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. Author manuscript; available in PMC: 2022 May 31.
Published in final edited form as: Subst Use Misuse. 2021 Jul 29;56(12):1807–1814. doi: 10.1080/10826084.2021.1954026

Cross-Sectional Associations of Multiple Tobacco Product Use with Depressive and Anxiety Symptoms among Young Adult E-Cigarette Users

Sam N Cwalina a, Lauren R Pacek b, Jessica L Barrington-Trimis a, Alayna P Tackett a, Mary Ann Pentz a
PMCID: PMC9153521  NIHMSID: NIHMS1810947  PMID: 34320919

Abstract

Background:

Tobacco users with mental health conditions are a vulnerable population in tobacco research, yet few studies have evaluated the association of depressive and anxiety symptoms with multiple tobacco product (MTP) use among young adult electronic cigarette (ENDS) users.

Methods:

Cross-sectional survey data on U.S. young adult past 30-day ENDS users (N = 2348) were collected via Amazon MTurk from May-July 2019. Binary logistic regressions evaluated the association of tobacco use pattern (exclusive ENDS use, ENDS + one other tobacco product [OTP; dual use], ENDS + two or more OTPs [poly-use]) with depressive (PHQ-9) and anxiety (GAD-7) symptoms. Among MTP users (n = 1736), we evaluated the association of ENDS use relative to OTP use and same-day MTP use with depressive and anxiety symptoms.

Results:

The sample included 26% exclusive ENDS, 27% dual, and 47% poly-users. We observed a gradient-relationship for depressive and anxiety symptoms: poly-users had greater odds of depressive and anxiety symptoms compared to dual users (aOR = 1.86 [95%CI:1.50–2.30] and aOR = 1.61 [95%CI:1.30–2.01], respectively), and dual users had greater odds of depressive and anxiety symptoms compared to exclusive ENDS users (aOR = 1.42 [95%CI:1.11–1.81] and aOR = 1.56 [95%CI:1.20–2.02], respectively). MTP users who used ENDS more often than OTPs (vs. less often than OTPs) had greater odds of depressive (aOR = 1.38 [95%CI:1.06–1.80]) and anxiety (aOR = 1.37 [95%CI:1.04–1.79]) symptoms.

Conclusions:

The majority of young adult past 30-day ENDS users in this sample reported OTP use. Future research on MTP use should distinguish between dual and poly-use. Tobacco prevention efforts for young adults with mental health symptoms are needed.

Keywords: Multiple tobacco product use, e-cigarettes, depressive symptoms, anxiety symptoms, young adults

Introduction

Tobacco users with mental health conditions (such as depression and anxiety) are considered a priority population for tobacco control (King et al., 2018), which additionally includes individuals who use two or more tobacco products concurrently (i.e. multiple tobacco product [MTP] use). Individuals with mental health conditions are more likely to use tobacco products compared to those without mental health conditions (King et al., 2018; Williams et al., 2013), and this may be driven by a desire for individuals with mental health conditions to use nicotine as a means to self-medicate symptoms of depression or anxiety (Gehricke et al., 2007; Khantzian, 1997), such as difficulty concentrating or irritability. Previous research has established strong bidirectional associations between mental health conditions and cigarette smoking (Boden et al., 2010; Fluharty et al., 2017; Prochaska et al., 2017) and electronic nicotine delivery system (ENDS) use (Bandiera et al., 2016, 2017; Cummins et al., 2014), but few studies have investigated associations between depressive and anxiety symptomology and MTP use among young adults. Nationally-representative data show that 20% of young adults have at least one mental health condition (Cummins et al., 2014), and approximately 28% of United States (U.S.) young adult tobacco users report MTP use – the greatest of any other adult age group (Cornelius, 2020).

