Adolescents with mental health symptoms more likely to use multiple nicotine products, international research finds

A recent study led by Emily Hackworth, a 2024 graduate of the Arnold School’s Ph.D. in Health Promotion, Education, and Behavior, and co-authors has found that youth (ages 16–19) with internalizing mental health symptoms (e.g., anxiety, depression, sadness, loneliness) are more likely to turn to nicotine products (particularly electronic cigarettes) than their peers. Published in Nicotine and Tobacco Research, the study also revealed that the pandemic and its aftermath has likely played a role in this relationship.

“Internalizing mental health symptoms are highly prevalent among adolescents but are rarely diagnosed or treated until adulthood,” says Hackworth, who is currently a postdoctoral associate at the University of Minnesota’s Masonic Cancer Center. “These untreated individuals are at risk for adverse outcomes, such as suicide as well as substance and tobacco use—which largely account for life expectancies that are 25 years shorter than their peers.”

Eighty-seven percent of people who smoke report their first use of tobacco products as occurring before age 18, with the majority of these youth continuing their use into adulthood. Prior research had already established a bi-directional relationship between cigarette smoking and mental health, and adolescents are particularly vulnerable to this pairing due to the drastic physiological, psychosocial and emotional changes that occur during this key developmental stage.

This project aimed to discover whether this use was limited to certain types of nicotine products (e.g., combustible, such as traditional cigarettes, vs. non-combustible, such as e-cigarettes) or a combination of the increasing variety of products available to consumers. Using data from the International Tobacco Control Adolescents Tobacco and Vaping Survey, the researchers examined the self-reported behaviors and symptoms of more than 80,000 16–19-year-olds in Canada, England and the United States between 2020 and 2023. Their analysis showed that internalized mental health symptoms were strongly associated with both combustible and non-combustible use of nicotine products, followed by the sole use of non-combustible products.

“Non-combustible product use may have a particularly strong relationship with poor mental health among adolescents, though we need additional research to better understand this connection,” Hackworth says.

“What we do know is that these trends are largely driven by e-cigarette use. Therefore, efforts to reduce youth e-cigarette use may consider emphasizing its relationship with mental health. Further, efforts to promote e-cigarette use as a less harmful alternative to cigarette smoking should be aware of the association between vaping and youth mental health.”

Co-authors include Desiree Vidaña-Pérez (HPEB), Riley O’Neal (HPEB), Minji Kim (HPEB), Jennifer Fillo (HPEB), David Hammond (University of Waterloo), and James Thrasher (HPEB).