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To inform early intervention, this study describes correlates of substance use among young people with serious mental illness (SMI) enrolled in integrated care in community mental health settings. 227 adults ages 18–35 were assessed for clinical characteristics and substance use. Logistic regressions were used to describe relationships between substance use and participant characteristics. Over a third (38.9%) reported daily cannabis, 15.9% past month other illicit drug, 13.5% frequent/heavy alcohol and 47.4% any of these; 50.2% reported daily tobacco smoking and 23.3% current vaping. Daily cannabis and tobacco were the most common combination. Alcohol, drug, and cannabis with tobacco were associated with higher mental health symptoms but not with emergency room or hospital utilization. Cannabis and other substance use was common and associated with higher symptoms but not with greater hospital utilization, suggesting that early intervention could prevent long-term negative consequences. [ABSTRACT FROM AUTHOR]

INTRODUCTION The e-cigarette market is large and diverse. Traditional smoking cessation trials involving a control group and a 6-month observation period are an inefficient methodology for testing the multiple treatment options e-cigarettes provide for harm reduction in cigarette smokers. We determined when product substitution occurred in the e-cigarette provision arm of an e-cigarette substitution trial for cigarette smokers who were not interested in quitting. METHODS We conducted a secondary analysis of 120 cigarette smokers with severe mental illness (recruitment 2017-2020) who were given disposable e-cigarettes for 8 weeks and assessed at weeks 0 (t0), 2, 4, 6, and 8. We explored product substitution through visit-to-visit correlations in change in product use, then developed a dual process growth model for cigarette and e-cigarette use to test the association between increases in e-cigarette use and concurrent decreases in cigarettes smoked. RESULTS Mean age of the participants was 45.9 years, and 42.7% smoked >20 cigarettes per day. Almost all product substitution occurred between t0 and t2. For the average smoker (18 cigarettes per day), t2 cigarette frequency decreased by 0.39 (95% CI: -0.56 - -0.22) cigarettes for each additional e-cigarette session. There was effect modification (p=0.033), such that baseline light smokers (<10 cigarettes/day) had no significant decrease in t2 cigarette frequency, regardless of their initial increase in e-cigarette use, while heavy smokers (38 cigarettes/day) switched products nearly on a one-to-one basis. CONCLUSIONS In this study, most product substitution occurred early, and heavier smokers had larger t2 decreases in cigarettes/day with increased e-cigarette use. If confirmed with replication studies, the findings could suggest establishment of a novel outcome for e-cigarette studies - early product substitution - and support the value of short-term comparative effectiveness trials that compare multiple potentially lower harm tobacco products. [ABSTRACT FROM AUTHOR]

Background: Young adults with serious mental illness (SMI) are over twice as likely to smoke cigarettes than those in the general population, but little research has evaluated the efficacy of interventions for this group. While smartphone apps are a promising tool to address this need, their usability should be evaluated among young adults with psychotic disorders, whose symptoms and cognitive impairments may be a barrier to app use. Methods: We compared usability and acceptability of National Cancer Institute apps (QuitGuide and quitSTART) between young adult smokers with SMI psychotic disorders and other SMI diagnoses. We evaluated objective app usability at the initial study visit and following 2 weeks of independent use via a video-recorded task-completion protocol. Perceptions of usability and acceptability were assessed with semi-structured interviews. Engagement was assessed with backend app use data. Results: Participants had a mean age of 29 years old (SD = 4). Of the participants without psychotic disorders (n = 10), all were diagnosed with SMI post-traumatic stress disorder (SMI-PTSD). QuitGuide objective task completion rates were high and similar between diagnosis groups, whereas quitSTART task completion was initially lower among users with psychotic disorder compared to users with SMI-PTSD at Visit 1, and improved by Visit 2. Mean app interactions, mean days of use, and median completed notifications were dramatically higher among quitSTART users compared to QuitGuide users. Compared to quitSTART users with SMI-PTSD, quitSTART users with psychotic disorders had similar daily app interactions over the first week of use (mean 3.8 ± 2.4 interactions), and numerically lower mean daily app interactions during the second week (1.9 ± 1.5 vs. 3.4 ± 2.5), whereas completed notifications remained stable among quitSTART users in both diagnosis groups over time. Qualitative comments indicated general acceptability of both apps among both diagnosis groups. Conclusions: Both QuitGuide and quitSTART were usable and appealing among young adult smokers with psychotic disorders and SMI-PTSD, although quitSTART engendered a dramatically greater level of engagement compared to QuitGuide. Initial coaching to support initiation and app notifications to promote prolonged engagement may be important for young adult smokers with psychotic disorders. Replication and efficacy testing for quitSTART is warranted. [ABSTRACT FROM AUTHOR]

