Given the rapid evolution in e-cigarette products and messaging, there remains a need to inform how smoking cessation treatment can be tailored for SUD clients who use both e cigarettes and tobacco cigarettes. The high rates of tobacco use and tobacco-related mortality among individuals with SUDs, and the complex, emerging questions regarding the effectiveness of e-cigarettes as smoking cessation aids, highlights the need for up-to-date information about e-cigarette use in this population. The purpose of this study was to characterize e-cigarette use among clients in residential SUD treatment and to identify the correlates of e cigarette use as a smoking cessation aid among current cigarette smokers. We conducted a secondary data analysis of 562 participants in 20 residential SUD treatment programs in California who were recruited as part of three separate studies. A description of the full sample of 20 programs can be found in Guydish and colleagues . Among the participating residential SUD treatment programs, some also offered behavioral health services for individuals who had recently been released from prison or individuals who sought treatment for both SUD and mental health diagnoses. All three studies evaluated interventions designed to reduce continued tobacco use and/or use of nicotine containing prod ucts among clients in residential SUD programs. This report uses the baseline data collected during the calendar year of 2019. Research staff collected baseline data in the course of scheduled site visits at the participating programs. Eligible clients were both smokers and non-smokers enrolled in the program on the day of the site visit. All participants provided informed consent and completed the survey using an iPad with a pre-populated unique participant research identification number. Respondents received a $20 gift card for their time. The Insti tutional Review Board of the University of California, San Francis coapproved all research procedures. Demographic characteristics collected for the survey included age, gender, race/ethnicity, and education.

Race/ethnicity was categorized as Hispanic/Latino, African American/Black, White/Caucasian,grow rack systems and other or multiple races. We dichotomized education as less than or equal to high school or general equivalency diploma versus some college or more. In all three studies respondents were asked to report the reason they sought treatment. In two studies they were asked whether they sought treatment mainly for a substance use problem, for both substance use and mental health problems, or for some other problem. One study included the same item but with an added response code for mental health problems. Self-reported reason for currently seeking treatment was coded into four categories: 1) SUD; 2) mental health disorder; 3) SUD and mental health disorder; or 4) other. Respondents were asked to report the primary drug for which they sought treatment: alcohol, amphetamines/methamphetamines, marijuana/cannabis, crack/cocaine, heroin, methadone, other opiates/ analgesics, other drug, and not in treatment for any SUD. Primary drug was coded into these categories: alcohol, stimulants , cannabis, opiates , other drugs, and not in treatment for a SUD. Current cigarette smokers were participants who reported having smoked at least 100 cigarettes during their lifetime and also reported being a current smoker at the time of the survey. Current smokers re ported the number of days per week they smoked cigarettes, number of cigarettes they smoked per day , whether they had a serious quit attempt in the past year , and whether they wanted help quitting smoking . They were also asked about their attitudes toward quitting smoking by rating items on a five-point Likert scale ranging from strongly disagree to strongly agree about the extent to which they: a) had the required skills to quit smoking, b) were concerned about their smoking, and c) believed that counseling by a clinician would help them to quit smoking . The sample for this analysis comprised 332 participants who re ported current cigarette smoking. Bivariate analyses were used to compare those who had ever used e-cigarettes for smoking cessation to those who had never used e-cigarettes for smoking cessation, on de mographic variables, substance use, smoking behaviors, readiness to quit smoking, and perceptions of the harms of e-cigarettes. For the questions that asked about attitudes toward quitting smoking, we combined the strongly agree and agree categories to describe percent agreement for each item.

For the readiness to quit smoking variable, we collapsed the precontemplation and contemplation stages of change categories. We used the Student’s t-test for continuous variables and the Pearson’s chi-square test or Fisher’s exact test for categorical variables. Next, we conducted a multivariable logistic regression analysis to examine independent associations between predictor variables and the dependent variable of ever use versus never use of e-cigarettes for smoking cessation. All variables were included in the model if they were significant at a p ≤ 0.10 in the bivariate comparisons .The generalized estimating equation methodwas applied for correlated data. SAS software was used to conduct all analyses . In this study of clients in residential SUD treatment, almost half of current cigarette smokers had ever used e-cigarettes to quit smoking. Results of the multivariable logistic regression showed that smokers who sought treatment for both a SUD and mental health dis order were more than twice as likely to have ever used e-cigarettes as asmoking cessation aid compared to those who sought treatment for an SUD alone. Our finding is consistent with other studies that have found higher rates of e-cigarette ever use among individuals with versus without a mental health disorder . Current smokers who have a mental health disorder may perceive e-cigarettes as an alternate nicotine option compared to traditional to bacco cigarettes. For example, a national survey of US adults found that current smokers with as compared to those without a mental health disorder reported thinking more about the health benefits of using electronic nicotine delivery devices , and a study of chronic smokers with serious mental illness and history of failed treatment-facilitated quit attempts who were provided with e-cigarettes for 4 weeks found high ratings of enjoyment, satisfaction, and willingness to buy e-cigarettes . It is also possible that individuals with mental health disorders may be using e-cigarettes to self-medicate psy chiatric symptoms or to alleviate the side effects of psychiatric medi cations. A qualitative study of social media posts that examined the use of e-cigarettes among people with mental illness found that vapers used e-cigarettes to alleviate stress and psychiatric symptoms such as anxiety, depression, intrusive thoughts, and to offset the side effects of prescribed psychotropic medications . Other noteworthy results included that current cigarette smokers who perceived that e-cigarettes were not as harmful or equally as harmful as tobacco cigarettes were more likely to have ever used e cigarettes as a smoking cessation aid. The finding that some current smokers perceived e-cigarettes to be as harmful as tobacco cigarettes yet used them to quit smoking may appear counterintuitive.

