Objective: The authors examined prospective associations between tobacco product use and mental health and substance use problems among U.S. adolescents and adults.

Methods: Covariate-adjusted models using discrete-time survival analysis of five annual waves (2013-2014 to 2018-2019) were used to examine the links between specific tobacco product use and mental health and substance use problems among adolescent and adult participants in the nationally representative Population Assessment of Tobacco and Health study. The sample included up to 32,320 adults and 13,651 adolescents.

Results: Among adolescents, externalizing problems predicted cigarette, electronic nicotine delivery system (ENDS), and hookah use. Sex-specific findings were found for female subjects (internalizing problems predicted cigarette, ENDS, and cigar use) and male subjects (externalizing problems predicted cigar and smokeless tobacco use). Among adults, cigarette use predicted internalizing and externalizing problems; ENDS use was associated bidirectionally with internalizing problems. Across age groups, use of each tobacco product predicted substance use problems, and substance use problems predicted ENDS use.

Conclusions: Intervening when mental health problems are seen among adolescents may minimize tobacco uptake. Likewise, preventing tobacco use may curtail substance use problems, and treatment of substance use problems may reduce tobacco use. Findings highlight the critical need to incorporate the bidirectionality among mental health, tobacco use, and substance use into prevention and treatment efforts.

Keywords: Child/Adolescent Psychiatry; Epidemiology.