Introduction: People with serious mental illness (SMI) have high rates of smoking and need better access to cessation treatment. Mobile behavioral interventions for cessation have been effective for the general population, but are not usable by many with SMI due to cognitive impairments or severe symptoms. We developed a tailored mobile cessation treatment intervention with features to reduce cognitive load. Method: We enrolled 20 smokers with SMI and showed them how to use the program on a device of their choice. They were assessed at 8 weeks for intervention use, usability, satisfaction, smoking characteristics, and biologically verified abstinence. Results: Participants accessed an average of 23.6 intervention sessions (SD = 17.05; range 1–48; median = 17.5) for an average total of 231.64 minutes (SD = 227.13; range 4.89–955.21; median = 158.18). For 87% of the sessions, average satisfaction scores were 3 or greater on a scale of 1–4. Regarding smoking, 25% of participants had reduced their smoking and 10% had biologically verified abstinence from smoking at 8 weeks. Conclusion: Home and community use of this mobile cessation intervention was feasible among smokers with SMI. Further research is needed to evaluate such scalable approaches to increase access to behavioral treatment for this group. [ABSTRACT FROM AUTHOR]

Objective: The prevalence of cigarette smoking among adults with serious mental illness (SMI) remains high in the United States despite the availability of effective smoking cessation treatment. Identifying social influences on smoking and smoking cessation may help enhance intervention strategies to help smokers with SMI quit. The objective of this qualitative study was to explore social network influences on efforts to quit smoking among adults with SMI enrolled in a cessation treatment program. Methods: Participants were 41 individuals with SMI enrolled in a Medicaid Demonstration Project of smoking cessation at community mental health centers. A convenience sampling strategy was used to recruit participants for social network interviews exploring the influence of family, friends, peers, and significant others on quitting smoking. A team-based analysis of qualitative data involved descriptive coding, grouping coded data into categories, and identifying themes across the data. Results: Social barriers to quitting smoking included pro-smoking social norms, attitudes, and behaviors of social network members, and negative interactions with network members, either specific to smoking or that triggered smoking. Social facilitators to quitting included quitting with network members, having cessation role models, and social support for quitting from network members. Conclusions: Similar to the general population, social factors appear to influence efforts to quit smoking among individuals with SMI enrolled in cessation treatment. Interventions that leverage positive social influences on smoking cessation have the potential to enhance strategies to help individuals with SMI quit smoking. [ABSTRACT FROM AUTHOR]

Medicaid recipients with serious mental illness die 25–30 years earlier than people in the general population due to health conditions that are modifiable through lifestyle changes. Cardiovascular diseases from excess weight, smoking, and sedentary lifestyle contribute substantially to this life expectancy disparity. The current study evaluated the impact of incentives on participation in weight management programming (for overweight and obese adults) and smoking cessation treatment (for regular smokers). Participants were Medicaid recipients with disabling mental illness receiving services at any one of 10 community mental health centers across New Hampshire. Using an equipoise stratified randomized design, n = 1348 were enrolled and assigned to one of four weight management programs (Healthy Choices Healthy Changes: HCHC) and n = 661 were enrolled and assigned to one of three smoking cessation interventions (Breathe Well Live Well: BWLW). Following assignment to an intervention, participants were randomized to receive financial incentives (to attend weight management programs, or to achieve abstinence from smoking) or not. Data were collected at baseline and every 3 months for 12 months. New Hampshire's HCHC and BWLW programs were designed to address serious and preventable health disparities by providing incentivized health promotion programs to overweight/obese and/or tobacco-smoking Medicaid beneficiaries with mental illness. This study was an unprecedented opportunity to evaluate an innovative statewide implementation of incentivized health promotion targeting the most at-risk and costly beneficiaries. If proven effective, this program has the potential to serve as a national model for widespread implementation. [ABSTRACT FROM AUTHOR]

