Objective: To determine whether an association exists between electronic vapor product use (EVP) and suicidal behavior in middle and high school students
Methods: Multilevel logistic regression analysis for suicidal behaviors using data from the 2017 Vermont Youth Risk Behavior Survey.
Results: Middle school EVP users were significantly more likely to report suicidal behavior than non-users. No statistically significant association was found in high school students.
Discussion: While further study is necessary to clarify the relationship between EVP use and suicidal behavior, these findings highlight the need for suicide prevention and smoking cessation efforts

Awhaitey, Beth

Cao, Vy Bao

Donovan, Kelsey Gleason

Greene, Allison C

Kaya, Julia

Little, Chelsey

Williams, Courtney

English

UVM ScholarWorks

University of Vermont ScholarWorks @ UVM Master of Public Health Culminating Projects Larner College of Medicine 2019 Electronic vapor product use and suicidal behavior in adolescents Vy Bao Cao Allison C. Greene Courtney Williams Chelsey Little Julia Kaya See next page for additional authors Follow this and additional works at: https://scholarworks.uvm.edu/mphcp  Part of the Public Health Commons Recommended Citation Cao, Vy Bao; Greene, Allison C.; Williams, Courtney; Little, Chelsey; Kaya, Julia; Awhaitey, Beth; and Donovan, Kelsey Gleason, "Electronic vapor product use and suicidal behavior in adolescents" (2019). Master of Public Health Culminating Projects. 3. https://scholarworks.uvm.edu/mphcp/3 This Project is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion in Master of Public Health Culminating Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contact donna.omalley@uvm.edu. Author Vy Bao Cao, Allison C. Greene, Courtney Williams, Chelsey Little, Julia Kaya, Beth Awhaitey, and Kelsey Gleason Donovan This project is available at ScholarWorks @ UVM: https://scholarworks.uvm.edu/mphcp/3 Electronic vapor product use and suicidal behavior in adolescents Vy Cao, Allison C Greene, Courtney Williams, Chelsey Little, Julia Kaya, Beth Awhaitey, Kelsey Gleason Donovan  INTRODUCTION The global burden of suicide is substantial, claiming the lives of over 800,000 people each year.1  In the United States, suicide is the second leading cause of death among individuals ages 10 to 34; additional suicidal behaviors, including suicidal ideation and attempted suicide, contribute to significant morbidity in this demographic.2,3  The risk of developing a suicide plan or making a suicide attempt is markedly elevated immediately following the onset of ideation, with a greater than 100-fold increase in the odds of plan or attempt in the first 12 months.3   There has been considerable effort to identify youth at risk of suicidal behavior in order to appropriately target life-saving interventions. Tobacco use is of particular concern, as smokers have an 80% greater risk of death by suicide than non-smokers.1  Furthermore, early-onset tobacco use and daily consumption of cigarettes in adolescence are associated with subsequent self-injurious behavior and suicidal ideation in young adulthood.4 Electronic vapor products (EVPs) and their component parts are included in the definition of “tobacco product” by the U.S. Food and Drug Administration.5  EVPs are now the most commonly used tobacco product by American adolescents, with more than 3.5 million middle and high school students reporting current use of such devices.5  Recent research indicates that adolescents underestimate the health risks associated with EVP use.6  EVPs expose the user to nicotine, which alters brain development and may contribute to the onset of mood disorders and impulsivity.7  Evidence suggests that conditions such as depression and anxiety are associated with EVP use7, though a substantial gap remains in the literature regarding the relationship between EVPs and suicidal behavior.   The primary objective of this research was to determine whether an association exists between EVP use and suicidal behavior in adolescents in a Northeastern US State.  Specifically, we tested the hypothesis that EVP use is associated with creation of a suicide plan and/or suicide attempts in adolescents.  