Addiction-Related Outcomes of Nicotine and Alcohol Co-use: New Insights Following the Rise in Vaping

Abstract

Purpose: Nicotine and alcohol-containing products are some of the most commonly used substances of abuse and are both leading causes of preventable death. These substances also have significant interactions that have additive and, in some cases, multiplicative effects on the health consequences of their use. Thus, to reduce these negative consequences, it is important to understand the abuse liability of nicotine and alcohol in combination, especially in the most relevant use cases among those who are most vulnerable. Specifically, as tobacco cigarette use is continually decreasing, vaping is quickly replacing cigarettes as the primary mode of nicotine use. This pattern is especially true in adolescent populations in which vaping has grown considerably. Particularly concerning is that adolescents are more vulnerable than adults to the negative consequences of substance use. It is therefore imperative to revisit the literature as it relates to the rising state of co-use of vaping products with alcohol. Here, we review the clinical outcomes of nicotine and alcohol co-use as they relate to the abuse liability of each individually. Special attention is paid to adolescent findings, where available, as well as investigations that use nontobacco nicotine products as these may more accurately reflect the more recent trends of co-use.

Implications: Though nicotine alone has previously been considered a proxy for tobacco and tobacco cigarette use, combustible routes of administration have been decreasing. They are, instead, being replaced by e-cigarettes that do not involve other tobacco constituents and contain additional nonnicotine constituents of their own. Unfortunately, the literature remains limited with regard to e-cigarettes and their interactions with other substances, especially their prevalent co-use with alcohol. This review attempts to discuss the current literature on nicotine and alcohol co-use in the context of the vaping epidemic, predominantly focusing on addiction-related outcomes and why e-cigarette use may be unique.

Figure 1.

Properties of tobacco cigarettes, e-cigarettes, NRTs, and their overlapping relationships. For the purposes of this review, e-cigarettes are not considered a NRT. Though the FDA is working to ban menthol in cigarettes, mentholated cigarettes are still currently available; thus, for now all nicotine products have flavors in common. Depending on whether e-cigarettes contain nicotine salt or base, they may be more likely to overlap with cigarettes or NRTs. There is significant overlap between each nicotine product allowing for some understanding of e-cigarette properties to be gleaned from past literature. Past findings, therefore, have validity for directing future clinical and preclinical studies observing the effects of e-cigarettes directly.