Introduction: Smokers with severe mental illness (SMI) are more likely to start smoking and less likely to quit. Menthol may facilitate smoking progression, dependence, and maintenance by reducing harshness and irritation from smoking and providing a unique sensory experience during use. High rates of menthol use have been reported in smokers with SMI, but information on young adults with SMI has not been reported.Methods: This study provides a secondary analysis to assess the impact of menthol use in a pilot trial of brief tobacco interventions. Participants were assessed at baseline and again at a 3-month follow-up with structured interviews and breath carbon monoxide to confirm self-reported 7-day abstinence at follow-up.Results: Participants included 81 young adult smokers with SMI, mean age of 24.2 years (SD = 3.6; range 18-30). Overall, 58% of the group reported that they recently used a menthol-flavored product. Menthol use was correlated with race (African American [18/21, 85.7%] vs. White [24/53, 45.3%] or other race [5/7, 71.4%]; χ2 = 10.7, p = .005) and more lifetime psychiatric hospitalizations (t = 2.39, p = .02), but not with cigarettes per day, nicotine dependence, quit attempts over the follow-up period, nor with achieving biologically confirmed abstinence at the follow-up assessment.Conclusions: The high prevalence of menthol-flavored cigarette use in this study group is consistent with previous reports of high rates of menthol use among young adults, Blacks, and middle-aged SMI smokers. This study supports existing evidence that policies to restrict menthol flavoring in combustible tobacco products could reduce smoking in young adults with SMI.Implications: High rates of menthol use have been reported in middle-aged smokers with SMI, but information on young adults with SMI has not been reported. In this study, more than half (58%) of 81 young adult smokers with SMI used a menthol-flavored product. Menthol use was associated with race and with history of psychiatric hospitalizations. The research supports existing evidence that policies to restrict menthol flavoring in combustible tobacco products could reduce smoking in young adults with SMI. [ABSTRACT FROM AUTHOR]

Significance: Young adults with schizophrenia, bipolar disorder and other severe mental illnesses (SMI) have high rates of smoking, but little research has evaluated predictors of cessation activity and treatment utilization in this group.Methods: We assessed attitudes, beliefs, social norms, perceived behavioral control, intention, quit attempts, treatment utilization, and cessation among 58 smokers with SMI, age 18-30, enrolled in a randomized pilot study comparing a brief interactive/motivational vs. a static/educational computerized intervention. Subjects were assessed at baseline, post intervention, and 3-month follow-up.Results: Over follow-up, one-third of participants self-reported quit attempts. Baseline measures indicating lower breath CO, greater intention to quit, higher perceptions of stigma, higher perceptions of psychological benefits of smoking, and greater symptom distress were associated with quit attempts, whereas gender, diagnosis, social support, attitudes about smoking, and use of cessation treatment were not. In the multivariate analysis, lower breath CO, higher intention to quit and symptom distress were significantly related to quit attempts. Only 5% of participants utilized verified cessation treatment during follow-up. Consistent with the Theory of Planned Behavior, attitudes, social norms and perceived behavioral control regarding cessation treatments correlated significantly with intention to use treatment. Norms and beliefs about treatment were somewhat positive and some improved after intervention, with a pattern significantly favoring the interactive intervention, but intentions to use treatments remained low, consistent with low treatment utilization.Conclusions: Perceptions of traditional cessation treatments improved somewhat after brief interventions, but most young adult smokers with SMI did not use cessation treatment. Instead, interventions led to quit attempts without treatment. [ABSTRACT FROM AUTHOR]

Schizophrenia and schizoaffective disorder are schizophrenia spectrum disorders that cause significant disability. Among individuals who have schizophrenia or schizoaffective disorder, alcohol use disorder (AUD) is common, and it contributes to worse outcomes than for those who do not have co-occurring substance use disorder. Common neurobiological mechanisms, including dysfunction in brain reward circuitry, may explain the high rates of co-occurrence of schizophrenia and AUD or other substance use disorders. Optimal treatment combines pharmacologic intervention and other therapeutic modalities to address both the psychotic disorder and AUD. Further research on the etiology of these co-occurring disorders and on treatment of affected individuals is needed. [ABSTRACT FROM AUTHOR]

