Elsevier

Journal of Psychiatric Research

Volume 73, February 2016, Pages 71-78
Journal of Psychiatric Research

Psychiatric comorbidity in adolescent electronic and conventional cigarette use

https://doi.org/10.1016/j.jpsychires.2015.11.008Get rights and content

Highlights

  • Relative to conventional cigarette only users, e-cigarette only users reported lower levels of internalizing mental health syndromes and traits.

  • Depression, panic disorder, and inability to experience pleasure (i.e., anhedonia) were higher in e-cigarette only users vs. non-users.

  • For externalizing mental health and anhedonia, comorbidity was lowest in non-users, moderate in single-product users (conventional or e-cigarette), and highest in dual users.

  • Adolescent e-cigarette use is characterized by emotional problems midway between non-use and conventional cigarette use. Dual use is associated with pervasive psychiatric comorbidity.

Abstract

The popularity of electronic (e−) cigarettes has greatly increased recently, particularly in adolescents. However, the extent of psychiatric comorbidity with adolescent e-cigarette use and dual use of conventional (combustible) and e-cigarettes is unknown. This study characterized psychiatric comorbidity in adolescent conventional and e-cigarette use. Ninth grade students attending high schools in Los Angeles, CA (M age = 14) completed self-report measures of conventional/e-cigarette use, emotional disorders, substance use/problems, and transdiagnostic psychiatric phenotypes consistent with the NIMH-Research Domain Criteria Initiative. Outcomes were compared by lifetime use of: (1) neither conventional nor e-cigarettes (non-use; N = 2557, 77.3%); (2) e-cigarettes only (N = 412, 12.4%); (3) conventional cigarettes only (N = 152, 4.6%); and (4) conventional and e-cigarettes (dual use; N = 189, 5.6%). In comparison to adolescents who used conventional cigarettes only, e-cigarette only users reported lower levels of internalizing syndromes (depression, generalized anxiety, panic, social phobia, and obsessive-compulsive disorder) and transdiagnostic phenotypes (i.e., distress intolerance, anxiety sensitivity, rash action during negative affect). Depression, panic disorder, and anhedonia were higher in e-cigarette only vs. non-users. For several externalizing outcomes (mania, rash action during positive affect, alcohol drug use/abuse) and anhedonia, an ordered pattern was observed, whereby comorbidity was lowest in non-users, moderate in single product users (conventional or e-cigarette), and highest in dual users. These findings: (1) raise question of whether emotionally-healthier (‘lower-risk’) adolescents who are not interested in conventional cigarettes are being attracted to e-cigarettes; (2) indicate that research, intervention, and policy dedicated to adolescent tobacco-psychiatric comorbidity should distinguish conventional cigarette, e-cigarette, and dual use.

Introduction

Mid-adolescence is a vulnerable developmental period for cigarette smoking uptake, the onset of mental health conditions, and the emergence of comorbid tobacco use and mental health problems (Upadhyaya et al., 2002). The over-representation of smoking among adolescents with mental health problems generalizes across various conditions (e.g., depressive, mania, anxiety, alcohol/drug use disorders), remains robust after controlling for confounders, and is mediated by theoretically-relevant factors suggesting a causal relation (e.g., beliefs that smoking has mood-modulating effects) (Audrain-McGovern et al., 2012, Upadhyaya et al., 2002). The rapid emergence and appeal of novel tobacco and nicotine products such as electronic (e−) cigarettes raises the question as to whether the same adolescent subgroup with mental health problems is at risk for using these products (Cummins et al., 2014). This is important to address because this population may be particularly vulnerable to nicotine addiction, given that neural plasticity during adolescence and neuropathology in psychiatric conditions can enhance the brain's sensitivity to nicotine (Balfour and Ridley, 2000, Counotte et al., 2011, Sinha, 2008).

E-cigarettes—electronic devices that deliver inhaled nicotine and emulate the sensorimotor properties of conventional (combustible) cigarettes—are gaining popularity among adolescents. According to 2014 estimates, past 30 day use of e-cigarettes is more common than conventional cigarettes among U.S. 8th- (9% vs. 4%) and 10th- (16% vs. 7%) graders, and many adolescent e-cigarette users have never tried conventional cigarettes (Johnston et al., 2015). E-cigarettes may be an attractive alternative to conventional cigarettes among youth because of beliefs that they are less harmful, addictive, malodorous, and costly than conventional cigarettes (Peters et al., 2013). Furthermore, e-cigarettes come in flavors appealing to youth and may be easier to obtain than conventional cigarettes because of inconsistent enforcement of restrictions against sales to minors (Collaco et al., 2015). Such factors may facilitate e-cigarette initiation in adolescents who would not otherwise smoke conventional cigarettes and may perhaps have fewer risk factors for smoking (Wills et al., 2015)—including mental health problems.

