Association Between Mental Health and Nicotine/Tobacco Use by Disaggregated Gender Identities Among U.S. Adolescents, 2020–2023
Abstract
Purpose:
Adolescents with internalizing mental health (IMH) symptoms are more likely to use nicotine/tobacco products; however, the association with gender identity remains unclear. We examined differences in the relationship between IMH symptoms and nicotine/tobacco use by gender identity.
Methods:
Data came from the U.S. arm of the International Tobacco Control Youth Tobacco and Vaping Survey, an online cross-sectional survey of adolescents aged 16–19, conducted from 2020 to 2023 (n = 28,959). Current nicotine/tobacco use was categorized as: (1) no use, (2) exclusive combustible product use, (3) exclusive noncombustible product use, and (4) use of both product types. Current depression and anxiety symptoms were aggregated into an IMH symptoms variable (yes/no). Gender identity was determined based on responses to questions regarding current gender identity and sex assigned at birth. Analyses examined differences in IMH symptoms and nicotine/tobacco use by gender identity and the potential moderating role of gender identity in the relation between IMH symptoms and nicotine/tobacco use.
Results:
Risk for nicotine/tobacco use and IMH symptoms varied across gender identities. Transgender women reported the highest prevalence of any product use (29%) followed by transgender men (24%), cisgender men (22%), cisgender women (19%), and gender nonconforming (GNC) adolescents (14%). GNC adolescents reported the highest prevalence of IMH symptoms (85%), followed by transgender men (80%), cisgender women (67%), transgender women (65%), and cisgender men (45%). We found significant interactions between IMH symptoms and gender identity (p < 0.0001).
Conclusion:
This study revealed the importance of disaggregating GNC and transgender identities in research related to nicotine/tobacco use and mental health among adolescents.
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Data availability statement
Data are available upon reasonable request. Deidentified data will be made available to researchers who provide a methodologically sound proposal for use in achieving the goals of the approved proposal. Proposals should be submitted to D.H.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Health Canada. Sponsors had no role in the study design; collection, analysis, and interpretation of data; writing of the article; or decision to submit the article for publication.
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Article first published online: February 20, 2026
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