Patterns of concurrent cigarette, alcohol, and e-cigarette use: Off-setting or additive behaviors?

Time-Varying Determinants of Changes in E-Cigarette Relative Harm Perception Among US Young Adults

BACKGROUND

Current e-cigarette use has increased among young adults in the USA despite a consistent decrease in perceiving e-cigarettes as less harmful than cigarettes over time. This study examined time-varying predictors associated with the changes in e-cigarette relative harm perception over time among US young adults.

METHODS

Data were from the 2013-2018 Population Assessment of Tobacco and Health (PATH) Study for young adults (18-24 years). A time-varying effect model (TVEM) was applied to examine the association between the relative harm perception change and the associated time-varying predictors.

RESULTS

Of the 8427 young adults, the prevalence of those who perceived e-cigarettes as less harmful than cigarettes decreased from 50.3% in Wave 1 (2013-2014) to 27.7% in Wave 4 (2016-2018). Young adults who were male were more likely to perceive e-cigarettes as less harmful than cigarettes over time (OR = 1.58; 95%CI, 1.53-1.64). In addition, the changes in e-cigarette relative harm perception were less noticeable among those with advanced degrees, who had non-combustible smoke-free home rules, who held negative tobacco-related attitudes, and those who were current e-cigarette users or ever used alcohol (all p values < 0.05).

CONCLUSIONS

A decline was observed in US young adults who perceived e-cigarettes as less harmful than cigarettes from the PATH Study across four waves (2013-2018). The study findings underscore the importance of risk communication that focuses on harm perception profiles and the need for appropriate interventions to balance the considerations of e-cigarette use among young adults.

Addiction-Related Outcomes of Nicotine and Alcohol Co-use: New Insights Following the Rise in Vaping

PURPOSE

Nicotine and alcohol-containing products are some of the most commonly used substances of abuse and are both leading causes of preventable death. These substances also have significant interactions that have additive and, in some cases, multiplicative effects on the health consequences of their use. Thus, to reduce these negative consequences, it is important to understand the abuse liability of nicotine and alcohol in combination, especially in the most relevant use cases among those who are most vulnerable. Specifically, as tobacco cigarette use is continually decreasing, vaping is quickly replacing cigarettes as the primary mode of nicotine use. This pattern is especially true in adolescent populations in which vaping has grown considerably. Particularly concerning is that adolescents are more vulnerable than adults to the negative consequences of substance use. It is therefore imperative to revisit the literature as it relates to the rising state of co-use of vaping products with alcohol. Here, we review the clinical outcomes of nicotine and alcohol co-use as they relate to the abuse liability of each individually. Special attention is paid to adolescent findings, where available, as well as investigations that use nontobacco nicotine products as these may more accurately reflect the more recent trends of co-use.

IMPLICATIONS

Though nicotine alone has previously been considered a proxy for tobacco and tobacco cigarette use, combustible routes of administration have been decreasing. They are, instead, being replaced by e-cigarettes that do not involve other tobacco constituents and contain additional nonnicotine constituents of their own. Unfortunately, the literature remains limited with regard to e-cigarettes and their interactions with other substances, especially their prevalent co-use with alcohol. This review attempts to discuss the current literature on nicotine and alcohol co-use in the context of the vaping epidemic, predominantly focusing on addiction-related outcomes and why e-cigarette use may be unique.

Changes in harm perception of ENDS and their predictors among US adolescents: findings from the population assessment of tobacco and health (PATH) study, 2013-2018

Electronic nicotine delivery systems (ENDS) use has dramatically increased in the US. This study aimed to characterize changes in ENDS harm perception over time and associated predictors among US adolescents. Data from the 2013-2018 Population Assessment of Tobacco and Health Study (PATH) for adolescents (12-17 years) were utilized. Trend analyses were employed to delineate changes in comparative and absolute ENDS harm perception over a four-year interval. We applied a time-varying effect model (TVEM) to examine the associations between the changes in harm perception and associated predictors. The results suggest that perception of ENDS as less harmful than cigarettes significantly decreased from 54.3% at Wave 1 (2013) to 30.4% at Wave 4 (2018) (P < 0.001). Perception of ENDS as no or little harm decreased from 35.9% at Wave 1 to 16.9% at Wave 4 (P < 0.001). These changes in harm perception were less robust among males, adolescents who did not have positive tobacco-related attitudes, and those with smoke-free home rules (P's < 0.05). Additionally, having ever used ENDS or alcohol were more likely to be associated with reduced ENDS-related harm perception over time (P's < 0.05). Our results show that while ENDS-related harm perception have generally increased, this does not appear to be equally experienced across all adolescents, potentially highlighting the importance of at-risk groups and targets for intervention. This study can help identify individuals at risk of ENDS initiation because of their favorable ENDS harm perception profile, as well as guide the development of ENDS risk communication interventions for adolescents.

