Sex-specific associations between tobacco use and youth mental health: prospective and cross-sectional findings from the LoRDIA Program

INTRODUCTION: Tobacco use is disproportionately common among individuals with mental health problems, yet the direction of this association remains unclear. It is also uncertain whether this relationship varies by sex or by type of tobacco product. This study aimed to further characterize the association between tobacco use and mental health symptoms during adolescence, with a particular focus on sex differences and product type. METHODS: Data were drawn from the Swedish prospective cohort Longitudinal Research on Development In Adolescence (LoRDIA). Tobacco use (cigarette smoking and/or Swedish snus) was examined longitudinally from ages 12/13 to 17 in relation to psychosomatic symptoms, and cross-sectionally at age 17 with respect to depressive symptoms and suicidal ideation. RESULTS: Longitudinal analyses performed on 1592 adolescents showed that tobacco initiation was associated with worsening of psychosomatic health, particularly among girls. Cross-sectional analyses at age 17 showed that tobacco use was associated with higher odds of depressive symptoms and suicidal ideation after adjusting for sex, self-rated socioeconomic status, and risk consumption of alcohol. In sex-stratified cross-sectional analyses, tobacco use (cigarettes and/or snus) was associated with psychological distress especially among girls. Similarly, dual product use and high frequency of use were associated with higher levels of psychosomatic symptoms in girls only. Exclusive snus was uncommon and findings inconclusive. CONCLUSION: These findings highlight pronounced sex differences in the association between tobacco use and adolescent mental health, with greater vulnerability observed among girls. Further research is needed to clarify the role of snus in mental health outcomes, particularly in female populations.