The prevalence of smoking is substantially higher among people with mental health conditions (see Section 9A.3), and a growing body of research suggests the same is true for vaping. In Australia in 2022–2023, people with a mental health condition were twice as likely as those without such conditions to currently use e-cigarettes (12% versus 6%). Similarly, people experiencing high or very high levels of psychological distress were four times more likely than those with low distress levels to report current vaping.1 Many studies have found an association between vaping and mental illness among young people,2-17 including increased depressive symptoms, perceived stress, anxiety disorder symptoms, suicide‑related behaviours,18-23 ADHD,24 eating disorders,25,26 and internalising and externalising problems.27,28 Among adults, research has also found a relationship between vaping and psychological distress29,30 and mental health symptoms.31-38
The increased prevalence of e-cigarette use among individuals with mental illness may stem from a misperception that nicotine use is helpful for alleviating feelings of depression, stress, anxiety or boredom (i.e., the ‘self-medication’ hypothesis).39 Smoking was traditionally condoned and even encouraged among people with mental illness based on the misperception that it was helpful for managing psychiatric symptoms.40 Limited prospective and longitudinal studies have shown that depressive symptoms predict subsequent vaping uptake and dependence which the authors suggest that, similar to smoking, may indicate self-medicating among people who vape.41-43 Despite common beliefs about smoking potentially alleviating mental health symptoms, recent evidence suggests the reverse is true; smoking worsens mental health, while quitting smoking improves mental health and quality of life.40 Perceptions that smoking is beneficial for mental health-related symptoms can be largely attributed to the temporary alleviation of nicotine withdrawal symptoms.40
To date, studies examining the relationship between vaping and mental health are largely cross-sectional, which cannot establish the direction of the relationship; that is, whether mental illness is a risk factor for taking up vaping, whether vaping causes mental illness, or both.6 Emerging evidence suggests that like smoking, vaping may play a role in poorer mental health. For example, a study among adolescents found that vaping was associated with worsening symptoms of depression.44 Research in Canada found that there was a reduced risk of mood and anxiety disorders among young people following the implementation of a ban on e-cigarette sales to minors.5 Among adults, longitudinal research in the UK found an association between e-cigarette uptake and adverse mental health,45 and a recent meta-analysis found a bidirectional relationship between depression and vaping.46 A longitudinal study in the US found that among adults who exclusively vaped, those that quit experienced significant improvements in both quality of life and mental health outcomes. These improvements were most pronounced among people with existing mental health issues.47 While some studies have not found elevated mental health symptoms following vaping uptake,43,48 they suggest that factors such as length of follow-up, nicotine content and frequency of use may affect this relationship and should be considered in future research.
A number of potential mechanisms could underlie the role of vaping in poorer mental health. The relationship may be attributable to nicotine as well as other constituents in e-cigarette aerosols, including exposure to trace metals.2 Prolonged nicotine exposure during adolescence can adversely affect neurodevelopment,7 and can increase the risk of developing psychiatric disorders, cognitive impairment and attention deficits49-51 (see Section 18.6.2). More broadly, research on chronic nicotine use suggests that the constant cycle of nicotine withdrawal throughout each day induces psychological symptoms such as depressed mood, anxiety, and agitation, which could worsen mental health over time.40 Nicotine, flavours, and other toxic constituents found in e-cigarette liquids and aerosols have the potential to disrupt dopamine pathways in the brain (which are associated with reward and pleasure),31,52 as well as induce oxidative stress and trigger inflammatory responses, all of which may contribute to adverse mental health outcomes.31
Given the disproportionate burden of smoking-related harm experienced by people with mental illness, some researchers53-56 and organisations57 have advocated the use of e-cigarettes as a smoking reduction or cessation aid for people with mental disorders (see Section 18.7 for a detailed discussion of the effectiveness of e-cigarettes for quitting smoking). Some preliminary evidence suggests that vaping may be a helpful smoking cessation aid for people with psychiatric disorders.58-60 However, the long-term health and mental health risks and benefits of vaping among people with mental illness who smoke are largely unknown. Cross-sectional research in Canada did not find evidence of a reduction in depressive symptoms after quitting smoking among those who reported vaping compared to people who had quit smoking who did not vape, suggesting that vaping may undermine expected mental health benefits of smoking cessation.61 Further research is needed on vaping among people with mental health conditions, including its efficacy for quitting smoking and its effect on psychiatric symptoms. For people who exclusively vape, those with mental health issues appear to have similar success rates quitting as those without, highlighting the importance of providing cessation advice and support to people who want to quit vaping47 (see Section 18.11).
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References
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