Social support may be an effective strategy to increase engagement in cessation treatment for smokers with mental illness. The purpose of this pilot study was to assess the feasibility of a support person intervention linking smokers with mental illness to an online smoking cessation decision aid. We conducted a 12-week pilot study of a one-session telephone coaching intervention ("Care2Quit") to train nonsmoking family members and friends (i.e., support persons) to promote the use of an online cessation decision aid by smokers with mental illness. The primary aim of the study was to assess the feasibility of the support person intervention by examining recruitment, retention, adherence, and participant satisfaction. A secondary aim was to explore changes in the hypothesized mechanism underlying the intervention effect (i.e., cessation support provided) and primary outcome (i.e., smoker use of online cessation decision aid). Seventeen support persons enrolled, of which 94% (n = 16) completed the telephone coaching intervention. Eighty-eight percent of support persons rated the intervention as highly acceptable. Self-reported cessation supportive behaviors by the support person increased significantly by 6 weeks post intervention. Forty-one percent of smokers (n = 7) linked to support persons used the online cessation decision aid by 12 weeks following the support person's telephone coaching session. Preliminary results from this study demonstrate the feasibility of a support person intervention to promote the use of smoking cessation treatment among smokers with mental illness. Future research to evaluate the efficacy of the Care2Quit support partner intervention is warranted. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate health outcomes of a state-supported implementation in community mental health settings of an evidence-based lifestyle intervention for overweight and obese adults with serious mental illness.Methods: Weight and fitness outcomes were evaluated for 122 overweight or obese adults with serious mental illness in four community mental health centers (CMHCs) that were participating in a phased statewide implementation of the In SHAPE lifestyle intervention. Six- and 12-month outcomes were compared between two CMHCs that implemented In SHAPE in the first 12 months and two CMHCs with similar characteristics that implemented In SHAPE in a subsequent phase in the statewide implementation 12 months later.Results: Participants in the two In SHAPE sites (N=63 participants) lost significantly more weight (p=.003) and showed greater improvement in fitness (p=.011) compared with participants at the two usual care control sites (N=59 participants). At six months, nearly half (49%) of In SHAPE participants and at 12 months more than half (60%) of In SHAPE participants showed clinically significant cardiovascular risk reduction defined as ≥5% weight loss or improved fitness (>50 m [164 feet] increase on the six-minute walk test). The difference between the In SHAPE and control groups was not statistically significant.Conclusions: This natural experiment demonstrated promising public health benefits of a practical implementation of health promotion programming for overweight and obese adults with serious mental illness and offers a potential model for reducing risk of early mortality among individuals served by state-funded mental health centers nationwide. [ABSTRACT FROM AUTHOR]

Objective: Family beliefs about smoking and cessation may influence whether individuals with mental illness who smoke use effective cessation treatment. We surveyed family members online regarding beliefs about smoking and cessation among people with mental illness. Method: Two hundred fifty-six family members of individuals with mental illness completed an online survey. Responses were summarized andttests were used to compare responses based on the family member's smoking status.Results: One-quarter of respondents agreed that people with mental illness must smoke to manage mental health symptoms, nearly half (48%) expressed uncertainty about the whether nicotine replacement therapy is harmful for this population, and 69% believed that family members do not have the skills to help an individual with mental illness quit smoking.Conclusions: Misconceptions about smoking and mental illness and uncertainty about the safety of cessation treatment may interfere with family support for quitting smoking among people with mental illness. [ABSTRACT FROM PUBLISHER]

Many people are interested in using marijuana for therapeutic purposes as legalization expands across the country. The impact of marijuana depends upon the consumed potency and dose of its major psychoactive components, tetrahydrocannabinol and cannabidiol, which have very different psychiatric effects. This Open Forum discusses what is known about the impact of these marijuana constituents on people with serious mental illnesses, who may experience many adverse effects and more easily develop addiction with marijuana use. As use of medical marijuana increases, mental health clinicians can help prevent or address adverse effects by informing themselves and others about marijuana's effects and by coordinating with marijuana prescribers. [ABSTRACT FROM AUTHOR]

Abstract: Health concerns are common reasons for wanting to quit smoking among smokers with mental illnesses. Motivational interventions have used feedback from a carbon monoxide monitor to increase awareness of health concerns, but this device is not commonly available. Whether brief motivational interventions can be effective without this feedback is unknown. Using a randomized controlled trial, this study tested the effect of carbon monoxide feedback within a brief, multi-component, computerized motivational intervention among 124 smokers with schizophrenia or mood disorders. The main outcome was initiating cessation treatment over two months. Although participants in the carbon monoxide group increased their knowledge about the carbon monoxide, (χ2 =6.97, df=1, p=.008), the main and secondary outcomes did not differ significantly between groups. Overall, 32% of participants initiated treatment. This study suggests that a computerized motivational decision support system can lead users to initiate cessation treatment, and that carbon monoxide feedback is not a necessary component. [Copyright &y& Elsevier]

