Abstract
Objective:
Despite a decline in cigarette use, the dual use of cigarettes and electronic vaping products (EVPs) is a concerning pattern of nicotine consumption in the United States. Anxiety, a risk factor for tobacco use, may contribute to dual-use patterns; however, the association between daily anxiety symptoms and dual use of cigarettes and EVPs is not known. This study investigated associations between daily anxiety symptoms and dual cigarette and EVP use overall and by sex, race, and ethnicity.
Method:
Data are from the 2020–2022 National Health Interview Survey (n = 83,544). Multinomial logistic regression models, adjusted for sociodemographic factors, tobacco use, mental health services, and medication characteristics, examined the relationship between daily anxiety and current exclusive/dual cigarette and EVP use. Stratified analyses explored effect modification by sex, race, and ethnicity.
Results:
Among the sample, 13.0% reported daily anxiety symptoms, and 1.3% reported dual cigarette and EVP use. Daily anxiety was associated with increased odds of exclusive cigarette (odds ratio [OR] = 1.54, 95% CI [1.42, 1.68]), exclusive EVP (OR = 1.44, 95% CI [1.23, 1.68]), and dual use (OR = 2.16, 95% CI [1.77, 2.63]). Stratified analyses showed significant associations between dual use and daily anxiety among Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic Asian adults. Of note, Hispanic males and females, non-Hispanic White males and females, Black females, non-Hispanic Asian males, and females of another race/ethnicity had higher odds of dual use, whereas Asian females had lower odds.
Conclusions:
This study highlights heterogeneous relationships between daily anxiety and dual cigarette and EVP use at the intersection of sex, race, and ethnicity. Tailored interventions addressing persistent mental health symptoms are crucial for reducing tobacco use and associated disparities.
Tobacco use continues to be a leading cause of preventable morbidity and mortality in the United States (U.S. Surgeon General, 2014). Despite a decline in cigarette smoking among adults (Mattingly et al., 2021), dual use of cigarettes and electronic vaping products (EVPs) has become increasingly prevalent (Mattingly et al., 2021; O'Connor et al., 2022). In 2021, 2.2% of adult tobacco users reported engaging in this pattern (compared with 4.5% who solely use e-cigarettes and 11.7% who solely use cigarettes; Cornelius et al., 2023), which can pose risks for heavier tobacco consumption and greater dependence than using either product alone (Lee et al., 2023; Pisinger & Rasmussen, 2022; Snell et al., 2020).
Emerging evidence suggests that some adults may turn to cigarettes and EVPs as a means of managing negative emotional states, in line with the affective processing model of negative reinforcement (Lee et al., 2023; Versella et al., 2019). Anxiety is strongly linked to tobacco use, with people experiencing it being 60% more likely to have smoked in the past year compared with those in the general population who are nonsmokers (Smith et al., 2020). Further, dual use of tobacco products has been found to be significantly associated with users reporting mental health symptoms such as recent anxiety (Cwalina et al., 2021).
The relationship between dual use and anxiety symptoms is further complicated by the fact that it may function bidirectionally, with anxiety potentially leading to increased tobacco use and vice versa (Clendennen et al., 2023; Powers et al., 2021). For instance, the biochemical properties of nicotine, which can alleviate anxiety symptoms by temporarily activating pleasure and relaxation pathways, may make individuals with high anxiety levels more vulnerable to dual use of both cigarettes and EVPs, as this combination delivers an increased, rapid dose of nicotine compared with either product alone (McLeish et al., 2021; Morissette et al., 2007; Picciotto et al., 2002; Yingst et al., 2019). This dual use may also be initially appealing for those with anxiety, with both outcomes serving as a form of self-medication by helping to alleviate acute anxiety symptoms, thereby increasing the risk of comorbid nicotine dependence and anxiety disorders (Buckner et al., 2021; Cwalina et al., 2021). Notably, some dual users may be in the process of quitting cigarette use and using EVPs to reduce cravings, which may cause anxiety and exacerbate their urges to continue using both (Martinez et al., 2021). Therefore, understanding how anxiety symptoms influence dual-use patterns, as opposed to single-product use, is crucial for tailoring interventions aimed at reducing both nicotine dependence and anxiety (Clendennen et al., 2023; Grant et al., 2019; Versella et al., 2019).
Dual use of cigarettes and EVPs is more prevalent among certain sociodemographic groups, particularly younger adults ages 18–44 and non-Hispanic White men, but possible disparities at the intersection of sex, race, and ethnicity require additional investigation (Hirschtick et al., 2021; Masaki et al., 2022). Evidence suggests that individuals from marginalized populations may experience heightened stress and anxiety burdens influenced by systemic discrimination and social inequities (Meyer, 2003; Williams, 2018). This chronic stress can exacerbate anxiety symptoms and increase susceptibility to substance use as a coping mechanism (Williams, 2018). In addition, intersectional approaches highlight that individuals who experience multiple types of disadvantages—such as racial and gender minorities—may face unique stressors that compound mental health challenges (Aguirre et al., 2016; Kirkbride et al., 2024).
Individuals with multiple sociodemographic disadvantages, such as those intersecting racial, gender, and economic marginalization, often experience unique and compounded stressors that elevate their mental health risks, including anxiety symptoms (Crenshaw, 1989; Denise, 2014). Intersectionality provides a framework for understanding how overlapping identities and systemic inequities can intensify vulnerability to adverse health outcomes, including substance use, as individuals from these groups may turn to coping mechanisms like dual use of tobacco products to mitigate the impacts of chronic stress and anxiety (Bowleg, 2012; Culbreth et al., 2021). For example, studies have shown that Black women and other individuals at multiple intersections of marginalization are more likely to experience both structural discrimination and heightened mental health stressors, making them particularly susceptible to coping mechanisms like tobacco use (Cole, 2009; Thomas Tobin et al., 2022). This perspective suggests that examining dual use through an intersectional lens is crucial, as individuals facing multiple disadvantages may be disproportionately affected by the combined burdens of anxiety and tobacco use. Therefore, this study examines the association between daily anxiety symptoms and patterns of cigarette and EVP use among a nationally representative sample of U.S. adults. It also investigates the extent to which these associations vary by sex, race, and ethnicity and their interaction, hypothesizing that more frequent anxiety symptoms will be strongly associated with dual use among populations with multiple sociodemographic disadvantages.