The high prevalence of MTP use among young adults is concerning because MTP use is associated with greater risk of nicotine dependence relative to single product use (Ali et al., 2016; Gomez et al., 2020; Soule et al., 2015), and young adults are already more vulnerable to developing nicotine dependence compared to older adults (National Center for Chronic Disease Prevention and Health Promotion, 2012). The increasingly diverse tobacco product landscape may contribute to the high prevalence of MTP use among young adults (Rath et al., 2012), as well as potential associations between MTP use and mental health symptoms among this population. Compared to single product users, MTP users are more likely to be motivated by price (Le et al., 2019), thus, variation in prices across different products may contribute to MTP use. For example, little cigars and cigarillos can be sold inexpensively as small packs (e.g. two cigarillos in a pack for $1) whereas cigarettes can only be sold in packs of 20 (Smiley et al., 2018). Further, tobacco industry marketing tactics that reduce price points (such as coupons and other promotional discounts) may encourage product switching and appeal to young people (Brock et al., 2015; Moran et al., 2019). Exposure to tobacco advertisements is a key driver of tobacco use among young adults (National Center for Chronic Disease Prevention and Health Promotion, 2012), and tobacco advertisements intentionally target individuals with mental health symptoms by implying that their products promote relaxation and improve mood (Prochaska et al., 2017; National Cancer Institute, 2008). Moreover, there are a wide variety of available flavors offered across different tobacco products, and flavored tobacco products appeal to young adults (Delnevo et al., 2015; Villanti et al., 2013). Notably, young adults with mental health symptoms are more likely to use flavored tobacco products than those without mental health symptoms (Chen et al., 2018), and flavored tobacco use is associated with both depressive and anxiety symptoms (Cohn et al., 2016; Rath et al., 2016), as well as MTP use (Mantey et al., 2019).

Given the high prevalence of ENDS use, MTP use, and mental health conditions among young adults (Cornelius, 2020; Cummins et al., 2014), understanding how different MTP use patterns relate to mental health outcomes among young adult ENDS users is critical for developing prevention programs and tobacco control policies (Ali et al., 2016; Richter et al., 2017). MTP use can generally refer to both dual use (concurrent use of two products) and poly-use (concurrent use of more than two products), but few studies have explored associations between mental health symptoms and these distinct MTP use patterns. For example, MTP use is associated with depressive symptoms among adolescents and adults (Chido-Amajuoyi et al., 2021; Cho et al., 2018), and anxiety symptoms among adolescents (Cho et al., 2018), but it is unclear whether poly-users have greater odds of depressive or anxiety symptoms compared to dual users. One study found that adolescent dual users of ENDS and cigarettes had greater odds of mental health symptoms compared to exclusive ENDS users (Leventhal et al., 2016), but this finding has not been extended to young adults or ENDS users who use more than one additional product. Another study among adolescents found that poly-users reported greater nicotine dependence, were less likely to report quit intentions, and had decreased harm perceptions compared to dual users (Ali et al., 2016), thus, it is reasonable to suspect that there may be differences in mental health symptoms between young adult dual and poly-users. Additionally, few measures exist that seek to further characterize MTP use among young adults despite substantial variability in product combinations among MTP users.

To address these gaps in the literature, we recruited a sample of U.S. young adult ENDS users (18–25 years; N = 2348) from Amazon Mechanical Turk (MTurk) and investigated the associations of depressive and anxiety symptoms with three different MTP use measures: 1) tobacco product use pattern [exclusive ENDS use vs. ENDS + one additional product vs. ENDS + two or more additional products], 2) relative ENDS vs. other tobacco product (OTP) use [ENDS less often than OTP vs. ENDS more often than OTP vs. about the same amount], and 3) how often they use MTP in the same day [never/rarely vs. some days vs. most or every day]. We recruited young adult ENDS users specifically given that ENDS are the most commonly used tobacco product among this population (Cornelius, 2020).