Dual use of conventional and e-cigarettes is also common in adolescents (Johnston et al., 2015, Wills et al., 2015), raising the possibility that some adolescents may use e-cigarettes to substitute for conventional cigarettes in situations where smoking is restricted. Indeed, school bathrooms and staircases are among the most common places adolescents report using e-cigarettes (Peters et al., 2013). Given that adolescents with (vs. without) mental health symptoms are more prone to nicotine dependence (Upadhyaya et al., 2002), these populations could be more likely to initiate use of e-cigarettes to bridge situations when they are not able to smoke, which ultimately could perpetuate the over-representation of smoking among individuals with mental health problems.

While research has yet to characterize the psychiatric comorbidity with patterns of conventional and e-cigarette use in adolescents, a recent study of Hawaiian adolescents found that alcohol/marijuana use and other psychosocial risk factors (e.g., sensation seeking, rebelliousness, emotional/behavioral dysregulation) were highest in dual users, moderate in e-cigarette only users, and lowest in non-users (Wills et al., 2015). Most pairwise comparisons involving conventional cigarette only users were not significant in that study, perhaps limited by reduced statistical power due to the smaller size of this group (N = 53) (Wills et al., 2015). Given these findings, stratification of psychiatric comorbidity across dual use, single-product use, and non-use in adolescents is plausible.

The current study characterized the mental health of adolescents who reported ever using e-cigarettes, conventional cigarettes, both, or neither. To provide a wide-ranging picture of psychiatric comorbidity, traditional syndrome-based indices of various depressive, manic, anxiety, and substance use disorders were administered. Consistent with NIMH's Research Domain Criteria Initiative (Insel et al., 2010), we also assessed several transdiagnostic phenotypes implicated in multiple internalizing and externalizing psychopathologies and conventional cigarette use (e.g., impulsivity, anhedonia, distress tolerance; Leventhal and Zvolensky, 2015b). Up to this point, data on the psychiatric comorbidity associated with e-cigarette and dual use is virtually absent, leaving unclear as to how the mental health of these two groups compare to conventional cigarette users and non-users. Given that conventional cigarettes and e-cigarettes have both similarities (e.g., the experience of inhaling aerosol/smoke, nicotine intake) and differences (e.g., e-cigarettes are perceived as less harmful than conventional cigarettes; Ambrose et al., 2014), whether the patterns of psychiatric comorbidity are similar or different between e-cigarette only users and conventional cigarette users is unclear. As the first study to comprehensively characterize psychiatric comorbidity in adolescent e-cigarette and dual use, this study may yield data that is important to tobacco policy by identifying adolescent populations that are psychiatrically vulnerable and potentially at risk for use of traditional and emerging tobacco products. Such data could highlight the need to protect psychiatrically vulnerable adolescents from tobacco product use take via targeted tobacco product regulation and behavioral health prevention programming for this populations.

Section snippets

Participants and procedure

This report is based on a cross-sectional survey of substance use and mental health among 9th grade students enrolled in ten public high schools surrounding Los Angeles, CA, USA. The schools were recruited based on their adequate representation of diverse demographic characteristics. The percentage of students eligible for free lunch within each school (i.e., student's parental income ≤ 185% of the national poverty level) on average across the ten schools was 31.1% (SD = 19.7, range:

Results

Use of e-cigarettes only (12.4%) was more common than conventional cigarettes only (4.6%) and dual (5.7%) use, ps < 0.0001. Dual use was more common than conventional cigarette use only, p = 0.04. Demographic characteristics by group are reported in Table 1. Cronbach αs for continuous outcomes are reported in Table 2. The correlations between all of the continuous mental health measures can be found in Supplementary Table 1, which showed a wide range correlations across each pair of constructs

Discussion

This study is the first to comprehensively examine differences in psychiatric profiles between four different groups based on typologies of tobacco product use: (1) non-users; (2) e-cigarette only users; (3) conventional cigarette only users; and (4) dual users. This novel 4-group comparison is a critical innovation; with changes in the pattern of tobacco product use in the past several years, new typologies of adolescent tobacco product use have emerged, including both e-cigarette and dual use

Acknowldgements

Funding: This research was supported by National Institutes of Health Grant R01-DA033296, and the funding agency had no role in the design or execution of the study.

Disclosures: The authors report no potential conflicts of interests.

Author contributions: AML conducted the analyses and oversaw data collection. AML and JAM conceptualized and wrote the majority of the manuscript text. DRS, MGK, SS, JBU, and JBT aided in study conceptualization and provided feedback on drafts.

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