Method
Data and participants
This study used data from the 2020 (n = 31,568), 2021 (n = 29,482), and 2022 (n = 27,651) National Health Interview Survey (NHIS), with pooled data on adults ages 18 or older (n = 88,701). The NHIS is a nationally representative, cross-sectional, household interview survey conducted annually by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention on adults and youth within the United States. However, the latter were not included due to a lack of tobacco use questions for those less than 18 years of age. Response rates for adults were 48.9% (2020), 50.9% (2021), and 47.7% (2022). NHIS data are publicly available, and further information about the NHIS study design and sampling methodology is available online (NCHS, n.d.). We retained 94.0% of adults who had complete information on tobacco use, mental health, and sociodemographic variables, resulting in an analytic sample size of 83,544 (2020: n = 29,970; 2021: n = 27,777; 2022: n = 25,797).
Measures
Frequency of anxiety symptoms. Participants were asked, “How often do you feel worried, nervous, or anxious? Would you say daily, weekly, monthly, a few times a year, or never?” We defined daily anxiety symptoms as a dichotomous variable, assigning a value of 1 to adults who reported daily anxiety symptoms and a value of 0 to adults who reported anxiety symptoms less frequently (weekly, monthly, a few times a year, or never).
Exclusive and dual cigarette and EVP use. To define cigarette use, participants answered whether they currently smoked cigarettes every day, some days, or not at all. We categorized current cigarette use as never/former (i.e., not at all; 0) or current (i.e., every day or some days; 1) use. Similarly, participants indicated their current EVP use, and we categorized this variable as never/former (0) or current (1) use. From these two current use variables, we created a current exclusive and dual cigarette and EVP use variable, defined as never/former use of either product (0), exclusive cigarette use (1), exclusive EVP use (2), and dual use (3).
Covariates. This analysis included the following covariates: survey year (2020, 2021, 2022), age (18–29, 30–44, 45–64, ≥65 years), sex (male, female), race and ethnicity (Hispanic, non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, another race or ethnicity [American Indian/Alaska Native, Asian/Pacific Islander, and other group, other single and multiple races]), sexual orientation (heterosexual, lesbian/gay/bisexual/something else [LGB+]), highest educational attainment (high school graduate or less, some college, college graduate, graduate school), income level (low, middle, high), geographic location (large central metro, large fringe metro, medium and small metro, nonmetro; Ingram & Franco, 2014), current anxiety medication use (yes, no), received past-year mental health therapy services (yes, no), frequency of depression symptoms (daily, not daily or never), and other tobacco (i.e., cigars, pipes, smokeless) use (never/former, current).
Statistical analysis
Main analysis. We computed weighted prevalence estimates for each variable of interest among the analytic sample and compared distributions across exclusive and dual cigarette and EVP use using Rao–Scott chi-square tests of independence. To estimate the relationship between daily anxiety symptoms and current cigarette and EVP use, we used unadjusted and adjusted multinomial logistic regression models. Odds ratios (ORs) and associated 95% confidence intervals (CIs) were reported.
To explore whether results varied by the interaction of sex, race, and ethnicity, we included the following statistical interactions in additional adjusted models: (a) a two-way interaction between daily anxiety symptoms and race and ethnicity, (b) a two-way interaction between daily anxiety symptoms and sex, and (c) a three-way interaction between daily anxiety symptoms, sex, and race and ethnicity. We examined whether interactions were statistically significant using Wald tests. To explore effect modification of daily anxiety and tobacco use (i.e., exclusive cigarette, exclusive EVP, and dual use) by sex, race, and ethnicity, we ran additional stratified-specific adjusted multinomial logistic regression models. For all analyses, we accounted for the complex sampling methodology by using survey weights. All statistical analyses were performed using STATA/SE 18.0 statistical package (StataCorp LP, College Station, TX).
Sensitivity analysis. To enhance the robustness of our findings, we conducted sensitivity analyses using the Generalized Anxiety Disorder–7 (GAD-7) scale (Spitzer et al., 2006) to estimate the associations of clinically significant anxiety symptoms with cigarette and EVP use. This scale was available only in the 2022 NHIS data set. We compared associations using this scale to (a) main associations using the daily anxiety symptom measure in 2020–2022 and (b) associations using the daily anxiety symptom measure in only 2022. Given temporal variation in COVID-19 pandemic experiences across the study period (2020–2022), we hypothesized that daily anxiety and its association with tobacco use may vary by time. Therefore, we also stratified the main associations between daily anxiety symptoms and tobacco use by year to investigate the relationship between anxiety and tobacco use outcomes by year.
Results
Participant characteristics
Participation was balanced across survey years, with 33.4% in 2020, 33.4% in 2021, and 33.2% in 2022 (Table 1). The age distribution was proportional, with 20.0% in the 18–29 age group, 25.4% in the 30–44 age group, 32.4% in the 45–64 age group, and 22.0% age 65 and above. The sex distribution was roughly evenly split between females (51.5%) and males (48.5%). Non-Hispanic White adults constituted the majority at 63.3%, with adults who were Hispanic at 16.7%, non-Hispanic Black at 11.4%, non-Hispanic Asian at 5.9%, and all other races and ethnicities at 2.7%. Most adults identified as heterosexual (95.2%), and educational backgrounds varied, with 38.1% having a high school diploma or less and 12.4% completing graduate school. Income levels were spread between the three categories, with 27.1% low income, 29.7% middle income, and 43.2% high income. Geographic distribution revealed that 30.9% live in a large central metro, 24.7% in a large fringe metro, 30.5% in a medium and small metro, and 13.9% in a nonmetro area. Among the sample, 84.7% had never or formerly used tobacco. Exclusive cigarette use was reported by 10.5%, exclusive EVP use by 3.5%, and dual cigarette and EVP use by 1.3%. In addition, 11.2% accessed mental health therapy services, and 13.0% used anxiety medication in the past year. Finally, daily depression symptoms and daily anxiety symptoms were reported by 3.9% and 13.0% of the sample, respectively.
