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Anxiety symptoms and nicotine use among adolescents and young adults

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Anxiety symptoms and nicotine use among adolescents and young adults

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Content ANXIETY SYMPTOMS AND NICOTINE USE
AMONG ADOLESCENTS AND YOUNG ADULTS
By
Samantha Cwalina
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PREVENTATIVE MEDICINE (HEALTH BEHAVIOR))
May 2022
Copyright 2022 Samantha Cwalina
ii
Dedication

This dissertation is dedicated to Grandpa Cwalina, who moved on
to bigger and better things on October 22, 2021.

One of the last things Grandpa said to me was that he was proud of me. Grandpa never
missed an opportunity to tell me that he was proud of me, as well as his five other grandchildren,
and this was especially true when it came to education. Grandpa was one of eight children born
to Polish immigrants, and most of his siblings worked to support the family instead of attending
high school – he was only the second member of his family to graduate. So, it was a big deal to
him that all three of his kids and all six of his grandkids graduated from high school. He made it
clear that he believed in us and our abilities and even incentivized us to get good grades. When
we received our report cards from school every quarter, he agreed to pay us $1.00 for every A,
and $10.00 for straight A’s. I loved school and always got straight A’s anyway, so it was a
reliable source of income for most of the 90s. It is no surprise, then, that I chose a career where I
get paid to learn.
Grandpa is also an obvious inspiration for this dissertation and for the rest of my tobacco
control research career. I saw my grandpa smoke a lot of cigarettes throughout my life. Apart
from special occasions, Grandpa exclusively wore polo shirts that had a front left chest pocket
about the size of a pack of cigarettes in which he always kept his Pall Malls and a lighter. He
knew smoking was a bad habit and was making him sick, but he felt that it was too late for him
to quit because he started smoking when he was just a kid. He often lectured us kids about not
smoking. At the time, I couldn’t understand how he was able to give such sensible advice while
smoking a cigarette. Now I understand.
iii
Acknowledgements

First, I thank my chair, Dr. Mary Ann Pentz, for providing me this opportunity for
intellectual growth and exploration.
My co-chair, Dr. Jessica Barrington-Trimis, for the above and beyond academic support
as well as showing such kindness when I lost my grandpa in October.
The rest of my committee, for being so generous with your time and wisdom: Drs.
Jennifer Unger, Lourdes Baezconde-Garbanati, and Julie Cederbaum.
Anuja, for mentoring me through my first lead author paper.
Ugonna, for our academic glow up.
Heather, for the enthusiastic and unconditional support.
Many other faculty and postdocs at USC, for sharing valuable nuggets of wisdom
whether in formal mentorship settings or casual conversations.
Rachel, for the hour-long conversations about menthol cigarettes every month.
Lauren, for helping me collect the survey data used in Study 3.
USC TCORS, for providing funding support for the entirety of my dissertation.
Lilit, Sydney, Kiana, Sherri, and numerous other administrative staff.
The H&H data collection team.
Statisticians, data managers, and the IT team.
The over 5,000 research participants for taking the time to complete surveys.

Grandma, for helping me arrange dozens of stuffed animals on flights of stairs at your
house when I was a kid so that I could pretend to be a teacher in front of a lecture hall.
iv
My siblings, my first (human) students and my motivation for anything good that I’ve
done since I was two years old.
My parents, for every decision you made that led me to this achievement.
Cioci, for inspiring me with your love for education.
Craig, for the shoulder massages, bringing home snacks, always making sure I was
drinking enough water, and so many other ways you supported me through the good days and the
bad days.
Buddy, for being the goodest boy.
Jen/Aunt Jenny, for keeping me grounded and for all the career and life advice.
Tay, for being my #1 cheerleader regardless of whether I was winning or losing.

Lastly, this dissertation was submitted two years – almost to the day – after the WHO
declared the Coronavirus pandemic. Per the most recent data at the time of this writing, we have
lost over 950k people in the U.S. to COVID-19 (and almost 6 million worldwide). It is not
normal to be exposed to such prolonged mass deaths. The inconceivable grief, fear, and
frustration have permeated the zeitgeist, and it is impossible to know how this collective trauma
will affect the population as a whole in the decades to come. I feel grateful to have had the
opportunity to write my dissertation during this unique moment in history.

v
Table of Contents
Dedication ....................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iii
List of Tables ................................................................................................................................ vii
List of Figures .............................................................................................................................. viii
Abstract .......................................................................................................................................... ix
Chapter 1: Introduction ................................................................................................................... 1
Defining and Measuring Anxiety........................................................................................ 2
Nicotine and Tobacco Products .......................................................................................... 4
Theoretical Models Linking Nicotine Use and Anxiety Symptoms ................................... 7
Public Health Significance ................................................................................................ 11
Gaps in Knowledge ........................................................................................................... 14
Chapter 2: Prospective Associations of Anxiety Symptoms in Adolescence with Tobacco
Product Use Initiation in Early Adulthood ................................................................................... 20
Abstract ............................................................................................................................. 21
Introduction ....................................................................................................................... 23
Methods............................................................................................................................. 25
Results ............................................................................................................................... 27
Discussion ......................................................................................................................... 28
Conclusions ....................................................................................................................... 32
Chapter 3: Associations of Nicotine Vape and Cigarette Use with Anxiety Symptoms among
Adolescents and Young Adults ..................................................................................................... 37
Abstract ............................................................................................................................. 38
Introduction ....................................................................................................................... 40
Methods............................................................................................................................. 41
Results ............................................................................................................................... 44
Discussion ......................................................................................................................... 45
Conclusions ....................................................................................................................... 47
Chapter 4: Cross-Sectional Associations of Menthol Cigarette and Menthol-Flavored Vape Use
among Young Adults .................................................................................................................... 55
Abstract ............................................................................................................................. 56
vi
Introduction ....................................................................................................................... 58
Methods............................................................................................................................. 60
Results ............................................................................................................................... 63
Discussion ......................................................................................................................... 64
Conclusions ....................................................................................................................... 68
Chapter 5: Discussion ................................................................................................................... 73
Summary of findings......................................................................................................... 74
Implications....................................................................................................................... 75
Future Directions .............................................................................................................. 79
Strengths and Limitations ................................................................................................. 81
Conclusions ....................................................................................................................... 82
References ..................................................................................................................................... 83

vii
List of Tables

Table 1. Sample Characteristics for Study 1 ................................................................................. 33
Table 2. Frequencies and Odds Ratios for Vape Initiation in Early Adulthood ........................... 34
Table 3. Frequencies and Odds Ratios for Cigarette Initiation in Early Adulthood ..................... 35
Table 4. Sample Characteristics for Study 2 ................................................................................. 49
Table 5. Exposure and Outcome Variables by Wave ................................................................... 50
Table 6. Odds Ratios for Anxiety Symptoms by Wave ................................................................ 51
Table 7. Sample Characteristics for Study 3 ................................................................................. 69
Table 8. Frequencies and Odds Ratios for Elevated Anxiety ....................................................... 71

viii
List of Figures

Figure 1. DSM Diagnostic Criteria for Generalized Anxiety Disorder and GAD-7 Items .......... 17
Figure 2. RCADS Subscale Items ................................................................................................. 18
Figure 3. Conceptual Model for Three Studies ............................................................................. 19
Figure 4. Revised Children's Anxiety and Depression Scale Items .............................................. 36
Figure 5. Data Collection Timeline for Study 2 ........................................................................... 52
Figure 6. RCADS-GAD, GAD-7, and DSM-5 Diagnostic Criteria for Generalized Anxiety
Disorder................................................................................................................................. 53
Figure 7. Prevalence of Vape and Cigarette Use by Wave ........................................................... 54
Figure 8. Newport Boost Cigarettes.............................................................................................. 72

ix
Abstract

Adolescents and young adults (vs. older adults) with anxiety symptoms (vs. no
symptoms) have a disproportionately greater risk of developing nicotine dependence and
subsequent tobacco-attributable morbidity and mortality. Thus, preventing and reducing tobacco
use among young people with anxiety symptoms is of interest to public health. This high-risk
population may benefit from evidence-based anti-tobacco interventions that resonate with their
needs and experiences. Data are needed to develop such interventions. Prior research among
adult populations suggests a link between anxiety symptoms and cigarette use, but this
bidirectional association has received very little attention among adolescents and young adults,
and it is unclear whether potential associations extend to vape use. The overarching objective of
this dissertation was to investigate the associations of anxiety symptoms with vape and cigarette
use among adolescents and young adults across the tobacco use continuum, from initiation to
established use, utilizing data from prospective cohort and online panel survey studies. The
specific aims of this dissertation were to: 1) evaluate prospective associations of anxiety
symptoms measured in adolescence with initiation of vape and cigarette use in early adulthood,
2) examine cross-sectional associations of vape and cigarette use with anxiety symptoms across
three socio-environmental contexts, and 3) examine cross-sectional associations of menthol
cigarette and menthol-flavored vape use with anxiety symptoms among young adults. Findings
suggest that: 1) adolescents with panic symptoms are a particularly high-risk population for
cigarette initiation, 2) associations of cigarette use with anxiety symptoms are not significantly
influenced by the greater social context, and 3) menthol cigarettes might be more appealing to
young adults with anxiety symptoms than menthol-flavored vapes. Taken together, we
consistently found evidence of an association between anxiety symptoms and cigarette use, and
x
consistently did not observe associations between anxiety symptoms and vape use. These
differential associations are significant because cigarettes are more harmful to health than vapes.
Individuals with anxiety symptoms are more likely to develop nicotine dependence than those
without symptoms. Therefore, not only do young adults with anxiety symptoms have increased
risk of using a nicotine product, but they also have an increased risk of becoming dependent on a
product that substantially contributes to premature mortality. With recent increases in anxiety
symptoms among young people that are likely to worsen due to the COVID-19 pandemic, data
on young people with anxiety symptoms will become increasingly relevant for developing
evidence-based anti-tobacco interventions at the community and population level. Future
research should examine smoking motivations among young people with anxiety symptoms and
investigate potential associations between anxiety symptoms and vape use that were outside the
scope of this dissertation (such as nicotine formulation and frequency of menthol-flavored vape
use vs. other flavors).

Chapter 1: Introduction

2
Defining and Measuring Anxiety
Anxiety is “a state of anticipatory apprehension over possible deleterious happenings”
1

and such anticipatory apprehension can trigger a physiological stress response, commonly
referred to as a “fight or flight” response.
2
Anticipatory apprehension coupled with a stress
response can translate to both the psychological symptoms (e.g., excessive worry) and somatic
symptoms (e.g., rapid heart rate) of anxiety.
The stress response is evolutionarily adaptive and ordinarily plays an important role in
protecting an individual from physical and social stressors.
3,4
External stimuli are interpreted as
stressors (or not) primarily by the limbic system – comprised of the amygdala, hippocampus, and
hypothalamus; if the stimulus is deemed a stressor, the stress response is activated.
5,6
Activation
of the stress response triggers a cascade of physiological changes throughout the body, including
increased heart rate, pupil dilation, increased perspiration, increased blood flow to skeletal
muscles and away from smooth muscle in the digestive tract, and hypervigilance.
7
Physiological
symptoms dissipate after stressors have been dissolved, either by fighting back (fight) or by
running away (flight).
2,7,8
This is a useful and necessary brain function for human survival;
3,4
all
individuals experience these physiological reactions to perceived stressors.
8
However, what
qualifies as a stressor may vary across individuals. Among some, excessive worry about
potentially stressful events that may or may not happen can result in a stress response that is
chronically activated. Individuals experience anxiety when they believe themselves to be
incapable of managing potentially stressful events,
9,10
and this anxiety may further interfere with
performance in everyday life situations.
11

While anxiety is a universal human experience, efforts to identify individuals with an
overactive stress response are needed to provide individual treatment in clinical settings and to
3
study risk factors for and health consequences of chronically elevated anxiety. In clinical
settings, anxiety disorders are diagnosed by individual interviews and a set of diagnostic criteria
described in the DSM-5.
12
Diagnostic criteria used in clinical settings is the gold standard for
identifying individuals with elevated anxiety that may need treatment, and trained psychologists
can rule out other potential causes.
12
However, individual diagnostic interviews are time-
consuming and expensive, which has limited our ability to study individuals with anxiety
symptoms outside of clinical settings until recently. In survey research, several scales have been
developed based on DSM criteria for Generalized Anxiety Disorder to measure generalized
anxiety symptoms in the absence of clinical diagnostic interviews. The Generalized Anxiety
Disorder-7 (GAD-7) is a seven-question scale that assesses severity of symptoms related to
Generalized Anxiety Disorder over the past two weeks (Figure 1a).
13
Most published research
using the GAD-7 thus far have used adult populations (including young adults). The Revised
Children’s Anxiety and Depression Scale (RCADS) is another scale to assess severity related to
anxiety, and is typically used with children and adolescents.
14–17
The RCADS is a 47-item self-
report questionnaire that includes subscales for five different anxiety disorders (Generalized
Anxiety, Panic Disorder, Social Phobia, Obsessive-Compulsive Disorder, Separation Anxiety
Disorder) and depression.
14–16,18
Three of these subscales are used in this dissertation:
generalized anxiety (RCADS-GAD), panic disorder (RCADS-PD), and social phobia (RCADS-
SP) (Figure 1b). This dissertation utilized both the GAD-7 and the RCADS because we studied
the transition from adolescence to early adulthood, and the GAD-7 and RCADS are best suited
for each population respectively.

4
Nicotine and Tobacco Products
Nicotine is a psychoactive substance found naturally in tobacco leaf that acts on nicotinic
acetylcholine receptors (nAChRs) that are distributed widely throughout in the brain and consist
of various arrays of homomeric and heteromeric subunits, resulting in diverse pharmacological
effects that may affect behavior.
19,20
When activated by nicotine, nAChRs located on
dopaminergic neurons in the ventral tegmental area facilitate dopamine neurotransmission to the
nucleus accumbens, which are the key brain regions in the primary reward pathway.
21,22
As such,
nicotine develops strong positive reinforcement behaviors consistent with other substances with
high addiction potential.
23–25
Over time, nAChRs desensitize to nicotine, requiring greater
nicotine intake to achieve the same effects (tolerance). Another distinctive characteristic of
nicotine is its dual-reinforcement properties; it is a reinforcing substance itself and also has the
capacity to make other non-nicotine stimuli more rewarding.
26,27

Tobacco products are any products that are made or derived from tobacco that are
intended for human consumption, including any component, part, or accessory of a tobacco
product, and all consumer products that meet this definition are under regulatory oversight by the
U.S. Food and Drug Administration (FDA).
28
Nicotine is the primary addictive component in
tobacco products, and continued use leads to the development of nicotine dependence.
23
Nicotine
dependence is characterized by a cluster of cognitive, behavioral, and physiological symptoms,
12

and is thought to be primarily responsible for continued use of tobacco products that result in
high morbidity and mortality.
23
Chronic nicotine users who quit or reduce intake experience
withdrawal symptoms that cause significant distress or impairment in social, occupational, or
other important areas of functioning, such as insomnia, irritability, anxiety, and difficulty
concentrating; many tobacco users self-administer nicotine to relieve or avoid withdrawal
5
symptoms, which may impede quit attempts.
9
Nicotine’s widespread effects on the brain and its
enhancement of other non-nicotine stimuli likely contribute to continued nicotine self-
administration and unsuccessful quit attempts, and individuals with anxiety may be more
susceptible to such an effect.
29–33

Preventing tobacco use among youth is of particular importance. Exposure to nicotine
prior to age 25 (approximately when the prefrontal cortex and limbic system are fully matured)
induces long-lasting neuronal alterations that increase the likelihood of developing nicotine
dependence, cognitive deficits, and anxiety in adulthood.
6,20,34
Levels of dopamine and serotonin
decrease during adolescence, contributing to both reduced impulsive control and motivation to
increase levels of dopamine and serotonin through various activities, including nicotine use.
6,20

Further, compared to adults, adolescents experience greater short-term positive effects and
reduced adverse effects of nicotine.
6
Peer tobacco use is one of the most consistent and robust
predictors of tobacco use among young people, influencing both initiation and reinforcing use in
social settings via social acceptance (i.e., fitting in).
35–39
Most young people try their first tobacco
product while hanging out with friends,
36
and peer groups are the most common settings for
tobacco use.
40,41
Some young adults report purchasing vaping products directly from friends,
either in addition to or in lieu of online and in-store purchasing.
42

The most common tobacco products used among young people are cigarettes and e-
cigarettes (vapes).
43
Dual use (i.e., concurrent use of both cigarettes and vapes) of these products
is also common,
44
which is concerning because dual use increases risk of nicotine dependence
compared to single product use.
45
Among young adults, 18% of current vape users also smoke
cigarettes.
44
Over recent years, the nicotine vape product market has evolved rapidly, which has
led to volatile patterns in availability and prevalence of vaping. In 2017, newer generation pod
6
devices (such as JUUL) rapidly gained popularity,
46–58
which is thought to be at least partially
driven by aggressive marketing tactics on social media clearly targeting young people social
media,
57,59–62
as well as appealing flavors.
63–70
Although JUUL claims that their devices are
intended for use as a smoking cessation aid, several studies have shown that young people do not
use these devices for cessation;
71–75
rather, these pod devices are associated with dual use of
cigarettes,
75–78
as well as use of multiple vape devices
79–81
(such as flavored disposable devices
that also use salt-based nicotine).
47,82,83
Per Nielsen data, sales of all vaping products peaked in
August 2019 (at over $400 million).
84,85
Whereas previous generations of vaping devices used
free-base nicotine, JUUL and similar devices use salt-based nicotine,
86,87
which is significant
because pod devices that use salt-based nicotine are associated with greater nicotine dependence
relative older generation devices that use free-base nicotine.
69,77,78,88–93

Cigarettes and vapes differ in many important ways that may drive differential use
patterns among adolescents and young adults.
94
Vapes are more socially acceptable and easier to
conceal in public spaces compared to cigarettes,
95–98
and it is possible that tobacco users with
anxiety symptoms are more sensitive to these social pressures compared to those without
symptoms.
99
Social settings are also the most popular source for accessing vape products.
42,100

Further, vapes have a degree of novelty that is not true of cigarettes, which may increase
curiosity and subsequent experimentation among young adults (who are already more inclined to
take risks due to identity exploration).
40,41,101
Lastly, public perceptions of vaping and access to
vaping products varied as a consequence of evolving regulations (whereas regulations for
cigarettes have remained comparatively consistent) public perception ,
102–105
as well as health
scares.
106
For example, in August 2019, the CDC reported the first case of E-cigarette, or
7
Vaping, Product Use-Associated Lung Injury (EVALI),
107
and Nielsen data show that EVALI
deaths were associated with a decline in vape and cigarette sales.
84

Theoretical Models Linking Nicotine Use and Anxiety Symptoms
The Biopsychosocial Model
The Biopsychosocial Model takes into consideration psychological and social factors
when examining health risk behaviors with biological underpinnings.
108
Many biological,
psychological, and social factors influence tobacco initiation and continued use, as well as
anxiety symptoms, thus, a biopsychosocial framework is useful for understanding the association
between nicotine use and anxiety symptoms among adolescents and young adults. Self-
medication theory considers the biology of nicotine and psychology of anxiety when
contextualizing the association between nicotine use and anxiety symptoms. Emerging adulthood
theory, on the other hand, posits that the social environment explains much of the association
between anxiety symptoms and nicotine use.

Self-Medication Theory
By far, the most widely accepted explanation for the association between tobacco use and
anxiety is self-medication theory, which suggests that individuals with anxiety symptoms self-
administer nicotine to manage various anxiety-attributable symptoms.
109–111
Self-medication
theory addresses biopsychological factors by positing that the biological effects of nicotine are
used to satisfy a psychological problem (anxiety). A cycle develops where decreases in the
biological factor (nicotine withdrawal) leads to increased anxiety, prompting an individual to
self-administer nicotine, thereby satisfying the biological nicotine craving and reinforcing
8
behavior via negative reinforcement, leading to nicotine dependence. Indeed, coping with stress
is a commonly cited reason for smoking among young adults, and stressful experiences can
maintain cigarette smoking.
112,113
This may partially explain why individuals with anxiety
symptoms develop nicotine dependence faster and have a harder time quitting than those
without.
32,45,114–116
Some preclinical evidence supports this theory as well – experiments with
zebrafish found that nicotine reduced anxiogenic responses on behavioral tasks known to induce
anxiety.
117
Self-medication theory, however, does not take social factors into consideration.

Emerging Adulthood Theory
Emerging adulthood refers to the stage of development from approximately the late teens
through mid-twenties and is thought to be theoretically and empirically distinct from both
adolescence and adulthood.
118,119
This developmental period is characterized by significant
changes in nearly all aspects of life and social environments.
118–120
At this transitional juncture,
many directions are possible, and individuals obtain the necessary education or professional
training that will serve as the foundation for the careers for the remainder of their adult work
lives.
118
Not all of this change is experienced as positive, though; to some, increased
responsibilities, residential changes, or uncertainty about the future can increase stress and
anxiety.
Characteristics of early adulthood increase the risk of substance use, distinctly from
adolescent substance use, due to differences in socio-environmental contexts.
121
These contextual
changes may, at least in part, explain why the prevalence of substance use tends to increase
during adolescence, peak in the mid-twenties, then decline in the thirties.
121,122
Experiences that
are unique to early adulthood, including changing residences and attending college, are
9
associated with increased substance use.
121
While college attendance may serve as a risk factor
for alcohol use outcomes, those who attend college are less likely to use tobacco than their peers
who enter the workforce right after high school.
123,124
Successful transition into adulthood roles
is associated with decreasing drug use; however, failing to achieve the developmental tasks of
this period is associated with increased substance use and poor mental health.
121

When Dr. Jeffery Arnett first wrote of this theory in 1995, he also noted that he observed
a universal sense of optimism among emerging adults – most believed they had good chances of
living “better than their parents did” and finding a lifelong soulmate.
118
However, young adults
of today – nearly thirty years later – face a very different socioeconomic reality. The U.S.
Surgeon General recently issued an advisory on the rapidly increasing prevalence of mental
health symptoms among young people in recent years, with over one third of all high school
students reporting persistent feelings of sadness or hopelessness.
125
This report suggests several
sources of distress for young people of today: increases in social media use, which has led to
increased cyberbullying and exposure to distressing provocative content, income inequality,
systemic racism (which also has implications for tobacco control
126
), the opioid epidemic, gun
violence, and climate change. A survey of 10,000 young people about climate anxiety (i.e.,
anxiety about climate change) found that 59% were very or extremely worried, over 50% felt
said, anxious, powerless, helpless and guilty, and over 45% said their feelings about climate
change negatively affect their daily life and functioning.
127
The mental health crisis among
young people has undoubtedly been exacerbated by the COVID-19 pandemic,
125,128,129
which has
led to stressful life disruptions and exposure to inconceivable amounts of death and grief. The
psychological impacts of pandemics have been studied based on trends from prior pandemics,
and COVID-19 has shown psychosocial reactions consistent with prior pandemics (such as:
10
desperate pursuit of quack cures and folk remedies, civil unrest, rioting, and mass panic,
conspiratorial thinking, and exacerbation of anxiety symptoms).
130
It is possible that this once-in-
a-generation cataclysm prevents emerging adults of today from achieving the developmental
tasks of this period, which – among the generation who has also been hit the hardest with the
vaping and opioid epidemics – is associated with increased substance use and poor mental
health.
121
This could mean increases in tobacco use, which warrants attention from the tobacco
control research community.

