Psychiatric comorbidity in adolescent electronic and conventional cigarette use
Graphical abstract
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.
References (47)
- et al.
Perceptions of the relative harm of cigarettes and e-cigarettes among U.S. youth
Am. J. Prev. Med.
(2014) - et al.
Does delay discounting play an etiological role in smoking or is it a consequence of smoking?
Drug Alcohol Depend.
(2009) - et al.
Reward expectations lead to smoking uptake among depressed adolescents
Drug Alcohol Depend.
(2012) - et al.
The effects of nicotine on neural pathways implicated in depression: a factor in nicotine addiction?
Pharmacol. Biochem. Behav.
(2000) - et al.
Optimal scaling of the CAST and of SDS scale in a national sample of adolescents
Addict. Behav.
(2013) - et al.
Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale
Behav. Res. Ther.
(2000) - et al.
Development of the motivational system during adolescence, and its sensitivity to disruption by nicotine
Dev. Cogn. Neurosci.
(2011) - et al.
Development of the drug abuse screening test for adolescents (DAST-A)
Addict. Behav.
(2000) - et al.
Anxiety sensitivity in adolescents: factor structure and relationships to trait anxiety and symptoms of anxiety disorders and depression
Behav. Res. Ther.
(2001) - et al.
Cigarette smoking and psychiatric comorbidity in children and adolescents
J. Am. Acad. Child. Adolesc. Psychiatry
(2002)
The five factor model and impulsivity: using a structural model of personality to understand impulsivity
Pers. Individ. Dif.
The truth campaign: using counter marketing to reduce youth smoking, 2009 reduce youth smoking
Tobacco use among middle and high school students - United States, 2011-2014
MMWR Morb. Mortal. Wkly. Rep.
Identifying and characterizing adolescent smoking trajectories
Cancer Epidemiol. Biomarkers Prev.
Predictors of the onset of manic symptoms and a (hypo)manic episode in patients with major depressive disorder
PLoS One
The Temperament and Character Inventory (TCI): a Guide to its Development and Use
Electronic cigarette use and exposure in the pediatric population
JAMA Pediatr.
Use of e-cigarettes by individuals with mental health conditions
Tob. control
Integration of impulsivity and positive mood to predict risky behavior: development and validation of a measure of positive urgency
Psychol. Assess.
Electronic cigarettes and conventional cigarette use among U.S. adolescents: a cross-sectional study
JAMA Pediatr.
Youth risk behavior surveillance - United States, 2009. Morbidity and mortality weekly report
Surveill. Summ.
Revision of the Early Adolescent Temperament Questionnaire
Electronic cigarettes: abuse liability, topography and subjective effects
Tob. control
Cited by (140)
Factors associated with Korean adolescent's e-cigarette use by the severity level of generalized anxiety disorder (GAD-7)
2023, Journal of Affective DisordersAdolescent E-cigarette use: Rates, concerns, and policy implications
2023, Encyclopedia of Child and Adolescent Health, First EditionThe history of adolescent tobacco prevention and cessation programs and recommendations for moving forward
2023, Encyclopedia of Child and Adolescent Health, First EditionDepression and Suicidal Behavior in Adolescents
2023, Medical Clinics of North America