Table 1.
Weighted prevalence of characteristics for U.S. National Health Interview Survey respondents, 2020–2022 (n = 83,544)
| Variable | n (%) |
|---|---|
| Survey year | |
| 2020 | 29,970 (33.4) |
| 2021 | 27,777 (33.4) |
| 2022 | 25,797 (33.2) |
| Age, in years | |
| 18–29 | 10,379 (20.0) |
| 30–44 | 19,578 (25.4) |
| 45–64 | 27,364 (32.4) |
| ≥65 | 26,223 (22.0) |
| Sex | |
| Female | 45,375 (51.5) |
| Male | 38,169 (48.5) |
| Race and ethnicity | |
| Hispanic | 10,990 (16.7) |
| Non-Hispanic White | 57,022 (63.3) |
| Non-Hispanic Black | 8,657 (11.4) |
| Non-Hispanic Asian | 4,793 (5.9) |
| Another race or ethnicitya | 2,082 (2.7) |
| Sexual orientation | |
| Heterosexual | 79,788 (95.2) |
| LGB+ | 37,556 (4.8) |
| Highest educational attainment | |
| High school graduate or less | 27,169 (38.1) |
| Some college | 23,743 (29.0) |
| College graduate | 19,729 (20.5) |
| Graduate school | 12,903 (12.4) |
| Income levelb | |
| Low | 21,916 (27.1) |
| Middle | 24,269 (29.7) |
| High | 37,359 (43.2) |
| Geographic locationc | |
| LC metro | 24,742 (30.9) |
| LF metro | 19,612 (24.7) |
| M&S metro | 26,483 (30.5) |
| Nonmetro | 12,707 (13.9) |
| Current cigarette and/or EVP used | |
| Never/former | 71,554 (84.7) |
| Exclusive cigarette | 8,838 (10.5) |
| Exclusive EVP | 2,206 (3.5) |
| Dual cigarette and EVP | 946 (1.3) |
| Current other tobacco usee | |
| Never/former | 78,922 (93.9) |
| Current user | 4,622 (6.1) |
| Past-year mental health therapy | |
| Yes | 9,490 (11.2) |
| No | 74,054 (88.8) |
| Depression symptoms | |
| Daily | 3,410 (3.9) |
| Not daily or neverf | 80,134 (96.1) |
| Anxiety symptoms | |
| Daily | 10,410 (13.0) |
| Not daily or neverf | 73,134 (87.0) |
| Anxiety medication | |
| Yes | 11,474 (13.0) |
| No | 72,070 (87.0) |
Notes: LGB+ = respondents who chose gay, lesbian, bisexual, or something else; EVP = electronic vaping product.
Another race or ethnicity includes American Indian/Alaska Native, Asian/Pacific Islander and other group, other single and multiple races;
income level is based on a ratio of income to poverty threshold calculate by the U.S. Census Bureau;
locations are determined by the 2013 National Center for Health Statistics Urban–Rural classification scheme for counties or Metropolitan Statistical Areas (MSA; see www.cdc.gov.nchs/data_access/urban_rural.htm). LC metro = large central metro (population ≥1 million residents, entire population of largest principal city, completely contained in the largest principal city, or contains at least 250,000 residents of any principal city); LF metro = large fringe metro (population ≥1 million residents and does not qualify as an LC metro); M&S metro = medium and small metro (250,000–999,999 residents or in MSAs of <250,000); nonmetro = nonmetropolitan (micropolitan or noncore counties);
current cigarette and EVP use variables consist of respondents who chose “every day” and “some days”;
other tobacco includes cigars/cigarillos, tobacco pipes, and smokeless tobacco products;
the “not daily or never” variable includes “weekly,” “monthly,” “a few times a year,” and “never” responses.
Exclusive and dual cigarette and EVP use
Proportions of tobacco use patterns reported were similar across survey years (Table 2). Significant differences in proportions of cigarette and EVP use were found by age, sex, race and ethnicity, sexual orientation, educational attainment, income, and geographic location (p < .001 for all). Adults ages 18–29 years had higher rates of exclusive EVP use (1.8%) compared with other age groups, and females had lower cigarette and EVP use (4.8% using cigarettes and 1.5% using EVPs exclusively; 0.5% engaging in dual use) than males. In addition, college graduates (vs. high school or less), those with higher income levels (vs. low-income levels), and those living in nonmetro areas (compared with metro areas) had lower rates of cigarette and EVP use.
Table 2.
