U.S. Department of Health and Human Services


Date of this Version


Document Type



J Am Acad Child Adolesc Psychiatry 2018;57(12):944-954.


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Objective: To examine whether mental health problems predict incident use of 12 different tobacco products in a nationally representative sample of youth and young adults.

Method: This study analyzed Wave (W) 1 and W2 data from 10,533 12- to 24-year-old W1 never tobacco users in the Population Assessment of Tobacco and Health (PATH) Study. Self-reported lifetime internalizing and externalizing symptoms were assessed at W1. Past 12-month use of cigarettes, electronic nicotine delivery systems (ENDS), traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, other smokeless tobacco, bidis and kreteks (youth only), and dissolvable tobacco was assessed at W2.

Results:In multivariable regression analyses, high-severity W1 interalizing (adjusted odds ratio [AOR] = 1.5, 95% CI = 1.3 - 1.8) and externalizing (AOR=1.3, 95% CI=1.1-1.5) problems predicted W2 onset of any tobacco use compared to no/low/moderate severity. High-severity W1 internalizing problems predicted W2 use onset across most tobacco products. High-severity W1 externalizing problems predicted onset of any tabacco (AOR=1.6, 95% C1=1.3-1.8), cigarettes (AOR=1.4, 95% CI=1.0-2.0), ENDS (AOR=1.8, 95& CI=1.5-2.1), and cigarillos (AOR=1.5, 95% CI=1.0-2.1) among youth only.

Conclusion: Internalizing and externalizing problems predicted onset of any tobacco use. However, findings differed for internalizing and exter- nalizing problems across tobacco products, and by age, gender, and race/ethnicity. In addition to screening for tobacco product use, health care providers should screen for a range of mental health problems as a predictor of tobacco use. Interventions addressing mental health problems may prevent youth from initiating tobacco use.