Eating disorders linked to higher rates of vaping and smoking behaviors

Vaping has become one of the most widely adopted nicotine delivery methods of the past decade, particularly among adolescents and young adults, yet its relationship with mental health conditions remains surprisingly underexplored. Now, a large-scale study drawing on data from more than 6,100 participants suggests that individuals with eating disorders are substantially more likely than the general population to use nicotine in any form, whether through traditional cigarettes, electronic cigarettes, or both. The findings, published in the Journal of Eating Disorders, add a new dimension to the clinical picture of eating disorders and carry immediate implications for how clinicians screen and treat affected individuals.

The research team, led by Jessica S. Johnson of the Department of Psychiatry at the University of North Carolina at Chapel Hill, together with colleagues including Cynthia M. Bulik of the University of North Carolina and Karolinska Institutet, and Melissa A. Munn-Chernoff of Texas Tech University, analyzed data from the United States arm of the global Eating Disorders Genetics Initiative, known as EDGI. This initiative, funded by the National Institute of Mental Health, is one of the largest genetic studies of eating disorders ever undertaken and is registered as a clinical trial. From this resource, the investigators assembled a cohort of 6,128 participants, 95 percent of whom were female, with a mean age of 34.9 years.

What distinguished this study from prior work was its systematic comparison of nicotine use patterns across the full diagnostic spectrum of eating disorders. Participants fell into six groups based on lifetime diagnoses: anorexia nervosa only, which accounted for 37 percent of the sample; anorexia nervosa plus another eating disorder, at 21 percent; bulimia nervosa only, at 11 percent; bulimia nervosa combined with binge-eating disorder, at 14 percent; binge-eating disorder only, at 10 percent; and a comparison group of screened controls with no lifetime eating disorder diagnosis and no history of eating disorder behaviors, representing 7 percent of the cohort. This diagnostic granularity allowed the researchers to test not only whether eating disorders in general are linked to nicotine use, but whether specific diagnoses carry different risk profiles.

Each participant reported whether they had ever used nicotine, and the investigators classified them into four categories: never used nicotine, which comprised half the sample; vaped only, which accounted for 6 percent; smoked only, at 22 percent; and combined vaping plus smoking, which also represented 22 percent. Notably, nearly half of the cohort reported some form of lifetime nicotine use, a proportion that immediately stands out against the backdrop of declining smoking rates in the general population.

The statistical approach was carefully constructed to handle the large number of comparisons being made. The team used chi-square tests to examine categorical associations, analysis of variance to compare continuous measures across groups, and multinomial logistic regression to estimate the odds of belonging to each nicotine use category as a function of eating disorder diagnosis and symptom profile. Because the study tested many associations simultaneously, the researchers applied false discovery rate correction, a method that controls the expected proportion of false positives among statistically significant findings. Even under this stringent correction, the results were robust: lifetime nicotine use was significantly more common among every eating disorder group than among the screened controls, with corrected p values below 8.63 × 10⁻³.

The pattern of associations across diagnoses proved to be highly informative. Compared with participants whose only lifetime diagnosis was anorexia nervosa, those with bulimia nervosa only, anorexia nervosa plus another eating disorder, or bulimia nervosa combined with binge-eating disorder showed significantly higher odds of smoking, or of combined smoking and vaping, with corrected p values below 3.79 × 10⁻³. In other words, individuals whose illness included binge-eating episodes or features of more than one diagnostic category were the most likely to report cigarette smoking or dual use of both cigarettes and e-cigarettes. Vaping alone, however, told a somewhat different story: it was reported by only 6 percent of the sample, making it a less common pattern than smoking or dual use, yet still a meaningful one given the relative novelty of electronic cigarettes and the open question of whether they serve as an entry point to nicotine dependence among people vulnerable to eating disorders.

Perhaps the most clinically striking findings emerged when the researchers turned from diagnoses to specific behaviors. Eating disorder psychopathology is characterized by a set of recurrent behaviors, including binge eating and a range of compensatory actions intended to counteract perceived weight gain: self-induced vomiting, laxative misuse, diuretic misuse, diet pill use, fasting, and excessive exercise. The team examined how each of these behaviors related to nicotine use patterns. Binge eating and every compensatory behavior except excessive exercise were significantly associated with higher odds of lifetime smoking or dual use compared with never using nicotine, with corrected p values below 7.85 × 10⁻⁴. Purging, in particular, was linked to a greater likelihood of any lifetime nicotine use whatsoever, with a corrected p value below 0.017.

The selective exception of excessive exercise is noteworthy. Exercise is unique among eating disorder compensatory behaviors in that it does not involve the ingestion of any substance, and the finding suggests that the relationship between nicotine use and eating disorder pathology may be tied to behaviors that involve manipulating what enters the body, rather than to the overall severity of the illness. One plausible mechanism is appetite suppression. Nicotine is a well-documented anorectic agent that acts on central appetite-regulating circuits, and individuals who restrict their intake, binge, or purge may use nicotine, consciously or not, as a tool for weight and appetite control. The finding that purging was linked to any nicotine use, while binge eating and most compensatory behaviors were linked specifically to smoking and dual use, hints at a complex interplay between the pharmacological effects of nicotine and the behavioral repertoire of the eating disorder.

The study’s authors are careful to note that their data are cross-sectional, meaning that they capture associations at a single point in retrospective reporting and cannot establish whether nicotine use preceded, followed, or developed alongside the eating disorder. The cohort is also predominantly female, reflecting the demographic composition of the eating disorder patient population but limiting generalizability to male and gender-diverse individuals, who represent a significant and growing share of eating disorder cases. In addition, all data were self-reported, and participants were recruited through a genetics initiative, which may influence the representativeness of the sample. These limitations notwithstanding, the sheer size of the cohort and the rigor of the statistical corrections give the findings considerable weight.

The implications for clinical practice are direct and actionable. The authors conclude that clinicians working with patients who have or are at risk for eating disorders should routinely assess not only cigarette smoking but also vaping, and should consider how nicotine use is interrelated with eating disorder pathology rather than treating it as a separate, incidental habit. This matters because nicotine use is a modifiable risk factor, and because the health consequences of smoking and vaping compound the already serious medical complications of eating disorders, including cardiovascular strain, electrolyte disturbances, and bone density loss. For a patient using laxatives, inducing vomiting, or fasting while also vaping heavily, the cumulative physiological burden may be greater than either behavior alone would suggest.

The study also arrives at a moment when vaping among young people continues to be a major public health concern, and when the eating disorder field is increasingly attentive to the roles of substances, from alcohol to stimulants, in the initiation and maintenance of disordered eating. By showing that vaping is not merely a harmless social behavior in this population, but part of a broader pattern of lifetime nicotine use that clusters with bulimic presentations and purging behaviors, the research adds urgency to the call for integrated screening. As electronic cigarette use evolves and new nicotine products reach the market, understanding how these products intersect with psychiatric conditions such as eating disorders will be essential for protecting one of the most medically vulnerable populations in mental health care.