Methods

Participants

Participants were recruited via Amazon Mechanical Turk (MTurk), an online platform that has gained popularity among researchers because it allows for cost-effective, rapid survey data collection (Pacek et al., 2019; Strickland & Stoops, 2019). Previous studies using samples recruited from MTurk have concluded that the platform is suitable for measuring substance use, such as alcohol (Boynton & Richman, 2014), and that assessments of substance use remain stable with high internal consistency in the same individuals over time (Kim & Hodgins, 2017). Cross-sectional self-report data were collected anonymously from May-July 2019 (N = 2348). To qualify for the survey, participants had to be 18–25 years old, past 30-day ENDS users, and live in the United States.

Procedures

To determine eligibility, potential participants completed a three-question screener survey administered via MTurk which took, on average, less than one minute to complete. The screener survey included an unrelated question in order to help mask the true purpose of the study; this question asked how many days in the past week that they engaged in physical activity and was not used to determine eligibility. Two questions were used to determine eligibility: 1) “Please select your age range”, with response options including < 18 years, 18–25 years, 26–35 years, 36–50 years, and 51 > years, and 2) “In the past 30 days, which of the following tobacco products have you used? (select all that apply)”, with response options including Cigarettes; ENDS (including vape pens, cigalikes, JUUL, etc.), Hookah or water pipe tobacco, Cigars, Little cigars or cigarillos, Smokeless tobacco (dip, chew, snuff, etc.), Dissolvable, Pipe tobacco, and None of the above. In order to be eligible for the full survey, respondents must have indicated “18–25 years” for the first question and selected “ENDS” for the second question. For the second question, selection of other tobacco products in addition to e-cigarettes did not preclude participation, but use of ENDS was the determining factor for eligibility. If respondents were eligible, they received a passcode to unlock the full survey. On average, the full survey took participants approximately 20 min to complete. Respondents who completed the survey received $3.00 for participation. All data were collected anonymously. Three attention check questions (i.e. “If you are paying attention to this survey, please select option C from the list below,” “If you are paying attention, please select ‘Apple’ in the response options below,” “Which of the following objects have wheels?”) were included in the survey, and participants who failed one or more of the three were excluded from present analyses (n = 9).

Ethics statement

Participants provided passive informed consent prior to completing the survey. The study was considered exempt and approved by the University of Southern California Institutional Review Board.

Measures

Depressive symptoms

Depressive symptoms were measured with the Patient Health Questionnaire (PHQ-9). The PHQ-9 is comprised of nine questions that assess severity of depressive symptoms in the past two weeks based on DSM-IV criteria (Kroenke et al., 2001). On a four-point scale ranging from 0–3, with 0 indicating “not at all” and 3 indicating “nearly every day”, respondents indicated how often they have been bothered by specific depressive symptoms in the past two weeks. Numeric responses to these questions were summed (range = 0–27) then categorized as “depressive symptoms” (PHQ-9 score ≥ 10; n = 1020) or “no depressive symptoms” (PHQ-9 score < 10; n = 1319) per recommended scoring guidelines (Kroenke et al., 2001).

Anxiety symptoms

Anxiety symptoms were measured with the Generalized Anxiety Disorder-7 (GAD-7), a seven-question scale that assesses severity of symptoms related to Generalized Anxiety Disorder over the past two weeks (Spitzer et al., 2006). On a four-point scale that ranged from “not at all” to “nearly every day” (and numerically from 0–3, respectively), respondents indicated how often they have been bothered by specific symptoms in the past two weeks. Numeric responses to these seven questions were summed (range = 0–21) then categorized as “anxiety symptoms” (GAD-7 score ≥ 10; n = 813) or “no anxiety symptoms” (GAD-7 score < 10; n = 1526) per recommended scoring guidelines (Spitzer et al., 2006).

Tobacco product use patterns

Respondents were asked how often they used each of the following products in the past 30 days: cigarettes, ENDS, little cigars or cigarillos, hookah or water pipe, big cigars, smokeless tobacco, and dissolvable tobacco. Response options included: 0 days, 1–2 days, 3–5 days, 6–9 days, 10–19 days, 20–29 days, and all 30 days. Participants who only reported using ENDS in the past 30 days (i.e. more than zero days) were coded as “exclusive ENDS users”; participants who reported using ENDS and any one other tobacco product were coded as “dual users”, and those who reported using ENDS and any two or more tobacco products in the past 30 days were coded as “poly-users”.