Conceptual Model for Three Studies
All non-tobacco users begin at the initiation phase on the left of the tobacco use
continuum (Figure 2). At this stage, social factors are the most important and salient driving
factors of experimental tobacco use, and nicotine has positive reinforcing effects via positive
social feedback (e.g., fitting in).
9,131,132
Once an individual initiates tobacco use, the experimental
use period is when they decide whether they will continue or discontinue using tobacco products.
Still in the early stages on the tobacco use continuum, where positive reinforcement is still
sustaining behavior, individuals with anxiety might particularly enjoy nicotine-containing
tobacco products because, at low (versus high) doses, nicotine acts as a stimulant and releases
acetylcholine (ACh) and norepinephrine.
131
The resulting increased alertness may improve
concentration (decreased concentration is a symptom of anxiety). Positive mood may further
inhibit self-control over tobacco use behavior, because those in a positive mood (versus negative
mood) prefer activities that prolong happiness and delay unhappiness.
11
On the other hand, some
individuals with anxiety may be drawn to nicotine-containing tobacco products because, at high
(versus low) doses, nicotine produces sedative, relaxing effects via release of serotonin (5-
11
HT).
131
At the end of the present tobacco use continuum, the dependent phase is where negative
reinforcement is the dominating motive, and behavior is primary sustained via relief of
unpleasant withdrawal symptoms (which mimic anxiety symptoms).
12
The psychological and
physiological symptoms of nicotine withdrawal can lead to significant distress and disruptions to
daily functioning,
13
which then leads to poor cessation outcomes.
12
In theory (and ideally), this
tobacco use continuum continues past the dependent phase to the former use phase; however,
this dissertation will not address tobacco cessation.

Public Health Significance
Among young adults, the prevalence of anxiety symptoms nearly doubled between 2008
to 2018 (8% vs. 15%, respectively),
133
and a meta-analysis of over 80,000 youth globally found
that 20% experienced anxiety in 2020.
128
Prompted by these concerning trends, the U.S. Surgeon
General issued an advisory calling attention to the mental health crisis among young people in
December 2021.
125
In his opening letter, Dr. Vivek H. Murphy writes,
“Our obligation to act is not just medical – it’s moral.”
The justification for research on mental health among young people is irrefutably
compelling and is also directly relevant to tobacco control research because young adults with
anxiety symptoms are more likely to use tobacco products, develop nicotine dependence, and
experience greater difficulty quitting compared to peers without anxiety.
113,134
This contributes to
tobacco-related disparities that may have significant generational implications.
14,15

The human brain develops rapidly from infancy, gradually slowing until approximately
age 25 when the brain is considered fully mature.
6,20
Consequently, information learned, and
habits formed prior to approximately age 25 are likely to persist throughout adulthood.
12
Preventing nicotine exposure during adolescence and early adulthood then is of particular
importance as increased neural plasticity during these critical developmental periods increases
the risk for nicotine dependence, thus, increasing the risk for continued tobacco use and tobacco-
related morbidity and mortality.
135
Emerging adulthood is a period of developmental
vulnerability that may exacerbate risk factors for tobacco use as individuals are more open to
changing their identity, perhaps parting ways with previous beliefs held during adolescence that
may have been protective against tobacco use.
118,119
The exact reasons for increased tobacco use
among this population are unclear, though increased stress/anxiety associated with the
developmental transition may, in part, explain the high prevalence of tobacco use among
emerging adults, if they use nicotine-containing tobacco products to self-medicate.
136

Health outcomes: Anxiety symptoms
It has been suggested that population-level interventions aimed to decrease anxiety
symptom severity would likely benefit public health as well as the global economy.
129,133
The
cascade of physiological changes triggered by the stress response increases the risk of chronic
disease and premature mortality when it is chronically activated. Chronic anxiety symptoms are
indicative of a chronically activated stress response (i.e., “fight or flight”), which can lead to a
number of physical health consequences, such as substance use disorders
137–139
and
cardiovascular disease.
140–143
Somatic manifestations of chronic anxiety symptoms (e.g.,
headaches and other chronic pain) result in more sick days, consequently decreasing
productivity, quality of life, and potential wages earned.
144

Chronic anxiety symptoms also impair cognitive functioning by disrupting goal-directed
behaviors and decision making,
145
as well as decreasing working memory capacity.
146
Decreased
13
cognitive functioning can decrease work productivity, resulting in poorer educational attainment
and job performance.
129
On top of the overactive stress response, the stress induced by new
onset, or exacerbation of, physical health problems may bring additional worries that further
compound the effects of chronic anxiety (health anxiety).
130,147
Moreover, individuals who seek
treatment for their anxiety symptoms (e.g., medications or psychotherapy) face further economic
burdens associated with healthcare costs that, in turn, leads to additional stress (financial stress is
one of the most commonly cited reasons for anxiety symptoms).
148

Health outcomes: Tobacco use
The adverse health consequences of cigarette smoking are well-documented and widely
accepted.
149
However, much less is known about the long-term health consequences of nicotine
vaping since vaping devices have only been on the U.S. tobacco product market for roughly a
decade.
57
In 2018 the National Academies of Sciences, Engineering, and Medicine (NASEM)
evaluated available data on the short-term effects of vaping and found substantial evidence that
e-cigarette aerosols can induce acute endothelial cell dysfunction and promote oxidative stress,
and chemicals present in e-cigarette aerosols (e.g., formaldehyde, acrolein) can cause DNA
damage.
150
Moreover, vaping devices that contain nicotine are addictive and can lead to nicotine
dependence, thereby sustaining long-term use leading to downstream tobacco-related morbidity
and mortality.
135
This is especially true among young adults whose brains have not yet reached
full developmental maturity.
6,20,135,151

14
Gaps in Knowledge
This dissertation attempts to address at least three critical gaps in the literature regarding
anxiety symptoms and tobacco use among adolescents and young adults. Previous research on
the relationship between anxiety symptoms and tobacco use among young people is limited,
which is surprising given the given the relatively high prevalence of both among this population.
Profound changes in the social environment after graduating high school increase vulnerability to
tobacco use and psychosocial stress, yet the transition from high school to early adulthood is
understudied in the tobacco use literature.
120
One’s social and self-identity changes significantly
from adolescence to young adulthood where there are new social environments and norms.
152

Increased neural plasticity and a malleable self-identity leave space to create healthy coping
skills and facilitate positive identity formation, which may decrease tobacco use among young
adults.
120
Thus, early adulthood is a critically important time for intervention, with the potential
to improve generational tobacco-related health outcomes.
120
Data are needed to aid development
of such interventions to ensure that the content is relevant and resonates with the target
population.
153
As with other priority populations in tobacco control research (e.g., Black
smokers, sexual and gender minorities), young adults with anxiety symptoms may benefit from
tailored interventions.
154
The lack of data on young adults with anxiety symptoms precludes our
ability to develop comprehensive tobacco control programing tailored to this uniquely high-risk
population.
155

A recent systematic review found that only four published studies have examined the
association between anxiety symptoms and vape use among young adults, and only one has
examined the association of anxiety symptoms and vape use among adolescents.
156
Among
young adults, one of the studies found that generalized anxiety symptoms predicted cigarette but
15
not vape use over a two-year follow-up,
157
while another found that generalized anxiety
symptoms predicted neither cigarette nor vape initiation over a one-year follow-up.
94
Among 9
th

grade students from Southern California, generalized anxiety, panic disorder, and social anxiety
symptoms were all cross-sectionally associated with lifetime cigarette use, but only panic
symptoms were associated with lifetime vape use.
158
This suggests that various anxiety
symptomology subtypes may have differential associations with vape and cigarette use among
young people. Understanding the temporality of the association between anxiety symptoms and
tobacco product use and how it may vary across different anxiety symptom subtypes can help
inform future research and tobacco control efforts.
Young adults are more likely to use menthol cigarettes compared to older adults (50% vs.
32% among past 30-day cigarette users, respectively),
159
and menthol smokers report worse
general mental health and greater psychological distress than those who smoke non-menthol
cigarettes.
160–162
Menthol is associated with positive, pleasurable, and other hedonistic responses
to nicotine, which may be disproportionately appealing to individuals with anxiety.
11,163
Thus,
nicotine’s capacity to reduce subjective feelings of anxiety coupled with the positive sensory
properties of menthol may at least partially explain the association between menthol tobacco and
anxiety. This hypothesis is further supported by an internal study conducted by RJ Reynolds:
“menthol smokers may be chronically less aroused and more sensitive to the effects of nicotine
than non-menthol smokers.”
164
Menthol stimulates TRPM8 receptors near nerve endings that are
associated with a “cooling” sensation in the mouth and throat,
165
which helps mask the otherwise
unpleasant taste of cigarette smoke and may increase exposure to nicotine compared to non-
menthol cigarettes.
166
That young people are more likely to use menthol cigarettes compared to
16
older adults is significant because menthol cigarettes are associated with greater nicotine
dependence relative to non-menthol cigarettes.
167–170

Previous research has found that menthol (vs. non-menthol) tobacco products are cross-
sectionally associated with anxiety symptoms among young adults,
163
but this relationship has
not been examined for vapes, which are the most common tobacco product among this
population.
43
Per self-medication theory,
109–111
the psychobiological properties of nicotine in the
brain may alleviate symptoms of anxiety, and the positive sensory properties of menthol may
relieve negative affect,
163
and this combination may strengthen the uptake of continued use if
desired effect is achieved (i.e., reduced anxiety, increased positive mood). Considering the
comparatively greater prevalence of both anxiety symptoms and menthol tobacco use among
young adults, it is important to understand the relationship between both high-risk behaviors to
develop effective data-driven tobacco control strategies.
163

In sum, because anxiety symptoms are associated with adverse physical health outcomes
and economic burdens, population-level and clinical efforts to mitigate anxiety symptoms would
likely benefit public health as a whole, as well as the global economy.
133,171
Tobacco control is
poised to support this effort by developing purposeful, evidence-based anti-tobacco interventions
that are tailored to the unique experiences of young people with anxiety. Because individuals
may experience anxiety symptoms that would not necessarily meet clinical diagnostic criteria,
12–
14

12
such tailored interventions have the potential to benefit a considerable portion of the
population.
133,172
This dissertation examines prospective and cross-sectional associations
between cigarette and vape use and anxiety symptoms among adolescents and young adults
which can collectively contribute to a nuanced foundation for future research.

17
Figure 1. DSM Diagnostic Criteria for Generalized Anxiety Disorder and GAD-7 Items
DSM-5 Diagnostic Criteria GAD-7 Items*
A) Excessive anxiety and worry about a number
of events of activities
3) Worrying too much about different things
7) Feeling afraid, as if something awful might happen
B) Person finds it difficult to control worry 2) Not being able to stop or control worrying
C) Anxiety and worry are associated with at least
three of the following:

Restlessness or feeling on edge
5) Feeling so restless it is hard to sit still
1) Feeling nervous, anxious, or on edge
Being easily fatigued
Difficulty concentrating
Irritability 6) Becoming easily annoyed or irritable
Muscle tension
4) Trouble relaxing
Sleep disturbance
D) Focus of anxiety or worry is not confined to
features of an Axis I disorder
GAD-7 unable to evaluate differential diagnoses
E) Anxiety, worry, or physical symptoms cause
significant distress or impairment in social,
occupational, or other important areas of
functioning
Degree of impairment not directly assessed with
GAD-7, but previous research shows that higher
GAD-7 scores strongly correlate with greater
functional impairment**

*Each of these items were presented following the question: “Over the last two weeks, how often have
you been bothered by the following problems?” Response options included “Not at all”, “Several days”,
“More than half the days”, and “Nearly every day” (numerically 0-3, respectively; GAD-7 score is
calculated by summing responses to each of the 7 items). The numbers represent the order that each item
is presented on the questionnaire.

**Functional impairment assessed with Medical Outcomes Study Short-Form General Health Survey,
which measures functional status in 6 dimensions: mental health, social functioning, general health
perceptions, bodily pain, role functioning, and physical functioning.
15,16
GAD-7 scores correlated most
strongly with mental health (0.75), followed by social functioning (0.46), general health perceptions
(0.44), bodily pain (0.36), role functioning (0.33), and physical functioning (0.30).
6

18
Figure 2. RCADS Subscale Items
Generalized symptoms
(RCADS-GAD)
Panic symptoms
(RCADS-PD)
Social symptoms
(RCADS-SP)
“How often do these things happen to you?”

[Never, Sometimes, Often, Always]
I worry about things.
All of a sudden, I feel really
scared for no reason at all.
I worry that I will do badly at my
schoolwork.
I worry that something awful
will happen to someone in my
family.
When I have a problem, my
heart beats really fast.
I worry I might look foolish.
I worry that bad things will
happen to me.
My heart suddenly starts to beat
too quickly for no reason.
I worry about making mistakes.
I worry that something bad will
happen to me.
I suddenly start to tremble or
shake when there is no reason
for this.
I worry what other people think
of me.
I worry about what is going to
happen.
When I have a problem, I get a
funny feeling in my stomach.
I feel afraid that I will make a
fool of myself in front of people.
I think about death.
I suddenly become dizzy or
faint when there is no reason for
this.
I worry when I think I have done
poorly at something.

I worry that I will suddenly get
a scared feeling when there is
nothing to be afraid of.
I feel worried when I think
someone is angry with me.

I feel scared when I have to take
a test.

I feel afraid if I have to talk in
front of my class.

*Each of these items were presented following the question: “Please fill in the bubble for the word that
shows how often each of these things happen to you.” Response options included: “Never”,
“Sometimes”, “Often”, and “Always”. Responses are coded as numeric variables (0-3) and summed to
determine if responses meet at least subclinical criteria for each individual anxiety disorder subtype

19
Figure 3. Conceptual Model for Three Studies

Adapted from BF Skinner’s behavioral reinforcement model,
173
Albert Bandura’s social cognitive theory,
9

and motivations for smoking described by Lujic et al.,
131

20

Chapter 2: Prospective Associations of Anxiety Symptoms in Adolescence
with Tobacco Product Use Initiation in Early Adulthood

21
Abstract

Objective: Alarming increases in anxiety symptoms among young people in recent years could
have implications for tobacco-related disparities. Prior work suggests a bidirectional association
between anxiety symptoms and cigarette use, but it is not clear whether these associations extend
to nicotine vape use among adolescents and young adults. Data on prospective associations of
anxiety symptoms with cigarette and vape initiation can be leveraged to develop clinical and
population-level anti-tobacco interventions tailored to this high-risk population. We examined
prospective associations of three anxiety symptomology subtypes assessed in adolescence with
initiation of vape and cigarette in early adulthood.
Methods: Self-report survey data were drawn from a cohort study of adolescents and young
adults in Southern California. Baseline data were collected in the fall of 2016, when participants
were in their senior year of high school, and follow-up data were collected from October 2018-
2020. The analytic sample was restricted to participants who did not ever use vapes, cigarettes,
hookah, nor cigars prior to baseline (N=1191). Two binary logistic regression models estimated
the odds of vape and cigarette initiation (vs. never use) in early adulthood as a function of three
anxiety symptomology subtypes measured with the Revised Children’s Anxiety and Depression
Scale (RCADS) in adolescence (symptoms vs. no symptoms): generalized anxiety (generalized),
panic disorder (panic), and social phobia (social). Covariates included race/ethnicity, gender, and
whether they qualified for free or reduced lunch.
Results: Among never tobacco users at baseline, 12% of the sample had generalized, 12% had
panic, and 15% had social symptoms. By follow-up, 32% had initiated nicotine vape use and
10% had initiated cigarette use. Panic symptoms were associated with greater odds of cigarette
initiation (aOR=2.07 [1.19-3.60]) but not vape initiation (aOR=1.25 [0.83-1.90]). Neither
22
generalized nor social symptoms showed significant associations with initiation of either
product.
Conclusion: Prospective associations of anxiety symptoms with tobacco product initiation may
vary by symptomology subtype and tobacco product type. Not only did adolescents with panic
symptoms have greater odds of new onset nicotine use in early adulthood, but they were also
more likely to use combustible cigarettes, which are substantially more harmful to health than
vapes. Future research should examine smoking motivations among young people with panic
symptoms, including social factors, which could aid development of anti-tobacco interventions
tailored to this high-risk population.

23
Introduction
The 2019 National Health Interview Survey of over 30,000 United States (U.S.) adults
found that approximately 18% of young adults (age 18-25) use tobacco products some days or
every day,
43
which is troublesome because individuals younger than age 25 have a greater risk of
developing nicotine dependence, thereby increasing the risk of long-term tobacco use and
attributable health outcomes.
135
Individuals with anxiety symptoms are similarly at greater risk
for nicotine dependence compared to those without symptoms.
32,45,114–116
As such, young adults
with anxiety symptoms are a uniquely vulnerable population in tobacco control research, and this
population may benefit from evidence-based tobacco prevention interventions at the community
and population level that are tailored to their specific needs and experiences.
154,174

The prevalence of anxiety symptoms among adolescents and young adults has increased
at alarming rates over the past several years, which is a significant threat to public
health.
125,128,133
There are several subtypes of anxiety disorders described in the DSM-5 and each
have unique sets of symptoms and diagnostic criteria.
12
Of note, it is possible to experience
symptoms consistent with one or more anxiety disorders subtypes without necessarily meeting
clinical diagnostic criteria. In survey research outside of the clinical setting, the Revised
Children’s Anxiety and Depression Scale (RCADS) is a well-validated tool designed to measure
the severity of symptoms (but not make diagnoses) for several subtypes of anxiety symptoms
(Figure 3).
14
Generalized anxiety (herein referred to as “generalized”) symptoms describe
excessive worry about a number of non-specific events and activities. Worries associated with
social phobia (“social”) symptoms are more specific to social situations where one might make a
mistake, feel embarrassed, or be judged by others. Social phobia is slightly different from social
anxiety; the latter describes worries associated with interpersonal social interactions.
12
The
24
worries associated with panic disorder (“panic”) are even more specific and to the somatic
symptoms associated with panic attacks. Panic attacks are experienced as sudden and intense
onset of several somatic symptoms of anxiety, such as rapid heart rate, shortness of breath, or
trembling or shaking. The distinctive diagnostic criterion for panic disorder is an excessive fear
of having another panic attack, meaning that an individual could experience recurrent panic
attacks but not meet diagnostic criteria if they do not also experience excessive worry about
future panic attacks (but everyone with panic disorder experiences recurrent and unexpected
panic attacks).
12
Generalized, panic, and social symptoms are all associated with greater nicotine
dependence, thus, preventing new onset nicotine use among young people with anxiety
symptoms is of urgent concern.
157,175–177
Population-level interventions to mitigate increasingly
high rates of anxiety symptoms among young people may benefit even individuals with
subclinical anxiety symptoms and,
133
due to anxiety-attributable loss of productivity and
healthcare utilization, benefit the global economy.
129,171

Although adolescents and young adults with poor mental health are a priority population
in tobacco control, prospective analyses of anxiety symptoms with vape and cigarette initiation
among adolescents and young adults are nearly nonexistent.
174
Two published studies have
examined prospective associations of anxiety symptoms with vape and cigarette use among
young adults. One found that anxiety symptoms predicted cigarette but not vape use over a two-
year follow-up,
157
while the other found that anxiety symptoms predicted neither cigarette nor
vape initiation over a one-year follow-up.
94
However, both of these utilized data from samples of
college students, which limits generalizability to the broader population of young adults, and
neither study examined panic or social symptoms. A cross-sectional analysis of 9
th
grade
students from an earlier wave of the cohort used in the present study found that generalized,
25
panic, and social symptoms were all associated with lifetime cigarette use, but only panic
symptoms were associated with lifetime vape use.
158
This suggests that various anxiety
symptomology subtypes may have differential associations with vape and cigarette use among
young people, and understanding these differential associations can inform tobacco prevention
interventions tailored to specific symptomology subtypes and tobacco products that are
particularly relevant to young people with anxiety. We sought to examine prospective
associations of three anxiety symptomology subtypes assessed during senior of high school
(generalized, panic, and social) with cigarette and vape initiation in early adulthood.

Methods
Participants
We utilized data from three recent waves of the Happiness & Health (H&H) Study, a
prospective population-based cohort of 3396 youth recruited in 2013 from 9
th
grade classrooms
in ten public high schools in the Los Angeles area. The cohort completed questionnaires in
classrooms through the end of high school and subsequently completed online questionnaires in
early adulthood. In the current study, baseline data were from senior year of high school (fall
2016 semester [N=2737]) and from two follow-up questionnaires (October 2018-October 2019
[N=2686] and May 2020-October 2020 [N=2436]) were used in analyses. The analytic sample
was restricted to participants who did not ever use e-cigarettes, cigarettes, hookah, nor cigars
prior to baseline (N = 1191).

26
Ethics Statement
This study was approved by the University of Southern California Institutional Review
Board. When participants were under the age of 18, parental informed consent and participant
assent was obtained prior to data collection. All participants over age 18 provided informed
consent, prior to data collection.

Measures
Anxiety symptoms: Presence of anxiety symptoms for three subtypes (generalized, panic,
and social) were assessed with the respective subscales of the Revised Children’s Anxiety and
Depression Scale (RCADS-GAD, RCADS-PD, and RCADS-SP, respectively).14 Exact item text
for each of the three subscales can be found in Figure 3. Respondents indicated how often the
statements presented are true on a four-point scale: Never (0), Sometimes (1), Often (2), Always
(3). Responses were summed then weighted. Respondents whose weighted scores met
subclinical or clinical threshold for each of the subscales were coded as having anxiety
symptoms for the respective subtype, and respondents whose scores were below the subclinical
threshold were coded as no anxiety symptoms.
Vape and cigarette initiation: At baseline, participants were asked if they had ever used e-
cigarettes, cigarettes, hookah, little cigars/cigarillos, or big cigars. Those who reported ever use
of any of these five product types were excluded from the analytic sample. Those who reported
ever vape use at follow-up were coded as “vape initiation” (vs. never use), and those who
reported ever cigarette use at follow-up were coded as “cigarette initiation” (vs. never use).
Covariates: Race (American Indian or Alaska Native, Asian, Black or African American,
Native Hawaiian or Pacific Islander, White, Multiracial, Other) and ethnicity (Hispanic/Latino
27
vs. not Hispanic/Latino) were assessed separately then combined into one four-level
race/ethnicity variable prior to analyses: Non-Hispanic white (ref), non-Hispanic Asian
American and Pacific Islander (AAPI), Hispanic/Latino (any race), and non-Hispanic
underrepresented racial groups. Gender included two response options: male and female.
Participants were asked whether they qualified for free or reduced lunch at school; those who
indicated that they qualified for either free or reduced lunch were categorized as qualifying for
free/reduced lunch (vs. did not qualify).