METHODS Data were obtained from the 2017 Vermont Youth Risk Behavior Survey (VT YRBS). The survey is administered biannually to youth in grades 6 through 12. Parental consent was obtained, and participation was anonymous and voluntary. The specific methodology of the YRBS is discussed elsewhere.8 This research meets exemption criteria outlined by the University of Vermont Committee on Human Research. Study Participants Participants included middle school students grades 6th-8th (N=13,887) and high school students grades 9th-12th (N=20,653). Demographics are reported in Table 1. Exposure EVP use was assessed using one survey question. Respondents who answered “Yes” to “Have you ever used an electronic vapor product?” were classified as ever users of EVP. Those who answered “No” were classified as never users. Outcome Suicidal behavior was assessed using three survey questions for middle school students and two survey questions for high school students. Respondents who answered “Yes” to any/all question(s) were considered to display suicidal behavior. Those who answered “No” were classified with no outcome.  Questions differed between the two surveys as follows: Middle School:   High School:   Statistical Analysis All statistical analyses were performed using SPSS v.25. Descriptive statistics and distributions were examined for all covariates. EVP use status and suicidal behavior were classified as dichotomous variables. Demographic variables and potential confounders were selected based on review of the literature. Two multivariable logistic regression models were constructed using stepwise selection of variables. Age, sex, and hunger status were included in both models, consistent with the literature.  Other variables accounted for in both models include feeling sad or hopeless, ever use of alcohol, marijuana, or other illicit substances, as well as being bullied or bullying someone else.  Predictors unique to each model are as follows: High school model: An interaction term for alcohol use and EVP use.   Question #14: “Have you ever seriously thought about killing yourself?”  Question #15: “Have you ever made a plan about how you would kill yourself?”  Question #16: “Have you ever tried to kill yourself?”   Question #27: “During the past 12 months, did you make a plan about how you would attempt suicide?”  Question #28 “During the past 12 months, how many times did you actually attempt suicide?” Middle school model: Ever use of tobacco, screen time duration, and interaction terms for age and EVP use and sex and EVP use. RESULTS Across all participants (middle and high school students), females were 22.7% less likely to report EVP use than males; however, they were 11.7% more likely to report suicidal ideation and/or attempted suicide. Significant predictors of suicidal behavior in middle and high school students are included in Table 1. Middle School EVP ever users were 6.84 (95% CI = 2.66, 17.63) times more likely to report suicidal behavior than never users, which was highly significant (p < 0.001; Table 1).  High School EVP ever users were 0.315 (95% CI = 0.46, 1.01) times less likely to report suicidal behavior than never users (Table 1). This relationship approaches significance (p = 0.056). Respondents who reported ever feeling sad or hopeless were 10.5 (95% CI= 9.35, 11.75) times more likely to report suicidal behavior than those who did not (Table 1).     DISCUSSION These data suggest that EVP use is strongly associated with the formation of a suicide plan and/or attempted suicide among middle school students (OR 6.48; CI 2.655, 17.626).   Total N %Adjusted OR         (95% CI)Total N %Adjusted OR(95% CI)13,824 20,477≤ 12 40.5 0.313 - 17 59.4 87.4≥ 18 12.313,717 20,319Male 51.3 50.9Female 48.7 49.113,887 20,653Yes 306 2.2 588 2.913,724 20,498Yes 1,207 8.8 6,882 33.613,887 20,653Yes 2,536 18.8 5,199 25.313,887 20,653Yes 6,261 45.8 10,638 52.613,887 20,653Yes 2,559 18.4 11,502 5713,887 20,653Yes 950 6.8 7,525 36.813,887 20,653Yes 7,336 53 5,644 27.313,887 20,653Yes 844 6.1 2,911 14.213,887 20,653Yes 1,190 8.6 2,854 13.9Alcohol use·EVP use1.41*(1.03, 1.94)Age·EVP Use0.823*              (0.683, 0.993)Sex·EVP Use0.561***          (0.398, 0.789)1.31                         (.914, 1.87)AgeFor each variable, the number of students for whom data were available is given as the total number. Due to rounding, not all percentages total 100.                                                                                                       A Chi-square test was performed for all dichotomous and ordinal variables and a two-sample z-test was performed for continuous variables.                                                                                                         