or mental-health history could still influence results.

Conclusions

This longitudinal study shows that higher COVID-19 stress during remote learning increased later susceptibility to vaping, which then raised the odds of e-cigarette and cannabis vaping two years after schools reopened. For families, this means teaching coping skills, watching for stress, and asking direct questions about vaping. For schools and communities, prevention should target susceptibility, both in person and through engaging digital tools that can continue during disruptions. Policymakers and clinicians should expect stress-driven risk during crises and build fast, scalable supports to protect teen brain health and school success.