Statistical Analyses
Descriptive statistics were calculated with the PROC FREQ procedure in SAS v. 9.4.
Then, binary logistic regression models (PROC LOGISTIC) were used to estimate odds ratios
and 95% confidence intervals for vape and cigarette initiation (vs. never use) as a function of
three anxiety subtypes (symptoms vs. no symptoms). Two co-adjusted models (one for each
outcome) were run that included all three primary predictors as well as sociodemographic
covariates (race/ethnicity, gender, and free/reduced lunch). Minimally adjusted odds ratios and
95% confidence intervals were also generated for each exposure and outcome combination (6
estimates total).

Results
Sample characteristics
Nearly half of the sample identified as Hispanic/Latino ethnicity (42%; n=496), followed
by non-Hispanic AAPI (26%; n=313), then non-Hispanic white (16%; n=191) (Table 1). There
were more females (58%; n=689) than males (41%; n=492). For free/reduced lunch, 40%
28
(n=474) qualified and 56% (n=668) did not qualify. At baseline, 12% had elevated generalized
anxiety symptoms (n=147), 12% had elevated panic symptoms (n=140), and 15% had elevated
social symptoms (n=184). At follow-up, 32% had initiated vaping (n=385) and 10% had initiated
smoking (n=123).

Vape and cigarette initiation
Neither generalized, panic, nor social symptoms were significantly associated with vape
initiation in early adulthood (Table 2). Generalized anxiety symptoms showed a negative
association (aOR=0.77 [95% CI: 0.49-1.20]), while panic and social symptoms showed positive
associations (aOR=1.25 [0.83-1.90] and aOR=1.29 [0.87-1.92], respectively).
Among those with panic symptoms, 18% initiated smoking by the follow-up wave (vs.
9% among those without panic symptoms), and this symptomology subtype was associated with
greater odds of smoking initiation at follow-up in both unadjusted and adjusted models
(aOR=2.07 [1.19-3.60]; Table 3). In co-adjusted models, generalized anxiety symptoms showed
a positive association that did not reach statistical significance (aOR=1.27 [0.67-2.38]) and social
symptoms showed a null association (aOR=0.97 [0.53-1.77]).

Discussion
This study among adolescents and young adults from Southern California provides novel
insight into prospective associations of anxiety symptomology subtypes with tobacco vape and
cigarette initiation during early adulthood. Our primary findings were: 1) more than one-third of
young adults who did not use tobacco products during adolescence had initiated use of at least
one tobacco product within three years of graduating high school, 2) one in four adolescent never
29
tobacco users had at least one subtype of anxiety symptoms, and 3) panic symptoms in
adolescence were positively associated with cigarette initiation in early adulthood. Given that
12% of adolescents in our sample had panic symptoms, and nationally representative data show
that 28% of the general population will experience at least one panic attack in their lifetime,
172

anti-smoking interventions that are tailored to individuals with panic symptoms have the
potential to resonate with a sizable portion of the population. Such interventions should be
evidence-based, and our findings suggest that tailoring interventions to the experiences of
individuals with panic symptoms is worth further investigation. Future research might examine
underlying motivations for smoking among those with panic symptoms.
Our finding that panic symptoms were not associated with vaping initiation is
inconsistent with self-medication theory. The differential associations observed in the present
study are significant because, within the biopsychological framework of self-medication theory,
any nicotine-containing product would accomplish the desired goal of using nicotine to self-
medicate anxiety symptoms; however, if the prospective association of anxiety symptoms with
tobacco initiation was purely driven by psychobiological motivations (i.e., nicotine self-
medication), then we would not have found differential associations of panic symptoms with
vaping and smoking initiation. Socio-environmental factors likely drive the selection of the
specific nicotine product that an individual with panic symptoms ultimately uses to self-
medicate, such as peer influences which are particularly salient among young people.
35,36,40,42,178

This finding is also significant because – coupled with our finding that panic symptoms were
associated with cigarette initiation – not only are adolescents with panic symptoms more like to
initiate nicotine use in early adulthood, they are also more likely to initiate with cigarettes which
are (based on current evidence) substantially more harmful to health than nicotine vapes.
150

30
Because adolescents and young adults are more likely to develop nicotine dependence, and
consequently smoking-related disease, preventing initiation among non-users and preventing
escalation among experimental users with panic symptoms might reduce tobacco-related health
disparities.
120,136,154

We found that panic symptoms in adolescence were positively associated with early
adulthood cigarette initiation. Given that the physiological effects of nicotine mimic panic
symptoms (e.g., increased heart rate and respiration), most prior work (in mostly clinical samples
of adults) makes the a priori assumption that cigarette use precedes panic symptoms, although
there is evidence of a bidirectional association.
175,179,180
While our finding is consistent with self-
medication theory,
109–111,181
it is unclear why individuals with panic symptoms would be
motivated to self-administer a drug that might feel like a panic attack. It is possible that
individuals with panic symptoms are more likely to experience the sedative effects of nicotine
because of differences in smoking behavior. An in-lab puff topography study among 124 non-
treatment seeking adult cigarette smokers found differences in puff trajectories between those
with and without a history of panic attacks, such that individuals with a history of panic attacks
prefer steady and gradual increases in nicotine levels opposed to a rapid increase followed by a
drop in nicotine levels.
182
This suggests that individuals with panic symptoms make a deliberate
and conscious effort to smoke each cigarette, which may be primarily driven by preventing
withdrawal symptoms, opposed to those without panic symptoms who may be primarily
motivated by relieving withdrawal symptoms. More research into potential differences in
smoking motivations would be useful for developing anti-tobacco interventions tailored to
individuals with panic symptoms.
31
Despite the notable contributions the present study makes to the understanding of anxiety
symptoms with tobacco initiation among young people, it is not without limitations. The RCADS
subscales alone are insufficient for clinical diagnostics, thus, what is represented in the present
study are anxiety symptoms that are associated with various anxiety disorder subtypes described
in the DSM-5. It is unlikely that everyone who was coded as having elevated symptoms in our
sample would meet the full diagnostic criteria in a clinical setting. However, the RCADS is a
well-validated approach to estimating severity of anxiety symptomology (whether clinically
significant or not) when diagnostic interviews are not feasible.
14,14,16
Data were drawn from a
cohort of adolescents and young adults from southern California, so it is unclear the extent to
which our findings extend to other regions in the U.S. The follow-up data collection period
ended in October 2020, approximately seven months following the onset of the COVID
pandemic and subsequent lockdown orders in California, and this unparalleled socio-
environmental context may have affected tobacco use behaviors among young adults in our
sample.

32
Conclusions
Adolescents and young adults with anxiety symptoms are a priority population in tobacco
control, and our findings suggest that adolescents with panic symptoms are at a particularly
greater risk of smoking initiation in early adulthood. Given rapid increases in anxiety symptoms
among young people in recent years, preventing smoking initiation among this high-risk
population will become increasingly relevant in tobacco-related disparities research. Future
research should further explore smoking motivations among young people with panic symptoms
and examine associations of anxiety symptomology subtypes and tobacco use among young
adults after they have already initiated.

33
Table 1. Sample Characteristics for Study 1

TOTAL
N = 1191
N (col %)
Race/ethnicity
Non-Hispanic white 191 (16%)
Non-Hispanic AAPI 313 (26%)
Hispanic/Latino 496 (42%)
NH underrepresented 170 (14%)
Gender
Male 492 (41%)
Female 689 (58%)
Free/reduced lunch
Did not qualify 668 (56%)
Qualified 474 (40%)
Generalized symptoms
No 965 (81%)
Yes 147 (12%)
Panic symptoms
No 970 (81%)
Yes 140 (12%)
Social symptoms
No 925 (78%)
Yes 184 (15%)
Vaping initiation
No 806 (68%)
Yes 385 (32%)
Smoking initiation
No 1068 (90%)
Yes 123 (10%)
Hookah initiation
No 1082 (91%)
Yes 109 (9%)
Cigar initiation
No 1124 (94%)
Yes 67 (6%)
Column percentages may not sum to 100% due to missing data.

34
Table 2. Frequencies and Odds Ratios for Vape Initiation in Early Adulthood

N (row %) OR (95% CI)

Never
use
Vaping
initiation
minimally adjusted co-adjusted
Generalized symptoms
No 651 (67%) 314 (33%) ref ref
Yes 102 (69%) 45 (31%) 0.94 (0.64-1.38) 0.77 (0.49-1.20)
Panic symptoms
No 662 (68%) 308 (32%) ref ref
Yes 89 (64%) 51 (36%) 1.26 (0.86-1.84) 1.25 (0.83-1.90)
Social symptoms
No 632 (68%) 293 (32%) ref ref
Yes 119 (65%) 65 (35%) 1.22 (0.87-1.71) 1.29 (0.87-1.92)

Minimally adjusted models (3 total) included a single exposure variable and demographic variables. One
co-adjusted model included all three exposure variables as well as demographic variables. Generalized
Anxiety, Panic Disorder, and Social Phobia were measured at baseline with the RCADS subscales
(RCADS-GAD, RCADS-PD, and RCADS-SP, respectively).

35
Table 3. Frequencies and Odds Ratios for Cigarette Initiation in Early Adulthood
N (row %) OR (95% CI)

Never
use
Cigarette
initiation
minimally adjusted co-adjusted
Generalized symptoms
No 872 (90%) 93 (10%) ref ref
Yes 127 (86%) 20 (14%) 1.52 (0.89-2.59) 1.27 (0.67-2.38)
Panic symptoms
No 882 (91%) 88 (9%) ref ref
Yes 115 (82%) 25 (18%) 2.25 (1.37-3.70) ** 2.07 (1.19-3.60) *
Social symptoms
No 834 (90%) 91 (10%) ref ref
Yes 162 (88%) 22 (12%) 1.25 (0.75-2.07) 0.97 (0.53-1.77)

Minimally adjusted models (3 total) included a single exposure variable and demographic variables. One
co-adjusted model included all three exposure variables as well as demographic variables. Generalized
Anxiety, Panic Disorder, and Social Phobia were measured at baseline with the RCADS subscales
(RCADS-GAD, RCADS-PD, and RCADS-SP, respectively). Vaping initiation was defined as ever e-
cigarette use at the follow-up wave. * p < 0.05; ** p < 0.01

36
Figure 4. Revised Children's Anxiety and Depression Scale Items

RCADS-GAD RCADS-PD RCADS-SP
“How often do these things happen to you?”

[Never, Sometimes, Often, Always]
I worry about things.
All of a sudden, I feel really
scared for no reason at all.
I worry that I will do badly at
my schoolwork.
I worry that something awful
will happen to someone in my
family.
When I have a problem, my
heart beats really fast.
I worry I might look foolish.
I worry that bad things will
happen to me.
My heart suddenly starts to beat
too quickly for no reason.
I worry about making mistakes.
I worry that something bad will
happen to me.
I suddenly start to tremble or
shake when there is no reason
for this.
I worry what other people think
of me.
I worry about what is going to
happen.
When I have a problem, I get a
funny feeling in my stomach.
I feel afraid that I will make a
fool of myself in front of
people.
I think about death.
I suddenly become dizzy or
faint when there is no reason for
this.
I worry when I think I have
done poorly at something.

I worry that I will suddenly get
a scared feeling when there is
nothing to be afraid of.
I feel worried when I think
someone is angry with me.

I feel scared when I have to take
a test.

I feel afraid if I have to talk in
front of my class.
37

Chapter 3: Associations of Nicotine Vape and Cigarette Use with Anxiety
Symptoms among Adolescents and Young Adults

38
Abstract
Objective: The early adulthood developmental period is associated with increased anxiety
symptoms and susceptibility to tobacco use. Despite high rates of vape use and anxiety
symptoms among adolescents and young adults, the association between the two has received
relatively little attention in the tobacco literature. Prior work on the association between anxiety
symptoms and cigarette use has yielded inconsistent results. It is possible that the associations of
vape and cigarette use with anxiety symptoms vary across developmental stages in early
adulthood. Understanding how the association of tobacco use behaviors with anxiety symptoms
may vary across different developmental stages in early adulthood can help inform evidence-
based anti-tobacco programming tailored to the specific experiences among young people with
anxiety symptoms, which may reduce tobacco-related mental health disparities. We examined
cross-sectional associations of nicotine vape and cigarette use with anxiety symptoms at three
different timepoints in early adulthood.
Methods: Three waves of data were drawn from a cohort study in Southern California Wave 1
(W1; adolescence; N=2737) was measured in the fall of 2016; Wave 2 (W2; early adulthood;
N=2686) from October 2018-2019, and Wave 3 (W3; COVID-19 pandemic; N=2436) from
May-October 2020. Anxiety symptoms were measured with the Revised Children’s Anxiety and
Depression Scale (RCADS) at W1 and the Generalized Anxiety Disorder-7 (GAD-7) at W2 and
W3. Two binary logistic regression models at each wave estimated odds ratios (OR [95% CI])
for anxiety symptoms as a function of 1) past six-month vape and cigarette use and 2) past thirty-
day vape and cigarette use (yes vs. no). Covariates included race/ethnicity, gender, financial
status.
Results: 12% of adolescents and 19% of young adults had anxiety symptoms. Past 6-month
cigarette use was associated with anxiety symptoms at W1 (OR=1.98 [1.15-3.43]), W2 (1.70
39
[1.19-2.43]), and W3 (OR=1.80 [1.26-2.57]), and past 6-month vape use was not associated with
anxiety symptoms at W1 (OR=0.82 [0.52-1.29]), W2 (0.97 [0.76-1.25]), nor W3 (OR=1.29
[0.99-1.67]). Past 30-day cigarette use was only associated with anxiety symptoms at W3
(OR=1.71 [1.12-2.60]), not at W1 (OR=1.32 [0.66-2.62]) or W2 (OR=1.50 [0.99-2.26]). Past 30-
day nicotine vape use was not associated with anxiety symptoms at W1 (OR=1.25 [0.71-2.22]),
W2 (OR=0.88 [0.65-1.19]), nor W3 (1.23 [0.93-1.65]).
Conclusion: Cigarette use was associated with anxiety symptoms at three distinct developmental
phases in early adulthood, but vape use was not. This is significant because cigarettes are more
harmful to health than vapes, and disproportionate cigarette use among young people with
anxiety symptoms may further drive tobacco-related disparities. Evidence-based anti-tobacco
programming tailored to young people with anxiety symptoms might focus on cigarette use,
specifically, based on our findings.

40
Introduction
The developmental transition from adolescence to early adulthood is characterized by
profound changes in nearly all aspects of life, which may influence anxiety symptoms, tobacco
use, or the association between the two. During adolescence, an immature prefrontal cortex and
greater hormone levels can impact tobacco use behavior and anxiety symptoms.
6
In early
adulthood, rapid transitions in one’s social environment (e.g., residential changes)
118,119
can
increase vulnerability to psychosocial stress and anxiety,
120
as well as tobacco use.
183
This is
significant because adolescents and young adults and individuals with anxiety symptoms are
more likely to develop nicotine dependence,
29,30,32,135,184
which indirectly contributes to tobacco-
related morbidity and mortality via sustained tobacco use.
23
Thus, young people with anxiety
symptoms are a uniquely vulnerable population that may benefit from anti-tobacco interventions
tailored to their needs and experiences.
155

Amidst the already increased susceptibility to tobacco use characteristic of early
adulthood, young adults in recent years now bear the public health burden of the vaping
epidemic that began in approximately 2017. During their most vulnerable period of development,
Monitoring the Future reported a record increase in vaping among young people from 2017-
2018.
58
Consequently, many regulatory bodies attempted to curb this epidemic with various
policies, such as flavor restrictions,
18585
which resulted in ever-changing access to vape products
and emergence of new products seeking to fill market voids.
47,104,186
These frequent market shifts
played out over a relatively short period of time (approximately three years). Then, in 2020,
young adults were again burdened with another public health crisis: the COVID-19 pandemic.
Anxiety symptoms among young people have increased rapidly in recent years,
133
and the
COVID-19 pandemic will undoubtedly exacerbate the already declining mental health among
41
young people of today.
125,128,130
It is not yet clear whether any changes in tobacco use, or its
association with anxiety symptoms, during the COVID-19 pandemic will persist.
187–194195

To better understand how the association of nicotine use and anxiety may change over the
early adulthood developmental period, we examined cross-sectional associations of nicotine vape
and cigarette use with anxiety symptoms at three distinct developmental periods using data from
a cohort study in Southern California. First, we evaluated this association among adolescents
during senior year of high school (fall 2016), then young adults prior to turning age 21 (October
2018-2019), then young adults after turning 21 (May-Oct 2020).

Methods
Participants
We utilized data from three recent waves of the Happiness & Health (H&H) Study, a
prospective cohort of 3396 youth recruited in 2013 from 9
th
grade classrooms in ten public high
schools in the Los Angeles area. The cohort completed questionnaires in classrooms through the
end of high school and subsequently completed online questionnaires in early adulthood. Wave 1
(W1) data were collected in the fall of 2016, Wave 2 (W2) from October 2018-October 2019,
and Wave 3 (W3) from May-October 2020 (Figure 4).

Ethics Statement
This study was approved by the University of Southern California Institutional Review
Board. When participants were under the age of 18, parental informed consent and participant
assent was obtained prior to data collection. All participants over age 18 provided informed
consent, prior to data collection.
42
Measures
Nicotine vape and cigarette use: At each wave, and separately for each product type,
participants were asked if they had used e-cigarettes or cigarettes in the past six months; a
response of “Yes” was considered past 6-month use of that respective product (vs. no past 6-
month use). Participants were asked how many days they used e-cigarettes and cigarettes in the
past thirty days (range: 0-30); participants who said they smoked on more than zero days were
considered past 30-day users of the respective product (vs. no past 30-day use)
Anxiety symptoms: Generalized anxiety symptoms (yes vs. no) served as a binary
outcome variable (Figure 5). At W1, anxiety symptoms were measured using the Generalized
Anxiety subscale of the Revised Children’s Anxiety and Depression Scale (RCADS-GAD),
which includes six items and is an appropriate standardized measure for use with adolescents.
14,16

Respondents whose scores met borderline or clinical threshold were coded as having anxiety
symptoms, and respondents whose scores did not meet borderline or clinical threshold were
coded as not having symptoms. At W2 and W3, anxiety symptoms were instead measured using
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 and is an appropriate
standardized measure for use with young adults and adults.
13
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 last two weeks.
Numeric responses to these seven questions were summed (range=0-21) then categorized as
“elevated anxiety symptoms” (GAD-7 score > 10) or “minimal anxiety symptoms” (GAD-7
score < 10) per recommended scoring guidelines provided by the survey developer.
43
Covariates: Race and ethnicity were ascertained at W1 and were considered time
invariant in the present study. Race (American Indian or Alaska Native, Asian, Black or African
American, Native Hawaiian or Pacific Islander, White, Multiracial, Other) and ethnicity
(Hispanic/Latino vs. not Hispanic/Latino) were assessed separately then combined into one four-
level race/ethnicity variable prior to analyses: non-Hispanic Asian American and Pacific Islander
(AAPI), non-Hispanic white, Hispanic/Latino (any race), and non-Hispanic underrepresented
racial groups. At W1, gender included two response options: male and female. Income level was
assessed separately at each wave. At W1, participants were asked whether they qualified for free
or reduced lunch at school; those who indicated that they qualified for either free or reduced
lunch were categorized as qualifying for free/reduced lunch (vs. did not qualify). At W2 and W3,
the Subjective Financial Situation scale (SFS) was used to estimate income level.
196
Participants
were asked to consider their current financial situation with the following response options: live
comfortably, meet needs with a little left, just meet basic expenses, and do not meet basic
expenses. Live comfortably was categorized as high SFS, meet needs with a little left as
moderate SFS, and just meet basic expenses and do not meet basic expenses were collectively
considered low SFS.

Statistical Analyses
Descriptive statistics were calculated with the PROC FREQ procedure in SAS v. 9.4.
Then, binary logistic regression models (PROC LOGISTIC) were used to estimate odds ratios
and 95% confidence intervals for anxiety symptoms (vs. no symptoms) at each wave. The four
primary predictors of interest included past 6-month vape use (vs. no past 6-month use), past 6-
month cigarette use (vs. no past 6-month use), past 30-vape use (vs. no past 6-month use), and
44
past 30-day cigarette use (vs. no past 6-month use). Two co-adjusted models were run at each
wave, and both included race/ethnicity, gender, and income level as covariates: 1) past 6-month
vape and past 6-month cigarette use and 2) past 30-day vape and past 30-day cigarette use.

Results
Sample characteristics
Because sociodemographic variables did not differ substantially across waves,
frequencies were generated among a collapsed sample of participants who contributed to at least
one wave in the present study (N=3147) (Table 4). Nearly half (47%; n=1484) were
Hispanic/Latino ethnicity, followed by NH AAPI (17%; n=539), then NH white (16%; n=510);
16% (n=511) fell into the underrepresented racial groups category. There were more females
(46%; n=1460) than males (39%; n=1239). At W1, 40% qualified for free or reduced lunch
(n=1227). At W2, 34% were coded as having high SFS (n=1081), 22% as moderate SFS
(n=678), and 20% as low SFS (n=633). Similarly, at W3, 33% had high SFS (n=1055), 23%
moderate SFS (n=710), and 19% low SFS (n=596).

Vape and cigarette use
The prevalence of past 6-month vape use more than doubled between W1 (12%) and W2
(25%), then remained the same in W3 (25%) (Table 5 and Figure 6). The prevalence of past 30-
day vape use also more than doubled between W1 (6%) and W2 (14%), then increased slightly
by W3 (19%). For cigarette use, past 6-month use increased steadily across all three waves (6%,
9%, and 10%, respectively), as did past 30-day cigarette use (4%, 6%, and 7%, respectively).

45
Anxiety symptoms
At W1, 12% were coded as having anxiety symptoms based on RCADS scores (n=329).
The prevalence of anxiety symptoms was 19% for both W1 (n=516) and W2 (n=463). Past 6-
month cigarette use was associated with anxiety symptoms at W1 (OR=1.98 [1.15-3.43]), W2
(1.70 [1.19-2.43]), and W3 (OR=1.80 [1.26-2.57]), and past 6-month vape use was not
associated with anxiety symptoms at W1 (OR=0.82 [0.52-1.29]), W2 (0.97 [0.76-1.25]), nor W3
(OR=1.29 [0.99-1.67]) (Table 6). Past 30-day cigarette use was only associated with anxiety
symptoms at W3 (OR=1.71 [1.12-2.60]), not at W1 (OR=1.32 [0.66-2.62]) or W2 (OR=1.50
[0.99-2.26]). Past 30-day nicotine vape use was not associated with anxiety symptoms at W1
(OR=1.25 [0.71-2.22]), W2 (OR=0.88 [0.65-1.19]), nor W3 (1.23 [0.93-1.65]).