Dual and poly-use patterns

Dual and poly-users were then asked two additional follow-up questions that further assessed MTP use patterns: 1) relative ENDS vs. OTP use and 2) same-day MTP use. To assess relative ENDS vs. OTP use, participants were asked, “How often did you use ENDS compared to [OTPs] in the past 30 days?” with the following response options: ENDS less often than OTPs, ENDS more often than OTPs, or about the same amount. To assess same-day MTP use, participants were asked, “How often did you use more than one tobacco product on the same day in the past 30 days?” Response options included: Never, only used one product per day, Rarely (1 day per week or less), Some days (2–3 days per week), Most days (4–5 days per week), and Every day or nearly every day (6–7 days per week). These five response categories were then collapsed into three levels for present analyses to facilitate interpretation of study results: Never/rarely (n = 713), Some days (n = 677), and Most or every day (n = 346).

Covariates

Logistic regression models adjusted for gender identity (female/feminine, male/masculine, other), sexual orientation (straight, bisexual, gay/lesbian, other), race/ethnicity (AAPI, Black/African American, Hispanic/Latinx [any race], White, Multiracial), subjective financial situation (low, moderate, high) (Williams et al., 2017), and frequency of past 30-day ENDS use (1–9 days, 10–19 days, 20–29 days, all 30 days). We additionally adjusted for frequency of past 30-day OTP use (1–9 days, 10–19 days, 20–29 days, all 30 days) in the dual and poly-use pattern models (relative ENDS vs. OTP and same-day MTP use).

Statistical analyses

Depressive symptoms (vs. none) and anxiety symptoms (vs. none) served as dichotomous outcome variables in six total binary logistic regression models as a function of each of the three tobacco use pattern measures: a) tobacco use pattern, b) relative ENDS vs. OTP use and c) same-day MTP use. Adjustment variables included gender identity, sexual orientation, race/ethnicity, and subjective financial situation. All survey questions were forced response so there are no concerns with missing data. All analyses were performed in SAS v 9.4 (SAS, 2014).

Results

Sample characteristics

Among the overall sample (n = 2339), 44% of the sample had depressive symptoms (i.e. PHQ-9 ≥ 10) and 35% had anxiety symptoms (i.e. GAD-7 ≥ 10; Table 1). The most common tobacco product use pattern was poly-use (47%), followed by dual use (27%), then exclusive ENDS use (26%). Among respondents who reported past 30-day use of any OTP in addition to ENDS (n = 1736), the most common OTP used was combustible cigarettes (61%), followed by hookah (40%), then little cigars or cigarillos (39%). Among the subsample of dual and poly-users (n = 1736), more than half (56%) of dual and poly-users in our sample reported using ENDS more often than OTPs, and 32% reported using ENDS less often than OTPs (11% used ENDS and OTPs about the same amount). Regarding same-day MTP use, only 20% reported using more than one tobacco product in a single day “most or every day”, whereas 39% and 41% reported same-day MTP on “some days” and “never/rarely”, respectively.

Table 1.

Sample characteristics.