Proportions of cigarette and electronic vaping product (EVP) use among adults who are current and never/former users overall and by sociodemographic characteristics (n = 83,544)
| Proportions of never/former, cigarette, EVP, and dual use | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Never/former | Exclusive cigarette | Exclusive EVP | Dual cigarette and EVP | ||||||
| Sociodemographic characteristics | n | % | n | % | n | % | n | % | pa |
| Overall | 71,554 | 84.7 | 8,838 | 10.5 | 2,206 | 3.5 | 946 | 1.3 | |
| Survey year | <.001 | ||||||||
| 2020 | 25,882 | 28.4 | 3,240 | 3.8 | 614 | 0.9 | 234 | 0.3 | |
| 2021 | 23,728 | 28.4 | 2,959 | 3.4 | 743 | 1.1 | 347 | 0.5 | |
| 2022 | 21,944 | 27.9 | 2,639 | 3.3 | 849 | 1.5 | 365 | 0.5 | |
| Age, in years | <.001 | ||||||||
| 18–29 | 8,679 | 16.8 | 608 | 1.1 | 873 | 1.8 | 219 | 0.4 | |
| 30–44 | 16,229 | 20.8 | 2,216 | 3.1 | 762 | 1.1 | 371 | 0.5 | |
| 45–64 | 22,715 | 27.1 | 3,926 | 4.5 | 444 | 0.5 | 282 | 0.3 | |
| ≥65 | 23,931 | 20.0 | 2,091 | 1.8 | 127 | 0.1 | 74 | 0.1 | |
| Sex | <.001 | ||||||||
| Female | 39,650 | 44.7 | 4,263 | 4.8 | 1,008 | 1.5 | 454 | 0.5 | |
| Male | 31,904 | 40.0 | 4,575 | 5.7 | 1,198 | 2.0 | 492 | 0.8 | |
| Race and ethnicity | <.001 | ||||||||
| Hispanic | 9,787 | 15.0 | 836 | 1.2 | 263 | 0.4 | 104 | 0.2 | |
| Non-Hispanic White | 48,437 | 52.6 | 6,301 | 7.2 | 1,587 | 2.5 | 697 | 1.0 | |
| Non-Hispanic Black | 7,289 | 9.6 | 1,159 | 1.4 | 150 | 0.2 | 59 | 0.9 | |
| Non-Hispanic Asian | 4,439 | 5.4 | 231 | 0.3 | 87 | 0.1 | 36 | 0.04 | |
| Another race or ethnicity | 1,602 | 2.1 | 311 | 0.4 | 119 | 0.2 | 50 | 0.1 | |
| Sexual orientation | <.001 | ||||||||
| Heterosexual | 68,613 | 81.0 | 8,411 | 10.0 | 1,926 | 3.0 | 838 | 1.2 | |
| LGB+ | 2,941 | 3.7 | 427 | 0.5 | 280 | 0.4 | 108 | 0.1 | |
| Highest educational attainment | <.001 | ||||||||
| High school graduate or less | 21,409 | 29.9 | 4,562 | 6.1 | 777 | 1.5 | 425 | 0.7 | |
| Some college | 19,689 | 24.1 | 2,847 | 3.1 | 847 | 1.3 | 360 | 0.5 | |
| College graduate | 18,158 | 18.9 | 1,034 | 0.9 | 420 | 0.5 | 117 | 0.1 | |
| Graduate school | 12,302 | 11.8 | 395 | 0.4 | 162 | 0.2 | 44 | 0.04 | |
| Income level | <.001 | ||||||||
| Low | 16,991 | 21.0 | 3,862 | 4.5 | 629 | 1.0 | 434 | 0.6 | |
| Middle | 20,521 | 24.8 | 2,759 | 3.3 | 725 | 1.1 | 264 | 0.4 | |
| High | 34,042 | 38.9 | 2,217 | 2.7 | 852 | 1.4 | 248 | 0.3 | |
| Geographic location | <.001 | ||||||||
| LC metro | 21,849 | 27.1 | 2,020 | 2.5 | 667 | 1.0 | 206 | 0.3 | |
| LF metro | 17,206 | 21.4 | 1,721 | 2.1 | 503 | 0.9 | 182 | 0.2 | |
| M&S metro | 22,320 | 25.3 | 3,082 | 3.6 | 739 | 1.1 | 342 | 0.5 | |
| Nonmetro | 10,179 | 10.9 | 2,015 | 2.3 | 297 | 0.5 | 216 | 0.3 | |
| Current other tobacco use | <.001 | ||||||||
| Never/former | 68,461 | 80.8 | 7,827 | 9.2 | 1,892 | 2.9 | 741 | 1.0 | |
| Current user | 3,092 | 3.9 | 1,011 | 1.3 | 314 | 0.5 | 205 | 0.3 | |
| Past-year mental health therapy | <.001 | ||||||||
| Yes | 7,575 | 8.8 | 1,191 | 1.4 | 511 | 0.8 | 213 | 0.3 | |
| No | 63,979 | 75.9 | 7,647 | 9.1 | 1,695 | 2.7 | 733 | 1.0 | |
| Depression symptoms | <.001 | ||||||||
| Daily | 2,339 | 2.59 | 782 | 0.91 | 170 | 0.25 | 119 | 0.16 | |
| Not daily or never | 69,215 | 82.14 | 8,056 | 9.59 | 2,036 | 3.22 | 827 | 1.15 | |
| Anxiety symptoms | <.001 | ||||||||
| Daily | 7,764 | 9.5 | 1,809 | 2.2 | 527 | 0.8 | 310 | 0.4 | |
| Not daily or never | 63,790 | 75.2 | 7,029 | 8.3 | 1,679 | 2.6 | 636 | 0.9 | |
| Anxiety medication | <.001 | ||||||||
| Yes | 8,995 | 10.1 | 1,721 | 1.9 | 513 | 0.7 | 245 | 0.3 | |
| No | 62,559 | 74.6 | 7,115 | 8.6 | 1,693 | 2.7 | 701 | 1.0 | |
Notes: LGB+ = respondents who chose gay, lesbian, bisexual, or something else; LC metro = large central metro (population ≥1 million residents, entire population of largest principal city, completely contained in the largest principal city, or contains at least 250,000 residents of any principal city); LF metro = large fringe metro (population ≥1 million residents and does not qualify as an LC metro); M&S metro = medium and small metro (250,000–999,999 residents or in Metropolitan Statistical Areas of <250,000).
Rao–Scott chi-square test of independence comparing proportions of each sociodemographic characteristic by never/former, cigarette only, EVP only, and dual use.