Discussion
We examined cross-sectional associations of cigarette and nicotine vape use with anxiety
symptoms across three recent waves of data (each representing a distinct developmental period)
drawn from a diverse cohort of young adults from Southern California. We found that 1) past
six-month cigarette use was positively associated with anxiety symptoms at all three waves, 2)
past thirty-day cigarette use was associated with anxiety symptoms at the COVID wave but not
at other waves, 3) neither past six-month nor past thirty-day vape use were associated with
anxiety symptoms. The spike in vape prevalence observed from adolescence to early adulthood
in the present study is consistent with a prior analysis of PATH data showing that susceptibility
to vapes and cigarettes peaked between ages 18 and 19
183
and aligns with the timing of the
vaping epidemic (W1 was collected in 2016 and W2 in 2018-2019). Our findings lend consistent
46
evidence suggesting a link between anxiety symptoms and cigarette use, but not vape use, among
young people.
Since approximately 2017, rapid and reactive changes in the vaping product market
created an environment where access to various vaping products was constantly changing.
Piecemeal regulatory attempts to curb the vaping epidemic contributed to an unstable and
uncertain vaping product market that may have influenced tobacco use.
85

47,104,186185
In contrast,
cigarette regulations remained consistent during this time frame in the state of California (T21
had already been in effect since June of 2016). The product consistency and reliable access to
cigarettes – opposed to the uncertainty associated with a destabilized vaping product market –
may have been uniquely appealing to young adults with anxiety symptoms. Future research
might explore whether tobacco control policies that restrict access to cigarettes influence
cigarette use among young adults with anxiety symptoms.
Given that W3 was the first wave of the study that participants were legally able to
purchase tobacco products in the state of California, it is somewhat surprising that we did not
observe an substantial increase in tobacco use between W2 and W3. This, of course, could easily
be explained by the COVID-19 pandemic, which may have introduced barriers to tobacco
use.
190,195,197
Additionally, based on our data collection timeline, EVALI may have also
influenced tobacco use behavior during the COVID-19 wave (W3). Per Nielsen data, the sales
of all vaping products peaked in August 2019 (at over $400 million),
84,85
which is the same
month that the CDC reported the first case of E-cigarette, or Vaping, Product Use-Associated
Lung Injury (EVALI).
107
Some evidence suggests that health scares related to EVALI may have
affected tobacco use among young people, perhaps because 37% of EVALI cases were among
young adults. One study of 3,536 adolescents and young adults (aged 15-25 years) conducted
47
between September 2019 and January 2020 found that awareness of and fears about EVALI were
associated with greater perceived risks of nicotine vaping among both current and non-users, as
well as greater odds of intending to quit in the future among current users.
106
Further, an analysis
of Nielsen sales data found that EVALI deaths were associated with a decline in vape and
cigarette sales.
84
Thus, health fears associated with EVALI, coupled with additional health scares
brought on by COVID, may have discouraged tobacco use among our cohort.
This study is not without limitations. Because all three analytic samples were drawn from
the same cohort, it is unclear whether findings were driven by external changes in the social
environment or whether they are due to natural developmental maturity that would have occurred
regardless of the greater context. Anxiety symptoms were measured with the RCADS-GAD in
the adolescent wave and with the GAD-7 in both early adulthood waves, so the extent to which
associations between the adolescent and early adulthood waves are comparable is unclear.
Further, neither of these questionnaires alone are sufficient for a clinical diagnosis of an anxiety
disorder; clinical diagnostic interviews are necessary to rule out other causes.
12
However, these
measures have been shown to reliably ascertain anxiety symptoms in survey research when such
formal interviews are not feasible.
13,14
We only examined and adjusted for variables that were
available at all three waves to maintain consistency. The data collection period for the second
wave was twice as long as the first and third waves.

Conclusions
Young people with anxiety symptoms are a priority population in tobacco control
research given their overlapping increased risk of developing nicotine dependence. As such,
data-driven tobacco control interventions are needed to protect this group from long-term health
48
consequences of tobacco use and anxiety symptoms. Fortunately, this period of greater
vulnerability also means that population-level interventions aimed to prevent tobacco use and
mitigate anxiety symptoms among this age group would be expected to have the greatest long-
term benefits.
120,133
Adolescents and young adults with anxiety symptoms may benefit from
tailored anti-smoking interventions, specifically.

49
Table 4. Sample Characteristics for Study 2

Participants who contributed to at least one of the three waves (N=3147). Frequencies and column
percentages for sociodemographic variables. Column percentages may not sum to 100% due to missing
data.

N (col %)
Race/ethnicity
Non-Hispanic white 510 (16%)
Non-Hispanic AAPI 539 (17%)
Hispanic/Latino 1484 (47%)
Non-Hispanic underrepresented 511 (16%)
Gender (W1)
Male 1239 (39%)
Female 1460 (46%)
Free/reduced lunch (W1)
Did not qualify 1333 (42%)
Qualified 1277 (40%)
Subjective Financial Situation (W2)
High 1081 (34%)
Moderate 678 (22%)
Low 633 (20%)
Subjective Financial Situation (W3)
High 1055 (34%)
Moderate 710 (23%)
Low 586 (19%)
50
Table 5. Exposure and Outcome Variables by Wave
N (col %)

Wave 1
N = 2737
Wave 2
N = 2686
Wave 3
N = 2436
Past 6-month vape
None 2377 (87%) 1877 (70%) 1831 (75%)
Yes 334 (12%) 669 (25%) 597 (25%)
Past 6-month cigarette
None 2534 (93%) 2308 (86%) 2186 (90%)
Yes 158 (6%) 238 (9%) 242 (10%)
Past 30-day vape
No 2557 (93%) 2153 (80%) 1979 (81%)
Yes 158 (6%) 388 (14%) 457 (19%)
Past 30-day cigarette
No 2597 (95%) 2371 (88%) 2272 (93%)
Yes 109 (4%) 169 (6%) 164 (7%)
Anxiety symptoms
No 2088 (76%) 1843 (69%) 1895 (78%)
Yes 329 (12%) 516 (19%) 463 (19%)

Frequencies and column percentages for exposure and outcome variables by wave. Column percentages
may not sum to 100% due to missing data

51
Table 6. Odds Ratios for Anxiety Symptoms by Wave
Wave 1 Wave 2 Wave 3
Past 6-month vape
No ref ref ref
Yes 0.82 (0.52-1.29) 0.97 (0.76-1.25) 1.29 (0.99-1.67)
Past 30-day vape
No ref ref ref
Yes 1.25 (0.71-2.22) 0.88 (0.65-1.19) 1.23 (0.93-1.65)
Past 6-month cigarette
No ref ref ref
Yes 1.98 (1.15-3.43) ** 1.70 (1.19-2.43) ** 1.80 (1.26-2.57) **
Past 30-day cigarette
No ref ref ref
Yes 1.32 (0.66-2.62) 1.50 (0.99-2.26) 1.71 (1.12-2.60) *

Two co-adjusted models at each wave included either both past six-month variables or both past thirty-
day variables, as well as sociodemographic covariates (race/ethnicity, gender, income level). In Wave 1
(adolescence), anxiety was measured with the RCADS-GAD. In Waves 2 and 3 (early adulthood), anxiety
was measured with the GAD-7. * p < 0.05; ** P < 0.01

Figure 5. Data Collection Timeline for Study 2

June 2016 T21 law enacted in California
198

2017-2018 Spike in vaping among young people
58

November 2018 JUUL “voluntarily” pulls sweet-flavored pods from retail stores (available online until
October 2019)
85

August 2019 Nielsen vape sales peak (only includes retail brick-and-mortar stores, not online or local
vape shops)
84,85

September 2019 EVALI cases peak (37% of cases were among young adults)
107

November 2019 EVALI linked to vitamin E acetate found in some THC vaping products, opposed to
nicotine vapes
107

January 2020 FDA announces that sweet-flavored pod-style cartridges will be prohibited as of February
2020
185

53
Figure 6. RCADS-GAD, GAD-7, and DSM-5 Diagnostic Criteria for Generalized Anxiety
Disorder
RCADS-GAD GAD-7 DSM-5
“How often do these
things happen to you?”

Never, Sometimes, Often,
Always
“Over the last two weeks, how
often have you been bothered by
the following problems?”

Not at all, Several days, More
than half the days, Nearly every
day
A., B., and at least three C.

Symptoms cause significant distress,
have been present on most days in
the past 6 months, and are not better
explained by other causes.
I worry about things.
Worrying too much about
different things.
A. Excessive worry about a number
of events or activities
I worry that something
awful will happen to
someone in my family.
Not being able to stop or control
worrying.
B. Difficult to control worrying
I worry that bad things
will happen to me.
Feeling nervous, anxious, or on
edge. C. At least three of the following:
1. Restlessness or feeling on edge
2. Easily fatigued
3. Difficulty concentrating
4. Irritability
5. Muscle tension
6. Sleep disturbance
I worry that something
bad will happen to me.
Feeling so restless it is hard to sit
still.
I worry about what is
going to happen.
Trouble relaxing.
I think about death.
Becoming easily annoyed or
irritable.

Feeling afraid, as if something
awful might happen.

54
Figure 7. Prevalence of Vape and Cigarette Use by Wave

Anxiety symptoms were measured with the RCADS-GAD in W1 and with the GAD-7 in W2 and W3.
0
5
10
15
20
25
30
Nicotine vapes Cigarettes Nicotine vapes Cigarettes
Past 6-month use Past 30-day use
Prevalence (%)
Wave 1
N=2737
Wave 2
N=2686
Wave 3
N=2436

Chapter 4: Cross-Sectional Associations of Menthol Cigarette and Menthol-
Flavored Vape Use among Young Adults

56
Abstract
Objective: Both young adults and individuals with anxiety symptoms have greater risks of
developing nicotine dependence, thus, young adults with anxiety symptoms are a priority
population in tobacco control. Menthol cigarettes may be associated with anxiety symptoms
among young adults, but this association has not been examined for menthol-flavored vapes.
Such data are relevant for evolving regulations on menthol-flavored tobacco products.
Methods: Young adult (18-25 years old) past-month vape users were recruited via MTurk to
provide anonymous survey data between May-July 2019 (N=2339). Binary logistic regression
evaluated the associations of past-month menthol cigarette use (vs. non-menthol) and past-month
menthol vape use (vs. non-menthol) with anxiety symptoms (GAD-7 score > 10; yes vs. non
[ref]). One co-adjusted model included both primary predictors of interest, as well as nicotine
dependence (measured with the HONC), daily past month use of any tobacco product (vs. non-
daily past month use), and sociodemographic covariates (race/ethnicity, gender, and subjective
financial situation).
Results: In our sample of young adult past month vape users, 35% had anxiety symptoms, 43%
used menthol-flavored vapes, and among past month cigarette users (n=1435), 67% used
menthol cigarettes (41% of full N=2339 sample). The majority (68%) had at least one HONC
symptom and 26% reported daily use of any tobacco product. Past month menthol cigarette use
was positively associated with anxiety symptoms (aOR=1.28 [1.00-1.65]), but past month
menthol-flavored vape use was not (aOR=1.04 [0.82-1.31]).

57
Conclusion: Future research might examine more specific characteristics of menthol-flavored
vapes, such as across nicotine formulations and concentrations that might explain differences in
these findings. It is possible that factors beyond self-medication may explain the significant
association with menthol cigarettes, such as sensory properties unique to combustion or exposure
to menthol cigarette advertising.
58
Introduction
Individuals with mental health symptoms, including anxiety symptoms, are more likely to
use tobacco and have poorer cessation outcomes compared to those without, driving tobacco-
related disparities.
43,136,154
Considering that individuals younger than age 25 are at greater risk of
developing nicotine dependence, thereby increasing the risk for continued tobacco use and
downstream tobacco-related morbidity and mortality,
135
young adults with anxiety symptoms are
a distinctly vulnerable population in tobacco control. Understanding the nuances in the
relationship of tobacco use with anxiety symptoms among young adults is critical for developing
evidence-based interventions aimed to mitigate both anxiety symptoms and tobacco use in the
short-term, thereby improving long-term health outcomes.
Young adults with anxiety symptoms are more likely to use menthol cigarettes (opposed
to non-menthol),
163
which is concerning because menthol cigarettes are associated with greater
nicotine dependence and greater difficulty quitting.
199
The prevailing theory for the association
of tobacco use generally with anxiety symptoms is self-medication theory (i.e., individuals self-
administer nicotine-containing tobacco products to manage symptoms),
109,110
and menthol may
“boost” the perceived benefits derived from nicotine self-administration. Menthol creates
pleasant “cooling” sensations in the mouth and throat, and is associated with positive,
pleasurable, and other hedonistic responses to nicotine, all of which may be disproportionately
appealing to individuals with anxiety, above and beyond the reinforcing effects of nicotine.
163–165

Although cigarettes and vapes are distinct classes of products that carry distinct health risks and
social norms, they both deliver nicotine and therefore have the capacity to “self-medicate”
anxiety symptoms. Thus, it is reasonable to suspect that menthol-flavored vapes might also be
associated with anxiety. Albeit menthol-flavored vapes are not nearly as popular among young
59
adults as are sweet flavors.
200,201
However, some prior bans on flavored vape products have
excluded tobacco and menthol flavors from the prohibition, and some evidence suggests that,
when sweet-flavored are removed from the market, sales of menthol flavors increase. For
example, when vape brand JUUL withdrew their fruit-flavored vape pods from retail stores in
November 2018, Nielsen Scantrack data showed an immediate increase in menthol-flavored
JUUL pods being purchased,
85
and a similar increase in menthol-flavored vape products was
observed after JUUL removed their mint-flavored pods.
64
Thus, understanding correlates of
menthol-flavored vape use has relevance for future tobacco policy and research.
The association of tobacco use with anxiety symptoms among young adults has received
relatively little attention in the literature, particularly for novel tobacco products such as e-
cigarettes (vapes). A recent systematic review found only four studies that examined associations
of vaping and anxiety symptoms among young adults.
174
Only one of these four studies reported
a positive association – those who had ever used vapes (opposed to never use) were more likely
to have anxiety symptoms.
202
Two other studies found that anxiety symptoms were associated
with current cigarette use but not current vape use,
157,203
and one study did not find longitudinal
associations of anxiety symptoms with neither vape nor cigarette initiation.
94
All four studies
were conducted among samples of college students with limited generalizability and did not
examine the role of flavors. To address this gap, we collected anonymous survey data from
young adult past month vape users (N=2339) via Amazon MTurk and examined associations of
past month menthol cigarette and menthol-flavored vape use with anxiety symptoms as separate
product categories. Further, given limited data on the association of past month vaping with
anxiety symptoms among young adults in general,
174
we also examined associations of nicotine
60
dependence (measured with the Hooked On Nicotine Checklist) and frequency of past month
tobacco use (daily use vs. non-daily use) with anxiety symptoms.

Methods
Participants
Participants were recruited via Amazon Mechanical Turk (MTurk).
204–206
Anonymous
self-report data were collected from May-July 2019 (N=2339). To determine eligibility, potential
participants completed a brief screener survey administered via MTurk, and eligible participants
were then invited to participate in the full survey. To qualify for the full survey, participants had
to be adults 18-25 years old, used vapes at least once in the past 30-days, and live in the United
States. Further details on data collection procedures have been described previously.
207

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
Menthol Product Use: To determine menthol (vs. non-menthol) vape use, participants
were asked, “In the last 30 days, which flavors did you usually use (select all that apply).”
Response options included: flavorless, tobacco flavored, menthol or mint, sweet (fruit, candy,
dessert, buttery, etc.), and another flavor. Participants who selected “menthol or mint” were
coded as menthol users, and those who did not select “menthol or mint” were coded as non-
61
menthol users, regardless of other flavor categories selected. Use of menthol cigarettes was
assessed separately and only to those who said they used cigarettes in the past thirty days.
Participants who used cigarettes on more than 0 days were asked whether they used menthol,
non-menthol, or both menthol and non-menthol cigarettes; those who selected “menthol” or
“both menthol and non-menthol” were coded as menthol cigarette users, and those who selected
“non-menthol” were coded as non-menthol cigarette users.
Nicotine Dependence: Nicotine dependence was measured with the 6-item Hooked on
Nicotine Checklist (HONC).
208
Participants responded “Yes” (1) or “No” (0) to the following: 1)
Have you ever tried to quit tobacco, but couldn’t? 2) Do you use tobacco now because it is really
hard to quit? 3) Have you ever felt like you were addicted to tobacco? 4) Do you ever have
strong cravings to use tobacco? 5) Have you ever felt like you really needed to use tobacco? 6) Is
it hard to keep from using tobacco in places where you are not supposed to, like school or work?
“Yes” responses are summed to calculate the HONC score (range: 0-6), then dichotomized for
analysis (one or more symptoms vs. no symptoms).
Frequency Of Use: Participants were asked on how many days in the last 30 days they
had used vapes, cigarettes, hookah, and little cigars/cigarillos/big cigars with the following
response categories: 0 days, 1-2 days, 3-5 days, 6-9 days, 10-19 days, 20-29 days, and all 30
days. Frequency of past 30-day use for each product was modeled as a continuous predictor by
recoding as the mean value of each of the seven ordinal categories (i.e., rounding up to the
nearest integer) as follows: 0 days (0 days), 2 days (1-2 days), 4 days (3-5 days), 8 days (6-9
days), 15 days (10-19 days), 25 days (20-29 days), and 30 days (all 30 days).
209
Frequency of
past 30-day use ranged from 0-30 for cigarettes, hookah, and cigars, but ranged from 1-30 for
vapes. A categorical variable was created to represent daily use; those who said that they used
62
any tobacco product on all thirty days were coded as “daily use” and those who did not report
using any tobacco products on all thirty days were considered non-daily users (ref).
Anxiety Symptoms: Anxiety symptoms were assessed using the Generalized Anxiety
Disorder-7 (GAD-7), a seven-question scale that measures severity of symptoms related to
Generalized Anxiety Disorder over the past two weeks.
13
On a four-point scale that ranged from
“not at all” (0) to “nearly every day” (3), respondents indicated how often they have been
bothered by specific symptoms in the last two weeks. Numeric responses to these seven
questions were summed (range: 0-21) then categorized as “elevated anxiety symptoms” (GAD-7
score > 10) or “minimal anxiety symptoms” (GAD-7 score < 10) per recommended scoring
guidelines provided by the survey developer.
Covariates: Race (American Indian or Alaska Native, Asian, Black or African American,
Native Hawaiian or Pacific Islander, White, Multiracial, Other) and ethnicity (Hispanic/Latino
vs. not Hispanic/Latino) were assessed separately then combined into one three-level
race/ethnicity variable prior to analyses: non-Hispanic white (ref), Hispanic/Latino any race, and
non-Hispanic underrepresented racial groups. Response options for gender included:
male/masculine, female/feminine, transgender female, transgender male, non-binary/non-
conforming, or something else not listed. This variable was collapsed into three levels prior to
analyses (male, female, underrepresented gender identities). The Subjective Financial Situation
scale (SFS) was used to estimate income level.
196
Participants were asked to consider their
current financial situation with the following response options: live comfortably, meet needs
with a little left, just meet basic expenses, and do not meet basic expenses. Live comfortably was
categorized as high SFS, meet needs with a little left as moderate SFS, and just meet basic
expenses and do not meet basic expenses were collectively considered low SFS.
63
Statistical Analyses
Descriptive statistics were calculated with the PROC FREQ procedure in SAS v. 9.4.
Elevated anxiety symptoms (vs. minimal) served as a dichotomous outcome variable in four
minimally unadjusted and one co-adjusted logistic regression model as a function of past month
menthol cigarette use, past month menthol vape use, nicotine dependence, and frequency of
tobacco use. PROC LOGISTIC was used to generate unadjusted and adjusted odds ratios and
95% confidence intervals. Minimally adjusted models included a single exposure variable and
sociodemographic covariates (race/ethnicity, gender, and SFS), and the co-adjusted model
included all four primary exposure variables and covariates.

Results
Sample characteristics
More than half (62%; n=1448) were non-Hispanic white and 17% (n=402) were of
Hispanic/Latino ethnicity (Table 7). Gender was approximately balanced with 47% female
(n=1095) and 51% male (n=1198); 2% (n=46) were coded as underrepresented identities. One in
five were coded as High SFS (20%; n=478), followed by Moderate SFS (43%; n=998), then Low
SFS (37%; n=863). Nearly half (45%; n=1054) used two or more additional tobacco products in
the past month, and 30% (691) used one additional product; 25% (n=594) were exclusive vape
users. HONC scores ranged from 0-6 with a mean score of 2.53 (SD=2.21); 68% had at least one
nicotine dependence symptom (n=1595). One in four (26%) used at least one tobacco product
every day out of the past thirty days (n=617). The most common product used in the past month
was cigarettes (61%; n=1435), followed by cigars (43%; n=997), then hookah (40%; n=932).
Out of the past month cigarette users (n=1435), 67% (n=955) used menthol cigarettes in the past
64
month and 33% (n=480) used non-menthol cigarettes. Forty-three percent (43%; n=1013) used
menthol vapes in the last month.

Anxiety symptoms
Based on GAD-7 scores, 35% (n=813) had anxiety symptoms. Past month use of menthol
cigarettes was positively associated with anxiety symptoms in both minimally adjusted
(OR=1.34 [1.07-1.68]) and co-adjusted (OR=1.28 [1.00-1.65]) models, but past month menthol
vape use was not associated with anxiety symptoms in either model (co-adjusted OR=1.04 [0.82-
1.31]; Table 8). Nicotine dependence was positively associated with anxiety symptoms in both
minimally adjusted (OR=2.34 [1.72-3.20]) and co-adjusted (OR=2.23 [1.63-3.06]) models. Daily
(vs. non-daily) tobacco use was positively associated with anxiety symptoms in the minimally
adjusted model (OR=1.31 [1.04-1.65]) but this effect was no longer significant after co-
adjustment for other predictors (co-adjusted OR=1.19 [0.94-1.50]).

