Association Between Electronic-Cigarette Use and Atopic Dermatitis among United States Adults.

Atopic dermatitis (AD) is a prevalent inflammatory skin condition with multifactorial etiologies, ranging from genetic to environmental factors that contribute to the underlying immune dysregulation.1Chong A.C. Visitsunthorn K. Ong P.Y. Genetic/environmental contributions and immune dysregulation in children with atopic dermatitis.J Asthma Allergy. 2022; 15: 1681-1700https://doi.org/10.2147/JAA.S293900Crossref PubMed Scopus (4) Google Scholar Cigarette smoke is a commonly encountered environmental factor that has been linked to AD1Chong A.C. Visitsunthorn K. Ong P.Y. Genetic/environmental contributions and immune dysregulation in children with atopic dermatitis.J Asthma Allergy. 2022; 15: 1681-1700https://doi.org/10.2147/JAA.S293900Crossref PubMed Scopus (4) Google Scholar; however, there is a lack of research investigating the relationship between electronic-cigarette (e-cigarette) usage and AD among a representative United States (US) population. E-cigarettes are tobacco-free devices that heat up variable concentrations of nicotine into an inhalable aerosol.2Cho J.H. Paik S.Y. Association between electronic cigarette use and asthma among high school students in South Korea.PLoS One. 2016; 11e0151022https://doi.org/10.1371/journal.pone.0151022Crossref Scopus (148) Google Scholar,3Khachatoorian C. Luo W. McWhirter K.J. Pankow J.F. Talbot P. E-cigarette fluids and aerosol residues cause oxidative stress and an inflammatory response in human keratinocytes and 3D skin models.Toxicol In Vitro. 2021; 77105234https://doi.org/10.1016/j.tiv.2021.105234Crossref PubMed Scopus (6) Google Scholar Further exploration of this relationship among a large US population is vital because many US adults are e-cigarette users.4Mayer M. Reyes-Guzman C. Grana R. Choi K. Freedman N.D. Demographic characteristics, cigarette smoking, and e-cigarette use among US adults.JAMA Netw Open. 2020; 3e2020694https://doi.org/10.1001/jamanetworkopen.2020.20694Crossref Scopus (83) Google Scholar We investigated the association between AD and e-cigarette use in a large US population of adults (aged ≥18 years) using the 2021 National Health Interview Survey data. Our study included 28,563 individuals (Table I). The association between AD and e-cigarette use was assessed by multivariable logistic regression analyses utilizing STATA/MP 17.0. Additionally, we controlled for various confounding variables in our models (Table II).Table ICharacteristics of adults aged ≥18 years in NHIS 2021CharacteristicAtopic dermatitis‡Atopic dermatitis status was assessed by the question “Have you ever been told by a doctor or other health professional that you had eczema or atopic dermatitis?” (weighted %, [95% CI])†Weighted percentage was calculated using NHIS survey design parameters.No atopic dermatitis‡Atopic dermatitis status was assessed by the question “Have you ever been told by a doctor or other health professional that you had eczema or atopic dermatitis?” (weighted %, [95% CI])†Weighted percentage was calculated using NHIS survey design parameters.P valuePrevalence (n/N, weighted %)2119/28,563 (7.4)26,444/28,563 (92.6)N/AElectronic-cigarette§Electronic-cigarette use was assessed by the question “Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life? (Electronic cigarettes [e-cigarettes] and other electronic vaping products include JUULs, vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors, such as fruit, mint, or candy)” Yes23.0 (20.8-25.3)17.1 (16.5-17.8)<.0001∗Values that are statistically significant (2-sided P ≤ .05) are in bold. No77.0 (74.7-79.2)82.9 (82.2-83.5)Smoking Yes34.9 (32.5-37.3)34.5 (33.6-35.3).7 No65.1 (62.7-67.5)65.5 (64.7-66.4)Asthma Yes28.6 (26.1-31.1)12.5 (12.0-13.0)<.0001∗Values that are statistically significant (2-sided P ≤ .05) are in bold. No71.5 (68.9-73.9)87.5 (87.0-88.0)Diabetes Yes10.4 (9.0-12.1)9.5 (9.1-10.0).2 No89.6 (87.9-91.0)90.5 (90.1-90.9)Received public assistance or welfare payments Yes4.5 (3.5-5.8)3.3 (3.0-3.6).02∗Values that are statistically significant (2-sided P ≤ .05) are in bold. No95.5 (94.2-96.6)96.8 (96.4-97.0)Mean age (yrs) ± SD45.7 ± 18.148.3 ± 18.5<.001∗Values that are statistically significant (2-sided P ≤ .05) are in bold. SexMale37.5 (35.2-39.9)49.2 (48.5-49.9)<.0001∗Values that are statistically significant (2-sided P ≤ .05) are in bold.Female62.5 (60.2-64.8)50.8 (50.1-51.5)Race/Ethnicity Non-Hispanic White66.3 (63.6-68.8)62.9 (61.3-64.5)<.0001∗Values that are statistically significant (2-sided P ≤ .05) are in bold. Hispanic11.1 (9.6-12.9)17.2 (15.9-18.7) Non-Hispanic Black13.5 (11.6-15.6)11.4 (10.5-12.3) Other9.2 (7.8-10.8)8.5 (7.8-9.3)Education Some/no high school6.7 (5.4-8.2)9.5 (8.9-10.2)<.0001∗Values that are statistically significant (2-sided P ≤ .05) are in bold. High school graduate/GED equivalent23.0 (20.8-25.5)28.8 (27.9-29.6) Some college/associate degree/college degree54.0 (51.4-56.6)48.8 (47.9-49.7)Postgraduate degree16.3 (14.6-18.1)12.9 (12.3-13.5)COPD Yes7.0 (6.0-8.2)4.4 (4.1-4.7)<.0001∗Values that are statistically significant (2-sided P ≤ .05) are in bold. No93.0 (91.8-94.0)95.6 (95.3-95.9)COPD, Chronic obstructive pulmonary disease; GED, general education development; NHIS, National Health Interview Survey; SD, standard deviation.∗ Values that are statistically significant (2-sided P ≤ .05) are in bold.† Weighted percentage was calculated using NHIS survey design parameters.‡ Atopic dermatitis status was assessed by the question “Have you ever been told by a doctor or other health professional that you had eczema or atopic dermatitis?”§ Electronic-cigarette use was assessed by the question “Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life? (Electronic cigarettes [e-cigarettes] and other electronic vaping products include JUULs, vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors, such as fruit, mint, or candy)” Open table in a new tab Table IIAssociation between atopic dermatitis and electronic-cigarette use among adults (aged ≥18 years) in NHIS 2021Atopic dermatitisE-cigarette use (weighted % [95% CI])†Weighted percentage was calculated using NHIS survey design parameters.OR (95% CI)P valueAOR‡Logistic regression models were adjusted for age, education, race, income, sex, diabetes, cigarette-smoking status, asthma, and body mass index (BMI). (95% CI)P valueAll participants (aged ≥18 yrs) Yes23.0 (20.8-25.3)1.45 (1.27-1.65)<.001∗Values that are statistically significant (2-side P value ≤.05).1.35 (1.16-1.58)<.001∗Values that are statistically significant (2-side P value ≤.05). No17.1 (16.5-17.8)1.00 (Reference)1.00 (Reference)Males Yes23.8 (20.3-27.6)1.22 (0.99-1.51).061.08 (0.86-1.37).5 No20.3 (19.4-21.3)1.00 (Reference)1.00 (Reference)Females Yes22.5 (19.9-25.3)1.79 (1.52-2.10)<.001∗Values that are statistically significant (2-side P value ≤.05).1.63 (1.34-1.99)<.001∗Values that are statistically significant (2-side P value ≤.05). No14.0 (13.2-14.8)1.00 (Reference)1.00 (Reference)Excluding cigarette-smoking participants Yes14.4 (12.1-17.1)1.68 (1.35-2.08)<.001∗Values that are statistically significant (2-side P value ≤.05).1.61 (1.28-2.02)<.001∗Values that are statistically significant (2-side P value ≤.05). No9.1 (8.5-9.8)1.00 (Reference)1.00 (Reference)AD, Atopic dermatitis; AOR, adjusted odds ratio; E-cigarette, electronic-cigarette; OR, odds ratio.∗ Values that are statistically significant (2-side P value ≤.05).† Weighted percentage was calculated using NHIS survey design parameters.‡ Logistic regression models were adjusted for age, education, race, income, sex, diabetes, cigarette-smoking status, asthma, and body mass index (BMI). Open table in a new tab COPD, Chronic obstructive pulmonary disease; GED, general education development; NHIS, National Health Interview Survey; SD, standard deviation. AD, Atopic dermatitis; AOR, adjusted odds ratio; E-cigarette, electronic-cigarette; OR, odds ratio. Approximately 7.4% (weighted) of individuals in our analysis had AD; 23% (weighted) reported e-cigarette use compared with 17% (weighted) of individuals without AD (Table I). After adjusting for confounders (Table II), there was a significant association between e-cigarette use and AD among adults aged ≥18 years (adjusted odds