Total (n = 2339) Depressive Symptoms a n = 1020 (44) Anxiety Symptoms b n = 813 (35)
N (col %) N (row %) N (row %)
Gender identity
 Female/feminine 1095 (47) 497 (45) 426 (39)
 Male/masculine 1198 (51) 495 (41) 364 (30)
 Other c 46 (2) 28 (61) 23 (50)
Sexual orientation
 Straight 1643 (70) 620 (38) 472 (29)
 Bisexual 437 (19) 276 (63) 237 (54)
 Gay/lesbian 123 (5) 61 (50) 58 (47)
 Other d 136 (6) 63 (46) 46 (34)
Race
 White 1448 (62) 591 (41) 490 (34)
 AAPI e 205 (9) 66 (32) 51 (25)
 Black or African American 227 (10) 106 (47) 74 (33)
 Hispanic/Latinx (any race) 402 (17) 233 (58) 176 (44)
 Multiracial 57 (2) 24 (42 22 (39)
Subjective financial situationf
 Low 863 (37) 456 (53) 357 (41)
 Moderate 998 (43) 398 (40) 319 (32)
 High 478 (20) 166 (35) 137 (29)
Frequency of past 30-day ENDS use
 1–9 days 1221 (52) 521 (43) 402 (33)
 10–19 days 419 (18) 172 (41) 147 (35)
 20–29 days 293 (13) 142 (48) 120 (41)
 All 30 days 406 (17) 185 (46) 144 (35)
Tobacco product use pattern g
 Exclusive ENDS 603 (26) 187 (31) 147 (24)
 Dual use 641 (27) 249 (39) 210 (33)
 Poly-use 1095 (47) 584 (53) 456 (42)
  Relative ENDS vs. OTP use h
   ENDS less often than OTP 562 (32) 272 (48) 217 (39)
   ENDS more often than OTP 980 (56) 478 (49) 373 (38)
   About the same amount 194 (11) 83 (43) 76 (39)
  Same-day MTP use h
   Never/rarely 713 (41) 327 (46) 262 (37)
   Some days 677 (39) 335 (49) 266 (39)
   Most or every day 346 (20) 171 (49) 138 (40)
  Frequency of past 30-day OTP use
   1–9 days 967 (56) 405 (42) 308 (32)
   10–19 days 274 (16) 147 (54) 111 (41)
   20–29 days 194 (11) 114 (59) 100 (52)
   All 30 days 301 (17) 167 (55) 147 (49)
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a

N(%) of individuals with PHQ-9 scores greater than or equal to 10.

b

N(%) of individuals with GAD-7 scores greater than or equal to 10.

c

Other includes: non-binary, transgender, and other.

d

Other includes: asexual, queer, questioning, pansexual, and other.

e

AAPI includes Asian, American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander.

f

“Low” represents “do not meet basic expenses” and “just meet basic expenses”; “Moderate” represents “meet needs with a little left”; “High” represents “live comfortably”.

g

Dual use defined as past 30-day ENDS and any one additional tobacco product; Poly-use defined as past 30-day ENDS use and any two or more additional tobacco products.

h

Only asked to dual and poly-users (combined n = 1736).

The overall sample was approximately equally balanced between self-identified females and males (47% and 51%, respectively), and the majority identified as heterosexual (70%; Table 1). The majority of respondents were Non-Hispanic White (62%), followed by Hispanic/Latinx (any race; 17%), then Non-Hispanic Black (10%). 37%, 43%, and 20% had low, moderate, and high subjective financial situations, respectively.

Tobacco product use patterns

We observed a similar ordered pattern for depressive and anxiety symptoms across the three tobacco product use patterns after adjusting for gender, sexual orientation, race/ethnicity, subjective financial situation, and frequency of past 30-day ENDS use (Figure 1). Compared to exclusive ENDS users, both dual users (aOR = 1.40 [1.10–1.80]; p < 0.01) and poly-users (aOR = 2.62 [2.09–3.29]; p < 0.01) had significantly greater odds of depressive symptoms; additionally, poly-users had significantly greater odds of depressive symptoms compared to dual users (aOR = 1.86 [1.51–2.31]; p < 0.01). Poly-users had significantly greater odds of anxiety symptoms compared to dual users (aOR = 1.60 [1.28–2.00]; p < 0.01) and exclusive ENDS users (aOR = 2.45 [1.93–3.11]; p < 0.01), and dual users had significantly greater odds of anxiety symptoms compared to exclusive ENDS users (aOR = 1.53 [1.18–1.98]; p < 0.01).

Figure 1.

Figure 1.

