The association between internalizing and externalizing severity with current use of cigarettes, e-cigarettes, and alcohol in adults: Wave 1 of the Population Assessment of Tobacco and Health (PATH) study

Highlights

• Internalizing/externalizing severity varies by alcohol, cigarette, E-cigarette use.

• Cigarette/alcohol use and alcohol-exclusive use is associated with internalizing.

• E-cigarette/alcohol use is associated with externalizing.

• Nicotine dependence likely mediates these associations.

Abstract

Introduction

Concurrent tobacco/alcohol use is common in adults, and associated with the severity of symptoms experienced by those with mental health disorders. However, few studies have explored this relationship across different combinations of tobacco products [i.e., conventional cigarette (CC) and electronic cigarette (EC)] and alcohol.

Methods

Data from the Wave 1 (2013–2014) Population Assessment of Tobacco and Health study were used. A total of 15,947 adults aged 18 years or older with complete study information were included. Multinomial logistic regression analyses were performed to determine the relationship between lifetime internalizing/externalizing severity and past 30-day use of tobacco and alcohol, adjusting for nicotine dependence (ND), sex, age, race, education, and income.

Results

Internalizing severity was more strongly associated with CC and alcohol use (moderate AOR = 1.47, 95% CI = 1.22–1.77; high AOR = 1.29, 95% CI = 1.03–1.61) as well as alcohol-exclusive use (moderate AOR = 1.58, 95% CI = 1.27–1.96; high AOR = 1.31, 95% CI = 1.05–1.64) while externalizing severity was more strongly associated with EC and alcohol use (high AOR = 2.97, 95% CI = 1.84–4.81, moderate AOR = 2.29, 95% CI = 1.53–3.43) when accounting for ND compared to none. The relationship between externalizing severity with EC use was dependent on alcohol being used with EC.

Conclusions

The associations between psychopathology (internalizing vs. externalizing severity) varies by different combinations of alcohol, CC, and EC. Further, these relationships may be mediated through ND. Future investigations into the comorbidity between mental disorder symptoms with tobacco and alcohol use should consider use of specific substances as well as their combination.

Introduction

Tobacco and alcohol are two of the most common substances used in the United States (US) (Bobo and Husten, 2000, National Institute on Alcohol Abuse and Alcoholism, 2007). In 2018, approximately 20.9% of US adults were current conventional cigarette (CC) smokers and 55.3% reported drinking alcohol in the past month (Centers for Disease Control and Prevention., 2019, Creamer et al., 2019, SAMHSA, 2018). Among individuals with alcohol use disorder, 23.8% also had nicotine dependence and 12.9% of individuals with nicotine dependence also had alcohol use disorder (National Insitute on Drug Abuse, 2018). Concurrent use of CC and alcohol represents a major public health concern because they have been associated with more negative health outcomes such as increased risk of cardiovascular disease, cirrhosis, head and neck cancers, liver cancer, pancreatitis, and psychiatric comorbidity than the exclusive use of either substance (Adams, 2017, Cross et al., 2017, Verplaetse and McKee, 2017). To date, it is unclear whether the factors associated with co-occurring tobacco and alcohol use are specific to CC or extend to electronic cigarettes (EC).

Although dual use of EC and CC is common and increasing in the US (Maglia, Caponnetto, Di Piazza, La Torre, & Polosa, 2018), the trends related to this form of tobacco use with alcohol remain unclear. In 2018, 57.3% and 25.2% of former CC users were engaged in ever-use and current-use of ECs, respectively (Villarroel, Ph, Cha, Ph, Vahratian, & Ph, 2020). Approximately 9.7% of current EC users also engaged in CC use (Villarroel et al., 2020). In 2014, about 16% of current smokers were also current EC users (Schoenborn & Gindi, 2015). Recent studies have reported that current EC users are at an increased risk of harmful alcohol use compared to EC non-users (Hershberger et al., 2016, Roberts et al., 2018), with dual CC and EC use resulting in more past-month total drinks compared to exclusive-EC users (Roberts, Verplaetse, Peltier, Moore, Gueorguieva, & McKee, 2020). However, compared to studies of CC use and alcohol, there is far less knowledge regarding the co-occurring use of EC and alcohol. Consequently, there is a need to examine the use of EC, CC, and alcohol, which may be associated with more severe or different risk factors than dual or exclusive use of any of these three substances.

Internalizing (e.g., depression and anxiety) and externalizing [e.g., attention-deficit hyperactivity disorder (ADHD) and conduct disorder] psychopathology (American Psychiatric American Psychiatric Association, 2013, Conway et al., 2017, Hasin and Grant, 2015, McClernon and Kollins, 2008, Smith et al., 2014, Ziedonis et al., 2008) are important mental health factors that have been consistently associated with exclusive use of either CC or alcohol. A meta-analysis reported that current CC smokers had a two-fold increased risk of depression relative to never and former CC users (Luger, Suls, & Weg, 2014). Further, adults with depression are more likely to smoke and are less likely to be successful at quitting than adults without depression (Mathew, Hogarth, Leventhal, Cook, & Hitsman, 2017). Whether this bidirectional association is maintained among EC users is unclear. The relationship between the use of alcohol, CC, and EC, and internalizing and externalizing psychopathology is currently undetermined. Prior studies of the relationship between psychopathology and tobacco products, specifically EC, as well as alcohol typically focus on youth and young adults. These findings indicate that ECs are commonly used with other substances (i.e., CC, alcohol, marijuana and opiates) and associated with mental health symptomatology (i.e., diagnosis of ADHD, PTSD, anxiety, and substance use disorders) (Grant et al., 2019, Hefner et al., 2019, Vallone et al., 2020, Wong et al., 2019). However, it is unclear if these associations are specific to youth and young adults, or if they also occur across adulthood.

This study addresses the aforementioned knowledge gaps by examining the association of lifetime mental disorder symptom severity and past 30-day combinations of CC, EC, and alcohol use. We asked the following questions: (1) is there an association between internalizing/externalizing severity across combinations of CC, EC, and alcohol use in US adults, and (2) is there a difference in severity based on tobacco product type (CC vs. EC)? We expect (1) a significant, positive association between internalizing/externalizing severity across all combinations of CC, EC, and alcohol use. For exploratory aim (2), we expect that this association varies with type and number of tobacco products used (i.e., CC associated with internalizing; EC associated with externalizing/internalizing; CC + EC associated with internalizing/externalizing).