Adults with daily anxiety symptoms had lower exclusive cigarette use (2.2%), exclusive EVP use (0.8%), and dual cigarette and EVP use (0.4%) compared to those with non-daily or no anxiety symptoms. Moreover, adults currently using anxiety medication (vs. no anxiety medication) had lower proportions of exclusive cigarette use (1.9%) and dual cigarette and EVP use (0.3%). Likewise, adults who reported going to therapy for their mental health had lower proportions of exclusive cigarette use (1.4%) and dual cigarette and EVP use (0.3%) compared with those not attending therapy. Finally, adults experiencing daily depression symptoms had lower proportions for exclusive cigarette (0.91), exclusive EVP (0.25), and dual (0.16) use compared with those who did not have daily depression symptoms.
Associations between daily anxiety symptoms and exclusive and dual cigarette and EVP use
Results from the adjusted multinomial logistic regression model (Table 3) revealed that those reporting daily anxiety symptoms had increased odds of exclusive cigarette use (OR = 1.54, 95% CI [1.42, 1.68]), exclusive EVP use (OR = 1.44, 95% CI [1.23, 1.68]), and dual cigarette and EVP use (OR = 2.16, 95% CI [1.77, 2.63]).
Table 3.
Multivariate multinomial logistic regression models examining associations of anxiety with cigarette and electronic vaping product (EVP) use
| Variable | Current cigarette, EVP, and dual usea | ||
|---|---|---|---|
| Exclusive cigarette OR [95% CI]b | Exclusive EVP OR [95% CI]b | Dual cigarette and EVP OR [95% CI]b | |
| Anxiety symptoms (ref.: nondaily) | |||
| Daily | 1.54 [1.42, 1.68] | 1.44 [1.23, 1.68] | 2.16 [1.77, 2.63] |
| Survey year (ref.: 2020) | |||
| 2021 | 0.94 [0.88, 1.01] | 1.23 [1.07, 1.42] | 1.47 [1.19, 1.82] |
| 2022 | 0.91 [0.85, 0.98] | 1.69 [1.46, 1.95] | 1.69 [1.37, 2.07] |
| Age, in years (ref.: 18–29) | |||
| 30–44 | 2.94 [2.62, 3.30] | 0.59 [0.52, 0.67] | 1.26 [1.02, 1.55] |
| 45–64 | 3.05 [2.62, 3.40] | 0.21 [0.18, 0.24] | 0.63 [0.51, 0.78] |
| ≥65 | 1.44 [1.28, 1.61] | 0.06 [0.05, 0.08] | 0.15 [0.11, 0.20] |
| Sex (ref.: male) | |||
| Female | 0.73 [0.68, 0.77] | 0.74 [0.66, 0.82] | 0.72 [0.61, 0.86] |
| Race and ethnicity (ref.: non-Hispanic White) | |||
| Hispanic | 0.38 [0.34, 0.43] | 0.39 [0.34, 0.46] | 0.36 [0.27, 0.47] |
| Non-Hispanic Black | 0.80 [0.72, 0.88] | 0.38 [0.31, 0.47] | 0.35 [0.24, 0.49] |
| Non-Hispanic Asian | 0.53 [0.44, 0.64] | 0.59 [0.46, 0.76] | 0.58 [0.37, 0.91] |
| Another race or ethnicity | 0.99 [0.75, 1.30] | 1.11 [0.84, 1.45] | 1.07 [0.67, 1.71] |
| Sexual orientation (ref.: heterosexual) | |||
| LGB+ | 1.24 [1.08, 1.43] | 1.53 [1.27, 1.84] | 1.62 [1.23, 2.13] |
| Income level (ref.: low) | |||
| Middle | 0.67 [0.62, 0.72] | 0.98 [0.86, 1.13] | 0.62 [0.50, 0.77] |
| High | 0.41 [0.38, 0.44] | 0.88 [0.77, 1.02] | 0.41 [0.32, 0.52] |
| Education (ref.: high school or less) | |||
| Some college | 0.66 [0.62, 0.71] | 0.93 [0.82, 1.05] | 0.77 [0.64, 0.93] |
| College graduate | 0.29 [0.26, 0.32] | 0.46 [0.39, 0.53] | 0.28 [0.22, 0.36] |
| Graduate school | 0.18 [0.16, 0.21] | 0.32 [0.26, 0.39] | 0.19 [0.14, 0.28] |
| Geographic location (ref.: LC metro) | |||
| LF metro | 0.99 [0.90, 1.09] | 0.97 [0.84, 1.12] | 0.94 [0.74, 1.20] |
| M&S metro | 1.14 [1.05, 1.25] | 0.95 [0.83, 1.09] | 1.22 [0.98, 1.52] |
| Nonmetro | 1.27 [1.15, 1.40] | 0.82 [0.67, 1.00] | 1.29 [0.99, 1.68] |
| Depression (ref.: nondaily) | |||
| Yes | 1.42 [1.23, 1.63] | 1.26 [0.99, 1.60] | 1.56 [1.18, 2.06] |
| Past-year mental health therapy (ref.: no) | |||
| Yes | 1.08 [0.98, 1.20] | 1.35 [1.15, 1.57] | 1.32 [1.03, 1.68] |
| Anxiety medication (ref.: yes) | |||
| No | 0.83 [0.76, 0.91] | 0.71 [0.60, 0.84] | 0.85 [0.67, 1.09] |
| Other tobacco use (ref.: never/former) | |||
| Current | 2.32 [2.08, 2.59] | 2.82 [2.39, 3.34] | 5.17 [4.18, 6.40] |
Notes: Bolded text indicates statistical significance (p < .05). Ref. = reference; LC metro = large central metro (population ≥1 million residents, entire population of largest principal city, completely contained in the largest principal city, or contains at least 250,000 residents of any principal city); LF metro = large fringe metro (population ≥1 million residents and does not qualify as an LC metro); M&S metro = medium and small metro (250,000–999,999 residents or in Metropolitan Statistical Areas of <250,000).
Outcome referent group: never/former use of either cigarettes or EVPs;
odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for age, sex, race and ethnicity, sexual orientation, education, income, geographic location, other tobacco use, past-year mental health therapy services, and anxiety medication.
