Association Between Mental Health and Nicotine/Tobacco Use by Disaggregated Gender Identities Among U.S. Adolescents, 2020–2023

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.