Understanding the Complex Relationship Between E-cigarette Use, Other Substance Use, and Mental Health in Adolescence

Publications on adolescent e-cigarette use in this journal typically focus on e-cigarette and tobacco product use and their interrelationship. However, the authors of three publications on adolescent e-cigarette in this issue of Nicotine and Tobacco Research highlight the utility of expanding this focus beyond use of these two products to include non-nicotine substance use and mental health conditions. In total, these articles reveal a concerning picture of a small group of adolescents who use multiple substances, including e-cigarettes, and have or are at risk of developing a serious mental health condition in the future.

Each article highlights robust relationships between e-cigarette use and mental health conditions or e-cigarette use and other substance use. In a systematic review of 40 articles, Becker et al.¹ summarized evidence for an association between e-cigarette use and internalizing problems, depression, disordered eating, externalizing problems, attention-deficit/hyperactivity disorder, conduct disorder, impulsivity, and perceived stress. The authors identified serious limitations in study design but concluded that these relationships are feasible given similar findings for cigarettes. Using 2017 US Youth Risk Behavior Survey data, Gilbert et al.² found that of the 12% of adolescents who had used an e-cigarette at least once in the past 30 days, over 90% had also used at least one other substance in the same period. Over 87% of adolescents who were past 30-day e-cigarette/other substance users had used alcohol; 76% had used tobacco; and 66% had used cannabis. More frequent e-cigarette use was also associated with past 30-day use of a greater number of substances. In an analysis of the Population Assessment of Tobacco and Health Survey adolescent sample, Weinberger et al.³ examined the relationship between past 30-day cannabis, cigarette, and e-cigarette use at two time points. The authors found that past 30-day cannabis users at wave 1 had a 3.1–7.6 greater odds of initiating cigarette or e-cigarette use at wave 2, or of being a past 30-day cigarette, e-cigarette, or dual user at wave 2.

The relationship between cigarette smoking, other substance use, and mental health conditions should not be a surprise to a reader of Nicotine and Tobacco Research. Adults with a psychiatric diagnosis or who use illicit substances are more likely to smoke cigarettes and less likely to quit than otherwise similar adults.^4–6 As in the adult literature, the authors of these three articles are careful avoid making causal statements about the relationship between e-cigarette use, other substance use, and mental health conditions. Regardless of directionality, it is reasonable to assume that adolescents with a mental health condition or with a vulnerability to develop a mental health condition and who use a range of substances, including e-cigarettes, will be at increased risk of any number of harms in the near and long term.

Though each team of authors focused on slightly different topics, they came to similar and complementary conclusions. Becker et al. suggest that clinicians see adolescent e-cigarette use as “an indicator of behavioral health risk” given correlations between e-cigarette use and mental health conditions. Similarly, Gilbert et al. conclude that “…e-cigarette screening should include the assessment of other substances, especially alcohol.” And, as summarized by Weinberger et al., “[c]ontinued success in tobacco control—specifically toward reducing smoking among adolescents—may require focusing on cannabis, e-cigarette, and cigarette use in public health education, outreach, and intervention efforts.” Taken together, these articles suggest that to understand the causes and consequences of e-cigarette use in adolescence, research should include assessment of other substances—especially alcohol, cannabis, and cigarettes—as well as mental health conditions.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://dbpia.nl.go.kr/ntr.

Funding

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under grant number R15 DA047606. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of Interests

None declared.

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