Moral Injury and Nicotine Dependence from Electronic Cigarettes Among Women Veterans: A Behavioral Economic Perspective

Background While moral injury is associated with adverse health behaviors among veterans, no studies have examined the association between e-cigarette consumption among women veterans and moral injury.Methods Using a nicotine continuum of harm perspective, we recruited women veterans who used e-cigarettes or e-cigarettes + combustible cigarettes (n = 55) via Amazon MTurk and Reddit from June 2023 to September 2024. Women veterans completed the e-cigarette purchase task (e-CPT) assessing the relative reinforcing value (RRV) of e-cigarettes, the e-cigarette Fagerstrom Test for Cigarette Dependence (e-FTCD), and the Moral Injury Symptom Scale (MISS-M-SF). We estimated five e-CPT demand indices and calculated an exponential demand model stratified by moral injury status (i.e., probable vs. unlikely). Comparisons were adjusted for dual user status, length of service, and e-FTCD scores.Results Those with probable moral injury were more likely than unlikely morally injured veterans to be dual users (p = 0.02). Probable morally injured veterans exhibited significantly higher demand for e-cigarettes than unlikely morally injured veterans (p = 0.01). Average e-cigarette consumption at $0 was significantly higher (M = 118.6 vs. M = 29.9) in probable versus unlikely morally injured veterans (p = 0.03).Conclusions This study offers preliminary evidence of the RRV of using e-cigarettes in morally injured women veterans.