Study Overview: Gender Identity, Mental Health, and Nicotine Use Among U.S. Adolescents
February 27, 2026 — According to a study published in LGBT Health, researchers analyzed data from the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey (U.S. sample, 2020–2023; ages 16–19; n=28,959). The study examined the relationship between internalizing mental health (IMH)—a combined indicator of depressive and anxiety symptoms—and current nicotine/tobacco product use, while assessing the moderating role of gender identity.
Data Source and Methodology
The analysis drew on responses from 28,959 U.S. adolescents aged 16–19 collected between 2020 and 2023. Current nicotine/tobacco use was categorized into four groups:
- No use
- Combustible products only
- Non-combustible products only
- Dual use (both combustible and non-combustible products)
Gender identity was classified based on responses to “current gender identity” and “assigned sex at birth.” Gender nonconforming (GNC) and transgender identities were presented as separate analytical categories.
Differences in Current Nicotine/Tobacco Use by Gender Identity
The results showed substantial variation in product use across gender identity groups.
- Transgender women: approximately 29% (highest)
- Transgender men: approximately 24%
- Cisgender men: approximately 22%
- Cisgender women: approximately 19%
- GNC adolescents: approximately 14% (lowest)
These findings indicate distinct usage patterns across identity categories rather than a uniform trend.
Internalized Mental Health Symptoms Across Groups
Rates of internalized symptoms (depression/anxiety) also differed markedly by gender identity:
- GNC adolescents: approximately 85% (highest)
- Transgender men: approximately 80%
- Cisgender women: approximately 67%
- Transgender women: approximately 65%
- Cisgender men: approximately 45% (lowest)
This distribution highlights significant disparities in mental health burden among adolescent subgroups.
Significant Interaction Between Mental Health and Gender Identity
The study reported a statistically significant interaction between internalized symptoms and gender identity (p<0.0001). This suggests that the strength and direction of the association between mental health symptoms and product use type vary depending on gender identity group.
Stratified Analysis: Product Type Associations
In stratified models, the associations between internalized symptoms and product type differed across groups:
- Cisgender men: Higher probability of internalized symptoms associated with combustible-only, non-combustible-only, and dual use.
- Cisgender women: Higher probability of internalized symptoms associated with non-combustible-only and dual use, but no significant association with combustible-only use.
- Transgender group (combined due to sample size limitations): Internalized symptoms were less likely to be associated with combustible-only and dual use.
- GNC adolescents: Internalized symptoms were more likely to be associated with non-combustible-only use.
These differentiated patterns underscore the complexity of the relationship between product type and mental health status.
Research Implications: The Need for Identity-Specific Analysis
The study concludes that transgender and GNC identities should be analyzed and reported separately in adolescent nicotine/tobacco and mental health research. Aggregating these groups may obscure meaningful differences in risk patterns and health outcomes.
Potential Industry and Regulatory Impacts
1. Expansion of Risk Framing to Vulnerable Subgroups
Regulatory and public health discussions may increasingly shift from focusing solely on product attributes to considering user demographics. Greater emphasis may be placed on risks to vulnerable adolescent subgroups, particularly those with elevated mental health burdens. This could intensify scrutiny of targeted marketing practices, youth access controls, and distribution channels.
2. Structured Assessment of Mental Health Linkages
As research further quantifies the relationship between internalized symptoms and specific product types across gender identity groups, regulatory frameworks may require more detailed population-level impact analyses. Companies may need to incorporate nuanced subgroup data into risk communications, product submissions, and public health impact assessments.
3. Policy Focus on Non-Combustible and Dual-Use Patterns
The findings show differentiated distributions of non-combustible-only use and dual use across gender identity groups. Policymakers may increasingly integrate mental health and social vulnerability considerations when distinguishing regulatory narratives between combustible and non-combustible nicotine products.