Exploring the Association of e-Cigarette and/or Cannabis Use with Heavy Episodic Drinking among Ontario Adults

Background: The use of electronic cigarettes and cannabis has significantly increased in recent years, which raises public health concerns. There are also concerns about the association of these substances with drinking behaviors. The main objective of the present study is to examine the association of e-cigarettes and/or cannabis use with heavy episodic drinking (HED) among Ontario adults. Methods: The sample consisted of 5,564 adults from the Monitor Survey in 2018 and 2019. Cannabis and e-cigarette use reflected any use of the substances in the past 12 months. HED was defined as consumption of four/five or more drinks on a single occasion at least monthly in the past 12 months. Odds ratios (OR) were estimated from logistic regression models accounting for complex survey design and sociodemographic factors. Results: Overall, the prevalence of HED was 17.5% in 2018 and 2019. Among participants who reported both e-cigarette and cannabis use, about one-half (50.4%) reported HED at least monthly. Adjusting for covariates, the odds of HED were 5.71 (95%CI, 3.92-8.30) times higher among those who reported both e-cigarette and cannabis use compared to those who used neither substance. Conclusions: The use of e-cigarettes and cannabis are significantly associated with heavy episodic drinking among adults, indicating that those who engage in the dual use of e-cigarette and cannabis may be an important group to target with intervention programs.

Anxiety sensitivity, pain severity and co-use of cigarettes and e-cigarettes among adults with chronic pain

Anxiety sensitivity (fear of potential negative consequences of anxiety-related symptoms/sensations) has been identified as a transdiagnostic factor in comorbid pain and nicotine dependence and evidence suggests that anxiety sensitivity may be indirectly associated with nicotine use via greater pain severity. Therefore, this study tested the hypothesis that anxiety sensitivity is associated with cigarette and e-cigarette use/co-use directly and indirectly via greater pain severity. Participants included 273 online survey respondents with chronic musculoskeletal pain (34% female; Mage = 32.9). Anxiety sensitivity was positively associated with cigarette smoking, e-cigarette use and cigarette/e-cigarette co-use (ps < .05). Furthermore, anxiety sensitivity was indirectly and positively associated with cigarette smoking, e-cigarette use and co-use via greater chronic pain severity. Pain severity may play an important role in associations between anxiety sensitivity and nicotine dependence and prospective research should examine temporal/causal effects of anxiety sensitivity in relation to pain severity and nicotine/tobacco use.

Factors and HCV treatment outcomes associated with smoking among people who inject drugs on opioid agonist treatment: secondary analysis of the PREVAIL randomized clinical trial

Background

Cigarette smoking has emerged as a leading cause of mortality among people with hepatitis C virus (HCV). People who inject drugs (PWID) represent the largest group of adults infected with HCV in the US. However, cigarette smoking remains virtually unexplored among this population. This study aimed at (1) determining prevalence and correlates of cigarette smoking among HCV-infected PWID enrolled in opiate agonist treatment programs; (2) exploring the association of smoking with HCV treatment outcomes including adherence, treatment completion and sustained virologic response (SVR); and 3) exploring whether cigarette smoking decreased after HCV treatment.

Methods

Participants were 150 HCV-infected PWID enrolled in a randomized clinical trial primarily designed to test three intensive models of HCV care. Assessments included sociodemographics, presence of chronic health and psychiatric comorbidities, prior and current drug use, quality of life, and HCV treatment outcomes.

Results

The majority of the patients (84%) were current cigarette smokers at baseline. There was a high prevalence of psychiatric and medical comorbidities in the overall sample of PWID. Alcohol and cocaine use were identified as correlates of cigarette smoking. Smoking status did not influence HCV treatment outcomes including adherence, treatment completion and SVR. HCV treatment was not associated with decreased cigarette smoking.