Effect modification by sex
In the model with the two-way interaction between daily anxiety symptoms and sex, the interaction was not statistically significant (p = .55). However, we stratified models by sex to examine stratified-specific estimates to explore the direction and magnitudes of associations. For females, experiencing daily anxiety symptoms was significantly associated with exclusive cigarette use (OR = 1.42, 95% CI [1.27, 1.58]), exclusive EVP use (OR = 1.48, 95% CI [1.21, 1.82]), and dual use (OR = 2.47, 95% CI [1.85, 3.28]). Males also showed increased odds for daily anxiety symptoms and exclusive cigarette (OR = 1.65, 95% CI [1.44, 1.89]), exclusive EVP (OR = 1.38, 95% CI [1.08, 1.76]), and dual use (OR = 1.93, 95% CI [1.45, 2.55]).
Effect modification by race and ethnicity
In the model with the two-way interaction between daily anxiety symptoms and race and ethnicity, the interaction was significant (p = .02). For exclusive cigarette use, Hispanic adults (OR = 1.55, 95% CI [1.07, 2.19]), non-Hispanic Black adults (OR = 2.01, 95% CI [1.54, 2.61]), non-Hispanic White adults (OR = 1.43, 95% CI [1.30, 1.57]), and adults of other races (OR = 1.67, 95% CI [1.05, 2.65]) who reported daily anxiety symptoms all showed increased odds of exclusive cigarette use. For exclusive EVP use, the pattern was less common but still present among Hispanic adults (OR = 1.63, 95% CI [1.02, 2.61]) and non-Hispanic White adults (OR = 1.40, 95% CI [1.17, 1.67]) who reported daily anxiety symptoms. Finally, significantly increased odds for dual use were observed in Hispanic adults (OR = 5.08, 95% CI [2.87, 8.99]), non-Hispanic Black adults (OR = 3.02, 95% CI [1.28, 7.15]), non-Hispanic White adults (OR = 1.75, 95% CI [1.41, 2.18]), and non-Hispanic Asian adults (OR = 4.29, 95% CI [1.28, 14.51]) who reported daily anxiety symptoms.
Effect modification by the interaction of sex and race and ethnicity
In the model with the three-way interaction between daily anxiety symptoms, sex, and race and ethnicity, the interaction was statistically significant (p < .001; Table 4). Hispanic females (OR = 1.79, 95% CI [1.13, 2.85]), non-Hispanic White males (OR = 1.39, 95% CI [1.25, 1.71]) and females (OR = 1.39, 95% CI [1.23, 1.57]), non-Hispanic Black males (OR = 2.95, 95% CI [2.04, 4.26]), and males identifying as another race and ethnicity (OR = 2.38, 95% CI [1.16, 4.86]) who reported daily anxiety symptoms showed significantly increased odds of exclusive cigarette use. Exclusive EVP use and daily anxiety were most prominent among Hispanic females (OR = 1.92, 95% CI [1.06, 3.48]), non-Hispanic White females (OR = 1.49, 95% CI [1.19, 1.88]), and males identifying as another race and ethnicity (OR = 2.42, 95% CI [1.05, 5.57]) compared with other racial groups and genders. Dual-use patterns and daily anxiety symptoms were highest among Hispanic females (OR = 9.99, 95% CI [4.13, 24.18]), non-Hispanic Black females (OR = 6.16, 95% CI [1.70, 22.31]), and non-Hispanic Asian males (OR = 7.06, 95% CI [1.75, 28.39]). In addition, Hispanic males (OR = 2.81, 95% CI [1.27, 6.18]), non-Hispanic White males (OR = 1.75, 95% CI [1.28, 2.39]) and females (OR = 1.82, 95% CI [1.36, 2.46]), as well as females from another race and ethnicity (OR = 3.97, 95% CI [1.19, 13.26]) who reported daily anxiety were more likely to report dual use. Of note, Asian females who reported daily anxiety had lower odds of dual use (OR = 0.25, 95% CI [0.08, 0.82]).
Table 4.
Adjusted multinomial two- and three-way logistic regression models examining associations of anxiety with cigarette and electronic vaping product (EVP) use stratified by sex, race and ethnicity, and combined
| Anxiety symptoms (daily) | Current cigarette, EVP, and dual usea | ||
|---|---|---|---|
| Dual cigarette and EVP OR [95% CI] | Exclusive cigarette OR [95% CI] | Exclusive EVP OR [95% CI] | |
| Sexb | |||
| Female | 1.42 [1.27, 1.58] | 1.48 [1.21, 1.82] | 2.47 [1.85, 3.28] |
| Male | 1.65 [1.44, 1.89] | 1.38 [1.08, 1.76] | 1.93 [1.45, 2.55] |
| Race/ethnicityc | |||
| Hispanic | 1.55 [1.07, 2.19] | 1.63 [1.02, 2.61] | 5.08 [2.87, 8.99] |
| Non-Hispanic White | 1.43 [1.30, 1.57] | 1.40 [1.17, 1.67] | 1.75 [1.41, 2.18] |
| Non-Hispanic Black | 2.01 [1.54, 2.61] | 1.37 [0.67, 2.79] | 3.02 [1.28, 7.15] |
| Non-Hispanic Asian | 0.87 [0.44, 1.75] | 1.21 [0.37, 3.92] | 4.29 [1.28, 14.51] |
| Another race or ethnicity | 1.67 [1.05, 2.65] | 1.62 [0.84, 3.13] | 1.78 [0.69, 4.67] |
| Sex and race/ethnicityd | |||
| Male Hispanic | 1.35 [0.83, 2.20] | 1.41 [0.67, 2.83] | 2.81 [1.27, 6.18] |
| Female Hispanic | 1.79 [1.13, 2.85] | 1.92 [1.06, 3.48] | 9.99 [4.13, 24.18] |
| Male non-Hispanic White | 1.46 [1.25, 1.71] | 1.28 [0.97, 1.68] | 1.75 [1.28, 2.39] |
| Female non-Hispanic White | 1.39 [1.23, 1.57] | 1.49 [1.19, 1.88] | 1.82 [1.36, 2.46] |
| Male non-Hispanic Black | 2.95 [2.04, 4.26] | 1.58 [0.50, 5.01] | 1.78 [0.63, 4.99] |
| Female non-Hispanic Black | 1.37 [0.96, 1.94] | 1.08 [0.50, 2.36] | 6.16 [1.70, 22.31] |
| Male non-Hispanic Asian | 1.10 [0.51, 2.37] | 1.57 [0.36, 6.75] | 7.06 [1.75, 28.39] |
| Female non-Hispanic Asian | 0.43 [0.08, 2.25] | 0.80 [0.21, 3.06] | 0.25 [0.08, 0.82] |
| Male another race or ethnicity | 2.38 [1.16, 4.86] | 2.42 [1.05, 5.57] | 0.75 [0.19, 2.93] |
| Female another race or ethnicity | 1.08 [0.63, 1.85] | 1.00 [0.38, 2.59] | 3.97 [1.19, 13.26] |
Notes: Bolded text indicates statistical significance (p < .05).