ratio, 1.35; 95% CI, 1.16-1.58; P < .001) (Table II). Subgroup analyses further revealed a significant association between e-cigarette use and AD among females (P < .001), but not males (P = .5) (Table II). In addition, the significant association between e-cigarette use and AD (adjusted odds ratio, 1.61; 95% CI, 1.28-2.02; P < .001) persisted even after excluding individuals with a history of cigarette smoking. Our findings suggest a significant association between AD and e-cigarette use among adults in the United States; however, the directionality of this relationship remains unknown. E-cigarettes may promote a proinflammatory state within the lungs, leading to the exacerbation of asthmatic symptoms.2Cho J.H. Paik S.Y. Association between electronic cigarette use and asthma among high school students in South Korea.PLoS One. 2016; 11e0151022https://doi.org/10.1371/journal.pone.0151022Crossref Scopus (148) Google Scholar The postulated mechanism for inflammation, which is supported by experimental animal models, is primarily because of e-cigarettes inducing a T helper 2 (Th2) response.2Cho J.H. Paik S.Y. Association between electronic cigarette use and asthma among high school students in South Korea.PLoS One. 2016; 11e0151022https://doi.org/10.1371/journal.pone.0151022Crossref Scopus (148) Google Scholar Moreover, Khachatoorian et al3Khachatoorian C. Luo W. McWhirter K.J. Pankow J.F. Talbot P. E-cigarette fluids and aerosol residues cause oxidative stress and an inflammatory response in human keratinocytes and 3D skin models.Toxicol In Vitro. 2021; 77105234https://doi.org/10.1016/j.tiv.2021.105234Crossref PubMed Scopus (6) Google Scholar discussed the inflammatory response and oxidative stress triggered in human cultured keratinocytes with exposure to e-cigarette fluids. Many contents within e-cigarette fluids have been shown to exert cytotoxic damage; however, propylene glycol, one of the main active ingredients, is the primary culprit for inducing an inflammatory response.3Khachatoorian C. Luo W. McWhirter K.J. Pankow J.F. Talbot P. E-cigarette fluids and aerosol residues cause oxidative stress and an inflammatory response in human keratinocytes and 3D skin models.Toxicol In Vitro. 2021; 77105234https://doi.org/10.1016/j.tiv.2021.105234Crossref PubMed Scopus (6) Google Scholar Therefore, direct skin contact with e-cigarette fluids and e-cigarette systemic inhalation may elicit a Th2 response. Conversely, it is possible that individuals with AD are more likely to use e-cigarettes. It has been postulated that the emotional changes observed in those with AD may result in increased rates of smoking5Kantor R. Kim A. Thyssen J.P. Silverberg J.I. Association of atopic dermatitis with smoking: a systematic review and meta-analysis.J Am Acad Dermatol. 2016; 75: 1119-1125.e1https://doi.org/10.1016/j.jaad.2016.07.017Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar; therefore, the same may also hold true for e-cigarettes. Limitations include a self-reported diagnosis of AD, inability to control for all confounding variables, and lack of an established timeline between e-cigarette use and AD symptoms. The self-reporting nature of the survey makes it difficult to extrapolate the subtypes of dermatitis. Additionally, the data did not ascertain the nicotine content of the e-cigarettes. Further studies are needed to explore the pathophysiologic mechanisms of this relationship. Dr Wu is or has been an investigator, consultant, or speaker for AbbVie, Almirall, Amgen, Arcutis, Aristea Therapeutics, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, DermTech, Dr. Reddy's Laboratories, Eli Lilly, EPI Health, Galderma, Janssen, LEO Pharma, Mindera, Novartis, Pfizer, Regeneron, Samsung Bioepis, Sanofi Genzyme, Solius, Sun Pharmaceutical, UCB, and Zerigo Health. Dr Maul has served as advisor and/or received speaking fees and/or participated in clinical trials sponsored by AbbVie, Almirall, Amgen, BMS, Celgene, Eli Lilly, LEO Pharma, Janssen-Cilag, MSD, Novartis, Pfizer, Pierre Fabre, Roche, Sanofi, UCB. Authors Smith, Engel, Devjani, Javadi, and Collier have no conflicts of interest to declare.