Discussion
Our cross-sectional study among a large sample of U.S. young adult past month vape
users found that menthol cigarettes, but not menthol vapes, were positively associated with
anxiety symptoms. This is consistent with previous research showing a positive association of
menthol tobacco product use with anxiety symptoms among young adults,
163
and we build on
this work by examining this association separately for cigarettes and vapes – the two most
common tobacco products among young adults. However, our finding is not consistent with self-
medication theory in the context of mentholated tobacco. If the psychobiological interaction
between menthol and nicotine was distinctively important for self-medication of anxiety
65
symptoms, then we would have observed significant associations of both menthol cigarettes and
menthol-flavored vapes with anxiety symptoms. Rather, social and environmental factors likely
drive the association of menthol cigarette use and anxiety symptoms among young adults, such
as sensory properties specific to combustion or predatory pro-tobacco marketing.
Despite the observed association of menthol cigarette use with anxiety symptoms in the
present study, we did not find a significant association of menthol-flavored vapes with anxiety
symptoms. There are at least several possible explanations for our null finding. The properties of
menthol change significantly during combustion, and these changes are distinct from those that
occur during vaporization. Combustible cigarettes also contain thousands of other chemicals that
may interact with nicotine when combusted and inhaled. Vapes are sold in a wide variety of non-
tobacco flavors whereas cigarettes are only sold as menthol or non-menthol; if young adults with
anxiety are indeed attracted to the sensory properties of menthol as previously suggested,
163
the
desired sensory effects may be achieved via flavors other than menthol (e.g., sweet flavors,
which are overwhelmingly preferred among this population) or other additives that can mimic or
enhance menthol’s effects.
165
Exposure to tobacco marketing is a key driver of tobacco use
among young people,
135
and the tobacco industry disproportionally targets individuals with
mental health symptoms by implying that their products promote relaxation pro-tobacco
marketing.
210
To our knowledge, such targeted marketing of menthol-flavored vapes towards
individuals with mental health symptoms has not yet been documented. Thus, targeted marketing
may partially explain the significant association of menthol cigarette use with anxiety symptoms,
and lack of targeted marketing may partially explain the null association of menthol-flavored
vapes with anxiety symptoms.
66
Our finding a positive association of menthol cigarette use with anxiety symptoms among
young adults is consistent with prior work.
163
It is well-understood that menthol cigarettes
facilitate smoking uptake, are more difficult to quit compared to non-menthol cigarettes, and are
a significant driver of tobacco-related disparities in use patterns and health outcomes.
167
In April
2021, the FDA announced its intent to ban menthol as a “characterizing flavor” in cigarettes,
which has the potential to improve public health.
211
The tobacco industry is motivated to keep
menthol products on the market, and exploiting regulatory loopholes and technicalities is a key
component of the tobacco industry’s business model.
105
Tobacco scientists can help FDA
develop specific policy components by providing data in support of specific definitions. For
example, if the legal definition for “characterizing flavor” is left too vague, tobacco
manufacturers can easily evade menthol flavor restrictions based on what we already know.
A few months after the FDA announced their imminent menthol ban, R.J. Reynolds
conveniently released Newport “Boost” cigarettes, which feature a capsule in the filter that that
the user can crush to add menthol flavoring to a previously non-menthol cigarette (and another
option to add more menthol on top of an already mentholated cigarette; Figure 7). This design
has been used by Camel Crush cigarettes since 2008, and more recently a vape company
mimicked this concept to evade vape flavor restrictions,
104
but this design has new implications
in light of a menthol cigarette ban, and the timing of this product release is suspicious (and
illegal). Newport Boost cigarettes and the like are technically manufactured as non-menthol
cigarettes with a mentholated flavor capsule in the filter and could technically be smoked as a
non-menthol cigarette if the user doesn’t crush the flavor capsule, which presents a clear
exploitable loophole based on a technicality. Focus group data showed that young adult menthol
cigarette users enjoyed the interactive “crushing” experience of Camel Crush cigarettes,
212

67
suggesting that young adults (and potentially other groups who disproportionately use menthol
cigarettes, including those with anxiety symptoms) may be at greater risk for continued cigarette
use if these menthol flavor capsule cigarettes are indeed excluded from the menthol ban.
Tobacco control scientists might monitor the prevalence of and examine correlates of menthol
flavor capsule cigarettes, specifically, to assist FDA with regulating these products
Moreover, all cigarettes contain some level of menthol, but not all are characterized and
marketed as menthol.
165,213,214
Without a precedent for menthol levels in non-menthol
characterized cigarettes, this exposes another opportunity for the tobacco industry to potentially
evade menthol cigarette regulations. Menthol enhances the effects of nicotine even at low
levels,
165,215,216
so one potential regulatory option could be to ban menthol as a tobacco additive
altogether. Alternatively, a maximum threshold level of menthol could be established wherein
the highest dose of menthol that does not enhance nicotine’s psychobiological effects is used as a
“cutoff” level that could be enforceable via biochemical verification of the product. Exploring
the feasibility and anticipated implications of these approaches is another area of future research
for tobacco scientists; the agency can only include these critical details in regulatory policies if
there are data supporting such details.
Results should be interpreted in light of several limitations. Although the GAD-7 was
developed based on DSM-IV criteria for Generalized Anxiety Disorder, greater GAD-7 scores
alone are not sufficient for a clinical diagnosis of an anxiety disorder; clinical diagnostic
interviews are necessary to rule out other causes. However, this measure has been shown to
reliably assess the severity of anxiety symptoms in survey research when such formal interviews
are not feasible.
13
Due to survey design, we were not able to measure the frequency of menthol
vape use relative to use of other vape flavors in the past month. Considering that all past month
68
cigarette users in our sample also used vapes in the past month (but not all vape users smoked
cigarettes), it is possible that our observed effect of menthol was instead driven by dual use of
two tobacco products, which we previously found to be positively associated with anxiety
symptoms compared to exclusive vape use.
207
However, if menthol did not play a significant role
in this association, then we would not have found differences between menthol and non-menthol
cigarette use. The cross-sectional nature of present analyses does not allow us to draw
conclusions about temporal relationships. Self-report and self-selection bias are inherent to
online survey studies. Although previous analyses have found that results from MTurk samples
are consistent with results derived from probability sampling methods,
206
the generalizability of
the present study’s findings is unclear.

Conclusions
The association of menthol-flavored tobacco use with anxiety symptoms among young
adults may vary across tobacco product types, suggesting that biopsychology of nicotine alone
does not fully explain the association of anxiety symptoms with menthol tobacco use among
young adult vape users. Rather, sensory properties specific to combustion or disproportionate
exposure to menthol cigarette advertising may at least partially drive this relationship. Future
research should examine associations of anxiety symptoms with other menthol-flavored vape
product characteristics, such as nicotine formulation, that were not available to investigate in the
present study. Further, data are needed to support inclusion of precise, data-driven language into
the FDA’s menthol cigarette ban policy that will limit foreseeable opportunities for menthol
cigarette manufacturers to exploit regulatory loopholes.

69
Table 7. Sample Characteristics for Study 3
N (col %) M (SD)
Race/ethnicity
Non-Hispanic white 1448 (62%) -
Hispanic/Latino 402 (17%) -
Non-Hispanic underrepresented 489 (21%) -
Gender
Male 1198 (51%) -
Female 1095 (47%) -
Underrepresented identities 46 (2%) -
Subjective Financial Situation
High 478 (20%) -
Moderate 998 (43%) -
Low 863 (37%) -
Past 30-day tobacco use pattern
Exclusive vape use 594 (25%) -
Dual use 691 (30%) -
Poly-use 1054 (45%) -
Nicotine dependence
No HONC symptoms 744 (32%) -
One or more HONC symptoms 1595 (68%) -
Past month daily vape use
No 1933 (83%) -
Yes 406 (17%) -
Past month cigarette use
No 904 (39%) -
Yes 1435 (61%) -
Daily cigarette use (n=1435)
No 1200 (84%) -
Yes 235 (16%) -
Past month hookah use
No 1407 (60%) -
Yes 932 (40%) -
Daily hookah use (n=932)
No 908 (97%) -
Yes 24 (3%) -
Past month cigar use
No 1342 (57%) -
Yes 997 (43%) -
Daily cigar use (n=997)
No 946 (95%) -
Yes 51 (5%) -
Past month daily tobacco use (any product)
No 1722 (74%) -
Yes 617 (26%) -
Frequency of past month use (# days)
Vape (range: 1-30) - 13.39 (10.45)
70
Cigarette (range: 0-30) - 7.30 (10.11)
Hookah (range: 0-30) - 2.78 (5.67)
Cigar (range: 0-30) - 3.39 (6.54)

Table 8. Frequencies and Odds Ratios for Elevated Anxiety

Minimally adjusted models (four total) included a single exposure variable in addition to
race/ethnicity, gender, and subjective financial status. One co-adjusted model included all four
exposure variables and sociodemographic covariates.
* p < 0.05; ** p < 0.01

No anxiety
symptoms
N = 1526
Anxiety
symptoms
N = 813
minimally adjusted co-adjusted
N (row %) N (row %) OR (95% CI) OR (95% CI)
Past-month menthol cigarette use
Non-menthol 310 (65%) 170 (35%) ref ref
Menthol 551 (58%) 404 (42%) 1.34 (1.07-1.68) ** 1.28 (1.00-1.65) *
No past month
cigarette use
665 (74%) 239 (26%) - -
Past-month menthol vape use
Non-menthol 865 (65%) 461 (35%) ref ref
Menthol 661 (65%) 352 (35%) 1.00 (0.84-1.19) 1.04 (0.82-1.31)
Nicotine dependence
No HONC symptoms 573 (77%) 171 (23%) ref ref
One or more HONC
symptoms
953 (60%) 642 (40%) 2.34 (1.72-3.20) ** 2.23 (1.63-3.06) **
Daily tobacco use (any product)
Non-daily use 1159 (67%) 563 (33%) ref ref
All 30 days 367 (59%) 250 (41%) 1.31 (1.04-1.65) * 1.19 (0.94-1.50)
Figure 8. Newport Boost Cigarettes

73

Chapter 5: Discussion

74
Summary of findings
The overall goal of this dissertation was to examine associations of nicotine vape and
cigarette use with anxiety symptoms among adolescents and young adults across the tobacco use
continuum, from initiation to established use. Young people and individuals with anxiety
symptoms have a disproportionately greater risk of developing nicotine dependence and
subsequent tobacco-related morbidity and mortality via sustained tobacco use. This high-risk and
uniquely vulnerable population may benefit from evidence-based anti-tobacco interventions that
resonate with their needs and experiences, and this dissertation provides preliminary evidence for
intervention components that may be worthy of future study.
The purpose of Study 1 was to examine prospective associations of specific sub-types of
anxiety symptoms that have been identified in adolescence (generalized, panic, and social) with
initiation of vape and cigarette use in early adulthood. Although the study design did not allow
us to draw conclusions related to temporality, findings provide some evidence that non-tobacco
product users with panic symptoms in adolescence were more vulnerable to cigarette initiation in
early adulthood compared to their peers without symptoms.
Study 2 built upon Study 1 by examining cross-sectional associations of vape and
cigarette use with generalized anxiety symptoms across three waves – each representing a
distinct developmental period – to better understand the association of vape and cigarette use
with generalized anxiety symptoms. We found that past six-month cigarette use was positively
associated with generalized anxiety symptoms among adolescents and young adults, and past 30-
day cigarette use was additionally positively associated with generalized anxiety symptoms in
the COVID pandemic wave.
75
Lastly, Study 3 examined the independent roles of menthol cigarette and menthol-
flavored vape use in the association with anxiety symptoms among young adults given that
menthol is known to enhance the effects of nicotine.
165,166,215,217,218
We found that menthol
cigarettes, but not menthol-flavored vapes, were cross-sectionally associated with anxiety
symptoms, suggesting social influences, sensory properties related to combustion, or exposure to
menthol cigarette advertising may explain previously reported associations of menthol tobacco
use with anxiety symptoms among young adults.
163

Implications
Early adulthood is a critical developmental period for tobacco interventions as tobacco
use habits developed during this time are likely to persist into adulthood.
120,135
Findings from this
dissertation have implications for anti-smoking mass media campaigns, tobacco-related health
disparities, and psychosocial distress associated with the COVID-19 pandemic.

Mass media anti-tobacco campaigns
Mass media campaigns widely disseminate health-related information to large
populations on various channels, such as television, radio, and social media platforms.
153,219–221

Young people spend a uniquely high amount of time consuming and engaging with various types
of media, including television and movies, streaming services, social media, and video games.
152

Young adults who spend more time on social media are more likely to report anxiety
symptoms,
222
suggesting that social media campaigns show promise for reaching young people
with anxiety symptoms.
219
Such campaigns might focus on tobacco prevention among those who
already have anxiety symptoms. Our findings suggest that campaigns targeted toward coping
76
with or preventing anxiety might focus on cigarettes specifically because this product showed
associations with panic symptoms in Study 1 and generalized anxiety symptoms in both Study 2
and Study 3. For example, adolescents with panic symptoms had greater odds of cigarette
initiation in early adulthood, and individuals with panic symptoms are more likely to smoke to
relieve negative affect,
175
so an effective anti-smoking campaign might provide coping skills that
will interrupt the cycle of negative reinforcement.
223

224
Because individuals may experience
anxiety symptoms that may not necessarily meet clinical diagnostic criteria,
12–14
such tailored
interventions have the potential to benefit a considerable portion of the population.
133,172

Tobacco-related health disparities
Similar to other tobacco-related health disparities,
154,225
individuals with anxiety
symptoms are more likely to experience poor tobacco-attributable health outcomes, such as
substance use disorders
137–139
and cardiovascular disease.
140–143
Empirical research on the
association between anxiety symptoms and nicotine use among young adults can be leveraged to
develop more effective tobacco control strategies aimed to reduce tobacco-related health
disprarities.
155
We found that not only were anxiety symptoms associated with nicotine use
among adolescents and young adults, but use of combustible cigarettes rather than vapes were
associated with anxiety symptoms. This is significant because cigarettes are substantially more
harmful to health than vapes,
150
and contribute to other tobacco-related health disparities.
226–228

Young people and individuals with anxiety symptoms both have disproportionately high rates of
nicotine use, and both groups are also more likely to develop nicotine dependence,
31,135,188,229

thereby increasing the risk for downstream tobacco-related morbidity and mortality via sustained
tobacco use and exposure to disease-causing agents. Cigarettes are known to cause numerous
77
short- and long-term adverse health consequences,
149
so disproportionate use of cigarettes,
specifically, among young people with anxiety symptoms may set the stage for future tobacco-
related mental health disparities.
Beyond tobacco-related mental health disparities, the scope of this dissertation may also
have implications for racial and ethnic disparities (e.g., Black and Hispanic/Latino young adults).
Systemically minoritized racial and ethnic groups are more likely to experience psychosocial
stress attributable to identity-based discrimination.
230,231
Similar to the physiological effects of
anxiety, experiencing discrimination activates the body’s stress responses, increasing long-term
exposure to cortisol which is linked to participation in unhealthy behaviors, including tobacco
use.
232,233
Indeed, perceived discrimination is cross-sectionally associated with anxiety symptoms
across various samples of college students and adults with social identities that are systematically
marginalized in the U.S.
234–237
Although there is mixed evidence regarding the association
between perceived discrimination and vape use among young people,
238
prior work has shown
that perceived discrimination is positively associated with current cigarette use among diverse
adult samples,
239,240
and prospective analyses have found that perceived discrimination in
adolescence influences cigarette use in emerging adulthood among Hispanic and African
American young adults.
241–243
If minoritized groups are more likely to experience anxiety
symptoms, and anxiety symptoms are associated with tobacco use, then experiencing
discrimination could contribute to tobacco-related mental health disparities. In the present study,
we did not observe significant differences in anxiety symptoms by race; it is possible that survey
measures used (GAD-7 and RCADS-GAD) do not capture discrimination-attributable stress,
which is measured in survey research with the Everyday Discrimination Scale.
244–251

78
COVID-19 pandemic
Pandemics have profound and pervasive psychological impacts, including increased
levels of anxiety symptoms across entire populations that may persist for months or years,
especially among those who already experienced anxiety symptoms prior to the pandemic.
130
In
particular, health anxiety (i.e., hypervigilance to bodily changes and sensations)
147,252
has been
shown to increase during prior pandemics,
130
which may cause significant distress or excessive
utilization of healthcare services.
130,147,252
Indeed, several studies have found increases in stress
and anxiety since the onset of COVID-19,
128,252–257
so much so that recent work has defined and
developed measures for COVID stress disorder.
259

Interventions to mitigate pandemic-related stress have relevance for tobacco research
since “stress relief” is a common reason for nicotine use among young adults in prior work.
260
In
Study 2, we found that anxiety symptoms were associated with both past six-month and past 30-
day cigarette use among young adults in the wave collected during the COVID-19 pandemic
(May-October 2020), which is further concerning because one study among college students
found that anxiety was associated with greater nicotine dependence during the COVID-19
pandemic.
188
The COVID-19 pandemic – and specifically the subsequent lockdown of non-
essential businesses – changed access to tobacco products and tobacco product use among
adolescents and young adults.
189,261–264
Some evidence suggests that vape shops were
noncompliant with pandemic lockdown orders.
190
Some vape shops capitalized on the pandemic
by giving away essential supplies with vape product purchases (e.g., hand sanitizer, face masks,
and toilet paper, all of which were in short supply at the beginning of the pandemic)
197
and
introducing delivery services.
265
Focus group data suggest that most young adults were able to
79
find their vape products online with the exception of cigars.
195
“Stockpiling” of vaping products
was also common.
190,195

Unsurprisingly, cigarette smoking is associated with poorer COVID-related outcomes.
266

The EVALI outbreak peaked just six months before COVID-19 was declared pandemic, and the
primary presenting symptoms of both include difficulty breathing. Consequently, there were
several reported cases of misdiagnoses.
192,267
Risk communication messages linking smoking
with COVID-19 may discourage smoking as well as vaping,
194,268
thus, tobacco control efforts
may capitalize on this opportunity (just as the tobacco industry has capitalized on this
opportunity). Future research is urgently needed to develop mental health interventions in light
of the pervasive and extreme psychological toll attributable to the COVID-19 pandemic that may
influence tobacco use patterns among young people.
130,253,258,259,269
Interventions tailored to
adolescents and young adults would be expected to have the greatest long-term public health
benefits.
120,133

Future Directions
We consistently found no association between vape use and anxiety symptoms across
studies, and this finding is inconsistent with self-medication theory. Understanding potential
drivers of vape use among young people is a worthwhile area of research given high rates of use
among young people and lack of data on the long-term health effects.
94
Future work should
examine the association between anxiety symptoms and vape use more closely with emphasis on
specific product characteristics, including menthol flavors and nicotine formulation, that may
disproportionately appeal to young people with anxiety. Moreover, existing work in this area has
also been limited to associations of vape use with generalized anxiety symptoms;
174
although
80
generalized anxiety symptoms are the most common among the general population,
12
other
subtypes (such as panic disorder and social phobia symptoms) may be important for further
understanding this relationship among young adults. In addition to examining other anxiety
subtypes, other methodological approaches could help elucidate motivations or reasons for
nicotine use among individuals with anxiety. Most of the research conducted to date on non-
clinical populations of young people (such as those utilized in this dissertation) has relied on
self-report survey methods to investigate the association between anxiety symptoms and nicotine
use. Mixed methods research that incorporates qualitative focus groups or in-depth interviews
with participants could help create a more holistic understanding of this relationship, and
potentially identify differences in reasons for use of cigarettes versus vaping products that were
outside the scope of this dissertation.
Further, we found that menthol cigarettes were associated with anxiety symptoms, which
is consistent with prior research and self-medication theory.
109–111,163,181
Many other systemically
marginalized groups (e.g., Black and Hispanic smokers, sexual and gender minorities) also have
disproportionately high rates of menthol cigarette use,
226–228
which contributes to tobacco-related
health disparities because menthol cigarettes facilitate smoking uptake and are more difficult to
quit than non-menthol cigarettes.
167
Menthol interacts directly with nicotine to enhance
nicotine’s reinforcing value.
165,215,216
Menthol is associated with positive, pleasurable, and other
hedonistic responses to nicotine, which may be disproportionately appealing to individuals with
anxiety.
163
The FDA recently announced intent to ban menthol “characterized” cigarettes, which
has the potential to reduce tobacco-related health disparities,
270–273
but specifics of this policy
have not been communicated. Developing thoughtful and evidence-based regulatory language is
necessary to reduce the possibility of menthol cigarette manufactures from exploiting regulatory
81
loopholes from non-specific language. Given that the tobacco industry has nearly limitless
resources to challenge new regulations,
155,274
FDA needs a large body of consistent evidence to
support regulatory language that tobacco companies are likely to exploit. As such tobacco
regulatory scientists should examine these menthol flavor capsule cigarettes more closely,
including monitoring prevalence, examining sociodemographic correlates, evaluating appeal and
addictive potential relative to non-menthol cigarettes, and toxicology to confirm contents in these
flavor capsules.

Strengths and Limitations
This dissertation has several notable strengths. We studied the association between vape
and cigarette use and anxiety symptoms across the early adulthood transitional period known to
increase psychosocial stress and susceptibility tobacco use, and this population has received
relatively little attention in the tobacco literature.
120,174
Most prior research on the association of
vape use with anxiety symptoms among young adults has been limited to samples of college
students,
174
and our samples included young adults not enrolled in a degree program (in addition
to those who were enrolled). We used validated questionnaires based on DSM criteria to measure
anxiety symptoms (RCADS and GAD-7).
13,14
However, due to survey design, anxiety symptoms
were ascertained with the RCADS among adolescents and with the GAD-7 among young adults.
Therefore, the extent to which their prevalence and associations with cigarette use can be
compared is unclear. Data used in Study 1 and Study 2 are from adolescents and young adults
from Southern California, which may limit generalizability to other regions in the U.S. In
addition, while survey designs employed in this dissertation allowed for relatively large-scale
and rapid data collection, these methods did not allow for more intensive, lengthy qualitative
82
interview data. Across all studies, small cell sizes for the non-Hispanic Black racial category
precluded our ability to report results stratified by race.
126

Conclusions
This dissertation provides a strong foundation of preliminary evidence regarding the
association between anxiety symptoms and nicotine use among young people. Data on this
association will likely become increasingly relevant to tobacco control research, given that the
alarmingly rapid increases in anxiety symptoms among young people in recent years are likely to
persist due to the anticipated long-term psychological effects of the COVID-19 pandemic. We
found consistent evidence that cigarette use was associated with anxiety symptoms among both
adolescents and young adults, and vape use was not associated with anxiety symptoms among
neither adolescents nor young adults. Population-level anti-tobacco interventions (e.g., mass
media campaigns) that are tailored to young people with anxiety symptoms might focus on
preventing and reducing cigarette use, rather than vape use. Such interventions have the potential
to reduce tobacco-related disparities in morbidity and mortality attributable to mental health
symptoms. Future research should examine smoking motivations among young people with
anxiety symptoms, investigate potential associations between anxiety symptoms and vaping
product characteristics (such as nicotine formulation), and study potential differential effects by
various tobacco use behaviors (such as use frequency) that were outside the scope of this
dissertation.

