Associations Between Perceived Stress, Mental Distress, and Susceptibility to Multiple Tobacco Product Uptake Among U.S. Adolescents and Young Adults Who Have Never Smoked
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2024
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The prevalence of single combustible tobacco product use has decreased among adolescents and young adults (AYAs) in recent years, but the introduction of alternative tobacco products has led to increases in dual- or poly-use, especially among AYAs. Understanding susceptibility to multiple tobacco product (MTP) use is crucial, as it predicts initiation and subsequent use. Mental distress, including stress and mental health symptoms, may influence susceptibility and harm perceptions, yet this area remains underexplored in the literature. This dissertation aims to fill this gap by examining the influence of mental distress on susceptibility to MTP use among AYAs and whether it alters harm perceptions. By addressing these questions, this research aims to develop effective prevention techniques to prevent substance use initiation and reduce susceptibility among vulnerable populations, ultimately improving long-term health outcomes.Chapter 1 of this dissertation further introduces the background and context of this critical issue at the intersection of mental health and tobacco uptake among the AYA population in the United States, setting the stage for understanding the multifaceted relationship between mental health, stress, tobacco use, and susceptibility among AYAs, and laying a strong foundation for the subsequent chapters' detailed exploration and analysis. The theoretical framework guiding the dissertation is introduced to provide a structured lens through which to examine the complex interplay of factors influencing tobacco use behaviors among AYAs. This framework incorporates theories from psychology, public health, and dependence studies, offering a comprehensive approach to understanding the pathways and mechanisms that contribute to susceptibility and initiation of tobacco product use in this vulnerable population. Chapter 2 was a systematic scoping review which employed the Joanna Briggs Institute (JBI) method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to explore factors associated with multiple tobacco product (MTP) susceptibility, uptake, and use among U.S. adolescents and young adults. A comprehensive search strategy in PsycINFO and PubMed databases yielded 52 eligible articles published from 2013 onwards. Data extraction focused on demographic, individual, familial, social, environmental, and societal factors influencing MTP use. Key findings revealed higher susceptibility to MTP use among older adolescents and males, with Hispanic and Non-Hispanic Black adolescents also exhibiting elevated susceptibility to MTP use. Factors such as intentions to use tobacco, peer and parental tobacco use, and limited exposure to pro-smoking media were associated with susceptibility to MTP use. Additionally, e-cigarette use was linked to subsequent cigarette smoking initiation, while experimentation with MTP was influenced by parental use and tobacco marketing exposure. Progression to MTP use involved concurrent use of multiple products, with sociodemographic characteristics and environmental influences playing significant roles. These findings underscore the complex interplay of factors shaping tobacco use behaviors among adolescents and young adults, highlighting areas for further research and targeted interventions. Chapter 3 employed two pilot studies to examine the relationship between mental health factors (perceived stress, anxiety, and depression) and susceptibility to hookah tobacco smoking among adolescents and young adults; examining differences based on susceptibility status and exploring the predictive role of these factors while considering known risk factors and covariates. Statistical analyses using were conducted across two studies to explore demographic characteristics and predictor variables related to susceptibility and smoking status among young adults. Chi-square tests, t-tests (Study 1), and ANOVAs (Study 2) were utilized for comparisons, alongside bivariate logistic regression and proportional logistic regression for relationship exploration. Findings from Study 1 revealed that perceived stress was a significant predictor, with susceptible young adults reporting higher stress levels, indicating a potential link to susceptibility to hookah tobacco smoking (HTS). Peer acceptability and harm perceptions also emerged as influential factors. Study 2 showed differences in psychological distress levels between non-susceptible individuals and hookah users, highlighting the role of psychological factors in HTS behaviors. A positive linear trend in stress, anxiety, and depression levels from susceptibility status transitions (i.e., from non-susceptible, to susceptible, to use) underscored the need for comprehensive interventions targeting multiple risk factors. The consistent predictive power of perceived stress emphasizes its importance in addressing susceptibility to HTS among young adults. These findings advocate for tailored interventions addressing psychological, social, and demographic factors collectively to reduce susceptibility and prevent HTS initiation effectively. Chapter 4 utilized a national dataset (the Population Assessment on Tobacco and Health) to explore longitudinal links between multiple tobacco product (MTP) susceptibility, mental health symptoms, product harm perceptions and initiation of MTP use among AYAs in the US. We first examined whether increased externalizing and internalizing symptoms predicted changes in susceptibility to MTP use. Longitudinal parallel-process (LPP) modeling was used, involving multilevel modeling (MLM) and structural equations modeling (SEM) considering age group as the major predictor. We also examined whether harm perceptions mediated any relationships between mental distress and susceptibility, adjusting for covariates. We then examined if harm perceptions predicted MTP uptake. Cox-proportional hazard regression analyzed relationships between harm perceptions and MTP uptake. A linear regression model estimated longitudinal relationships between harm perceptions and susceptibility status. Mediation analysis determined if susceptibility status mediated the relationship between harm perceptions and MTP uptake. Lastly, as an exploratory analysis, we examined the interaction between mental distress and susceptibility on MTP uptake. We utilized intercepts and slopes for each variable in analyses to provide insights into how these factors evolve over time. Among a sample of AYAs who reported never smoking cigarettes, e-cigarettes, hookah tobacco, nor cigars (traditional, filtered, and cigarillos) at Wave 1, we found that non-susceptible individuals had higher perceived harm and lower mental health symptoms than susceptible individuals. Susceptibility was highest during the transition from ages 12-14 to 15-17, highlighting a critical period for intervention. Young adults showed higher initiation rates of MTP by Wave 6, emphasizing the need for targeted interventions during the transition to adulthood. Unexpectedly, higher initial levels of mental distress were associated with reduced susceptibility to MTP use, challenging conventional assumptions. Perceptions of harm mediated these relationships variably, indicating complex pathways influencing MTP use initiation. Further investigation using Cox-proportional hazard regression models confirmed that higher initial and increasing perceptions of harm over time were protective against MTP initiation. However, contrary to expectations, higher initial harm perceptions were associated with increased susceptibility initially. Initial susceptibility partially mediated the relationship between perceptions of harm and MTP initiation, highlighting nuanced interactions. The study suggests that while mental distress influences susceptibility and perceptions of harm, its direct moderation effect on MTP initiation was not significant. These findings underscore the importance of developmental stages and social contexts in shaping MTP use behaviors, advocating for tailored interventions during critical transitions to mitigate tobacco use among AYAs. Chapter 5 concludes the dissertation by synthesizing its findings from all chapters, discussing their implications and recommendations for future research.
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Frisbee, Suzanne Michelle (2024). Associations Between Perceived Stress, Mental Distress, and Susceptibility to Multiple Tobacco Product Uptake Among U.S. Adolescents and Young Adults Who Have Never Smoked. Dissertation, Duke University. Retrieved from https://hdl.handle.net/10161/31971.
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