Background: Recent studies show that 75-85% of people with schizophrenia spectrum disorders in the United States smoke cigarettes, compared with 23% of the general population. Moreover, people with these illnesses on average have life expectancies 25 years lower than the general population, and smoking is a contributor. Aims: To review intervention research and evaluate the methods and clinical findings associated with attempts to eliminate, or reduce, smoking in people with schizophrenia spectrum disorders. Methods: PubMed and PsychInfo were searched from early 1990 through 2007 with select keywords. Thirteen treatment studies addressing smoking cessation interventions in people with schizophrenia spectrum disorders or severe mental illness were identified. Results: Nicotine replacement therapy, psychosocial interventions, and bupropion have been studied. Overall, treatment compliance was moderate, quit rates were low, and relapse to smoking was high. Modest evidence supports the efficacy of bupropion and/or nicotine replacement combined with psychosocial interventions, and of specific psychosocial interventions combined with nicotine replacement. Conclusion: Preliminary data show modest efficacy of nicotine replacement therapy, psychosocial interventions, and bupropion. Future studies should address motivation, effectiveness, new interventions, long-term interventions, and methods. [ABSTRACT FROM AUTHOR]

Objective: Approximately half of the people who have serious mental illnesses experience a co-occurring substance use disorder at some point in their lifetime. Integrated dual disorders treatment, a program to treat persons with co-occurring disorders, improves outcomes but is not widely available in public mental health settings. This report describes the extent to which this intervention was implemented by 11 community mental health centers participating in a large study of practice implementation. Facilitators and barriers to implementation are described. Methods: Trained implementation monitors conducted regular site visits over two years. During visits, monitors interviewed key informants, conducted ethnographic observations of implementation efforts, and assessed fidelity to the practice model. These data were coded and used as a basis for detailed site reports summarizing implementation processes. The authors reviewed the reports and distilled the three top facilitators and barriers for each site. The most prominent cross-site facilitators and barriers were identified. Results: Two sites reached high fidelity, six sites reached moderate fidelity, and three sites remained at low fidelity over the two years. Prominent facilitators and barriers to implementation with moderate to high fidelity were administrative leadership, consultation and training, supervisor mastery and supervision, chronic staff turnover, and finances. Conclusions: Common facilitators and barriers to implementation of integrated dual disorders treatment emerged across sites. The results confirmed the importance of the use of the consultant-trainer in the model of implementation, as well as the need for intensive activities at multiple levels to facilitate implementation. Further research on service implementation is needed, including but not limited to clarifying strategies to overcome barriers. [ABSTRACT FROM AUTHOR]

The article reports on the study which describes the development and psychometric evaluation of a paper-and-pencil test to asses mental health provider attitudes and knowledge about Integrated Dual Disorders Treatment (IDDT). It states that in the sample of clinicians who were implementing IDDT in two mental health centers, the test showed good internal consistency, inter-rater reliability, and for a subsample who took the test twice, significant improvement over time.

A 29-year-old Caucasian man was brought to the emergency department by the police after he was found wandering barefoot through the snow on Main Street. The police had been called after passers-by reported that the man seemed intoxicated and was acting strangely. When an officer approached the man, he became belligerent and agitated and angrily exclaimed that they had no reason to question him. Using some force, the police brought him to the emergency department. The psychiatrist who interviewed him noted a strong smell of alcohol and signs of psychosis; the man demonstrated a clear thought disorder, and he appeared to be responding to internal voices. A physical examination was unremarkable. His urine was positive for cannabis by dipstick test, and an alcohol breath test was positive. Given the absence of further information about him, the patient was admitted to the crisis service, where he promptly fell asleep. Four hours later, he was less intoxicated. A history was obtained and a mental status examination was performed. As far as could be determined, he had been receiving treatment at a local mental health center, but he had stopped taking his medication (risperidone) 4 weeks earlier and had relapsed to heavy use of alcohol and cannabis. During this period he had been essentially homeless, a situation that presented increasing difficulty for him given the recent cold weather and snow. [ABSTRACT FROM AUTHOR]