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Proportion of young adult enDS users with depressive and anxiety symptoms by tobacco use pattern.adjusted odds ratios and 95% confidence intervals displayed for each between-group comparison for both depressive symptoms (defined as PHQ-9 scores greater than or equal to 10) and anxiety symptoms (defined as GaD-7 scores greater than or equal to 10). “Dual use” was defined as past 30-day use of one additional tobacco product, and “poly-use” was defined as past 30-day use of two or more additional tobacco products.

Dual and poly-use patterns

Among past 30-day ENDS users who used at least one additional tobacco product, those who used ENDS more often than OTPs had significantly greater odds of depressive symptoms (aOR = 1.38 [1.06–1.80]; p = 0.02) and anxiety symptoms (aOR = 1.37 [1.04–1.79]; p = 0.02) compared to those who used ENDS less often than OTPs after adjusting for demographic variables, frequency of past 30-day ENDS use, and frequency of past 30-day OTP use (Table 2). We further tested for interactions by tobacco use pattern (i.e. dual vs. poly-use) and these interaction terms were not significant (p’s > 0.05), implying that relative ENDS vs. OTP use was associated with depressive and anxiety symptoms regardless of whether ENDS users only used one additional tobacco product (dual use) or more than one additional tobacco product (poly-use). Same-day MTP was not significantly associated with depressive or anxiety symptoms.

Table 2.

Unadjusted and adjusted odds ratios for depressive and anxiety symptoms among dual and poly-users (n = 1736).

Depressive symptoms Anxiety symptoms
uOR (95% CI) p-value aOR (95% CI) p-value uOR (95% CI) p-value aOR (95% CI) p-value
Relative ENDS vs. OTP use
 ENDS less often than OTP – – – – – – – –
 About the same amount 0.80 (0.57, 1.11) 0.18 0.97 (0.69, 1.38) 0.88 1.02 (0.73, 1.43) 0.89 1.34 (0.94, 1.92) 0.11
 ENDS more often than OTP 1.02 (0.82, 1.25) 0.89 1.38 (1.06, 1.80) 0.02 0.98 (0.79, 1.21) 0.83 1.37 (1.04, 1.79) 0.02
Same-day MTP use
 Never/rarely – – – – – – – –
 Some days 1.16 (0.94, 1.43) 0.18 1.01 (0.80, 1.28) 0.93 1.11 (0.90, 1.38) 0.33 0.97 (0.76, 1.23) 0.78
 Most or every day 1.15 (0.89, 1.49) 0.28 0.90 (0.67, 1.21) 0.50 1.14 (0.88, 1.49) 0.32 0.87 (0.65, 1.18) 0.39
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Relative ENDS vs. OTP use was assessed with the following, “How often did you use ENDS compared to other tobacco products in the past 30 days?” Same-day MTP use was assessed with the following, “How often did you use more than one tobacco product on the same day in the past 30 days?” Adjusted models controlled for gender identity, sexual orientation, race/ethnicity, subjective financial situation, frequency of ENDS use, and frequency of OTP use.

Discussion

Among young adult ENDS users in this sample, 74% reported MTP use (27% dual use and 47% poly-use). We found that participants’ tobacco use pattern was associated with increased odds of depressive and anxiety symptoms, such that dual users had greater odds compared to exclusive ENDS users, and poly-users had greater odds than dual users and exclusive ENDS users. We further evaluated the association of two novel measures related to MTP use patterns (relative ENDS vs. OTP use and same-day MTP use) with depressive and anxiety symptoms. In this study, MTP users who said they used ENDS more often than OTPs in the past 30 days had greater odds of depressive and anxiety symptoms compared to those who said they used ENDS less often than OTPs, but same-day MTP use was not significantly associated with depressive or anxiety symptoms. Prevention efforts that are tailored to young adult ENDS users are needed to deter concurrent use of OTPs among this population.

