The Association Between Psychological Distress and Electronic Cigarette Use in the United States, 2016-2018 Open Access

Bennett, Catherine (Spring 2021)

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Background: Electronic cigarettes (e-cigarettes) have been marketed as alternatives to traditional tobacco cigarettes. In 2016, the FDA issued a regulation that defined e-cigarettes as tobacco products and required more stringent sales and marketing regulations. E-cigarettes can have deleterious health effects, and patients with mental illness are vulnerable to these health effects. Studies have shown that patients with mental illness are more likely to use e-cigarettes, and the risk of using e-cigarettes is higher among people who have a history of mental illness. 

Methods: In this cross-sectional study, we sought to investigate the association between psychological distress and e-cigarette use among participants in the National Health Interview Survey (NHIS) from 2016-2018. Using binary logistic regression, we modelled the primary outcome of interest, ever e-cigarette use, as a function of psychological distress, measured using the Kessler 6 (K6) scale.

Results: Psychological distress was associated with e-cigarette use in a dose-response fashion, although the magnitude of the association differed somewhat among never, former, and current traditional cigarette smokers. For example, based on the 2016 NHIS data, the odds ratios (95% CI) estimates for K6 scores of 1-2, 3-5, 6-10 and 11-24 (using persons with K6 score of 0 as reference) were 1.62 (1.19-2.22), 2.04 (1.51-2.75), 3.78 (2.62-5.47), and 4.71 (2.54-8.75), respectively, among persons who had never smoked traditional cigarettes. The results for 2017 and 2018 were generally similar. When e-cigarette use was analyzed using K6 score as a dichotomous variable (0-12 versus 13-24), the odds of e-cigarette use were higher among participants with K6 scores between 13 and 24 across all years and all smoking groups. 

Conclusions: This study indicates that patients with psychological distress are more likely to use electronic cigarettes and that this risk is modified by traditional cigarette smoking status. Moving forward, longitudinal research is necessary to better understand the direction of the association between mental and physical health and e-cigarette use in order to guide clinical recommendations and counseling efforts. In addition, clinicians need to understand the risks associated with e-cigarettes and work to counsel patients on these risks as well as on safer alternatives.

Table of Contents

Abbreviations: 2

Background: 3

Methods: 9

Results: 12

Discussion: 15

Public Health Implications: 19

References: 21

Figures and Tables: 25

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