.
83
References

1. Bandura A. On the Functional Properties of Perceived Self-Efficacy Revisited. J Manag.
2012;38(1):9-44. doi:10.1177/0149206311410606
2. Chand SP, Marwaha R. Anxiety. In: StatPearls. StatPearls Publishing; 2022. Accessed
February 18, 2022. http://www.ncbi.nlm.nih.gov/books/NBK470361/
3. Nesse R, Williams G. Why We Get Sick: The New Science of Darwinian Medicine.
Vintage Books; 1995.
4. Stein D. A neuro-evolutionary approach to the anxiety disorders. J Anxiety Disord.
1997;11(4):409-429.
5. Wand G. The anxious amygdala: CREB signaling and predisposition to anxiety and
alcoholism. J Clin Invest. 2005;115(10):2697-2699. doi:10.1172/JCI26436
6. Arain M, Haque M, Johal L, et al. Maturation of the adolescent brain. Neuropsychiatr Dis
Treat. 2013;9:449-461. doi:10.2147/NDT.S39776
7. Gibbons CH. Basics of autonomic nervous system function. Handb Clin Neurol.
2019;160:407-418. doi:10.1016/B978-0-444-64032-1.00027-8
8. McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the
brain. Physiol Rev. 2007;87(3):873-904. doi:10.1152/physrev.00041.2006
9. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory.
Prenctice-Hall, Inc.; 1986.
10. Bandura A. Self-Efficacy: The Exercise of Control. W H Freeman/Times Books/ Henry
Holt & Co; 1997:ix, 604.
11. Tahmassian K, Jalali Moghadam N. Relationship Between Self-Efficacy and Symptoms of
Anxiety, Depression, Worry and Social Avoidance in a Normal Sample of Students. Iran J
Psychiatry Behav Sci. 2011;5(2):91-98.
12. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th Ed.). Washington, DC.
13. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing
generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.
doi:10.1001/archinte.166.10.1092
14. Chorpita BF, Yim L, Moffitt C, Umemoto LA, Francis SE. Assessment of symptoms of
DSM-IV anxiety and depression in children: a revised child anxiety and depression scale.
Behav Res Ther. 2000;38(8):835-855. doi:10.1016/s0005-7967(99)00130-8
84
15. Chorpita BF, Moffitt CE, Gray J. Psychometric properties of the Revised Child Anxiety
and Depression Scale in a clinical sample. Behav Res Ther. 2005;43(3):309-322.
doi:10.1016/j.brat.2004.02.004
16. Piqueras JA, Martín-Vivar M, Sandin B, San Luis C, Pineda D. The Revised Child
Anxiety and Depression Scale: A systematic review and reliability generalization meta-
analysis. J Affect Disord. 2017;218:153-169. doi:kwon
17. Becker SP, Schindler DN, Luebbe AM, Tamm L, Epstein JN. Psychometric Validation of
the Revised Child Anxiety and Depression Scales-Parent Version (RCADS-P) in Children
Evaluated for ADHD. Assessment. 2019;26(5):811-824. doi:10.1177/1073191117735886
18. Mathyssek CM, Olino TM, Hartman CA, Ormel J, Verhulst FC, Van Oort FVA. Does the
Revised Child Anxiety and Depression Scale (RCADS) measure anxiety symptoms
consistently across adolescence? The TRAILS study. Int J Methods Psychiatr Res.
2013;22(1):27-35. doi:10.1002/mpr.1380
19. Changeux JP. Nicotine addiction and nicotinic receptors: lessons from genetically
modified mice. Nat Rev Neurosci. 2010;11(6):389-401. doi:10.1038/nrn2849
20. Leslie FM. Unique, long-term effects of nicotine on adolescent brain. Pharmacol Biochem
Behav. 2020;197:173010. doi:10.1016/j.pbb.2020.173010
21. Volkow ND, Morales M. The Brain on Drugs: From Reward to Addiction. Cell.
2015;162(4):712-725. doi:10.1016/j.cell.2015.07.046
22. Volkow ND, Wise RA, Baler R. The dopamine motive system: implications for drug and
food addiction. Nat Rev Neurosci. 2017;18(12):741-752. doi:10.1038/nrn.2017.130
23. Benowitz NL. Nicotine Addiction. N Engl J Med. 2010;362(24):2295-2303.
doi:10.1056/NEJMra0809890
24. Chaudhri N, Caggiula AR, Donny EC, Palmatier MI, Liu X, Sved AF. Complex
interactions between nicotine and nonpharmacological stimuli reveal multiple roles for
nicotine in reinforcement. Psychopharmacology (Berl). 2006;184(3-4):353-366.
doi:10.1007/s00213-005-0178-1
25. Grebenstein PE, Burroughs D, Roiko SA, Pentel PR, LeSage MG. Predictors of the
nicotine reinforcement threshold, compensation, and elasticity of demand in a rodent
model of nicotine reduction policy. Drug Alcohol Depend. 2015;151:181-193.
doi:10.1016/j.drugalcdep.2015.03.030
26. Donny EC, Chaudhri N, Caggiula AR, et al. Operant responding for a visual reinforcer in
rats is enhanced by noncontingent nicotine: implications for nicotine self-administration
and reinforcement. Psychopharmacology (Berl). 2003;169(1):68-76. doi:10.1007/s00213-
003-1473-3
85
27. Rupprecht LE, Smith TT, Schassburger RL, Buffalari DM, Sved AF, Donny EC.
Behavioral mechanisms underlying nicotine reinforcement. Curr Top Behav Neurosci.
2015;24:19-53. doi:10.1007/978-3-319-13482-6_2
28. United States Congress. Family Smoking Prevention and Tobacco Control Act. June 22,
2009.
29. Breslau N, Kilbey MM, Andreski P. Nicotine Dependence, Major Depression, and
Anxiety in Young Adults. Arch Gen Psychiatry. 1991;48(12):1069-1074.
doi:10.1001/archpsyc.1991.01810360033005
30. Kushner MG, Menary KR, Maurer EW, Thuras P. Greater Elevation in Risk for Nicotine
Dependence per Pack of Cigarettes Smoked Among Those With an Anxiety Disorder. J
Stud Alcohol Drugs. 2012;73(6):920-924.
31. Molas S, DeGroot SR, Zhao-Shea R, Tapper AR. Anxiety and Nicotine Dependence:
Emerging Role of the Habenulo-Interpeduncular Axis. Trends Pharmacol Sci.
2017;38(2):169-180. doi:10.1016/j.tips.2016.11.001
32. Moylan S, Jacka FN, Pasco JA, Berk M. Cigarette smoking, nicotine dependence and
anxiety disorders: a systematic review of population-based, epidemiological studies. BMC
Med. 2012;10:123. doi:10.1186/1741-7015-10-123
33. Buckner JD, Farris SG, Schmidt NB, Zvolensky MJ. Direct and Indirect Associations
Between Social Anxiety and Nicotine Dependence and Cessation Problems: Multiple
Mediator Analyses. Nicotine Tob Res. 2014;16(6):807-814. doi:10.1093/ntr/ntt285
34. Levine A, Huang Y, Drisaldi B, et al. Molecular mechanism for a gateway drug:
epigenetic changes initiated by nicotine prime gene expression by cocaine. Sci Transl
Med. 2011;3(107):107ra109. doi:10.1126/scitranslmed.3003062
35. Cavallo DA, Kong G, Ells DM, Camenga DR, Morean ME, Krishnan-Sarin S. Youth
generated prevention messages about electronic cigarettes. Health Educ Res.
2019;34(2):247-256. doi:10.1093/her/cyz001
36. Groom AL, Vu THT, Landry RL, et al. The Influence of Friends on Teen Vaping: A
Mixed-Methods Approach. Int J Environ Res Public Health. 2021;18(13):6784.
doi:10.3390/ijerph18136784
37. Tucker JS, Ellickson PL, Klein DJ. Predictors of the transition to regular smoking during
adolescence and young adulthood. J Adolesc Health. 2003;32(4):314-324.
doi:10.1016/S1054-139X(02)00709-7
38. Perikleous EP, Steiropoulos P, Paraskakis E, Constantinidis TC, Nena E. E-Cigarette Use
Among Adolescents: An Overview of the Literature and Future Perspectives. Front Public
Health. 2018;6:86. doi:10.3389/fpubh.2018.00086
86
39. Tamulevicius N, Martinasek MP, Moss SJ, Pfeffer I, Gibson-Young LM, Yahaya M. An
Analysis of Associations Between Electronic Nicotine Delivery System Users. Respir
Care. 2020;65(3):355-361. doi:10.4187/respcare.07172
40. Hall MG, Pepper JK, Morgan JC, Brewer NT. Social Interactions as a Source of
Information about E-Cigarettes: A Study of U.S. Adult Smokers. Int J Environ Res Public
Health. 2016;13(8):788. doi:10.3390/ijerph13080788
41. Pepper JK, Lee YO, Watson KA, Kim AE, Nonnemaker JM, Farrelly MC. Risk Factors
for Youth E-Cigarette “Vape Trick” Behavior. J Adolesc Health Off Publ Soc Adolesc
Med. 2017;61(5):599-605. doi:10.1016/j.jadohealth.2017.05.010
42. Cwalina SN, Braymiller JL, Leventhal AM, Unger JB, McConnell R, Barrington-Trimis
JL. Prevalence of Young Adult Vaping, Substance Vaped, and Purchase Location Across
5 Categories of Vaping Devices. Nicotine Tob Res Off J Soc Res Nicotine Tob. Published
online November 16, 2020. doi:10.1093/ntr/ntaa232
43. Cornelius ME. Tobacco Product Use Among Adults — United States, 2019. MMWR Morb
Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6946a4
44. Mayer M, Reyes-Guzman C, Grana R, Choi K, Freedman ND. Demographic
Characteristics, Cigarette Smoking, and e-Cigarette Use Among US Adults. JAMA Netw
Open. 2020;3(10):e2020694. doi:10.1001/jamanetworkopen.2020.20694
45. Ali M, Gray TR, Martinez DJ, Curry LE, Horn KA. Risk Profiles of Youth Single, Dual,
and Poly Tobacco Users. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2016;18(7):1614-
1621. doi:10.1093/ntr/ntw028
46. Tan ASL, Soneji SS, Choi K, Moran MB. Prevalence of using pod-based vaping devices
by brand among youth and young adults. Tob Control. 2020;29(4):461-463.
doi:10.1136/tobaccocontrol-2019-055064
47. Williams RS. Industry Watch: The rise of disposable JUUL-type e-cigarette devices. Tob
Control. 2020;29(E1):e134-e135. doi:10.1136/tobaccocontrol-2019-055379
48. Cullen KA, Gentzke AS, Sawdey MD, et al. e-Cigarette Use Among Youth in the United
States, 2019. JAMA. Published online November 5, 2019. doi:10.1001/jama.2019.18387
49. Fadus MC, Smith TT, Squeglia LM. The rise of e-cigarettes, pod mod devices, and JUUL
among youth: Factors influencing use, health implications, and downstream effects. Drug
Alcohol Depend. 2019;201:85-93. doi:10.1016/j.drugalcdep.2019.04.011
50. Hrywna M, Bover Manderski MT, Delnevo CD. Prevalence of Electronic Cigarette Use
Among Adolescents in New Jersey and Association With Social Factors. JAMA Netw
Open. 2020;3(2):e1920961. doi:10.1001/jamanetworkopen.2019.20961
87
51. Ickes M, Hester JW, Wiggins AT, Rayens MK, Hahn EJ, Kavuluru R. Prevalence and
reasons for Juul use among college students. J Am Coll Health J ACH. 2020;68(5):455-
459. doi:10.1080/07448481.2019.1577867
52. Kanyadan V, Ganti L. E-cigarette Awareness among Young Adults: A Pilot Survey Study.
Cureus. 2019;11(7):e5234. doi:10.7759/cureus.5234
53. Kavuluru R, Han S, Hahn EJ. On the popularity of the USB flash drive-shaped electronic
cigarette Juul. Tob Control. 2019;28(1):110-112. doi:10.1136/tobaccocontrol-2018-
054259
54. Loukas A, Marti CN, Pasch KE, Harrell MB, Wilkinson AV, Perry CL. Rising vape pod
popularity disrupted declining use of electronic nicotine delivery systems among young
adults in Texas, USA from 2014 to 2019. Addict Abingdon Engl. Published online June
22, 2021. doi:10.1111/add.15616
55. Morean ME, Camenga DR, Bold KW, et al. Querying About the Use of Specific E-
Cigarette Devices May Enhance Accurate Measurement of E-Cigarette Prevalence Rates
Among High School Students. Nicotine Tob Res Off J Soc Res Nicotine Tob.
2020;22(5):833-837. doi:10.1093/ntr/nty240
56. Vallone DM, Bennett M, Xiao H, Pitzer L, Hair EC. Prevalence and correlates of JUUL
use among a national sample of youth and young adults. Tob Control. 2019;28(6):603-
609. doi:10.1136/tobaccocontrol-2018-054693
57. Walley SC, Wilson KM, Winickoff JP, Groner J. A Public Health Crisis: Electronic
Cigarettes, Vape, and JUUL. Pediatrics. 2019;143(6). doi:10.1542/peds.2018-2741
58. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Adolescent Vaping and
Nicotine Use in 2017-2018 - U.S. National Estimates. N Engl J Med. 2019;380(2):192-
193. doi:10.1056/NEJMc1814130
59. Ali FRM, Marynak KL, Kim Y, et al. E-cigarette advertising expenditures in the United
States, 2014–2018. Tob Control. Published online February 27, 2020:tobaccocontrol-
2019-055424. doi:10.1136/tobaccocontrol-2019-055424
60. Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth
and marketing of JUUL transformed the US retail e-cigarette market. Tob Control.
2019;28(2):146-151. doi:10.1136/tobaccocontrol-2018-054382
61. Jackler R, Chau C, Getachew B, et al. JUUL Advertising Over its First Three Years on the
Market. SRITA White Pap. Published online January 31, 2019.
62. Wagoner KG, King JL, Suerken CK, Reboussin BA, Cornacchione Ross J, Sutfin EL.
Changes in knowledge, perceptions and use of JUUL among a cohort of young adults. Tob
Control. Published online August 26, 2020. doi:10.1136/tobaccocontrol-2020-055651
88
63. Davis DR, Krishnan-Sarin S, Bold KW, et al. Differences in JUUL Appeal Among Past
and Current Youth JUUL Users. Nicotine Tob Res Off J Soc Res Nicotine Tob. Published
online November 28, 2020. doi:10.1093/ntr/ntaa246
64. Diaz MC, Donovan EM, Schillo BA, Vallone D. Menthol e-cigarette sales rise following
2020 FDA guidance. Tob Control. Published online September 23, 2020.
doi:10.1136/tobaccocontrol-2020-056053
65. Kong G, Bold KW, Morean ME, et al. Appeal of JUUL among adolescents. Drug Alcohol
Depend. 2019;205:107691. doi:10.1016/j.drugalcdep.2019.107691
66. Luo J, Chen L, Lu X, Yuan J, Xie Z, Li D. Analysis of potential associations of JUUL
flavours with health symptoms based on user-generated data from Reddit. Tob Control.
Published online July 24, 2020. doi:10.1136/tobaccocontrol-2019-055439
67. Morean ME, Bold KW, Kong G, et al. Adolescents’ awareness of the nicotine strength and
e-cigarette status of JUUL e-cigarettes. Drug Alcohol Depend. 2019;204:107512.
doi:10.1016/j.drugalcdep.2019.05.032
68. Pacek LR, Kozink RV, Carson CE, McClernon FJ. Appeal, subjective effects, and relative
reinforcing effects of JUUL that vary in flavor and nicotine content. Exp Clin
Psychopharmacol. 2021;29(3):279-287. doi:10.1037/pha0000481
69. Sargent JD, Stoolmiller M, Dai H, et al. First e-cigarette flavor and device type used:
Associations with vaping persistence, frequency, and dependence in young adults.
Nicotine Tob Res Off J Soc Res Nicotine Tob. Published online August 30, 2021:ntab172.
doi:10.1093/ntr/ntab172
70. Schneller LM, Bansal-Travers M, Goniewicz ML, McIntosh S, Ossip D, O’Connor RJ.
Use of Flavored E-Cigarettes and the Type of E-Cigarette Devices Used among Adults
and Youth in the US-Results from Wave 3 of the Population Assessment of Tobacco and
Health Study (2015-2016). Int J Environ Res Public Health. 2019;16(16).
doi:10.3390/ijerph16162991
71. Benson R, Hu M, Chen AT, Nag S, Zhu SH, Conway M. Investigating the Attitudes of
Adolescents and Young Adults Towards JUUL: Computational Study Using Twitter Data.
JMIR Public Health Surveill. 2020;6(3):e19975. doi:10.2196/19975
72. Chen-Sankey JC, Tan ASL, Moran MB, Soneji S, Lee SJ, Choi K. Sources of awareness,
perceptions, and use of JUUL e-cigarettes among adult cigarette smokers. PloS One.
2020;15(9):e0238377. doi:10.1371/journal.pone.0238377
73. Brett EI, Stevens EM, Wagener TL, et al. A content analysis of JUUL discussions on
social media: Using Reddit to understand patterns and perceptions of JUUL use. Drug
Alcohol Depend. 2019;194:358-362. doi:10.1016/j.drugalcdep.2018.10.014
89
74. Patel M, Cuccia AF, Zhou Y, Kierstead EC, Briggs J, Schillo BA. Smoking cessation
among US adults: use of e-cigarettes, including JUUL, and NRT use. Tob Control.
Published online September 21, 2020. doi:10.1136/tobaccocontrol-2020-056013
75. Patel M, Cuccia A, Willett J, et al. JUUL use and reasons for initiation among adult
tobacco users. Tob Control. 2019;28(6):681-684. doi:10.1136/tobaccocontrol-2019-
054952
76. Case KR, Hinds JT, Creamer MR, Loukas A, Perry CL. Who is JUULing and Why? An
Examination of Young Adult Electronic Nicotine Delivery Systems Users. J Adolesc
Health Off Publ Soc Adolesc Med. 2020;66(1):48-55.
doi:10.1016/j.jadohealth.2019.05.030
77. Leavens ELS, Smith TT, Natale N, Carpenter MJ. Electronic cigarette dependence and
demand among pod mod users as a function of smoking status. Psychol Addict Behav J
Soc Psychol Addict Behav. 2020;34(7):804-810. doi:10.1037/adb0000583
78. Sidani JE, Colditz JB, Barrett EL, et al. I wake up and hit the JUUL: Analyzing Twitter for
JUUL nicotine effects and dependence. Drug Alcohol Depend. 2019;204:107500.
doi:10.1016/j.drugalcdep.2019.06.005
79. Krishnan-Sarin S, Jackson A, Morean M, et al. E-cigarette devices used by high-school
youth. Drug Alcohol Depend. 2019;194:395-400. doi:10.1016/j.drugalcdep.2018.10.022
80. Lanza HI, Leventhal AM, Cho J, et al. Young adult e-cigarette use: A latent class analysis
of device and flavor use, 2018-2019. Drug Alcohol Depend. 2020;216:108258.
doi:10.1016/j.drugalcdep.2020.108258
81. Leavens ELS, Stevens EM, Brett EI, et al. JUUL electronic cigarette use patterns, other
tobacco product use, and reasons for use among ever users: Results from a convenience
sample. Addict Behav. 2019;95:178-183. doi:10.1016/j.addbeh.2019.02.011
82. Dai H, Hao J. Online popularity of JUUL and Puff Bars in the USA: 2019-2020. Tob
Control. Published online October 13, 2020. doi:10.1136/tobaccocontrol-2020-055727
83. Miech R, Leventhal A, Johnston L, O’Malley PM, Patrick ME, Barrington-Trimis J.
Trends in Use and Perceptions of Nicotine Vaping Among US Youth From 2017 to 2020.
JAMA Pediatr. 2021;175(2):185-190. doi:10.1001/jamapediatrics.2020.5667
84. Liber AC, Cahn Z, Diaz MC, Donovan E, Vallone D, Schillo B. The EVALI outbreak and
tobacco sales in the USA, 2014-2020. Tob Control. Published online December 15,
2021:tobaccocontrol-2021-056807. doi:10.1136/tobaccocontrol-2021-056807
85. Liber A, Cahn Z, Larsen A, Drope J. Flavored E-Cigarette Sales in the United States
Under Self-Regulation From January 2015 Through October 2019. Am J Public Health.
2020;110(6):785-787. doi:10.2105/AJPH.2020.305667
90
86. Harvanko AM, Havel CM, Jacob P, Benowitz NL. Characterization of Nicotine Salts in 23
Electronic Cigarette Refill Liquids. Nicotine Tob Res Off J Soc Res Nicotine Tob.
2020;22(7):1239-1243. doi:10.1093/ntr/ntz232
87. Morean ME, Kong G, Cavallo DA, Camenga DR, Krishnan-Sarin S. Nicotine
concentration of e-cigarettes used by adolescents. Drug Alcohol Depend. 2016;167:224-
227. doi:10.1016/j.drugalcdep.2016.06.031
88. Boykan R, Goniewicz ML, Messina CR. Evidence of Nicotine Dependence in Adolescents
Who Use Juul and Similar Pod Devices. Int J Environ Res Public Health. 2019;16(12).
doi:10.3390/ijerph16122135
89. Duell AK, Pankow JF, Peyton DH. Nicotine in tobacco product aerosols: “It’s déjà vu all
over again.” Tob Control. 2020;29(6):656-662. doi:10.1136/tobaccocontrol-2019-055275
90. Hajek P, Pittaccio K, Pesola F, Myers Smith K, Phillips-Waller A, Przulj D. Nicotine
delivery and users’ reactions to Juul compared with cigarettes and other e-cigarette
products. Addict Abingdon Engl. 2020;115(6):1141-1148. doi:10.1111/add.14936
91. Jackler RK, Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product
market. Tob Control. 2019;28(6):623-628. doi:10.1136/tobaccocontrol-2018-054796
92. Romberg AR, Miller Lo EJ, Cuccia AF, et al. Patterns of nicotine concentrations in
electronic cigarettes sold in the United States, 2013-2018. Drug Alcohol Depend.
2019;203:1-7. doi:10.1016/j.drugalcdep.2019.05.029
93. Voos N, Goniewicz ML, Eissenberg T. What is the nicotine delivery profile of electronic
cigarettes? Expert Opin Drug Deliv. 2019;16(11):1193-1203.
doi:10.1080/17425247.2019.1665647
94. Spindle TR, Hiler MM, Cooke ME, Eissenberg T, Kendler KS, Dick DM. Electronic
cigarette use and uptake of cigarette smoking: A longitudinal examination of U.S. college
students. Addict Behav. 2017;67:66-72. doi:10.1016/j.addbeh.2016.12.009
95. Lee SJ, Rees VW, Yossefy N, Emmons KM, Tan ASL. Youth and Young Adult Use of
Pod-Based Electronic Cigarettes From 2015 to 2019: A Systematic Review. JAMA
Pediatr. Published online June 1, 2020. doi:10.1001/jamapediatrics.2020.0259
96. Lee HY, Lin HC, Seo DC, Lohrmann DK. Determinants associated with E-cigarette
adoption and use intention among college students. Addict Behav. 2017;65:102-110.
doi:10.1016/j.addbeh.2016.10.023
97. Urman R, McConnell R, Unger JB, et al. Electronic Cigarette and Cigarette Social
Environments and Ever Use of Each Product: A Prospective Study of Young Adults in
Southern California. Nicotine Tob Res. 2018;21(10):1347-1354. doi:10.1093/ntr/nty097
91
98. Yingst JM, Lester C, Veldheer S, Allen SI, Du P, Foulds J. E-cigarette users commonly
stealth vape in places where e-cigarette use is prohibited. Tob Control. 2019;28(5):493-
497. doi:10.1136/tobaccocontrol-2018-054432
99. Horn K, Pearson JL, Villanti AC. Polytobacco Use and the “Customization Generation”-
New Perspectives for Tobacco Control. J Drug Educ. 2016;46(3-4):51-63.
doi:10.1177/0047237917722771
100. McKeganey N, Russell C, Katsampouris E, Haseen F. Sources of youth access to JUUL
vaping products in the United States. Addict Behav Rep. 2019;10:100232.
doi:10.1016/j.abrep.2019.100232
101. Baig SA, Pepper JK, Morgan JC, Brewer NT. Social identity and support for counteracting
tobacco company marketing that targets vulnerable populations. Soc Sci Med 1982.
2017;182:136-141. doi:10.1016/j.socscimed.2017.03.052
102. Wackowski OA, Sontag JM, Singh B, et al. From the Deeming Rule to JUUL-US News
Coverage of Electronic Cigarettes, 2015-2018. Nicotine Tob Res Off J Soc Res Nicotine
Tob. Published online February 13, 2020. doi:10.1093/ntr/ntaa025
103. Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among
youth and young adults. Tob Control. 2019;28(1):115-116. doi:10.1136/tobaccocontrol-
2018-054273
104. Cwalina SN, Leventhal AM, Barrington-Trimis JL. E-cigarette flavour enhancers:
Flavoured pod attachments compatible with JUUL and other pod-based devices. Tob
Control. Published online April 9, 2020. doi:10.1136/tobaccocontrol-2020-055618
105. Cwalina SN, McConnell R, Benowitz NL, Barrington-Trimis JL. Tobacco-free Nicotine -
New Name, Same Scheme? N Engl J Med. Published online December 18, 2021.
doi:10.1056/NEJMp2111159
106. Kreslake JM, Diaz MC, Shinaba M, Vallone DM, Hair EC. Youth and young adult risk
perceptions and behaviours in response to an outbreak of e-cigarette/vaping-associated
lung injury (EVALI) in the USA. Tob Control. 2022;31(1):88-97.
doi:10.1136/tobaccocontrol-2020-056090
107. Krishnasamy VP. Update: Characteristics of a Nationwide Outbreak of E-cigarette, or
Vaping, Product Use–Associated Lung Injury — United States, August 2019–January
2020. MMWR Morb Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6903e2
108. Engel GL. The need for a new medical model: a challenge for biomedicine. Science.
1977;196(4286):129-136. doi:10.1126/science.847460
109. Blume AW, Schmaling KB, Marlatt GA. Revisiting the self-medication hypothesis from a
behavioral perspective. Cogn Behav Pract. 2000;7(4):379-384. doi:10.1016/S1077-
7229(00)80048-6
92
110. Gehricke JG, Loughlin SE, Whalen CK, et al. Smoking to self-medicate attentional and
emotional dysfunctions. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2007;9 Suppl
4:S523-536. doi:10.1080/14622200701685039
111. Turner S, Mota N, Bolton J, Sareen J. Self-medication with alcohol or drugs for mood and
anxiety disorders: A narrative review of the epidemiological literature. Depress Anxiety.
2018;35(9):851-860. doi:10.1002/da.22771
112. Hiler M, Spindle TR, Dick D, Eissenberg T, Breland A, Soule E. Reasons for Transition
From Electronic Cigarette Use to Cigarette Smoking Among Young Adult College
Students. J Adolesc Health Off Publ Soc Adolesc Med. 2020;66(1):56-63.
doi:10.1016/j.jadohealth.2019.09.003
113. Bruijnzeel AW. Tobacco addiction and the dysregulation of brain stress systems. Neurosci
Biobehav Rev. 2012;36(5):1418-1441. doi:10.1016/j.neubiorev.2012.02.015
114. Yan Y, Sun S, Deng S, et al. A systematic review of anxiety across smoking stages in
adolescents and young adults. Subst Use Misuse. 2019;54(8):1408-1415.
doi:10.1080/10826084.2019.1581222
115. Piper ME, Baker TB, Benowitz NL, Jorenby DE. Changes in Use Patterns Over 1 Year
Among Smokers and Dual Users of Combustible and Electronic Cigarettes. Nicotine Tob
Res. 2019;22(5):672-680. doi:10.1093/ntr/ntz065
116. Dierker L, Donny E. The role of psychiatric disorders in the relationship between cigarette
smoking and DSM-IV nicotine dependence among young adults. Nicotine Tob Res Off J
Soc Res Nicotine Tob. 2008;10(3):439-446. doi:10.1080/14622200801901898
117. Duarte T, Fontana BD, Müller TE, Bertoncello KT, Canzian J, Rosemberg DB. Nicotine
prevents anxiety-like behavioral responses in zebrafish. Prog Neuropsychopharmacol Biol
Psychiatry. 2019;94:109655. doi:10.1016/j.pnpbp.2019.109655
118. Arnett JJ. Emerging adulthood: A theory of development from the late teens through the
twenties. Am Psychol. 2000;55(5):469-480. doi:10.1037/0003-066X.55.5.469
119. Lenz B. The transition from adolescence to young adulthood: a theoretical perspective. J
Sch Nurs Off Publ Natl Assoc Sch Nurses. 2001;17(6):300-306.
doi:10.1177/10598405010170060401
120. Villanti AC, Niaura RS, Abrams DB, Mermelstein R. Preventing Smoking Progression in
Young Adults: the Concept of Prevescalation. Prev Sci Off J Soc Prev Res.
2019;20(3):377-384. doi:10.1007/s11121-018-0880-y
121. Stone AL, Becker LG, Huber AM, Catalano RF. Review of risk and protective factors of
substance use and problem use in emerging adulthood. Addict Behav. 2012;37(7):747-775.
doi:10.1016/j.addbeh.2012.02.014
93
122. Chen P, Jacobson KC. Developmental trajectories of substance use from early adolescence
to young adulthood: Gender and racial/ethnic differences. J Adolesc Health.
2012;50(2):154-163. doi:10.1016/j.jadohealth.2011.05.013
123. Bachman JG, Freedman-Doan P, O’Malley PM, Johnston LD, Segal DR. Changing
patterns of drug use among US military recruits before and after enlistment. Am J Public
Health. 1999;89(5):672-677.
124. White HR, Bray BC, Fleming CB, Catalano RF. Transitions into and out of light and
intermittent smoking during emerging adulthood. Nicotine Tob Res. 2009;11(2):211-219.
doi:10.1093/ntr/ntn017
125. Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory. U.S. Dept of
Health and Human Services. Dec 7, 2021.
126. Cwalina SN, Ihenacho U, Barker J, Smiley SL, Pentz MA, Wipfli H. Advancing racial
equity and social justice for Black communities in US tobacco control policy. Tob
Control. Published online September 15, 2021. doi:10.1136/tobaccocontrol-2021-056704
127. Marks E, Hickman C, Pihkala P, et al. Young People’s Voices on Climate Anxiety,
Government Betrayal and Moral Injury: A Global Phenomenon. Social Science Research
Network; 2021. doi:10.2139/ssrn.3918955
128. Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global Prevalence of
Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A
Meta-analysis. JAMA Pediatr. 2021;175(11):1142-1150.
doi:10.1001/jamapediatrics.2021.2482
129. Mental health matters. Lancet Glob Health. 2020;8(11):e1352. doi:10.1016/S2214-
109X(20)30432-0
130. Taylor S. The Psychology of Pandemics: Preparing for the Next Global Outbreak of
Infectious Disease. First Edition. Cambridge Scholars Publishing; 2019.
131. Lujic C, Reuter M, Netter P. Psychobiological Theories of Smoking and Smoking
Motivation. Eur Psychol. Published online September 1, 2006. Accessed December 13,
2021. https://econtent.hogrefe.com/doi/abs/10.1027/1016-9040.10.1.1
132. Bandura A. Human Agency in Social Cognitive Theory. Am Psychol. 1989;44(9):1175-
1184.
133. Goodwin RD, Weinberger AH, Kim JH, Wu M, Galea S. Trends in anxiety among adults
in the United States, 2008–2018: Rapid increases among young adults. J Psychiatr Res.
2020;130:441-446. doi:10.1016/j.jpsychires.2020.08.014
134. Piper ME, Cook JW, Schlam TR, Jorenby DE, Baker TB. Anxiety diagnoses in smokers
seeking cessation treatment: relations with tobacco dependence, withdrawal, outcome and
94
response to treatment. Addict Abingdon Engl. 2011;106(2):418-427. doi:10.1111/j.1360-
0443.2010.03173.x
135. National Center for Chronic Disease Prevention and Health Promotion (US) Office on
Smoking and Health. Preventing Tobacco Use Among Youth and Young Adults: A Report
of the Surgeon General. Centers for Disease Control and Prevention (US); 2012. Accessed
August 26, 2020. http://www.ncbi.nlm.nih.gov/books/NBK99237/
136. King JL, Reboussin BA, Spangler J, Cornacchione Ross J, Sutfin EL. Tobacco product use
and mental health status among young adults. Addict Behav. 2018;77:67-72.
doi:10.1016/j.addbeh.2017.09.012
137. Merikangas KR, Mehta RL, Molnar BE, et al. Comorbidity of substance use disorders
with mood and anxiety disorders: results of the International Consortium in Psychiatric
Epidemiology. Addict Behav. 1998;23(6):893-907. doi:10.1016/s0306-4603(98)00076-8
138. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use
disorders and independent mood and anxiety disorders: results from the National
Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry.
2004;61(8):807-816. doi:10.1001/archpsyc.61.8.807
139. Esmaeelzadeh S, Moraros J, Thorpe L, Bird Y. Examining the Association and
Directionality between Mental Health Disorders and Substance Use among Adolescents
and Young Adults in the U.S. and Canada—A Systematic Review and Meta-Analysis. J
Clin Med. 2018;7(12):543. doi:10.3390/jcm7120543
140. Stoney CM, Kaufmann PG, Czajkowski SM. Cardiovascular disease: Psychological,
social, and behavioral influences: Introduction to the special issue. Am Psychol.
2018;73(8):949-954. doi:10.1037/amp0000359
141. Tully PJ, Harrison NJ, Cheung P, Cosh S. Anxiety and Cardiovascular Disease Risk: a
Review. Curr Cardiol Rep. 2016;18(12):120. doi:10.1007/s11886-016-0800-3
142. Emdin CA, Odutayo A, Wong CX, Tran J, Hsiao AJ, Hunn BHM. Meta-Analysis of
Anxiety as a Risk Factor for Cardiovascular Disease. Am J Cardiol. 2016;118(4):511-519.