To our knowledge, this is the first study to evaluate the association of depressive and anxiety symptoms with three mutually exclusive tobacco use patterns among young adult ENDS users. Our finding that poly-users had greater odds of depressive and anxiety symptoms compared to dual users builds upon prior research among adolescents that found increased risk of mental health conditions among dual users of ENDS and cigarettes (versus exclusive ENDS use) (Leventhal et al., 2016), as well as differences in nicotine dependence, quit intentions, and harm perceptions between dual and poly-users (Ali et al., 2016). As such, future research on MTP use and mental health symptoms should distinguish dual use from poly-use to ensure accurate estimates.

Among young adult ENDS users who used at least one additional tobacco product, we found that relative ENDS vs. OTP use was associated with depressive and anxiety symptoms, such that individuals who said they used ENDS more often than OTPs had greater odds of depressive and anxiety symptoms compared to those who said they used ENDS less often than OTPs. ENDS are more socially acceptable and easier to conceal in public spaces compared to OTPs (Lee et al., 2017; Urman et al., 2019; Yingst et al., 2019), and it is possible that MTP users with depressive or anxiety symptoms are more sensitive to these social pressures compared to those without symptoms. Additionally, newer generations of ENDS devices have highly efficient nicotine delivery profiles (Lee et al., 2020), which may be particularly attractive to tobacco users who self-administer nicotine to mitigate depressive or anxiety symptoms (Gehricke et al., 2007; Khantzian, 1997). Although we did not find significant associations between same-day MTP use and depressive or anxiety symptoms, future studies might evaluate the association of this measure with other outcomes, such as nicotine dependence, quit intentions, harm perceptions, or other health outcomes such as respiratory symptoms.

Individuals with mental health conditions are considered a vulnerable population in tobacco research, highlighting the need for tailored prevention programs that resonate with this population of tobacco users. Tailored prevention messaging should consider the self-medication hypothesis (Gehricke et al., 2007; Khantzian, 1997), which posits that individuals with mental health conditions use tobacco products to alleviate unwanted symptoms, such as difficulty concentrating or irritability (Kroenke et al., 2001; Spitzer et al., 2006). Suggested alternative coping strategies for reducing depressive and anxiety symptoms should be incorporated into tobacco prevention messaging, particularly for young adult MTP users. Additionally, given that 86% of direct email promotional marketing by tobacco companies include coupons or promotional discounts (Brock et al., 2015), which encourage product switching and MTP use (Moran et al., 2019), tobacco marketing regulations that restrict use of such coupons and promotional discounts may deter experimentation with other tobacco products among young adult tobacco users (Brock et al., 2015; Moran et al., 2019), including those with mental health symptoms.

Several limitations should be considered when interpreting results from present analyses. Cross-sectional data collected do not allow us to draw conclusions about temporal relationships between tobacco product use patterns and depressive or anxiety symptoms. Self-report and self-selection surveys are inherently subject to bias, and samples recruited via MTurk limit generalizability. To address potential recall bias, the survey asked about tobacco use patterns within the past 30 days, and the PHQ-9 and GAD-7 scales ask about symptom severity over the past two weeks, with the intention of making time frames relatively easy to recall.

Conclusion

Young adult ENDS users who used two or more OTPs concurrently had greater odds of depressive and anxiety symptoms compared to those who only used one additional product, and both of these MTP use patterns had greater odds of depressive and anxiety symptoms compared to exclusive ENDS users. Among MTP users, those who used ENDS more frequently than OTPs had greater odds of depressive and anxiety symptoms. Tobacco prevention efforts that simultaneously address mental health symptoms among young adults are needed.

Funding

Research reported in this publication was supported by grant number U54CA180905 from the National Cancer Institute at the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) Center for Tobacco Products (CTP), grant numbers K01DA042950 and K01DA043413 from the National Institute for Drug Abuse at NIH, K01HL148907 from the National Heart, Lung, and Blood Institute at the NIH, and grant 27-IR-0034 from the Tobacco Related Disease Research Program (TRDRP). The funder had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

Footnotes

Financial disclosure

The authors have no financial relationships relevant to this article to disclose.

Declaration of interest

The authors declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the article.

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