1. High rates of externalizing mental health problems among adolescents were strongly associated with initiation of e-cigarette use, combustible cigarette use, and dual use at one year-follow up.
2. Internalizing problems were associated with initiation of e-cigarette use, but not with combustible cigarette use or dual use.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Mental health disorders have been associated with increased combustible cigarette use among adolescents and adults. Less is known about the association between these disorders and e-cigarette use, which has recently emerged as a major public health concern. In this prospective cohort study, researchers used interview data to compare relative risk for initiation of e-cigarette and/or combustible cigarette use among adolescents with varying levels of externalizing and internalizing mental health problems. High externalizing problems were associated with a 2- to 6-fold higher relative risk of initiating e-cigarette or combustible cigarette use at 1-year follow-up, after adjustment for demographic factors and other substance use. Internalizing problems were associated with higher risk for initiation of e-cigarette use, but not with combustible cigarette or dual use.
These findings are limited by interview data that did not distinguish between experimental and sustained use. Furthermore, a screening rather than diagnostic tool was used to measure mental health problems. Nonetheless, the study is strengthened by its prospective, nationally-representative sample examining e-cigarette use in youth. For physicians, these findings highlight the importance of developing initiatives to prevent e-cigarette and combustible cigarette use among youth with mental health problems.
In-Depth [prospective cohort]: Researchers used the 2013 to 2015 Population Assessment of Tobacco and Health study to identify 7702 adolescents aged 12 to 17 years with no prior use of tobacco products. Participants were interviewed regarding substance use and past-year internalizing and externalizing problems at baseline, using the Global Appraisal of Individual Needs-Short Screener, and again at follow-up 1 year later. Multinomial logistic regression was used to analyze the relationship between mental health problems and initiation of e-cigarettes, combustible cigarettes, or dual-product use, with adjustment for sex, age, race, past-year marijuana and alcohol use, and parent education level.
High externalizing problems were strongly associated with initiation of e-cigarette use (adjust relative risk ratio [aRRR] = 2.78; 95% confidence interval [CI]: 1.76-4.40), combustible cigarette use (aRRR = 5.59; 95% CI: 2.63-11.90), and dual use (aRRR = 2.23; 95% CI: 1.15-4.31) at 1-year follow-up. Internalizing problems in adolescents were associated with initiation of e-cigarette use (aRRR = 1.61; 95% CI: 1.12-2.33) but not with combustible cigarette use or dual use.
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