Association between E-Cigarette Use and Depression in the Behavioral Risk Factor Surveillance System, 2016-2017

Key Points

Question: What is the association between electronic cigarette (e-cigarette) use and depression?

Findings: In this cross-sectional study of 892 394 participants in the Behavioral Risk Factor Surveillance System from 2016 to 2017, e-cigarette users had higher odds of reporting a history of clinical diagnosis of depression compared with participants who never used e-cigarettes. In addition, increased frequency of e-cigarette use was associated with incrementally higher odds of reporting depression.

Meaning: These findings highlight the need for longitudinal studies to examine the association between e-cigarette use and depression, which may be bidirectional.

Abstract

Importance: The prevalence of the use of electronic cigarettes (e-cigarettes) in the United States has grown rapidly since their introduction to the market more than a decade ago. While several studies have demonstrated an association between combustible cigarette smoking and depression, the association between e-cigarette use and depression has not been thoroughly studied.

Objective: To examine the association between e-cigarette use and depression in a nationally representative sample of the adult population in the United States.

Design, Setting, and Participants: Cross-sectional study of the Behavioral Risk Factor Surveillance System database, 2016 to 2017. The Behavioral Risk Factor Surveillance System is the largest national telephone-based survey of randomly sampled adults in the United States. A total of 892 394 participants with information on e-cigarette use and depression were included. Data analysis was conducted in May 2019.

Exposures: Electronic cigarette use status defined by self-report as never, former, or current use.

Main Outcomes and Measures  Self-reported history of a clinical diagnosis of depression.

Results: Of the 892 394 participants (414 326 [29.0%] aged ≥60 years; 502 448 [51.3%] women), there were 28 736 (4.4%) current e-cigarette users, of whom 13 071 (62.1%) were aged between 18 and 39 years. Compared with never e-cigarette users, current e-cigarette users were more likely to be single, male, younger than 40 years, and current combustible cigarette smokers (single, 120 797 [24.3%] vs 10 517 [48.4%]; men, 318 970 [46.6%] vs 14 962 [60.1%]; aged 18-39 years, 129 085 [32.2%] vs 13 071 [62.1%]; current combustible cigarette use, 217 895 [7.9%] vs 8823 [51.8%]). In multivariable adjusted models, former e-cigarette users had 1.60-fold (95% CI, 1.54-1.67) higher odds of reporting a history of clinical diagnosis of depression than never users, whereas current e-cigarette users had 2.10 (95% CI, 1.98-2.23) times higher odds. Additionally, higher odds of reporting depression were observed with increased frequency of use among current e-cigarette users compared with never users (daily use: odds ratio, 2.39; 95% CI, 2.19-2.61; occasional use: odds ratio, 1.96; 95% CI, 1.82-2.10). Similar results were seen in subgroup analyses by sex, race/ethnicity, smoking status, and student status.

Conclusions and Relevance: This study found a significant cross-sectional association between e-cigarette use and depression, which highlights the need for prospective studies analyzing the longitudinal risk of depression with e-cigarette use. If confirmed by other study designs, the potential mental health consequences may have regulatory implications for novel tobacco products.