The association between substance use, mental health and e-cigarette use in Tennessee

Background: E-cigarettes, also known as electronic nicotine delivery systems (ENDS), are the second most used tobacco product in the US. Cigarette smoking, alcohol, and tobacco use, which contribute to a large portion of disease burden caused by substance use disorders (SUDs), have all been shown to be associated with ENDS use. The co-occurrence of mental disorders and SUDs is well established despite unclear causality. Understanding the associations between e-cigarette use, substance use, and mental health disorders is imperative to understanding the full impact of ENDS use. The aim of our study is to examine these associations in Tennessee, where the prevalence of cigarette smokers and drug overdose deaths is higher than the national average. Methods: We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults aged 18 years, and extracted data for Tennessee (n=4,788). Logistic regression analysis was conducted to test the association between cigarette use, substance use, depression, and ENDS use. We controlled for income, race, educational status, health insurance status, race/ethnic minority status, and age. Results: Overall, 6.7% (n=320) of participants in our sample reported ENDS use. Results of our logistic regression model revealed that cigarette use (OR=2.58, 95% CI, 1.99,3.44), depression (OR=2.33, 95% CI, 1.82, 2.98), alcohol use (OR =2.50, 95% CI, 1.96, 3.20), male gender (OR =1.30, 95% CI, 1.02, 1.60), and no health insurance (OR =1.48, 95% CI, 1.02, 2.15) were associated with ENDS use, while race/ethnic minority status, low income, and non-completion of high school were not associated with ENDS use. Conclusion: Our results showed that cigarette use, alcohol use, and depression were associated with ENDS use in Tennessee after controlling for common confounders. Our results corroborate other studies that show a strong association between ENDS use, co-occurring substance use disorders, and mental disorders. This cross-sectional study from a sample in Tennessee can serve as the basis for future longitudinal research in this population