OR: odds ratio, CI: 95% confidence interval. * p ≤ 0.05 ** p ≤ 0.01 *** p ≤ 0.0011.12***(1.07, 1.17)Substance use2.03***              (1.65, 2.51)2.22***(1.96, 2.51)Tobacco use1.42***              (1.51, 1.75)Marijuana use1.42**                (1.13, 1.8)1.32***(1.15, 1.51)Been bullied/bullied others2.58***              (2.28, 2.91)2.02***(1.82, 2.25)≥3 hr. screen time/day1.40**                (1.81, 2.27)Alcohol use1.97***               (1.71, 2.27)0.645(0.36, 1.17)0.685(0.46, 1.01)Feeling sad/hopeless8.65**                  (7.6, 9.71)10.5***(9.35, 11.75)Risk FactorsInteraction TermsHunger status1.54**                 (1.11, 2.14)1.57***(1.25, 1.99)Table 1: Descriptive and Multilevel Logistic Regression Analysis for Suicidal BehaviorsMiddle School Students (N= 13,887) High School Students (N= 20,653)Demographic CovariatesSex4.34***                     (2.25, 8.35)1.29***(1.16, 1.44)EVP use6.84***               (2.66, 17.63)To our knowledge, this is the first investigation of the association between EVP use and adolescent suicidal behavior in the United States, though a recent study of South Korean students yielded similar results.9 Despite a greater proportion of high school students reporting use of EVPs, an association between use and suicidal behavior was not observed in this study. The transition to early adolescence is often accompanied by elevated emotional stress and an increased number of behavioral problems. Research suggests that there is a developmental lag between the onset of these emotional changes and the development of coping skills associated with cognitive maturation and cortical development of late adolescence.10  This gap may represent an important window for the onset of suicidal behaviors in vulnerable middle school students. While suicidal ideation peaks during middle school, the rate of suicide attempts and death is higher among high school students.11 Because our main outcome of interest includes both suicidal ideation and suicide attempts, further analysis is necessary to clarify the influence of EVP use on individual outcome variables. There are some important limitations to this study.  All data were derived from survey responses, which are self-reported and therefore subject to recall bias.  However, previous surveys designed by the CDC have demonstrated robust test-retest reliability, reducing concern for misreporting.8   This methodology is also prone to selection bias, as home-schooled and absent students are inherently excluded from the sample.  It should be noted that truancy has been associated with a higher likelihood of tobacco, drug, and alcohol use12; therefore, it is possible that this data set underestimates students’ use of EVPs.  PUBLIC HEALTH IMPLICATIONS This research identified a significant association between EVP use and suicidal ideation in middle school-aged children.  In light of the significant increase in completed suicide among children ages 10 through 14 between 1999 and 20172, this report underscores the need for  targeted suicide prevention strategies and smoking cessation initiatives.   References  1. Poorolajal J, Darvishi N. Smoking and Suicide: A Meta-Analysis. PLoS ONE. 2016;11(7):e0156348. 2. Hedegaard H, Curtin SC, Warner M. Suicide mortality in the United States, 1999-2017. Hyattsville, MD: National Center for Health Statistics;2018. 3. Nock MK, Borges G, Bromet EJ, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry : The Journal of Mental Science. 2008;192(2):98-105. 4. Korhonen T, Sihvola E, Latvala A, et al. Early-onset tobacco use and suicide-related behavior – A prospective study from adolescence to young adulthood. Addictive Behaviors. 2018;79:32-38. 5. Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018. MMWR Morbidity and Mortality Weekly Report. 2019;68(6):157–164. 6. Giovacchini CX, Pacek L, McClernon FJ, Que LG. Use and Perceived Risk of Electronic Cigarettes Among North Carolina Middle and High School Students. North Carolina Medical Journal. 2017;78(1):7-13. 7. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General—Executive Summary. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;2016. 8. Centers for Disease Control and Prevention. Methodology of the Youth Risk Behavior Surveillance System — 2013. MMWR Morbidity and Mortality Weekly Report. 2013;62(1). 9. Lee Y, Lee KS. Association of Depression and Suicidality with Electronic and Conventional Cigarette Use in South Korean Adolescents. Substance Use & Misuse. 2019:1-10. 10. Stoep AV, McCauley E, Flynn C, Stone A. Thoughts of death and suicide in early adolescence. Suicide & Life-threatening Behavior. 2009;39(6):599-613. 11. Singer JB, Erbacher TA, Rosen P. School-Based Suicide Prevention: A Framework for Evidence-Based Practice. School Mental Health. 2019;11(1):54-71. 12. Michaud PA, Delbos-Piot I, Narring F. Silent dropouts in health surveys: are nonrespondent absent teenagers different from those who participate in school-based health surveys? The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine. 1998;22(4):326-333.  

Electronic vapor product use and suicidal behavior in adolescents

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Electronic vapor product use and suicidal behavior in adolescents

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