doi:10.1016/j.amjcard.2016.05.041
143. Celano CM, Daunis DJ, Lokko HN, Campbell KA, Huffman JC. Anxiety Disorders and
Cardiovascular Disease. Curr Psychiatry Rep. 2016;18(11):101. doi:10.1007/s11920-016-
0739-5
144. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease
burden implications: a systematic review and meta-analysis. JAMA Psychiatry.
2015;72(4):334-341. doi:10.1001/jamapsychiatry.2014.2502
145. Park J, Moghaddam B. Impact of anxiety on prefrontal cortex encoding of cognitive
flexibility. Neuroscience. 2017;345:193-202. doi:10.1016/j.neuroscience.2016.06.013
95
146. Moran TP. Anxiety and working memory capacity: A meta-analysis and narrative review.
Psychol Bull. 2016;142(8):831-864. doi:10.1037/bul0000051
147. Asmundson GJG, Abramowitz JS, Richter AA, Whedon M. Health anxiety: current
perspectives and future directions. Curr Psychiatry Rep. 2010;12(4):306-312.
doi:10.1007/s11920-010-0123-9
148. Wallace K, Zhao X, Misra R, Sambamoorthi U. The Humanistic and Economic Burden
Associated with Anxiety and Depression among Adults with Comorbid Diabetes and
Hypertension. J Diabetes Res. 2018;2018:4842520. doi:10.1155/2018/4842520
149. National Center for Chronic Disease Prevention and Health Promotion (US) Office on
Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A
Report of the Surgeon General. Centers for Disease Control and Prevention (US); 2014.
Accessed August 26, 2020. http://www.ncbi.nlm.nih.gov/books/NBK179276/
150. National Academies of Sciences, Engineering, and Medicine, Health and Medicine
Division, Board on Population Health and Public Health Practice, Committee on the
Review of the Health Effects of Electronic Nicotine Delivery Systems. Public Health
Consequences of E-Cigarettes. (Eaton DL, Kwan LY, Stratton K, eds.). National
Academies Press (US); 2018. Accessed August 26, 2020.
http://www.ncbi.nlm.nih.gov/books/NBK507171/
151. National Center for Chronic Disease Prevention and Health Promotion (US) Office on
Smoking and Health. E-Cigarette Use Among Youth and Young Adults: A Report of the
Surgeon General. Centers for Disease Control and Prevention (US); 2016.
http://www.ncbi.nlm.nih.gov/books/NBK538680/
152. Mayhew A, Weigle P. Media Engagement and Identity Formation Among Minority
Youth. Child Adolesc Psychiatr Clin N Am. 2018;27(2):269-285.
doi:10.1016/j.chc.2017.11.012
153. Carson KV, Ameer F, Sayehmiri K, et al. Mass media interventions for preventing
smoking in young people. Cochrane Database Syst Rev. 2017;6:CD001006.
doi:10.1002/14651858.CD001006.pub3
154. Williams JM, Steinberg ML, Griffiths KG, Cooperman N. Smokers with behavioral health
comorbidity should be designated a tobacco use disparity group. Am J Public Health.
2013;103(9):1549-1555. doi:10.2105/AJPH.2013.301232
155. Cruz TB, Rose SW, Lienemann BA, et al. Pro-tobacco marketing and anti-tobacco
campaigns aimed at vulnerable populations: A review of the literature. Tob Induc Dis.
2019;17:68. doi:10.18332/tid/111397
156. Becker TD, Arnold MK, Ro V, Martin L, Rice TR. Systematic Review of Electronic
Cigarette Use (Vaping) and Mental Health Comorbidity Among Adolescents and Young
Adults. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2021;23(3):415-425.
doi:10.1093/ntr/ntaa171
96
157. Bierhoff J, Haardörfer R, Windle M, Berg CJ. Psychological Risk Factors for Alcohol,
Cannabis, and Various Tobacco Use among Young Adults: A Longitudinal Analysis.
Subst Use Misuse. 2019;54(8):1365-1375. doi:10.1080/10826084.2019.1581220
158. Leventhal AM, Strong DR, Sussman S, et al. Psychiatric comorbidity in adolescent
electronic and conventional cigarette use. J Psychiatr Res. 2016;73:71-78.
doi:10.1016/j.jpsychires.2015.11.008
159. Villanti AC, Mowery PD, Delnevo CD, Niaura RS, Abrams DB, Giovino GA. Changes in
the prevalence and correlates of menthol cigarette use in the USA, 2004-2014. Tob
Control. 2016;25(Suppl 2):ii14-ii20. doi:10.1136/tobaccocontrol-2016-053329
160. Young-Wolff KC, Hickman NJ, Kim R, Gali K, Prochaska JJ. Correlates and prevalence
of menthol cigarette use among adults with serious mental illness. Nicotine Tob Res Off J
Soc Res Nicotine Tob. 2015;17(3):285-291. doi:10.1093/ntr/ntu141
161. Hickman NJ, Delucchi KL, Prochaska JJ. Menthol use among smokers with psychological
distress: findings from the 2008 and 2009 National Survey on Drug Use and Health. Tob
Control. 2014;23(1):7-13. doi:10.1136/tobaccocontrol-2012-050479
162. Hooper MW, Zhao W, Byrne MM, et al. Menthol cigarette smoking and health, Florida
2007 BRFSS. Am J Health Behav. 2011;35(1):3-14. doi:10.5993/ajhb.35.1.1
163. Cohn AM, Johnson AL, Hair E, Rath JM, Villanti AC. Menthol tobacco use is correlated
with mental health symptoms in a national sample of young adults: implications for future
health risks and policy recommendations. Tob Induc Dis. 2016;14. doi:10.1186/s12971-
015-0066-3
164. Salgado MV, Glantz SA. Direct disease-inducing effects of menthol through the eyes of
tobacco companies. Tob Control. 2011;20(Suppl 2):ii44-ii48. doi:10.1136/tc.2010.041962
165. Ferris Wayne G, Connolly GN. Application, function, and effects of menthol in cigarettes:
a survey of tobacco industry documents. Nicotine Tob Res Off J Soc Res Nicotine Tob.
2004;6 Suppl 1:S43-54. doi:10.1080/14622203310001649513
166. Benowitz NL, Herrera B, Jacob P. Mentholated cigarette smoking inhibits nicotine
metabolism. J Pharmacol Exp Ther. 2004;310(3):1208-1215. doi:10.1124/jpet.104.066902
167. Benowitz NL, Samet JM. The Threat of Menthol Cigarettes to U.S. Public Health. N Engl
J Med. 2011;364(23):2179-2181. doi:10.1056/NEJMp1103610
168. Cwalina SN, Majmundar A, Unger JB, Barrington-Trimis JL, Pentz MA. Adolescent
menthol cigarette use and risk of nicotine dependence: Findings from the national
Population Assessment on Tobacco and Health (PATH) study. Drug Alcohol Depend.
2020;206:107715. doi:10.1016/j.drugalcdep.2019.107715
97
169. Alsharari SD, King JR, Nordman JC, et al. Effects of Menthol on Nicotine
Pharmacokinetic, Pharmacology and Dependence in Mice. PloS One.
2015;10(9):e0137070. doi:10.1371/journal.pone.0137070
170. Collins CC, Moolchan ET. Shorter time to first cigarette of the day in menthol adolescent
cigarette smokers. Addict Behav. 2006;31(8):1460-1464.
doi:10.1016/j.addbeh.2005.10.001
171. Chisholm D, Sweeny K, Sheehan P, et al. Scaling-up treatment of depression and anxiety:
a global return on investment analysis. Lancet Psychiatry. 2016;3(5):415-424.
doi:10.1016/S2215-0366(16)30024-4
172. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE. The epidemiology of
panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey
Replication. Arch Gen Psychiatry. 2006;63(4):415-424. doi:10.1001/archpsyc.63.4.415
173. Skinner BF. (1938). The behavior of organisms: An experimental analysis. Englewood
Cliffs, NJ: Prentice Hall.
174. Becker TD, Arnold MK, Ro V, Martin L, Rice TR. Systematic review of electronic
cigarette use (vaping) and mental health comorbidity among adolescents and young adults.
Nicotine Tob Res Off J Soc Res Nicotine Tob. Published online September 9, 2020.
doi:10.1093/ntr/ntaa171
175. Zvolensky MJ, Feldner MT, Leen-Feldner EW, McLeish AC. Smoking and panic attacks,
panic disorder, and agoraphobia: a review of the empirical literature. Clin Psychol Rev.
2005;25(6):761-789. doi:10.1016/j.cpr.2005.05.001
176. Dahne J, Hise L, Brenner M, Lejuez CW, MacPherson L. An experimental investigation
of the functional relationship between social phobia and cigarette smoking. Addict Behav.
2015;43:66-71. doi:10.1016/j.addbeh.2014.12.012
177. Watson NL, Heffner JL, McClure JB, Bricker JB. Relationships Between Social Anxiety
and Smoking-Specific Experiential Avoidance. J Dual Diagn. 2017;13(1):1-5.
doi:10.1080/15504263.2016.1248310
178. Barrington-Trimis JL, Berhane K, Unger JB, et al. Psychosocial Factors Associated With
Adolescent Electronic Cigarette and Cigarette Use. Pediatrics. 2015;136(2):308-317.
doi:10.1542/peds.2015-0639
179. Cosci F, Knuts IJE, Abrams K, Griez EJL, Schruers KRJ. Cigarette smoking and panic: a
critical review of the literature. J Clin Psychiatry. 2010;71(5):606-615.
doi:10.4088/JCP.08r04523blu
180. Isensee B, Wittchen HU, Stein MB, Höfler M, Lieb R. Smoking Increases the Risk of
Panic: Findings From a Prospective Community Study. Arch Gen Psychiatry.
2003;60(7):692-700. doi:10.1001/archpsyc.60.7.692
98
181. Khantzian EJ. The self-medication hypothesis of substance use disorders: a
reconsideration and recent applications. Harv Rev Psychiatry. 1997;4(5):231-244.
doi:10.3109/10673229709030550
182. Farris SG, Brown LA, Goodwin RD, Zvolensky MJ. Panic attack history and smoking
topography. Drug Alcohol Depend. 2017;171:84-90.
doi:10.1016/j.drugalcdep.2016.11.023
183. Pérez A, Bluestein MA, Kuk AE, Chen B, Sterling KL, Harrell MB. Age of Onset of
Susceptibility to Different Tobacco Products Among Non-Susceptible US Young Adults:
Findings from the Population Assessment of Tobacco and Health Study Waves 2-4 (2014-
2017). Tob Use Insights. 2021;14:1179173X211065643.
doi:10.1177/1179173X211065643
184. Goodwin RD, Lavoie KL, Lemeshow AR, Jenkins E, Brown ES, Fedoronko DA.
Depression, Anxiety, and COPD: The Unexamined Role of Nicotine Dependence.
Nicotine Tob Res. 2012;14(2):176-183. doi:10.1093/ntr/ntr165
185. FDA Finalizes Enforcement Policy on Unauthorized Flavored Cartridge-Based E-
Cigarettes That Appeal to Children, Including Fruit and Mint. U.S. Food and Drug
Administration. Jan 2, 2020.
186. Wang TW, Gentzke AS, Neff LJ, et al. Disposable E-Cigarette Use among U.S. Youth —
An Emerging Public Health Challenge. N Engl J Med. 2021;384(16):1573-1576.
doi:10.1056/NEJMc2033943
187. Abuse NI on D. Percentage of adolescents reporting drug use decreased significantly in
2021 as the COVID-19 pandemic endured. National Institute on Drug Abuse. Published
December 15, 2021. Accessed December 29, 2021. https://www.drugabuse.gov/news-
events/news-releases/2021/12/percentage-of-adolescents-reporting-drug-use-decreased-
significantly-in-2021-as-the-covid-19-pandemic-endured
188. Ayran G, Köse S, Küçükoğlu S, Aytekin Özdemir A. The effect of anxiety on nicotine
dependence among university students during the COVID-19 pandemic. Perspect
Psychiatr Care. 2022;58(1):114-123. doi:10.1111/ppc.12825
189. Clendennen SL, Case KR, Sumbe A, Mantey DS, Mason EJ, Harrell MB. Stress,
Dependence, and COVID-19–related Changes in Past 30-day Marijuana, Electronic
Cigarette, and Cigarette Use among Youth and Young Adults. Tob Use Insights.
2021;14:1179173X211067439. doi:10.1177/1179173X211067439
190. Berg CJ, Callanan R, Johnson TO, et al. Vape shop and consumer activity during COVID-
19 non-essential business closures in the USA. Tob Control. Published online October 19,
2020. doi:10.1136/tobaccocontrol-2020-056171
191. Czeisler M, Lane R, Petrosky E. Mental Health, Substance Use, and Suicidal Ideation
During the COVID-19 Pandemic - United States, June 24-30, 2020. MMWR Morb Mortal
Wkly Rep.; 2020:1049-1057.
99
192. Darmawan DO, Gwal K, Goudy BD, Jhawar S, Nandalike K. Vaping in today’s pandemic:
E-cigarette, or vaping, product use-associated lung injury mimicking COVID-19 in
teenagers presenting with respiratory distress. SAGE Open Med Case Rep.
2020;8:2050313X20969590. doi:10.1177/2050313X20969590
193. Gaiha SM, Cheng J, Halpern-Felsher B. Association Between Youth Smoking, Electronic
Cigarette Use, and COVID-19. J Adolesc Health Off Publ Soc Adolesc Med.
2020;67(4):519-523. doi:10.1016/j.jadohealth.2020.07.002
194. Grummon AH, Hall MG, Mitchell CG, et al. Reactions to messages about smoking,
vaping and COVID-19: two national experiments. Tob Control. Published online
November 2020. doi:10.1136/tobaccocontrol-2020-055956
195. Klein EG, Koopman Gonzalez S, Pike Moore S, Bohnert EJ, Quisenberry AJ, Trapl ES.
Pulling Your Mask down to Smoke: Qualitative Themes from Young Adults on Nicotine
Use during a Pandemic. Subst Use Misuse. 2021;56(4):437-441.
doi:10.1080/10826084.2020.1869264
196. Williams VF, Smith AA, Villanti AC, et al. Validity of a Subjective Financial Situation
Measure to Assess Socioeconomic Status in US Young Adults. J Public Health Manag
Pract JPHMP. 2017;23(5):487-495. doi:10.1097/PHH.0000000000000468
197. Ramamurthi D, Chau C, Jackler RK. Exploitation of the COVID-19 pandemic by e-
cigarette marketers. Tob Control. Published online August 27, 2020.
doi:10.1136/tobaccocontrol-2020-055855
198. Zhang X, Vuong TD, Andersen-Rodgers E, Roeseler A. Evaluation of California’s
‘Tobacco 21’ law. Tob Control. 2018;27(6):656-662. doi:10.1136/tobaccocontrol-2017-
054088
199. Tobacco Products Scientific Advisory Committee (TPSAC). Menthol Cigarettes and Public
Health: Review of the Scientific Evidence and Recommendations. Rockville, MD: Food
and Drug Administration, 2011.
200. Chen JC, Green KM, Arria AM, Borzekowski DLG. Prospective predictors of flavored e-
cigarette use: A one-year longitudinal study of young adults in the U.S. Drug Alcohol
Depend. 2018;191:279-285. doi:10.1016/j.drugalcdep.2018.07.020
201. Leventhal AM, Dai H. Prevalence of Flavored e-Cigarette Use Among Subpopulations of
Adults in the United States. JNCI J Natl Cancer Inst. 2020;113(4):418-424.
doi:10.1093/jnci/djaa118
202. Grant JE, Lust K, Fridberg DJ, King AC, Chamberlain SR. E-cigarette use (vaping) is
associated with illicit drug use, mental health problems, and impulsivity in university
students. Ann Clin Psychiatry Off J Am Acad Clin Psychiatr. 2019;31(1):27-35.
100
203. Berg CJ, Haardörfer R, Payne JB, et al. Ecological momentary assessment of various
tobacco product use among young adults. Addict Behav. 2019;92:38-46.
doi:10.1016/j.addbeh.2018.12.014
204. Pacek LR, Oliver JA, Sweitzer MM, McClernon FJ. Young adult dual combusted cigarette
and e-cigarette users’ anticipated responses to a nicotine reduction policy and menthol ban
in combusted cigarettes. Drug Alcohol Depend. 2019;194:40-44.
doi:10.1016/j.drugalcdep.2018.10.005
205. Strickland JC, Stoops WW. The use of crowdsourcing in addiction science research:
Amazon Mechanical Turk. Exp Clin Psychopharmacol. 2019;27(1):1-18.
doi:10.1037/pha0000235
206. Jeong M, Zhang D, Morgan JC, et al. Similarities and Differences in Tobacco Control
Research Findings From Convenience and Probability Samples. Ann Behav Med Publ Soc
Behav Med. 2019;53(5):476-485. doi:10.1093/abm/kay059
207. Cwalina SN, Pacek LR, Barrington-Trimis JL, Tackett AP, Pentz MA. Cross-Sectional
Associations of Multiple Tobacco Product Use with Depressive and Anxiety Symptoms
among Young Adult E-Cigarette Users. Subst Use Misuse. Published online July 29,
2021:1-8. doi:10.1080/10826084.2021.1954026
208. Wellman RJ, DiFranza JR, Savageau JA, Godiwala S, Friedman K, Hazelton J. Measuring
adults’ loss of autonomy over nicotine use: the Hooked on Nicotine Checklist. Nicotine
Tob Res Off J Soc Res Nicotine Tob. 2005;7(1):157-161.
doi:10.1080/14622200412331328394
209. Barrington-Trimis JL, Cho J, Ewusi-Boisvert E, et al. Risk of Persistence and Progression
of Use of 5 Cannabis Products After Experimentation Among Adolescents. JAMA Netw
Open. 2020;3(1):e1919792. doi:10.1001/jamanetworkopen.2019.19792
210. National Cancer Institute. The Role of the Media in Promoting and Reducing Tobacco
Use. Tobacco Control Monograph No. 19. Bethesda, MD: U.S. Department of Health and
Human Services, National Institutes of Health, National Cancer Institute. NIH Pub. No.
07-6242, June 2008.
211. FDA Commits to Evidence-Based Actions Aimed at Saving Lives and Preventing Future
Generations of Smokers. Food and Drug Administration. April 29, 2021.
212. Wackowski OA, Evans KR, Harrell MB, et al. In Their Own Words: Young Adults’
Menthol Cigarette Initiation, Perceptions, Experiences and Regulation Perspectives.
Nicotine Tob Res Off J Soc Res Nicotine Tob. 2018;20(9):1076-1084.
doi:10.1093/ntr/ntx048
213. Ai J, Taylor KM, Lisko JG, Tran H, Watson CH, Holman MR. Menthol Content in US
Marketed Cigarettes. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2016;18(7):1575-1580.
doi:10.1093/ntr/ntv162
101
214. Gordon SM, Brinkman MC, Meng RQ, et al. Effect of cigarette menthol content on
mainstream smoke emissions. Chem Res Toxicol. 2011;24(10):1744-1753.
doi:10.1021/tx200285s
215. Biswas L, Harrison E, Gong Y, et al. Enhancing effect of menthol on nicotine self-
administration in rats. Psychopharmacology (Berl). 2016;233(18):3417-3427.
doi:10.1007/s00213-016-4391-x
216. Zhang M, Harrison E, Biswas L, Tran T, Liu X. Menthol facilitates dopamine-releasing
effect of nicotine in rat nucleus accumbens. Pharmacol Biochem Behav. 2018;175:47-52.
doi:10.1016/j.pbb.2018.09.004
217. Brody AL, Mukhin AG, La Charite J, et al. Up-regulation of nicotinic acetylcholine
receptors in menthol cigarette smokers. Int J Neuropsychopharmacol. 2013;16(5):957-
966. doi:10.1017/S1461145712001022
218. Abobo CV, Ma J, Liang D. Effect of menthol on nicotine pharmacokinetics in rats after
cigarette smoke inhalation. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2012;14(7):801-
808. doi:10.1093/ntr/ntr287
219. Allen JA, Duke JC, Davis KC, Kim AE, Nonnemaker JM, Farrelly MC. Using mass media
campaigns to reduce youth tobacco use: a review. Am J Health Promot AJHP.
2015;30(2):e71-82. doi:10.4278/ajhp.130510-LIT-237
220. Wellings K, Macdowall W. Evaluating mass media approaches to health promotion: a
review of methods. Health Educ. 2000;100(1):23-32. doi:10.1108/09654280010309021
221. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health
behaviour. Lancet Lond Engl. 2010;376(9748):1261-1271. doi:10.1016/S0140-
6736(10)60809-4
222. Vannucci A, Flannery KM, Ohannessian CM. Social media use and anxiety in emerging
adults. J Affect Disord. 2017;207:163-166. doi:10.1016/j.jad.2016.08.040
223. Graham AL, Amato MS, Cha S, Jacobs MA, Bottcher MM, Papandonatos GD.
Effectiveness of a Vaping Cessation Text Message Program Among Young Adult e-
Cigarette Users: A Randomized Clinical Trial. JAMA Intern Med. 2021;181(7):923-930.
doi:10.1001/jamainternmed.2021.1793
224. Creamer MR, Delk J, Case K, Perry CL, Harrell MB. Positive Outcome Expectations and
Tobacco Product Use Behaviors in Youth. Subst Use Misuse. 2018;53(8):1399-1402.
doi:10.1080/10826084.2017.1404104
225. U.S. Department of Health an Human Services. Tobacco Use Among U.S. Racial/Ethnic
Minority Groups-African Americans, American Indians and Alaska Natives, Asian
Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General.
Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, Office on Smoking an Health, 1998.
102
226. African Americans and Tobacco Use. Tobacco-Related Disparities. Smoking & Tobacco
Use. U.S. Centers for Disease Control and Prevention. 2020.
227. Lesbian, Gay, Bisexual, and Transgender Persons and Tobacco Use. Tobacco-Related
Disparities. Smoking & Tobacco Use. U.S. Centers for Disease Control and Prevention.
2022.
228. Hispanics/Latinos and Tobacco Use. Tobacco-Related Disparities. Smoking & Tobacco
Use. U.S. Centers for Disease Control and Prevention. 2021.
229. Kushner MG, Menary KR, Maurer EW, Thuras P. Greater elevation in risk for nicotine
dependence per pack of cigarettes smoked among those with an anxiety disorder. J Stud
Alcohol Drugs. 2012;73(6):920-924. doi:10.15288/jsad.2012.73.920
230. Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence
and needed research. J Behav Med. 2009;32(1):20-47. doi:10.1007/s10865-008-9185-0
231. Davis BA. Discrimination: A Social Determinant of Health Inequities. Health Aff Blog.
Published online February 25, 2020. doi:10.1377/hblog20200220.518458
232. Dickerson SS, Gruenewald TL, Kemeny ME. Psychobiological Responses to Social Self
Threat: Functional or Detrimental? Self Identity. 2009;8(2-3):270-285.
doi:10.1080/15298860802505186
233. Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic
review. Psychol Bull. 2009;135(4):531-554. doi:10.1037/a0016059
234. Lowe SR, Tineo P, Young MN. Perceived Discrimination and Major Depression and
Generalized Anxiety Symptoms: In Muslim American College Students. J Relig Health.
2019;58(4):1136-1145. doi:10.1007/s10943-018-0684-1
235. Chen ACC, Szalacha LA, Menon U. Perceived discrimination and its associations with
mental health and substance use among Asian American and Pacific Islander
undergraduate and graduate students. J Am Coll Health J ACH. 2014;62(6):390-398.
doi:10.1080/07448481.2014.917648
236. Reitzel LR, Smith NG, Obasi EM, Forney M, Leventhal AM. Perceived distress tolerance
accounts for the covariance between discrimination experiences and anxiety symptoms
among sexual minority adults. J Anxiety Disord. 2017;48:22-27.
doi:10.1016/j.janxdis.2016.07.006
237. Bower KM, Thorpe RJ, LaVeist TA. Perceived racial discrimination and mental health in
low-income, urban-dwelling whites. Int J Health Serv Plan Adm Eval. 2013;43(2):267-
280. doi:10.2190/HS.43.2.e
238. Fahey MC, Morris JD, Robinson LA, Pebley K. Association between Perceived
Discrimination and Vaping among College Students. Subst Use Misuse. 2021;56(5):738-
741. doi:10.1080/10826084.2021.1887250
103
239. Unger JB. Perceived Discrimination as a Risk Factor for Use of Emerging Tobacco
Products: More Similarities Than Differences Across Demographic Groups and
Attributions for Discrimination. Subst Use Misuse. 2018;53(10):1638-1644.
doi:10.1080/10826084.2017.1421226
240. Purnell JQ, Peppone LJ, Alcaraz K, et al. Perceived discrimination, psychological distress,
and current smoking status: results from the Behavioral Risk Factor Surveillance System
Reactions to Race module, 2004-2008. Am J Public Health. 2012;102(5):844-851.
doi:10.2105/AJPH.2012.300694
241. Unger JB, Soto DW, Baezconde-Garbanati L. Trajectories of perceived discrimination
from adolescence to emerging adulthood and substance use among Hispanic youth in Los
Angeles. Addict Behav. 2016;53:108-112. doi:10.1016/j.addbeh.2015.10.009
242. Unger JB, Schwartz SJ, Huh J, Soto DW, Baezconde-Garbanati L. Acculturation and
perceived discrimination: predictors of substance use trajectories from adolescence to
emerging adulthood among Hispanics. Addict Behav. 2014;39(9):1293-1296.
doi:10.1016/j.addbeh.2014.04.014
243. Fagan P, Brook JS, Rubenstone E, Zhang C, Brook DW. Longitudinal precursors of young
adult light smoking among African Americans and Puerto Ricans. Nicotine Tob Res.
2009;11(2):139-147. doi:10.1093/ntr/ntp009
244. Clark R, Coleman AP, Novak JD. Brief report: Initial psychometric properties of the
everyday discrimination scale in black adolescents. J Adolesc. 2004;27(3):363-368.
doi:10.1016/j.adolescence.2003.09.004
245. Kim G, Sellbom M, Ford KL. Race/ethnicity and measurement equivalence of the
Everyday Discrimination Scale. Psychol Assess. 2014;26(3):892-900.
doi:10.1037/a0036431
246. Lehrer HM, Goosby BJ, Dubois SK, Laudenslager ML, Steinhardt MA. Race moderates
the association of perceived everyday discrimination and hair cortisol concentration.
Stress Amst Neth. 2020;23(5):529-537. doi:10.1080/10253890.2019.1710487
247. Lewis TT, Yang FM, Jacobs EA, Fitchett G. Racial/ethnic differences in responses to the
everyday discrimination scale: a differential item functioning analysis. Am J Epidemiol.
2012;175(5):391-401. doi:10.1093/aje/kwr287
248. Gonzales KL, Noonan C, Goins RT, et al. Assessing the Everyday Discrimination Scale
among American Indians and Alaska Natives. Psychol Assess. 2016;28(1):51-58.
doi:10.1037/a0039337
249. Kendzor DE, Businelle MS, Reitzel LR, et al. Everyday discrimination is associated with
nicotine dependence among African American, Latino, and White smokers. Nicotine Tob
Res Off J Soc Res Nicotine Tob. 2014;16(6):633-640. doi:10.1093/ntr/ntt198
104
250. Michaels E, Thomas M, Reeves A, et al. Coding the Everyday Discrimination Scale:
implications for exposure assessment and associations with hypertension and depression
among a cross section of mid-life African American women. J Epidemiol Community
Health. 2019;73(6):577-584. doi:10.1136/jech-2018-211230
251. Slemon A, Susan Dahinten V, Stones C, Bungay V, Varcoe C. Analysis of the social
consequences and value implications of the Everyday Discrimination Scale (EDS):
implications for measurement of discrimination in health research. Health Sociol Rev J
Health Sect Aust Sociol Assoc. Published online August 20, 2021:1-15.
doi:10.1080/14461242.2021.1969980
252. Asmundson GJG, Taylor S. How health anxiety influences responses to viral outbreaks
like COVID-19: What all decision-makers, health authorities, and health care
professionals need to know. J Anxiety Disord. 2020;71:102211.
doi:10.1016/j.janxdis.2020.102211
253. Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19
coronavirus and its impact on global mental health. Int J Soc Psychiatry. 2020;66(4):317-
320. doi:10.1177/0020764020915212
254. Hawes MT, Szenczy AK, Olino TM, Nelson BD, Klein DN. Trajectories of depression,
anxiety and pandemic experiences; A longitudinal study of youth in New York during the
Spring-Summer of 2020. Psychiatry Res. 2021;298:113778.
doi:10.1016/j.psychres.2021.113778
255. Hawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and
anxiety symptoms in adolescents and young adults during the COVID-19 pandemic.
Psychol Med. Published online 2021:1-9. doi:10.1017/S0033291720005358
256. Horigian VE, Schmidt RD, Feaster DJ. Loneliness, Mental Health, and Substance Use
among US Young Adults during COVID-19. J Psychoactive Drugs. Published online
October 28, 2020:1-9. doi:10.1080/02791072.2020.1836435
257. Golberstein E, Wen H, Miller BF. Coronavirus Disease 2019 (COVID-19) and Mental
Health for Children and Adolescents. JAMA Pediatr. 2020;174(9):819-820.
doi:10.1001/jamapediatrics.2020.1456
258. Hossain MM, Tasnim S, Sultana A, et al. Epidemiology of mental health problems in
COVID-19: a review. F1000Research. 2020;9:636. doi:10.12688/f1000research.24457.1
259. Asmundson GJG, Taylor S. Coronaphobia revisted: A state-of-the-art on pandemic-related
fear, anxiety, and stress. J Anxiety Disord. 2020;76:102326.
doi:10.1016/j.janxdis.2020.102326
260. Le D, Moran MB, Atnafou R, Matson PA, Jones MR, D’Souza G. E-cigarette Use,
Tobacco Product Polyuse, and Motivations for Use among Baltimore Young Adults.
Health Behav Policy Rev. 2019;6(5):427-437. doi:10.14485/hbpr.6.5.2
105
261. Miech R, Patrick ME, Keyes K, O’Malley PM, Johnston L. Adolescent drug use before
and during U.S. national COVID-19 social distancing policies. Drug Alcohol Depend.
2021;226:108822. doi:10.1016/j.drugalcdep.2021.108822
262. Sharma P, Ebbert JO, Rosedahl JK, Philpot LM. Changes in substance use among young
adults during a respiratory disease pandemic. SAGE Open Med.
2020;8:2050312120965321. doi:10.1177/2050312120965321
263. Sokolovsky AW, Hertel AW, Micalizzi L, White HR, Hayes KL, Jackson KM.
Preliminary impact of the COVID-19 pandemic on smoking and vaping in college
students. Addict Behav. 2021;115:106783. doi:10.1016/j.addbeh.2020.106783
264. Kalkhoran SM, Levy DE, Rigotti NA. Smoking and E-Cigarette Use Among U.S. Adults
During the COVID-19 Pandemic. Am J Prev Med. Published online October 6,
2021:S0749-3797(21)00499-2. doi:10.1016/j.amepre.2021.08.018
265. Gaiha SM, Lempert LK, Halpern-Felsher B. Underage Youth and Young Adult e-
Cigarette Use and Access Before and During the Coronavirus Disease 2019 Pandemic.
JAMA Netw Open. 2020;3(12):e2027572. doi:10.1001/jamanetworkopen.2020.27572
266. Popova L. Carpe covid: using COVID-19 to communicate about harms of tobacco
products. Tob Control. Published online November 12, 2020. doi:10.1136/tobaccocontrol-
2020-056276
267. Helfgott D, Capozzoli G, Madray J, et al. E-cigarette or vaping product use associated
lung injury (EVALI) in the time of COVID-19: A clinical dilemma. Pediatr Pulmonol.
Published online December 29, 2021. doi:10.1002/ppul.25804
268. White AM, Li D, Snell LM, et al. Perceptions of Tobacco Product-Specific COVID-19
Risk and Changes in Tobacco Use Behaviors Among Smokers, E-Cigarette Users, and
Dual Users. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2021;23(9):1617-1622.
doi:10.1093/ntr/ntab053
269. Dubey S, Biswas P, Ghosh R, et al. Psychosocial impact of COVID-19. Diabetes Metab
Syndr. 2020;14(5):779-788. doi:10.1016/j.dsx.2020.05.035
270. Gardiner PS. The African Americanization of menthol cigarette use in the United States.
Nicotine Tob Res. 2004;6 Suppl 1:S55-65.
271. Giovino GA, Gardiner PS. Understanding Tobacco Use Behaviors Among African
Americans: Progress, Critical Gaps, and Opportunities. Nicotine Tob Res Off J Soc Res
Nicotine Tob. 2016;18 Suppl 1:S1-6. doi:10.1093/ntr/ntv234
272. Delnevo CD, Ganz O, Goodwin RD. Banning Menthol Cigarettes: A Social Justice Issue
Long Overdue. Nicotine Tob Res. 2020;22(10):1673-1675. doi:10.1093/ntr/ntaa152
106
273. Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate activity, and
health disparities: tobacco industry targeting of inner cities. J Health Care Poor
Underserved. 2007;18(4 Suppl):10-38. doi:10.1353/hpu.2007.0120
274. Litigation Relevant to Regulation of Novel and Emerging Nicotine and Tobacco Products:
Comparison across Jurisdictions. World Health Organization. April 23, 2021.