Conclusions

The present study showed high prevalence of cigarette smoking among this population as well as identified correlates of smoking, namely alcohol and cocaine use. Cigarette smoking was not associated with HCV treatment outcomes. Given the detrimental effects that cigarette smoking and other co-occurring, substance use behaviors have on HCV-infected individuals’ health, it is imperative that clinicians treating HCV also target smoking, especially among PWID. The high prevalence of cigarette smoking among PWID will contribute to growing morbidity and mortality among this population even if cured of HCV. Tailored smoking cessation interventions for PWID along with HCV treatment may need to be put into clinical practice.

Trial registration

NCT01857245. Registered May 20, 2013.

Prospective association of e-cigarette and cigarette use with alcohol use in two waves of the Population Assessment of Tobacco and Health

BACKGROUND AND AIMS

Prior cross-sectional research finds that electronic cigarette (e-cigarette) use clusters with higher rates of harmful alcohol consumption in the United States adult population. The current study examined prospectively the association between e-cigarette use, cigarette use and the combined use of e-cigarettes and tobacco cigarettes and alcohol use outcomes.

DESIGN

A nationally representative multi-wave cohort survey (wave 1: September 2013-December 2014, wave 2: October 2014-October 2015).

SETTING

United States.

PARTICIPANTS

A representative sample of civilian, non-institutionalized adults who completed waves 1 and 2 of the Population Assessment of Tobacco and Health survey (n = 26 427).

MEASUREMENTS

Participants were categorized into exposure groups according to their e-cigarette and cigarette use during wave 1. Past 30-day alcohol use outcomes were (1) National Institute on Alcohol Abuse and Alcoholism (NIAAA)-defined hazardous alcohol use, (2) total alcohol drinks consumed and (3) alcohol-related consequences.

FINDINGS

After controlling for socio-demographic risk factors and alcohol use at wave 1, all exposure groups showed higher odds of hazardous alcohol use [adjusted odds ratios (aORs) = 2.05-2.12, all P < 0.001] and reported higher past-month total drinks (B = 0.46-0.70, all P < 0.001) and more alcohol consequences (B = 0.63-0.89, all P ≤ 0.10) at wave 2 compared with non-users. Cigarette users (B = 0.24, P = 0.038) and dual e-cigarette/cigarette users (B = 0.32, P = 0.038) reported higher past-month total drinks compared with e-cigarette users. There was no conclusive evidence that non-daily use of e-cigarettes or cigarettes predicted poorer alcohol use outcomes compared with daily use.

CONCLUSIONS

In the United States between 2013 and 2015, after adjustment for socio-demographic characteristics, cigarette and e-cigarette use were associated with alcohol use 1 year later.

Association between preference for using alcohol beverage-named e-liquids and alcohol use among high school youth

BACKGROUND

There are thousands of e-liquid flavors available, and some are named after alcohol beverages (e.g., "pina colada"). It is unclear whether use of e-liquids with alcohol beverage names is associated with adolescent alcohol use. E-cigarettes and alcohol are co-used in adolescents; therefore, it is important to investigate these associations.

METHODS

Eight Southeastern Connecticut high schools were surveyed in Spring 2015 (N = 7045). We examined the association between preference for using e-liquid flavors and alcohol drinking status (i.e., no past month alcohol use, past month alcohol use but no binge drinking, and past month binge drinking) in ever e-cigarette users (N = 1311).

RESULTS

Among ever e-cigarette users who preferred using e-liquids with alcohol beverage names (N = 111), 30.6 % had no past month alcohol use, 19.8 % had past month alcohol use but did not binge drink in the past month, and 49.5 % binge drank in the past month. Multinomial logistic regression (controlling for demographics and including other e-cigarette flavors that were highly endorsed, i.e., fruit and candy) revealed that the preferences of alcohol beverage-named-e-liquid (OR: 2.84, CI: 1.70-4.75) and fruit flavored e-liquids (OR: 1.55, CI: 1.14-2.11), but not candy flavored e-liquids was associated with past-month binge drinking compared to no past-month alcohol use.

CONCLUSION

This evidence suggests that the preference for using alcohol beverage- and fruit-named e-liquid flavors is associated with past-month binge drinking among adolescents. Understanding the associations between alcohol beverage-named e-liquids and alcohol use in adolescents may help inform tobacco regulatory strategies that aim to decrease the use/appeal of e-cigarettes.

