Associations Between Internalizing and Externalizing Symptoms on Subsequent Tobacco Product Initiation and Sustained...

Previous studies have found positive associations between internalizing and externalizing symptoms and the initiation of tobacco use among adolescents. However, few studies have examined the relationship between these symptoms and sustained tobacco use patterns or how they may vary as a function of sex. The current study examined whether these symptoms predict initiation and sustained use of multiple tobacco products within a longitudinal cohort design.

Waves 1-3 of the Population Assessment of Tobacco and Health Study (2013-2016) were used to assess relationships between internalizing and externalizing symptoms, sex, and tobacco use categories (cigarettes, e-cigarettes, poly-tobacco use, other tobacco use) in 6,170 adolescents (M age = 13.42, SD = 1.10) who were tobacco naive at Wave 1.

Internalizing and externalizing symptoms predicted initiation of several tobacco categories at the 2-year follow-up. Examining sustained use patterns revealed a more consistent relationship with externalizing symptoms across tobacco categories, whereas associations with internalizing symptoms were limited. Sex moderated the relationship between elevated internalizing symptoms and increased odds of subsequent e-cigarette and poly-tobacco initiation, with stronger relationships observed among females. In addition, the relationship between elevated externalizing symptoms and sustained other tobacco use was stronger in females as compared with males.

Although both internalizing and externalizing symptoms predict tobacco initiation across several product categories, externalizing symptoms may reflect a more reliable signal of sustained tobacco use in adolescents. Mental health symptoms and subsequent tobacco use differed by sex, with females demonstrating stronger relationships for several products.