Summary: A new study finds that adolescents who use e-cigarettes, conventional tobacco products (CTPs) such as cigarettes, cigars, hookah and pipes, or both, are significantly more likely to report symptoms of depression and anxiety than peers who do not use tobacco. Researchers analyzed responses from more than 60,000 U.S. middle and high school students surveyed between 2021 and 2023 using the National Youth Tobacco Survey.
Teens who reported dual use of e-cigarettes and combustible tobacco products showed the greatest likelihood of mental health symptoms. The results strengthen calls for targeted prevention efforts, combined tobacco control and mental health services, and policies to protect adolescent well-being.
Key Facts:
- Increased mental health risk: Adolescents who used tobacco products reported higher rates of depression and anxiety symptoms compared with non-users.
- Dual use poses the highest risk: Young people who used both e-cigarettes and combustible tobacco products had the largest increases in odds of depression and anxiety.
- Public health implications: Findings underscore the need for integrated, youth-focused mental health support and anti-tobacco programs.
Source: PLOS
Overview of the study
The study, led by Noor Abdulhay of West Virginia University and colleagues and published in PLOS Mental Health, examined the relationship between adolescent tobacco use and self-reported symptoms of depression and anxiety. Researchers used pooled data from the 2021–2023 National Youth Tobacco Survey (NYTS), a nationally representative survey of middle and high school students in the United States. By focusing on both electronic cigarettes and combustible tobacco products, and distinguishing exclusive versus dual use, the analysis provides a clearer picture of how different tobacco use patterns relate to adolescent mental health.
Study sample and tobacco use patterns
The analysis included 60,072 students who completed all questions used in the study. Overall, 21.37% of respondents reported ever using tobacco products. Breakdown of use patterns was: 9.94% ever used e-cigarettes only, 3.61% ever used combustible tobacco products (CTPs) only, and 7.80% reported ever using both e-cigarettes and CTPs (dual use).
Mental health measures and findings
Depression and anxiety symptoms were measured using the brief Patient Health Questionnaire (PHQ-4). Scores of 3 or higher on the depression or anxiety subscales were treated as probable cases. Overall psychological distress was categorized using the PHQ-4 total score into normal, mild, moderate, or severe distress.
Across the sample, 25.21% of adolescents met the threshold for depression symptoms and 29.55% met the threshold for anxiety symptoms. Compared with non-users, adolescents who reported any tobacco use had higher odds of depression and anxiety symptoms. Those with dual use histories consistently showed the highest adjusted odds ratios: 1.90 for depression symptoms, 1.58 for anxiety symptoms, and 1.75 for overall psychological distress, reflecting a substantially elevated likelihood of mental health problems relative to non-users. Exclusive e-cigarette users and exclusive CTP users also had significantly higher odds compared with non-users, though the magnitudes were lower than for dual users.
Interpretation and limitations
The study highlights a clear association between tobacco use and worse mental health outcomes in adolescents. The authors emphasize that the cross-sectional survey data cannot establish causality—tobacco use and mental health symptoms likely have a complex, bidirectional relationship. Still, the large, nationally representative sample and consistent associations across tobacco-use categories strengthen the evidence that tobacco use is linked with increased reports of depression and anxiety among youth.
Implications for policy and practice
These findings support integrated public health strategies that address both tobacco prevention and adolescent mental health. Tailored interventions—school- and community-based programs, screening for tobacco use in youth mental health settings, and mental health support in tobacco cessation efforts—may help reduce both substance use and psychological distress among adolescents. The study also informs ongoing policy discussions about reducing youth access to tobacco and e-cigarette products.
About this nicotine and mental health research news
Author: Charlotte Bhaskar
Source: PLOS
Contact: Charlotte Bhaskar – PLOS
Image: The image is credited to Neuroscience News
Original Research: Open access. “Mental health outcomes associated with electronic cigarette use, combustible tobacco use, and dual use among U.S. adolescents: Insights from the National Youth Tobacco Survey” by Noor Abdulhay et al., PLOS Mental Health.
Abstract
Mental health outcomes associated with electronic cigarette use, combustible tobacco use, and dual use among U.S. adolescents: Insights from the National Youth Tobacco Survey
Adolescence is a formative period for mental health, and recent years have seen rising rates of anxiety, depression, and suicide among U.S. youth. Tobacco use—particularly e-cigarettes and the combination of e-cigarettes with combustible tobacco—poses a potential threat to adolescent mental health. This study analyzes associations between tobacco use profiles and mental health outcomes using 2021–2023 NYTS data, with three-quarters of eligible students completing the survey across the three years.
Depression and anxiety symptoms were evaluated with the PHQ-4, using established cutoffs to generate binary indicators and to classify overall psychological distress. Tobacco use categories included ever e-cigarette-only, ever CTP-only, ever dual use, and non-use. Weighted multivariable logistic and ordinal regression models adjusted for potential confounders to estimate odds ratios and 95% confidence intervals.
Among 60,072 adolescents analyzed, 15,222 (25.21%) screened positive for depression symptoms and 17,790 (29.55%) screened positive for anxiety symptoms. Ever dual users had the highest adjusted odds of mental health symptoms—adjusted OR 1.90 for depression, 1.58 for anxiety, and 1.75 for overall psychological distress—compared with non-users. Exclusive e-cigarette and exclusive CTP use were also associated with higher odds relative to non-use.
The study underscores a significant association between different patterns of tobacco use and poorer mental health among adolescents, contributing evidence relevant to research, clinical practice, and policy aimed at reducing youth tobacco use and supporting adolescent mental health.