The association between alcohol, marijuana, illegal drug use and current use of E-cigarette among youth and young adults in Canada: results from Canadian Tobacco, Alcohol and Drugs Survey 2017

Background

E-cigarettes have grown in popularity around the world since 2003. Although marketed as a smoking cessation tool, e-cigarettes can lead to tobacco cigarette smoking in youth. In Canada, among all age groups, youth and young adults have the highest prevalence of e-cigarette use. The objective of this study was to assess the factors associated with e-cigarette use among youth and young adults in Canada, and to specifically examine the association between alcohol, marijuana and illicit drug use.

Methods

Data from the 2017 Canadian Tobacco, Alcohol and Drugs Survey were used. The sample was restricted to those aged 15–24 years (n = 10,322), and main outcome defined as ‘E-cigarette use in the past 30-days’. Multivariable logistic regression was performed to assess the association between the main outcome and substance use variables (illicit drug, marijuana and alcohol use), tobacco exposure variables, and demographic and health-related factors.

Results

6.2% Canadians aged 15–24 reported using e-cigarettes in the past 30-days, while 23.9% reported having ever tried e-cigarettes. Twenty-three percent of the past 30-day users reported using e-cigarettes every day and 72.5% of the past 30-day users reported having nicotine in their last e-cigarette. Additionally, youth aged 15–17 were 4.95 times more likely to be e-cigarette users as compared to those aged 22–24 (OR: 4.95, 95% CI: 3.1–7.9). Moreover, e-cigarette use was significantly associated with marijuana use (OR:4.17, 95% CI: 2.6–6.7) and alcohol use (OR: 5.08, 95% CI: 2.9–9.0), and approached significance with illicit drug use (OR: 1.68, 95% CI: 1.0–2.9). Furthermore, being a current smoker (OR: 2.93, 95% CI: 1.8–4.7) and male (OR: 2.28, 95% CI: 1.5–3.4) was significantly associated with the outcome.

Conclusion

This study is nationally representative and provides insight into e-cigarette use among youth and young adults aged 15–24 years. Given that e-cigarettes can be used as illicit drug delivery systems, more studies are needed to understand how Canadian youth and young adults are using e-cigarettes. Stricter restrictions on public e-cigarette smoking, and awareness campaigns informing youth of risks of e-cigarette smoking should be implemented.

Electronic Cigarette Use and Risk of Harmful Alcohol Consumption in the U.S. Population

BACKGROUND

Electronic cigarette (e-cigarette) use is an increasingly common method of nicotine delivery in the general population. It is well-established that tobacco users are at increased risk to engage in hazardous drinking and meet criteria for alcohol use disorder (AUD) relative to nonusers. Less is known, however, about the risk of harmful alcohol use among people who use e-cigarettes. The current study reports on the association between e-cigarette and alcohol use in the U.S. population using a nationally representative sample.

METHODS

Data from 36,309 adults who participated in the National Epidemiologic Survey on Alcohol and Related Conditions-Wave III were included in the study. The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) measured past-year e-cigarette and alcohol use outcomes. Based on past-year e-cigarette use, respondents were categorized as nonusers, nondaily users, or daily users. Alcohol use outcomes were drinking quantity/frequency, binge drinking frequency, AUD diagnostic status, and National Institute on Alcohol Abuse and Alcoholism-defined hazardous drinking status.

RESULTS

Controlling for demographic characteristics, daily and nondaily e-cigarette users showed increased risk of harmful alcohol use compared to e-cigarette nonusers, including hazardous drinking (adjusted odds ratios [AORs] = 1.69; 2.48), AUD (AORs = 1.89; 2.44), and binge drinking frequency (AORs = 1.30 to 3.30). Nondaily e-cigarette use was associated with higher levels of risk than was daily use. Secondary analyses examined alcohol use outcomes according to participants' patterns of dual tobacco cigarette/e-cigarette use. These analyses confirmed that e-cigarette use alongside tobacco cigarette use is associated with additive risk of harmful alcohol consumption, particularly among nondaily users.

CONCLUSIONS

E-cigarette users, particularly those who engage in nondaily and dual use, show elevated rates of harmful alcohol use. Heavy drinking may constitute a source of health risk among e-cigarette users.