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Background: E-cigarettes, also known as electronic nicotine delivery systems (ENDS), are the second most used tobacco product in the US. Cigarette smoking, alcohol, and tobacco use, which contribute to a large portion of disease burden caused by substance use disorders (SUDs), have all been shown to be associated with ENDS use. The co-occurrence of mental disorders and SUDs is well established despite unclear causality. Understanding the associations between e-cigarette use, substance use, and mental health disorders is imperative to understanding the full impact of ENDS use. The aim of our study is to examine these associations in Tennessee, where the prevalence of cigarette smokers and drug overdose deaths is higher than the national average. Methods: We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults aged 18 years, and extracted data for Tennessee (n=4,788). Logistic regression analysis was conducted to test the association between cigarette use, substance use, depression, and ENDS use. We controlled for income, race, educational status, health insurance status, race/ethnic minority status, and age. Results: Overall, 6.7% (n=320) of participants in our sample reported ENDS use. Results of our logistic regression model revealed that cigarette use (OR=2.58, 95% CI, 1.99,3.44), depression (OR=2.33, 95% CI, 1.82, 2.98), alcohol use (OR =2.50, 95% CI, 1.96, 3.20), male gender (OR =1.30, 95% CI, 1.02, 1.60), and no health insurance (OR =1.48, 95% CI, 1.02, 2.15) were associated with ENDS use, while race/ethnic minority status, low income, and non-completion of high school were not associated with ENDS use. Conclusion: Our results showed that cigarette use, alcohol use, and depression were associated with ENDS use in Tennessee after controlling for common confounders. Our results corroborate other studies that show a strong association between ENDS use, co-occurring substance use disorders, and mental disorders. This cross-sectional study from a sample in Tennessee can serve as the basis for future longitudinal research in this population.

Electronic nicotine delivery systems (ENDS) use, including e-cigarettes, has surpassed the use of conventional tobacco products. Emerging research suggests that susceptibility to e-cigarette use is associated with actual use among adolescents. However, few studies exist involving adolescents in high-risk, rural, socioeconomically distressed environments. This study examines susceptibility to and subsequent usage in school-going adolescents in a rural distressed county in Appalachian Tennessee using data from an online survey (N = 399). Relying on bivariate analyses and logistic regression, this study finds that while 30.6% of adolescents are ever e-cigarette users, 15.5% are current users. Approximately one in three adolescents are susceptible to e-cigarettes use, and susceptibility is associated with lower odds of being a current e-cigarette user (OR = 0.03; CI: 0.01–0.12; p < 0.00). The age of tobacco use initiation was significantly associated with decreased current use of e-cigarettes (OR = 0.89; CI: 0.83–0.0.97; p < 0.01). Overall, the results of this exploratory study suggest the need for larger studies to identify unique and generalizable factors that predispose adolescents in this high-risk rural, socioeconomically disadvantaged region to ENDS use. Nevertheless, this study offers insight into e-cigarette usage among U.S adolescents in rural, socioeconomically disadvantaged environments and provides a foundation for a closer examination of this vulnerable population.

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