Author ORCID Identifier

https://orcid.org/0009-0004-2820-1960

Semester

Fall

Date of Graduation

2025

Document Type

Dissertation

Degree Type

PhD

College

School of Public Health

Department

Epidemiology

Committee Chair

Ruchi Bhandari

Committee Member

Bethany Barone Gibbs

Committee Member

Sijin Wen

Committee Member

R. Constance Wiener

Abstract

Background: Tobacco use remains one of the leading causes of preventable disease and death in the United States (U.S.). Although conventional cigarette use among youth has declined, the use of electronic cigarettes (e-cigarettes) has become highly prevalent and poses emerging public health concerns. Adolescence represents a critical developmental period for both oral and mental health, making it essential to understand the consequences of tobacco and nicotine exposure during this stage. The goal of this dissertation is to examine the health impacts of tobacco use in adolescents across multiple domains. Specifically, this research (1) synthesizes existing evidence on the relationship between e-cigarette use and depression and suicide attempts, (2) evaluates associations between tobacco use and mental health, including depression, anxiety, and overall psychological distress, and (3) investigates the longitudinal association between different tobacco use profiles and oral health outcomes.

Methods: Three separate studies were conducted. The first study, a systematic review with meta-analysis of observational studies, assessed the association of e-cigarette use with depression and suicide attempt among adolescents who use e-cigarettes compared to adolescents who do not use e-cigarettes. Literature searches were conducted in PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature through May 2025. Random-effects models were used to pool standardized effect sizes and odds ratios. The second study was a cross-sectional analysis of the 2021-2023 National Youth Tobacco Survey (NYTS) to examine associations between tobacco use profiles (e-cigarette-only, combustible tobacco product (CTP)-only, dual use, and non-use) and mental health outcomes (depression, anxiety, and overall psychological distress). Depression, anxiety, and overall psychological distress symptoms were assessed using the Patient Health Questionnaire (PHQ-4). Weighted multivariable logistic and ordinal regression models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). The third study analyzed Waves 1-6 of the Population Assessment of Tobacco and Health (PATH) Study to evaluate associations between adolescent past-month tobacco use (e-cigarette-only, CTP-only, dual use, and no use) and dental health outcomes (dental caries, periodontal disease, and dental stains) using weighted Cox regression models adjusting for covariates. All analyses were conducted in R (v4.4.2).

Results: In the first study, eleven studies met inclusion criteria. Nine were included in the depression analysis and five in the analysis on suicide attempts. Pooled results indicated that adolescents who use e-cigarette had significantly higher risk of experiencing depression (r =0.08, 95% CI: 0.01–0.15) and of attempting suicide (OR=2.98, 95% CI: 1.70–5.23). In the second study, among 60,072 U.S. adolescents, 25.2% reported depression and 29.6% reported anxiety symptoms. Compared to adolescents who did not use tobacco, those who used both e-cigarettes and CTP had the highest odds of depression (aOR =1.90, 95% CI: 1.58-1.94), anxiety (aOR =1.58, 95% CI: 1.40-1.78), and overall psychological distress (aOR =1.75, 95% CI: 1.58-1.94). In the third study, among 15,788 adolescents, 22.2% experienced dental health issues during follow-up. Adolescents who engaged in dual use of both e-cigarettes and CTP had the highest risk of developing dental problems (HR = 1.31, 95% CI: 1.08-1.72).

Conclusion: Together, all three studies contribute to the growing body of evidence showing that e-cigarette use is not a harmless alternative to traditional tobacco products. This dissertation demonstrates that adolescents who use tobacco, particularly those who engage in dual use of e-cigarettes and CTP, experience significantly higher risks of poor mental and oral health outcomes. As the landscape of tobacco products continues to evolve, understanding the different impacts of e-cigarette use among adolescents remains essential for guiding effective public health action and protecting adolescent well-being.

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