However, a possible explanation for this finding may be that beyond perceived risk, having more positive affect toward e-cigarettes may have motivated its use for quitting smoking. In a nationally representative sample of US adults who were aware of e-cigarettes, Popova and colleagues found that images related to risk and disgust were frequently associated with cigarettes ,rolling flood tables but were less common for e-cigarettes . Moreover, they found that lower perceived risks of using e-cigarettes daily was associ ated with having more positive affect toward e-cigarettes, which in turn was associated with a higher likelihood of being a current e-cigarette user. Thus, in weighing the risks and benefits, a favorable attitude to ward e-cigarettes may influence cigarette smokers’ decision-making about whether to use e-cigarettes for quitting smoking. Our finding that younger cigarette smokers were more likely to use e cigarettes for smoking cessation is consistent with previous studies conducted with individuals receiving SUD treatment that have found younger age to be associated with ever using e-cigarettes . Although our findings for education and race/ ethnicity have wide confidence intervals, these findings are consistent with results of recent population studies demonstrating a greater reach of e-cigarette use among older adolescents and younger adults, those with higher education attainment, and people of White ethnicity . Future research among patients in SUD treatment focusing specifically on e-cigarette users to examine the sociodemographic and substance use characteristics of those who have successfully quit smoking would be helpful inmonitoring potential disparities in smoking cessation outcomes . Dual use of e-cigarettes and tobacco cigarettes was higher than what has been documented among some other samples of individuals with SUDs . Dual use of e-cigarettes and tobacco cigarettes among vulnerable populations such as those with SUDs and mental illness has raised concerns about the potential of e-cigarettes to maintain nicotine dependence . Dual users have higher exposure to nicotine and tobacco-related toxicants , and an increased risk for the adverse health effects asso ciated with the combined use of these products as compared with smoking alone . Moreover, users of nicotine delivery systems including e-cigarettes who also use other tobacco products are less likely to discontinue all tobacco use as compared with exclusive users of electronic nicotine delivery systems . A recent randomized clinical trial that compared the effectiveness of e cigarettes and nicotine replacement therapy , including product combinations for smoking cessation found that the 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the NRT group . However, among participants with 1- year abstinence, those in the e-cigarette group were more likely than those in the NRT group to use their assigned product at the 1 year follow up . Given the high prevalence of dual use of e-cigarettes and tobacco cigarettes among SUD treatment patients, it is critical for clinicians to ask patients not only about cigarette smoking but about all tobacco product use . Counseling messages for patients in SUD treatment programs should also include information about the potential harms of the dual use e-cigarettes and tobacco cigarettes and use of other tobacco products, and evidence of the effectiveness of FDA-approved smoking cessation medications that have proven effective in helping individuals quit smoking, particularly when used in combination with behavioral counseling . Limitations of the study should be noted.

The present study consisted mostly of men recruited from residential SUD treatment programs in a single state potentially limiting the generalizability of our findings to smokers living in other geographic regions of the country. However, our findings are similar to other studies of clients receiving SUD treatment , increasing our confidence that use of e-cigarettes is common in this population, and is viewed by SUD clients as an acceptable method for quitting smoking. Our study examined self-reported mental health sta tus, and did not examine differences in prevalence of e-cigarette use for smoking cessation across psychiatric diagnoses, because psychiatric di agnoses were not collected for all participants. Inaccurate medication reconciliation is the source of many medication-related misadventures leading to hospital admissions and patient morbidity and mortality.1 In randomized controlled studies, pharmacist-led discharge medication reconciliation interventions result in hospital cost avoidance and improve patient safety.1 Valproic acid is an antiepileptic medication commonly used to treat seizures, bipolar disorder, and migraine headache.2 Its mechanism of action includes sodium channel inhibition, T-type calcium channel inhibition, suppression of glutamate, and inhibition of γ-aminobutyric acid metabolism. VPA is available in a variety of dosage forms, and peak plasma concentrations are achieved rapidly .3 With toxic ingestions, absorption and subsequent peak may be delayed; one case report reported peak serum levels 17 hours post ingestion.4 Therapeutic concentrations of VPA range from 50 to 100 µg/L, and it is 80–90% plasma protein bound.3 Elimination occurs via first-order kinetics with a half-life of 5-20 hours; however, this can be prolonged up to 30 hours with toxicity.3 At toxic levels, VPA can cause central nervous system depression, respiratory depression, acute kidney injury, anion-gap metabolic acidosis, and electrolyte abnormalities . VPA is also associated with hepatotoxicity, pancreatitis, hyperammonemic encephalopathy, cerebral edema, and blood dyscrasias such as leukopenia, anemia, and thrombocytopenia. Treatment of VPA toxicity is largely supportive; however, it can include enhanced elimination methods such as charcoal hemoperfusion and hemodialysis . HD is known to clear toxins that are water soluble, have low volume of distribution, and are not highly bound to plasma proteins.