Study of Association Between E-cigarette Use in US Adults and Both Mental Health and Sleep Quality Using Behavioral Risk Factor Surveillance System (BRFSS) for Years 2017-2018

Authors: Jade Thomas, PharmD/MSCR Candidate Class of 2025, Megan Rimmer, PharmD/MSCR Candidate Class of 2025, Michael R. Jiroutek, DrPH, MS, Melissa A. Holland, PharmD, MSCR

Institution: Campbell University College of Pharmacy & Health Sciences, Department of Pharmaceutical & Clinical Sciences, Buies Creek, NC

Purpose: The use of e-cigarettes has rapidly increased over the past decade since being introduced as a healthier alternative to traditional tobacco products. Previous studies have indicated that there may be an association between e-cigarette use in adults and/or mental illnesses and sleep quality. However, past studies have focused solely on either mental health or sleep quality. This study aims to determine if there is an association between e-cigarette use and mental health and sleep quality, as well as other factors of interest.

Methods: This was an observational, retrospective, cross-sectional study of US adults that participated in the BRFSS in 2017 and 2018. Adults (defined as ≥ 18 years of age) that responded to the e-cigarette question, “Have you ever used an e-cigarette or other electronic vaping products, even just one time, in your entire life?” with a “yes” or “no” in the years 2017 and 2018 were eligible to be included in this study. This study was deemed not human subject research by the Campbell University Institutional Review Board due to the nature of the publicly available de-identified database. Multivariable logistic regression models were used to determine if there was an association between the outcome of e-cigarette use and mental health and sleep quality, as well as the following variables of interest that were available in the BRFSS datasets: hours slept per night, gender, marital status, race/ethnicity, education, military status, income, employment status, and geographical area. As recommended in the BRFSS user’s guide, appropriate statistical methodology was used in model construction to account for the non-simple random sample BRFSS survey design. Utilizing these analytical methods, the BRFSS survey design allows for the extrapolation of the survey analysis results to generate national estimates corresponding to those meeting the study inclusion/exclusion criteria. Odds ratios (OR) and associated 95% confidence intervals (CIs) were reported for each predictor variable in the models.

Results: During the years 2017 and 2018, an (unweighted) total of 698,964 BRFSS survey participants met the inclusion/exclusion criteria and were included in this study. From this survey data, users of electronic cigarettes are more likely to be male, white, single, employed, and to have not completed a college degree program. Further, we estimated that e-cigarettes were used by 21.3% of adults in the US meeting the study inclusion/exclusion criteria (41,277,190 e-cigarette users nationally). Based on the available data, there was a modest association between the number of days experiencing poor mental health and use of e-cigarettes (OR 1.02; 95% CI 1.01-1.03) as well as between the number of days experiencing poor sleep quality and e-cigarette use (OR 1.04; 95% CI 1.03-1.05). After adjusting for the other available factors of interest, these associations changed minimally [(OR 1.01; 95% CI 1.00-1.02) and (OR 1.03; 95% CI 1.01-1.04), respectively]. Thus, we estimate that for each additional day of poor mental health per month, the odds of using e-cigarettes increases by 1%, while for each additional day of poor-quality sleep per two weeks, the odds of using e-cigarettes increases by 3%, after adjusting for available covariates of interest.

Conclusion: A significant portion of US adults now appears to at least have tried e-cigarettes, if not using them on a regular basis. Thus, the weak statistical association found between e-cigarette use and poor mental health, and poor sleep quality is potentially clinically significant. Further research in the form of a longitudinal study is needed to continue investigating this association.