Full length articleCo-occurrence of tobacco product use, substance use, and mental health problems among adults: Findings from Wave 1 (2013–2014) of the Population Assessment of Tobacco and Health (PATH) Study
Introduction
The epidemiology of tobacco use in the United States (U.S.) is evolving, showing declines in adult cigarette use amidst steady use of some tobacco products, such as cigars and smokeless tobacco, and increasing use of other products, such as e-cigarettes and hookah (Agaku et al., 2014). Understanding how these changes in tobacco product use patterns are associated with substance use and mental health problems can strengthen existing tobacco control efforts, particularly in developing focused interventions among these vulnerable populations.
While several cross-sectional studies have explored the associations of some tobacco products and substances used among U.S. adults, none comprehensively examined the range of available tobacco products and substances (Blazer and Wu, 2012, Goodwin et al., 2014a, Zale et al., 2015). One nationally representative study among adults found a strong association between cigarette smoking and nonmedical prescription opioid use (Zale et al., 2015), whereas another study of middle-aged and older adults found that past year cigarette and cigar smokers were more likely to binge drink in comparison to non-smokers (Blazer and Wu, 2012). A study of college students found a significant association between hookah use and substance use, with the strongest association observed between hookah and alcohol use (Goodwin et al., 2014a). Research on the associations between tobacco use and mental illness among U.S. adults similarly focuses on cigarette use (Smith et al., 2014). A meta-analysis examining the association between cigarette use and depression found that, in cross-sectional studies, cigarette smoking was associated with nearly two-fold higher risk of depression compared to never and former smoking (Luger et al., 2014). Other studies focusing predominantly on internalizing (depression and anxiety) disorders produced mixed results. Some studies report that any tobacco product use, including cigarettes, cigars, pipe, and smokeless tobacco, was associated with past year internalizing mental health problems (Blazer and Wu, 2012, Choi et al., 2015), whereas other studies found no significant associations between tobacco use, including cigarette and hookah use, and depression or anxiety (Breslau et al., 1991, Goodwin et al., 2014a). Given the evolving tobacco use patterns among U.S. adults, an assessment of their associations with substance use and mental health problems across the wide range of nicotine delivery systems is warranted.
Gender differences in the prevalence of tobacco use, substance use, and mental health problems among adults have been consistently observed in the general population (Eaton et al., 2012, Office on Smoking and Health, 2001), but scant epidemiologic research has focused on gender differences in the patterns of co-occurrence of tobacco use, substance use, and mental health problems. The few studies examining the moderating effects of gender on these associations have focused only on cigarette use, a major limitation given the diversity of tobacco products available in the marketplace. Regarding the tobacco-substance use association, one study found that male daily cigarette smokers were more likely to report nonmedical prescription opioid use, whereas their female counterparts were more likely to report nonmedical prescription opioid dependence (Zale et al., 2015). Additionally, studies on gender differences in the association between tobacco use and mental health problems have focused mostly on internalizing problems, with equivocal results. One study found that female cigarette smokers were more likely to have current or past depression than male smokers (Husky et al., 2008), whereas another found no gender differences in depression among cigarette smokers, but instead found that female cigarette smokers were more likely than males to have an anxiety disorder (Goodwin et al., 2014b). Expanding this research beyond cigarette smokers may point to unique gender differences and profiles of vulnerability to tobacco product use between males and females (Sinha and Rounsaville, 2002).
Using Wave 1 data from the Population Assessment of Tobacco and Health (PATH) Study, the present study (1) examined co-occurrence of substance use and mental health problems across 10 tobacco products, and (2) examined the moderating effects of gender on these associations.
Section snippets
Study design
The PATH Study is a nationally representative, longitudinal cohort study of 45,971 U.S. adults (18 years and older) and youth (12 years and older) examining tobacco use and health. This paper reports Wave 1 (September 2013–December 2014) data from 32,202 adult participants with valid complete data on variables for the specific associations examined (United States Department of Health and Human Services, 2016). Participants were recruited via an address-based, area-probability sampling approach,
Socio-demographic and other characteristics
Approximately half of adults were between the ages of 18–44 (47.1%) and male (48.1%) (Table 2). More than two-thirds of adults (67.7%) reported using alcohol or any drug in the past year. While alcohol was the most commonly used substance (63.5%), 11.8% of adults reported past year use of marijuana. The proportion of adults with past year substance use problems was low (3.5%), whereas slightly more adults reported past year internalizing (11.6%) and externalizing (9.3%) problems.
Tobacco use and substance use
Across all
Discussion
This study is the first to document the co-occurrence of substance use, mental health problems, and tobacco use across the range of currently available tobacco products in a nationally representative sample of U.S. adults. Several findings have emerged that warrant further discussion. First, tobacco users were significantly more likely to use alcohol or any drug compared to non-tobacco users, and these findings were robust across substances. Second, tobacco users were more likely to report
Role of funding source
This manuscript is supported with Federal funds from the National Institute on Drug Abuse, National Institutes of Health, and the Food and Drug Administration, Department of Health and Human Services, under a contract to Westat (Contract No. HHSN271201100027C).
Disclaimer
The views and opinions expressed in this manuscript are those of the authors only and do not necessarily represent the views, official policy or position of the US Department of Health and Human Services or any of its affiliated institutions or agencies.
Contributors
Drs. Conway and Compton conceptualized and designed the study and approved the final manuscript as submitted. Dr. Conway, Ms. Green, and Dr. Silveira drafted the initial manuscript and approved the final manuscript as submitted. Ms. Kasza carried out the analyses, reviewed and revised the manuscript, and approved the final manuscript as submitted. Dr. Silveira performed quality assurance and control of the analyses. All others, including Drs. Borek, Kimmel, Sargent, Stanton, Reissig, Jackson,
Conflict of interest statement
W.M. Compton declares retirement account stock holdings in Pfizer, a manufacturer of tobacco cessation products. No other potential conflicts of interest were reported.
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