A growing body of research supports the effectiveness of integrated treatment for people with co-occurring severe mental illness and substance use disorders (dual disorders), but the effects of specific interventions are less clear. This review focuses on the effects of specific psychosocial interventions for dual disorders, including individual, group, and family modalities, as well as structural (e.g., case management model), procedural (e.g., contingency management), residential, and rehabilitation (e.g., vocational) interventions, with an emphasis on randomized controlled trials. Controlled research on specific individual interventions has focused mainly on motivation enhancement approaches for clients in the earlier stages of treatment, and has reported improved retention in treatment and substance abuse outcomes. Group interventions have been most extensively studied, with findings indicating that a variety of different treatment approaches specifically designed for dual disorder clients (e.g., emphasizing education, motivational enhancement, cognitive-behavioral counseling) are more effective at improving substance abuse outcomes than no group treatment or standard 12-Step approaches. Structural studies suggest that increasing the intensity of integrated dual disorder treatment produces only modest benefits. Residential dual disorder programs show great promise, especially for clients who are homeless and without psychosocial supports. Research on family therapy, procedural interventions, or rehabilitation is too premature at this time to draw any conclusions, although promising results have emerged in each area. Future avenues for research on specific interventions for dual disorders are considered. [ABSTRACT FROM AUTHOR]

This paper reports a case series of families participating in Integrated Family Treatment, a home-based parent training and family support program for parents with severe psychiatric disabilities. All 8 families who entered the program over 6 months were followed for 1 year. Seven families remained in treatment for more than 10 months and rated the program highly. Six of the seven parents (85.7%) remaining in treatment improved on one or more measure of parent skills. Integrated Family Treatment is a promising practice that warrants further study. [ABSTRACT FROM AUTHOR]

Describes the community mental health care for women with severe mental illness in the U.S. Importance of mental health interventions on family functioning; Increase risk of women for postpartum exacerbation; Benefits of medication use during pregnancy and breastfeeding.

Objective Social factors play an important role in quitting smoking in the general population, but relatively little is known about social influences on smoking cessation efforts among individuals with serious mental illness who suffer disproportionately high rates of smoking. This study examined social factors as predictors of using smoking cessation treatment among adults with serious mental illness. Methods We conducted a secondary analysis of data from a randomized study comparing two versions of a motivational decision support system for smoking cessation treatment including 124 smokers with schizophrenia or severe mood disorders. Hierarchical logistic regression with blocked entry of theoretically linked predictor variables was used to model two types of social influences (explicit and implicit) as predictors of using cessation group therapy or smoking cessation medication. Results Approximately 31% of participants initiated smoking cessation treatment during the 2-month follow-up. Hierarchical logistic regression analyses revealed that over and above demographic and personal factors, implicit social influences (others' approval of treatment) significantly predicted use of smoking cessation medication, while explicit social influences (smoking with others) significantly predicted use of cessation group therapy. Conclusions For people with serious mental illness, social factors appear to influence use of smoking cessation treatment above and beyond personal factors and may be specific to the type of treatment. These data support the need to further explore the role of social factors as potential leverage points for engagement in smoking cessation treatments in this population. [ABSTRACT FROM AUTHOR]

Objective: To examine whether mental health problems predict incident use of 12 different tobacco products in a nationally representative sample of youth and young adults.Method: This study analyzed Wave (W) 1 and W2 data from 10,533 12- to 24-year-old W1 never tobacco users in the Population Assessment of Tobacco and Health (PATH) Study. Self-reported lifetime internalizing and externalizing symptoms were assessed at W1. Past 12-month use of cigarettes, electronic nicotine delivery systems (ENDS), traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, other smokeless tobacco, bidis and kreteks (youth only), and dissolvable tobacco was assessed at W2.Results: In multivariable regression analyses, high-severity W1 internalizing (adjusted odds ratio [AOR] = 1.5, 95% CI = 1.3-1.8) and externalizing (AOR = 1.3, 95% CI = 1.1-1.5) problems predicted W2 onset of any tobacco use compared to no/low/moderate severity. High-severity W1 internalizing problems predicted W2 use onset across most tobacco products. High-severity W1 externalizing problems predicted onset of any tobacco (AOR = 1.6, 95% CI = 1.3-1.8), cigarettes (AOR = 1.4, 95% CI = 1.0-2.0), ENDS (AOR = 1.8, 95% CI = 1.5-2.1), and cigarillos (AOR = 1.5, 95% CI = 1.0-2.1) among youth only.Conclusion: Internalizing and externalizing problems predicted onset of any tobacco use. However, findings differed for internalizing and externalizing problems across tobacco products, and by age, gender, and race/ethnicity. In addition to screening for tobacco product use, health care providers should screen for a range of mental health problems as a predictor of tobacco use. Interventions addressing mental health problems may prevent youth from initiating tobacco use. [ABSTRACT FROM AUTHOR]