Outcome referent group: never/former use of either cigarettes or EVPs;
odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for age, race and ethnicity, sexual orientation, education, income, geographic location, other tobacco use, past-year mental health therapy services, and anxiety medication;
ORs and 95% CIs adjusted for age, sex, sexual orientation, education, income, geographic location, other tobacco use, past-year mental health therapy services, and anxiety medication;
ORs and 95% CIs adjusted for age, sexual orientation, education, income, geographic location, other tobacco use, past-year mental health therapy services, and anxiety medication.
Sensitivity analyses
Sensitivity analyses were conducted to assess the robustness of our findings by comparing the one-item daily anxiety measure with the GAD-7 measure, and the results are summarized in Supplemental Table 1. (Supplemental material appears as an online-only addendum to this article on the journal's website.) Using the daily anxiety measure used in the primary analysis, the OR for exclusive cigarette use from 2020 to 2022 was 1.67 (95% CI [1.54, 1.81]), and for 2022 alone, the OR was 1.64 (95% CI [1.43, 1.87]). When using the GAD-7 scale for 2022, the OR for exclusive cigarette use was slightly lower at 1.48 (95% CI [1.22, 1.78]). For exclusive EVP use, the OR from 2020 to 2022 was 1.51 (95% CI [1.30, 1.75]) using daily anxiety symptoms, with a similar OR of 1.44 (95% CI [1.14, 1.83]) in 2022. The GAD-7 scale in 2022 produced an OR of 1.50 (95% CI [1.14, 1.98]) for exclusive EVP use. For dual use of cigarettes and EVPs, the OR from 2020 to 2022 was 2.38 (95% CI [1.95, 2.89]), with the daily anxiety measure rising to 2.56 (95% CI [1.89, 3.48]) in 2022 and further to 2.78 (95% CI [1.89, 4.09]) with the GAD-7 scale in 2022.
To explore trends further, we conducted sensitivity analyses stratified by survey year (Supplemental Table 2). For exclusive cigarette use, ORs were 1.63 (95% CI [1.41, 1.88]) in 2020, 1.75 (95% CI [1.54, 2.00]) in 2021, and 1.64 (95% CI [1.43, 1.87]) in 2022. For exclusive EVP use, ORs were 1.42 (95% CI [1.04, 1.92]) in 2020, 1.62 (95% CI [1.27, 2.07]) in 2021, and 1.44 (95% CI [1.14, 1.83]) in 2022. For dual use of cigarettes and EVPs, ORs increased over time, with 2.00 (95% CI [1.29, 3.11]) in 2020, 2.48 (95% CI [1.79, 3.43]) in 2021, and 2.56 (95% CI [1.89, 3.48]) in 2022. These analyses demonstrate the consistency of the observed associations across different measures and periods, reinforcing the robustness of our findings.
Discussion
Our study explored the association between daily anxiety symptoms and current exclusive and dual cigarette and EVP use in a nationally representative sample of U.S. adults while also investigating potential disparities by the intersection of sex, race, and ethnicity. Our results showed that those who experienced daily anxiety symptoms had significantly greater odds of exclusive cigarette use, exclusive EVP use, and dual cigarette and EVP use. Results from stratified analyses by race and ethnicity were nuanced. Specifically, daily anxiety symptoms were associated with increased odds of exclusive cigarette use and dual cigarette and EVP use for adults who identified as Hispanic and non-Hispanic Black. For non-Hispanic Asian adults, daily anxiety symptoms were associated with increased odds of dual cigarette and EVP use but not exclusive use. Adults identifying as another race and ethnicity with daily anxiety symptoms showed increased odds of dual use. Non-Hispanic White individuals had the highest prevalence of use across all three tobacco categories, exclusive cigarette use, exclusive EVP use, and dual use, with statistically higher odds of use. However, these odds were even greater for other racial groups.
The two-way stratified interaction between sex and daily anxiety symptoms was not statistically significant. However, results of the three-way interaction between daily anxiety symptoms, sex, and race and ethnicity suggest heterogeneity in effects. Of note, non-Hispanic White males and females reporting anxiety symptoms had increased odds for all forms of tobacco use, whereas non-Hispanic Asian females reporting anxiety symptoms did not have higher odds for any form of tobacco use and, notably, significantly lower odds for dual use. The results highlight the complexity of these interactions and suggest that certain sociodemographic groups are more susceptible to the combined effects of anxiety and tobacco use. In addition, our sensitivity analyses indicated that irrespective of the specific measure of anxiety or the timeframe considered, consistent associations were observed between experiencing daily symptoms of anxiety and increased use of cigarettes and EVPs, both individually and in combination.
