Study: Links between internalizing mental health symptoms and nicotine/tobacco use vary by gender identity among U.S. adolescents

Key Takeaway

• Data: U.S. arm of the ITC Youth Tobacco and Vaping Survey, 2020–2023, ages 16–19, n=28,959
• Any current use prevalence: transgender girls ~29%, transgender boys ~24%, cisgender boys ~22%, cisgender girls ~19%, GNC ~14%
• IMH symptom prevalence: GNC ~85%, transgender boys ~80%, cisgender girls ~67%, transgender girls ~65%, cisgender boys ~45%
• Significant interaction between IMH symptoms and gender identity (p<0.0001)
• Stratified results: IMH symptoms associated with broader use categories among cisgender boys; with noncombustible and dual use among cisgender girls; with higher noncombustible use among GNC youth; and with lower combustible/dual use in the combined transgender group

2Firsts, Feb 27, 2026 – 

According to a study published in LGBT Health, researchers examined how internalizing mental health (IMH) symptoms (depression/anxiety symptoms combined) relate to current nicotine/tobacco use among U.S. adolescents, and whether gender identity moderates this relationship. The analysis used the U.S. arm of the International Tobacco Control Youth Tobacco and Vaping Survey, a repeat cross-sectional online survey of adolescents aged 16–19 conducted from 2020 to 2023 (n=28,959). 

Current nicotine/tobacco use was categorized into four groups: no current use, exclusive combustible use, exclusive noncombustible use, and use of both product types. Gender identity was derived from current gender identity and sex assigned at birth, with transgender and gender nonconforming (GNC) identities presented separately. 

The report said prevalence of any current product use differed across gender identities, with transgender girls reporting the highest prevalence (about 29%), followed by transgender boys (about 24%), cisgender boys (about 22%), cisgender girls (about 19%), and GNC adolescents (about 14%). It also reported IMH symptom prevalence was highest among GNC adolescents (about 85%), followed by transgender boys (about 80%), cisgender girls (about 67%), transgender girls (about 65%), and cisgender boys (about 45%). 

The study reported significant interactions between IMH symptoms and gender identity (p<0.0001), and stratified analyses indicated that the strength and direction of associations between IMH symptoms and nicotine/tobacco use categories varied by gender identity. 

The authors concluded that disaggregating GNC and transgender identities is important for research on nicotine/tobacco use and mental health among adolescents. 

From a risk-structure perspective:

The study indicates that nicotine and tobacco use rates vary significantly across gender identity groups, with particularly high prevalence among transgender youth, alongside markedly elevated levels of internalizing mental health symptoms  . In addition, the statistically significant interaction between mental health symptoms and nicotine use (p < 0.0001)  suggests that vulnerability is not evenly distributed across populations. For the industry, this signals a potential shift in regulatory and public health framing—from product-centered risk discussions to subgroup-specific vulnerability assessments.

From a regulatory exposure perspective:

As research increasingly quantifies associations between mental health conditions and nicotine product use within specific demographic subgroups, regulators may incorporate more granular population impact assessments into product evaluations, marketing oversight, and youth access control policies. This could expand compliance expectations beyond product characteristics to include demographic risk considerations.

To understand the detailed contents of the study, please read the original article.