Abstract (if available)

Abstract Adolescents and young adults (vs. older adults) with anxiety symptoms (vs. no symptoms) have a disproportionately greater risk of developing nicotine dependence and subsequent tobacco-attributable morbidity and mortality. Thus, preventing and reducing tobacco use among young people with anxiety symptoms is of interest to public health. This high-risk population may benefit from evidence-based anti-tobacco interventions that resonate with their needs and experiences. Data are needed to develop such interventions. Prior research among adult populations suggests a link between anxiety symptoms and cigarette use, but this bidirectional association has received very little attention among adolescents and young adults, and it is unclear whether potential associations extend to vape use. The overarching objective of this dissertation was to investigate the associations of anxiety symptoms with vape and cigarette use among adolescents and young adults across the tobacco use continuum, from initiation to established use, utilizing data from prospective cohort and online panel survey studies. The specific aims of this dissertation were to: 1) evaluate prospective associations of anxiety symptoms measured in adolescence with initiation of vape and cigarette use in early adulthood, 2) examine cross-sectional associations of vape and cigarette use with anxiety symptoms across three socio-environmental contexts, and 3) examine cross-sectional associations of menthol cigarette and menthol-flavored vape use with anxiety symptoms among young adults. Findings suggest that: 1) adolescents with panic symptoms are a particularly high-risk population for cigarette initiation, 2) associations of cigarette use with anxiety symptoms are not significantly influenced by the greater social context, and 3) menthol cigarettes might be more appealing to young adults with anxiety symptoms than menthol-flavored vapes. Taken together, we consistently found evidence of an association between anxiety symptoms and cigarette use, and consistently did not observe associations between anxiety symptoms and vape use. These differential associations are significant because cigarettes are more harmful to health than vapes. Individuals with anxiety symptoms are more likely to develop nicotine dependence than those without symptoms. Therefore, not only do young adults with anxiety symptoms have increased risk of using a nicotine product, but they also have an increased risk of becoming dependent on a product that substantially contributes to premature mortality. With recent increases in anxiety symptoms among young people that are likely to worsen due to the COVID-19 pandemic, data on young people with anxiety symptoms will become increasingly relevant for developing evidence-based anti-tobacco interventions at the community and population level. Future research should examine smoking motivations among young people with anxiety symptoms and investigate potential associations between anxiety symptoms and vape use that were outside the scope of this dissertation (such as nicotine formulation and frequency of menthol-flavored vape use vs. other flavors).

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Asset Metadata

Creator Cwalina, Samantha N. (author)

Core Title Anxiety symptoms and nicotine use among adolescents and young adults

School Keck School of Medicine

Degree Doctor of Philosophy

Degree Program Preventive Medicine (Health Behavior)

Publication Date 03/09/2022

Defense Date 02/24/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag adolescents and young adults,anxiety,Mental Health,nicotine,OAI-PMH Harvest,tobacco control,vaping

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Barrington-Trimis, Jessica L. (committee chair), Pentz, Mary Ann (committee chair), Baezconde-Garbanati, Lourdes (committee member), Cederbaum, Julie (committee member), Unger, Jennifer (committee member)

Creator Email cwalina@usc.edu,sn.cwalina@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC110816139

Unique identifier UC110816139

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Rights Cwalina, Samantha N.

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Source 20220321-usctheses-batch-916 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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