Teens with mental health problems were more likely to take up cigarettes, both electronic and regular, according to a longitudinal study.
Adolescents ages 12-17 with at least four externalizing symptoms — such as impulsive or disruptive conduct and substance use — were more likely to start using e-cigarettes (adjusted relative risk ratio 2.78, 95% CI 1.76–4.40), combustible cigarettes (aRRR 5.59, 95% CI 2.63–11.90), or both (aRRR 2.23, 95% CI, 1.15–4.31), compared to teens with low externalizing behaviors, reported Kira Riehm, MSc, of John Hopkins University, in Baltimore, Maryland, and colleagues.
Adolescents with four or more internalizing problems such as anxiety, depression, or somatic symptoms were at an increased risk of initiating e-cigarette but not combustible use, compared to teens with zero or nominal symptoms (aRRR 1.61, 95% CI 1.12–2.33), they wrote in Pediatrics.
“Our results are in line with existing literature that suggests a stronger connection between externalizing problems, like rebelliousness and sensation-seeking, and combustible cigarette use, than between internalizing problems and combustible cigarette use,” Riehm told MedPage Today in an email.
The recent surge in youth e-cigarette use, which the U.S. Surgeon General and the FDA declared an “epidemic” in 2018, has inspired a growing body of literature that shows teens are more likely to transition to tobacco cigarettes or other substances when using e-cigarettes.
Mental health problems are also a known risk factor for combustible cigarette use, suggesting a similar correlation could be found with e-cigarettes, Riehm said.
Whether this trend towards e-cigarettes is driven by peer pressure, youth experimentation, or a means of self-medicating underlying depression or anxiety is an important question to consider, said Sharon McGrath-Morrow, MD, of Johns Hopkins School of Medicine.
“That’s kind of the crux of this paper: Kids who are at risk for potential mental health problems such as internalizing and externalizing health issues may be the kids that are most vulnerable to starting e-cigarettes, and I think that’s a real concern,” McGrath-Morrow, who was not involved with the research, told MedPage Today.
This potentially compounded vulnerability is all the more reason to ensure teens are screened not only for their smoking history, but for mental health conditions that might be linked to these habits, Nicholas Chadi, MD, of Boston Children’s Hospital, told MedPage Today.
“We have to be careful when we think of e-cigarettes as substances because it falls in the bigger picture of substance use in general,” Chadi, who was also not involved with the research, said. “This is a two-way highway, where people with mental health problems are more likely to start using these substances, but the reverse is also true — people who start using these substances also have increased chances of developing mental health symptoms.”
Chadi emphasized that this study’s data looks at older models of e-cigarettes and that newer data may be even more striking because of the recent widespread use of newer e-cigarettes like the Juul, which came out in 2015.
Riehm and colleagues examined data from adolescents randomly selected from the first two waves of the Population Assessment of Tobacco and Health (PATH) study in 2013 and 2014, who were followed-up one year later in 2014 and 2015 through self-interviewing. Teens who reported using nicotine and/or tobacco products in the first wave of the study were excluded, making it less likely that smoking preceded mental health problems, the authors noted.
Participants who said they used e-cigarettes (including vape pens and personal vaporizers) “even one or two times” within the previous 12 months were considered to have initiated use. Combustible use was determined by answering “yes” to having smoked “even one or two puffs” of a cigarette in the past 12 months. Internalizing and externalizing symptoms were measured through responses to the Global Appraisal of Individual Needs–Short Screener (GAIN-SS).
Overall, 7,702 adolescents ages 12-17 (49.3% girls) were included, of which 65.5% were ages 12-14. Almost 70% of the group was white. Notably, 4.1% of participants reported initiating e-cigarettes, whereas 1.6% started using combustibles, and 1.4% used both, the authors reported.
High versus low levels of externalizing or internalizing problems were not differentially associated with e-cigarettes, combustible, or dual-use, suggesting “elevated mental health problems, particularly externalizing problems, increase the risk of initiating e-cigarette and combustible cigarette use uniformly,” the authors noted.
However, adolescents who reported using alcohol in the past year were significantly more likely to start using e-cigarettes, combustibles, or both. Marijuana use in the same time period was also significantly associated with combustible or dual-product use, the authors reported.
These findings are limited because the GAIN-SS is a screening measure to assess mental health symptoms, and not a diagnostic tool, the authors said. Also, this study excluded the use of additional nicotine or tobacco products such as hookah, chewing tobacco, or cigars, and the PATH data did not allow researchers to determine whether adolescents were infrequently experimenting with these products, or using them habitually.
Riehm was supported by the National Institute of Mental Health Psychiatric Epidemiology Training Program and the Canadian Institutes of Health Research.
Co-authors reported receiving support from the Brain and Behavior Research Foundation, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and Supernus Pharmaceuticals and PsychNostics.
The study was funded by the National Institutes of Health.