Our findings align with existing literature that highlights the intricate relationship between mental health and tobacco use, consistently demonstrating the co-occurrence of mental health conditions, such as anxiety, as they relate to dual tobacco product use (Chen et al., 2021; Masaki et al., 2022; Okunna, 2021; Weinberger et al., 2020). One potential explanation for this association is that dual use may offer greater and more immediate anxiety relief than exclusive use of either product alone as a result of the combined and varied effects of nicotine delivery from both cigarettes and EVPs, which could reinforce dependence as a coping mechanism in individuals with higher anxiety symptoms. Therefore, additional research is needed to examine the severity of mental health symptoms and use patterns, including frequency of use and dual or polytobacco use, to add to the existing literature on the comorbidity of mental health and tobacco use.
Our study adds to the current literature by examining the intersectionality of sex, race, and ethnicity in the context of the relationship between daily anxiety symptoms and dual cigarette and EVP use. Disparities by racial and ethnic group indicate the importance of tailoring interventions to address specific racially or ethnically salient contexts (Drope & Schluger, 2018; Nguyen-Grozavu et al., 2020), as certain groups demonstrate higher levels of tobacco use compared with others. Our findings, however, indicate that daily anxiety symptoms may play a significant role in Hispanic adults choosing to use tobacco in multiple ways. Hispanic female adults, specifically, had the strongest magnitude of association between daily anxiety symptoms and dual cigarette and EVP use, calling for a better understanding of these relationships among this population. On the other hand, Asian female adults had lower odds of dual use when reporting daily anxiety, whereas their male counterparts had the second highest odds of reporting dual use. A similar discrepancy was found among Black adults, with Black females reporting significantly higher odds of dual use when reporting daily anxiety; however, their male counterparts did not show a significant association with dual use even when experiencing daily anxiety.
Our three-way interaction findings suggest that complex, intersecting factors contribute to the likelihood of dual tobacco use among different sex, race, and ethnicity groups experiencing daily anxiety. One possible explanation is that cultural norms and sex-specific expectations surrounding each racial and ethnic group shape attitudes toward tobacco use and coping mechanisms. For example, Hispanic and Black females might experience unique sociocultural pressures or barriers to accessing mental health resources, leading them to adopt dual tobacco use as a more accessible or socially normative coping strategy for managing anxiety. Conversely, lower odds of dual use among Asian females could reflect cultural stigmas associated with female tobacco use within Asian communities, potentially deterring them from using tobacco products even when they experience daily anxiety (Ra et al., 2022). These variations highlight the importance of considering intersectional identities in understanding how social, cultural, and structural influences shape substance use behaviors in the context of mental health. Further research is essential to untangle these complex interactions and develop culturally tailored interventions that address the distinct needs of each subgroup.
Our study has important implications for public health efforts aiming to address the complexities of adult tobacco use patterns. Tailored interventions that consider both mental health and disparities driven by social identities are crucial to effectively reach specific populations such as those from marginalized identity groups. The elevated odds of dual use among individuals with daily anxiety symptoms, especially among Hispanic and non-Hispanic Black individuals, highlight the need for culturally informed outreach and cessation treatment for these groups. Screening individuals who use tobacco products for daily anxiety symptoms may be beneficial for intervention purposes. Undoubtedly, evolving patterns of nicotine use emphasize the necessity of continuously adapting public health strategies to address emerging challenges.
Future research should continue to explore the relationship between anxiety symptoms and tobacco use, including in the context of symptom severity and the evolving tobacco product market and use pattern landscapes. This comprehensive approach is essential for developing effective interventions and achieving the goal of reducing adult tobacco use and associated disparities, as outlined in the 2030 Healthy People initiative (Healthy People 2030, n.d.). Evolving dual/polytobacco use patterns further emphasize the importance of consistent definitions and research practices for improved surveillance and for the understanding of factors associated with the use of multiple tobacco products (Chen et al., 2021). Furthermore, to promote health equity, efforts focused on describing whether these relationships vary using an intersectionality lens are needed to enhance the equity impact of current and future tobacco control policies.
Limitations
This study has several limitations that warrant consideration. First, its cross-sectional design limits our ability to infer causal relationships between daily anxiety symptoms and cigarette and EVP use. Longitudinal study designs are essential to better discern causal pathways. Second, the reliance on self-report data introduces the potential for biases, such as recall and social desirability, necessitating caution in the interpretation of results. Third, the assessment of daily anxiety symptoms relied on a single-item measure, potentially oversimplifying the complexity of experiencing frequent anxiety symptoms or having an anxiety disorder. Finally, some racial and ethnic groups had small sample sizes (e.g., Asian females) reporting dual use and daily anxiety symptoms, which could result in potential underrepresentation or misrepresentation of the experiences of individuals from these racial and ethnic backgrounds. Despite these limitations, our study provides valuable insights into the nuanced relationship between daily anxiety symptoms and dual cigarette and EVP use, emphasizing the need for future research to address these complexities and refine public health interventions.
Conclusions
Our study offers insights into the relationship between daily anxiety symptoms and current exclusive and dual cigarette and EVP use among U.S. adults, emphasizing the salience of examining these associations at the intersection of sex, race, and ethnicity. We found a consistent association between daily anxiety symptoms and increased odds of exclusive cigarette use, exclusive EVP use, and dual cigarette and EVP use, aligning with existing literature on the co-occurrence of mental health issues and tobacco product use. Our stratified analysis by sex, race, and ethnicity revealed distinct patterns and heterogeneity. These findings have important implications for public health efforts, emphasizing continuous monitoring of tobacco use trends, adaptive strategies, and the development of tailored interventions that address the complex interplay between mental health and sociodemographic factors.
Footnotes
This research was supported, in part, by funding from the National Heart, Lung, and Blood Institute and the Center for Tobacco Products (U54HL120163), the National Institute on Drug Abuse (R25DA054015), and the National Cancer Institute (R01CA251478-04S1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the U.S. Food and Drug Administration, or the American Heart Association. The funding sponsors had no role in study design; data collection, analyses, or interpretation; manuscript preparation; or the decision to publish the results.
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